Tangshan People's Hospital Hepatobiliary Surgery Department
The liver is the largest in the abdominal cavitySubstantiveOrgans are important to the human bodyphysiological function。HepatocyteAnoxicTolerancePoor, sohepatic arteryandportal veinIt provides abundant blood supply and has large and smallbile ductAccompanying with blood vesselsbile。It is located deep in the right upper abdomen, with the lower chest wall andDiaphragmProtection of.However, due to the large size and fragile texture of the liver, once subjected to violence, it is easy to damage the abdominal cavityInternal hemorrhageOr bile leakageHemorrhagic shockorBile peritonitisThe consequences are serious and must be diagnosed and handled correctly in time.
According to the cause of injury, liver trauma is generally divided intoOpen injuryAnd closed injury.Open injuries generally include stab woundsFirearm woundEtc.The stab wound is relatively minor,Case fatality rateLow.Firearm injuries are open injuries caused by projectiles launched by gunpowderWar woundSee more in,Liver fireGun wound is the most common type of abdominal firearm wound.Open injury can be divided into blind tube injury andPenetrating woundTwo.Closed abdominal injuries are mostly blunt injuries, which are mainly caused by impact and extrusion, and are common on highwaystraffic accidentBuilding collapse, occasionally seen in falls, sports injuries or beatings.
Because closed abdominal injury is often accompanied by other organ injuries except liver trauma, and there is no sign of injury on the surface of the abdomen, it is relatively difficult to diagnose, leading to delayed treatmentBlunt injuryIt is dangerous, and the case fatality rate is often higher than that of open injury.
In case of superficial liver lacerationbileExtravasationNot much, and in a short timeInternal hemorrhageIt can stop by itself. Generally, it only has pain in the right upper abdomen, and rarely has shock and peritonitis.
Central typeHepatic ruptureorOpennessLiver injury The liver tissue is widely fragmented, generally involving large blood vessels andbile duct。Abdominal hemorrhage and bile extravasation are frequent, and patients with liver trauma often have acute shock symptoms andthe peritoneumIrritating symptoms.It is characterized by abdominal pain, pale face, fine pulse, and decreased blood pressure,Urine outputReduction, etc.Abdominal tendernessObviously,Abdominal muscle tension。With the increase of bleeding, the above symptoms are further aggravated.
Severe liver fragmentation or combinationHilum hepatisnearbyLarge blood vesselIn case of rupture, such asportal vein、Inferior vena cavaAnd so on, which may cause uncontrollable massive bleeding.largeVascular injuryCan lead to a large number ofPowerThe fatal hypovolemic shock caused by blood loss often dies in the process of treatment and loses the opportunity of surgical treatment.
There was no obvious change in the early stage of mild liver trauma.Because of the rapid loss of blood,Blood concentration, many patients do not appearhemoglobinBut in patients with liver traumaWhite blood cell countCan be raised.
（1）Abdominal punctureFor diagnosis of abdominal visceral rupture, especially forSubstantiveOrgan laceration is of great value.Generally speaking, it can be considered that there isVisceral injury。But it may be false when the amount of bleeding is smallNegative resultsTherefore, a negative puncture cannot exclude visceral injury.If necessary, multiple punctures at different locations and at different times, or diagnostic lavage of the abdominal cavity shall be performed to help diagnosis.
(2) Timing measurementred blood cell, hemoglobin andHematocritObserve the dynamic changes. If there is progressive anemia, it indicates internal bleeding.
（3）B-mode ultrasonic examinationNot only can we findHematoceleIt is also helpful for the diagnosis of hepatic subcapsular hematoma and intrahepatic hematoma, which is commonly used clinically.
(5) LiverradioactivityThe diagnosis of radionuclide scanning is not clearClosed injuryIf there is a suspected subcapsular or intrahepatic hematoma, the injury is not very urgent, and the patient's condition allowsisotopeLiver scan.Those with haematoma showed radioactive defect area in liver.
（6）Hepatic arteriographyFor some closed injuries that are really difficult to diagnose, such as suspected intrahepatic hematoma, this method can be used if the injury is not very urgent.Branches of intrahepatic artery can be seenaneurysmFormed orcontrast agentSpillover and other signs of diagnostic significance.It cannot be used as a routine inspection.
diagnosis
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It is easy to make a diagnosis of open liver injury, but attention should be paid to whether there areCombined thoracoabdominal injury。Closed injury with typical hemorrhagic shock andPeritoneal irritation signCombined with the history of trauma, it is easy to make a diagnosis.But for someConcomitant injuryOf patients with liver trauma, such asBrain traumaUnconscious,Multiple fracturesThose with shock, old, weak and unresponsive should be alert to avoid missed diagnosis.cirrhosisorliver cancerThe patient's liver rupture can be caused by slight trauma, so it should not be taken lightly.Closed abdominal injuryWhether there is liver injury is involved in the question of whether to open the abdomenaccuracyHigh requirements.When the diagnosis is in doubt, puncture through abdominal cavityPeritoneal lavageAnd other auxiliary examinations can help diagnosis.
treatment
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First, consider the patient's general condition and whether there isCompound injury, such as whether there is brain, lungBone injury。The reasonable treatment plan shall be determined according to the general condition and the priorities of the combined injuries.For patients with simple liver injury, actively correct hemorrhagic shock and actively prepare for surgery.
keeprespiratory tractSmooth and sufficient oxygen supply.Quickly establish more than two venous channels to ensure smooth blood transfusion and transfusion and avoid blood flow of important organsInadequate perfusion。When the patient's condition is improved and stable, make necessary checks, and make further diagnosistreatment planning 。In case of severe shock, blood transfusionfluid infusionActively operate while expanding the volume.
2. Non operative treatment
Indications for non-surgical treatment:
(1) Patients with grade I, II or III hematoma (AAST classification) without active bleeding and progressive expansion of hematoma.
（2）HemodynamicsIn stable cases, the amount of bleeding shall not exceed 600ml.
（3）Symptoms of peritonitisLight, the patient is conscious and can cooperate with the physical examination.
The patient should absolutely lie in bed for more than 2 weeks, calm and relieve pain, transfusion and fluid replacement, prevent infection, and correctly use hemostatic drugs.The choice of antibiotics is based on the bacteria that may exist in bile.Hemostatic drugs shall be used in combination with anticoagulant and anti fibrinolytic drugs, and if necessary, small amount shall be used in combinationvasoconstrictionAgent.It is feasible for patients with abdominal distentionGastrointestinal decompressionTo promote gastrointestinal functionfunctional recovery So that the blood accumulated in the abdomen can be easily absorbed.In some patients, selective hepatic arteriography can be used to find the bleeding focus and then embolize, with good results.
3. Surgical treatment
When patients with liver trauma have obvious symptoms of intraperitoneal hemorrhage, peritonitis, or abdominal organ injuries, shock should be corrected at the same timeExploratory laparotomy。Operativebasic principleFor:
