Liver injury debridement and drainage
Liver injury debridement drainage for surgical treatment of liver trauma. Although the liver has a thoracic protection, it has a large weight, a weak texture, and is fixed by the surrounding ligaments. Therefore, whether it is wartime or usual, whether it is a blunt or abdomen or a puncture injury, it is easy to damage and rupture, especially when the liver is pathologically enlarged. According to statistics, wartime liver injury accounts for 26.7% of abdominal trauma, and usually accounts for 16% to 30% of traffic accident injuries. In recent years, there has been an increase in the number of cases of liver trauma in Europe and the United States, which is related to the increase in car accidents and violent incidents. In addition, due to dystocia, liver crush injuries can also occur during neonatal delivery through a narrow birth canal or during labor induction. Liver trauma often combines with other organs, such as the brain, chest, other organs of the abdomen, and complex injuries of the pelvis and urethra. Therefore, in the process of diagnosis and treatment, it is necessary to avoid this.
The mortality rate of liver trauma during the First World War was as high as 66.8%. Although it was reduced after the war, it was still around 60%. During the Second World War, with the advancement of anti-shock and other resuscitation techniques, the mortality rate of liver trauma has dropped to 27%. In the battlefields of North Korea and Vietnam, the mortality rate of US military liver injury dropped to 14% and 8.5%, respectively, which is directly related to timely evacuation (investment of helicopters and other vehicles) and early surgery. The mortality rate of liver trauma in peacetime is About 10%. In general, the mortality rate of simple hepatic trauma and open hepatic trauma is low, while the mortality of complicated hepatic trauma and closed hepatic trauma is higher, and the latter two cases account for 12% to 42% of the total number of liver trauma. The case fatality rate accounts for more than 50%.
Liver trauma can be divided into open injury and closed injury. The former is mostly caused by knife wounds, bullet wounds and shrapnel injuries. The liver damage caused by shotguns is heavier than normal gunshot wounds. The latter is caused by blunt external forces such as blows, crushing, blasting, and falling, which cause the liver to be directly impacted or indirectly affected by the impact of the indirect impact, and the abdominal wall does not have a wound to communicate with the liver. According to pathological classification, hepatic closed injury can be divided into hepatic subcapsular hematoma, liver rupture with hepatic capsule tear (true rupture) and central hepatic rupture. In addition, the clinical classification is based on the severity of the trauma. For example, Zhongshan Hengming's IV degree classification, I degree: capsule tear liver parenchymal injury; II degree: wound length less than 3cm, less than 1cm light laceration; III degree: wound length 5 ~ 10cm, depth 1 ~ 4cm Larger laceration; IV degree: a wound with a starburst or comminuted burst. At present, it is considered that the classification of pathological changes according to the severity of trauma is beneficial to clinical treatment and prognosis.
The liver receives a double blood supply, the blood supply is very rich, and the liver has the function of generating and draining bile. Therefore, the consequences caused by liver damage are very serious, the hemorrhagic shock caused by bleeding, and the biliary peritonitis caused by bile leakage. Endanger the lives of the wounded. According to statistics, bleeding, infection and combined injury accounted for the top 3 in the cause of liver injury, respectively. Among them, major bleeding is the main cause of liver injury. Although minor subcapsular rupture is expected to be cured by strict observation with non-surgical treatment, the diagnosis of such minor injuries is difficult to determine. Therefore, liver trauma generally requires surgery. The timing of liver trauma surgery is very important. If you treat the shock patient immediately after the injury, the risk of surgery will increase. However, although the shock can not be corrected by a large number of blood transfusions, the operation time will be lost if the operation time is too late. The time of surgery should be determined according to the condition of the injury, whether there is a combined injury or shock. When there is no shock or only mild shock, surgery can be performed after appropriate intravenous rehydration. If moderate or severe shock occurs, if the blood transfusion is 1000-2000ml, the shock can not be corrected, and the operation should be performed quickly. The surgical treatment principle of liver trauma is consistent with the requirements of general trauma surgery, and should include debridement, hemostasis, elimination of dead space, suture wound and adequate drainage of liver trauma.Treating diseases: liver rupture Indication
Debridement and drainage of liver injury is suitable for patients with hepatic subcapsular hematoma complicated with hepatic injury;Preoperative preparation
1. The greatest risk of liver injury is hemorrhagic shock, especially when hepatic resection is required for severe liver injury. Generally, the amount of hemorrhage is large and accompanied by different degrees of shock. Anti-shock and resuscitation treatment should be actively carried out, including blood preparation. Blood transfusion, infusion, oxygen supply, correction of electrolyte and acid-base balance disorders, protection of kidney function, prevention of renal failure and so on. At the same time, prepare for emergency surgery to ensure adequate blood supply, improve and maintain blood pressure, such as blood transfusion 500 ~ 1000ml in a short period of time, blood pressure is still not good, that is, should be anti-shock, while performing rescue surgery, should not wait.
2. Most patients with hepatic vein injury are accompanied by hemorrhagic shock, refractory hypotension or combined damage of other organs, often dying before admission. Therefore, the first steps of preoperative treatment are active fluid resuscitation, blood transfusion, and infusion. The injured person quickly enters lactated Ringer's solution through the central vein or large limb vein within 15 minutes after admission; the infusion channel is mostly 2 or 3, and the upper extremity vein is selected. It is advisable to avoid loss of fluid input due to damage to the inferior vena cava and hepatic vein root. If the patient's blood pressure is still low, it indicates that there is a large amount of active bleeding. The patient should be stopped as soon as possible after the preoperative preparation, and the recovery should be continued as soon as possible to shorten the shock time. More than 90% of patients with shock for more than half an hour died, and a large number of cases reported a positive correlation between mortality and shock time.
3. Deep shock, blood pressure can not rise after transfusion in the short term, you can open the chest in the fifth intercostal space on the left side, temporarily block the blood flow of the aorta on the sputum, so that the blood pressure rises, maintain the blood supply of the heart and brain, until the open Healing at the injury site.
4. Serious combined injuries that are life-threatening should be dealt with first. If there is tension pneumothorax, measures such as chest drainage should be performed immediately to avoid serious breathing difficulties, hypoxia, cyanosis and shock, and even death.
5. Those with difficulty breathing should maintain good ventilation and oxygen supply in the early endotracheal intubation.
6. Prophylactic antibiotics. A dose is given before surgery, and then one or several doses are added at a certain interval according to the operation time and the half-life of the drug.
7. Open injury, the wound should be wrapped with sterile dressing, pressure bandage when a large number of bleeding, immediately surgery.
8. Place the stomach tube and catheter before surgery.Surgical procedure
1. Cut the hematoma capsule, remove the hematoma, broken liver tissue and submucosal empyema.
2. Ligation of the fractured intrahepatic bile duct and blood vessel, especially for the blood vessels still bleeding.
3. It is not necessary to suture the wound, place the double cannula at the wound, or place a convection flushing drainage tube.
4. For penetrating wounds deep into the liver, especially those with obvious pollution, as long as there is no bleeding associated with large intravascular hemorrhage, after rinsing and debridement, a drainage tube can be placed at both ends of the wound for simple drainage.
5. The abdominal cavity can be placed to drain the cigarette.