Liver rupture suture

Liver rupture and suture 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 Liver rupture and suture is suitable for simple hepatic parenchymal superficial laceration; multiple hepatic tissue with distant hepatic lobe or hepatic segment is less damaged by laceration; hepatic parenchymal laceration after hepatic subcapsular hematoma clearance . 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. Incision: The general choice is to take the short oblique incision under the right rib margin. The upper end is from the lower part of the xiphoid process, and the lower end is to the right anterior line. This makes it a "" shape. After the abdomen, it can be extended according to the results of the exploration. For simple liver injury, the lower end of the incision can be extended to the right midline to achieve good exposure. If the left outer lobe liver injury or spleen injury, the incision can be extended to the left along the left rib margin to the appropriate position. If the liver injury is serious, the preoperative shock appears early and is not easy to correct. You can also use the right upper abdomen midline incision to achieve rapid access to the abdomen. When the bleeding is controlled, the "" or "" shaped incision is appropriately extended according to the results of the exploration to fully expose the surgical field. 2. Control bleeding and exploration After entering the abdominal cavity, remove blood and blood clots. If there is still sharp bleeding in the rupture of liver tissue, the hepatic artery and portal vein can be controlled by intermittent blockade of the liver at normal temperature to temporarily block liver blood. Flow, each blocking time is generally 15 to 20 minutes. If the operation cannot be completed by one interruption, the blockage band can be relaxed, and the blood supply can be resumed after 5 minutes, and then the second block is performed, and the operation is repeated until the operation is completed. Hepatic rupture and bleeding can also be used to stop bleeding. After clearing the intra-abdominal hemorrhage and temporarily controlling the bleeding, the liver should be carefully explored. The right and left sides of the left lateral lobe of the liver should be explored with the right hand. The left, middle, visceral, hepatic and inferior fossa of the right lobe of the liver should be explored with the left hand. Veins and other places. The following three points must be identified in the exploration: 1 estimate the amount of blood loss and blood transfusion; 2 the location and extent of liver damage and determine the type of injury; 3 whether or not the tissue damage of other organs in the abdomen is combined, and the surgical method is determined according to the results of the exploration. 3. For superficial and regular liver laceration, completely remove the clots and inactivated liver tissue at the cleft, and decide whether to block the hilum according to the presence or absence of active bleeding. 4. Check the hepatic wound margin. If you can see the broken blood vessels (hepatic artery, portal vein, branch of hepatic vein) and bile duct branch, it should be clamped, and the No. 1 silk thread is ligated or sutured. 5. With the 10th silk thread, the wound edge should be sutured together with the liver capsule. The suture is 1.0~1.5cm from the wound edge and the needle spacing is 1cm. The suture should preferably pass through the bottom of the split, and do not leave the dead space. For deep hepatic laceration, if there is still bleeding in the laceration or the surrounding tissue is fragile and can not be directly sutured, the suture suture parallel to the wound margin can be made at 1.5 cm from the wound margin, and then the lateral suture in the suture suture. Stitching the wound. 6. Rinse the abdominal cavity, place double cannula drainage under the liver, and close the abdominal cavity layer by layer.

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