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处理肝脏损伤的外科技术

Authors
David G Jacobs, MD
Ashley Britton Christmas, MD, FACS
Section Editor
Heidi L Frankel, MD, FACS
Deputy Editor
Kathryn A Collins, MD, PhD, FACS
Translators
余枭, 主任医师，教授

引言

肝脏是最常受到损伤的腹部器官。大多数肝损伤较为轻微，通过非手术处理即可自愈，其非手术治疗方案包括观察及辅助性应用肝动脉造影和栓塞术。然而，大约有14%的肝损伤患者需要手术干预[1-4]。

当需要外科手术时，在保留肝实质的同时，应使用一系列方法来控制出血；肝切除仅用于严重的损伤。在剖腹手术刚开始时，损伤控制技术的使用，特别是肝脏周围填塞，可减小随后的外科操作的程度。

肝脏损伤的外科处理将总结在此。肝脏损伤的诊断和非手术处理将在别处详细讨论。 (参见“成人肝创伤的处理”)

肝脏解剖

肝脏分为左、右两叶，根据其血管或胆管分布进一步被细分为八段(图 1)。仅通过剪断肝脏的各个韧带附着(冠状韧带以及左、右三角韧带)(图 2)就使肝脏完全游离，从而可对肝脏的任一区段进行手术操作。

肝脏有来自门静脉和肝动脉的双重血供(图 2)。门静脉由脾静脉和肠系膜上静脉汇合而成，供应肝脏80%的血液，其余20%由肝动脉供应。

                      

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Literature review current through: 2017-06 . | This topic last updated: 2016-08-25.
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References
Top
  1. Croce MA, Fabian TC, Menke PG, et al. Nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients. Results of a prospective trial. Ann Surg 1995; 221:744.
  2. Malhotra AK, Fabian TC, Croce MA, et al. Blunt hepatic injury: a paradigm shift from operative to nonoperative management in the 1990s. Ann Surg 2000; 231:804.
  3. Fabian TC, Croce MA, Stanford GG, et al. Factors affecting morbidity following hepatic trauma. A prospective analysis of 482 injuries. Ann Surg 1991; 213:540.
  4. Tinkoff G, Esposito TJ, Reed J, et al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg 2008; 207:646.
  5. Poggetti RS, Moore EE, Moore FA, et al. Balloon tamponade for bilobar transfixing hepatic gunshot wounds. J Trauma 1992; 33:694.
  6. Badger SA, Barclay R, Campbell P, et al. Management of liver trauma. World J Surg 2009; 33:2522.
  7. Pachter HL, Spencer FC, Hofstetter SR, et al. Significant trends in the treatment of hepatic trauma. Experience with 411 injuries. Ann Surg 1992; 215:492.
  8. Huguet C, Nordlinger B, Bloch P, Conard J. Tolerance of the human liver to prolonged normothermic ischemia. A biological study of 20 patients submitted to extensive hepatectomy. Arch Surg 1978; 113:1448.
  9. Pachter HL, Feliciano DV. Complex hepatic injuries. Surg Clin North Am 1996; 76:763.
  10. Ivatury RR, Nallathambi M, Gunduz Y, et al. Liver packing for uncontrolled hemorrhage: a reappraisal. J Trauma 1986; 26:744.
  11. Carmona RH, Peck DZ, Lim RC Jr. The role of packing and planned reoperation in severe hepatic trauma. J Trauma 1984; 24:779.
  12. Parks RW, Chrysos E, Diamond T. Management of liver trauma. Br J Surg 1999; 86:1121.
  13. Kozar RA, Feliciano DV, Moore EE, et al. Western Trauma Association/critical decisions in trauma: operative management of adult blunt hepatic trauma. J Trauma 2011; 71:1.
  14. Rotondo MF, Schwab CW, McGonigal MD, et al. 'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993; 35:375.
  15. Baracco-Gandolfo V, Vidarte O, Baracco-Miller V, del Castillo M. Prolonged closed liver packing in severe hepatic trauma: experience with 36 patients. J Trauma 1986; 26:754.
  16. Krige JE, Bornman PC, Terblanche J. Therapeutic perihepatic packing in complex liver trauma. Br J Surg 1992; 79:43.
  17. Caruso DM, Battistella FD, Owings JT, et al. Perihepatic packing of major liver injuries: complications and mortality. Arch Surg 1999; 134:958.
  18. Nicol AJ, Hommes M, Primrose R, et al. Packing for control of hemorrhage in major liver trauma. World J Surg 2007; 31:569.
  19. Sharp KW, Locicero RJ. Abdominal packing for surgically uncontrollable hemorrhage. Ann Surg 1992; 215:467.
  20. Feliciano DV, Mattox KL, Burch JM, et al. Packing for control of hepatic hemorrhage. J Trauma 1986; 26:738.
  21. Achneck HE, Sileshi B, Jamiolkowski RM, et al. A comprehensive review of topical hemostatic agents: efficacy and recommendations for use. Ann Surg 2010; 251:217.
  22. Stone HH, Lamb JM. Use of pedicled omentum as an autogenous pack for control of hemorrhage in major injuries of the liver. Surg Gynecol Obstet 1975; 141:92.
  23. Fabian TC, Stone HH. Arrest of severe liver hemorrhage by an omental pack. South Med J 1980; 73:1487.
  24. Singh AK, Pancholi N, Patel J, et al. Omentum facilitates liver regeneration. World J Gastroenterol 2009; 15:1057.
  25. Moore FA, Moore EE, Seagraves A. Nonresectional management of major hepatic trauma. An evolving concept. Am J Surg 1985; 150:725.
  26. Strong RW, Lynch SV, Wall DR, Liu CL. Anatomic resection for severe liver trauma. Surgery 1998; 123:251.
  27. Asensio JA, Roldán G, Petrone P, et al. Operative management and outcomes in 103 AAST-OIS grades IV and V complex hepatic injuries: trauma surgeons still need to operate, but angioembolization helps. J Trauma 2003; 54:647.
  28. Cué JI, Cryer HG, Miller FB, et al. Packing and planned reexploration for hepatic and retroperitoneal hemorrhage: critical refinements of a useful technique. J Trauma 1990; 30:1007.
  29. Liu PP, Chen CL, Cheng YF, et al. Use of a refined operative strategy in combination with the multidisciplinary approach to manage blunt juxtahepatic venous injuries. J Trauma 2005; 59:940.
  30. Khaneja SC, Pizzi WF, Barie PS, Ahmed N. Management of penetrating juxtahepatic inferior vena cava injuries under total vascular occlusion. J Am Coll Surg 1997; 184:469.
  31. Burch JM, Feliciano DV, Mattox KL. The atriocaval shunt. Facts and fiction. Ann Surg 1988; 207:555.
  32. Buechter KJ, Sereda D, Gomez G, Zeppa R. Retrohepatic vein injuries: experience with 20 cases. J Trauma 1989; 29:1698.
  33. Rogers FB, Reese J, Shackford SR, Osler TM. The use of venovenous bypass and total vascular isolation of the liver in the surgical management of juxtahepatic venous injuries in blunt hepatic trauma. J Trauma 1997; 43:530.
  34. Baumgartner F, Scudamore C, Nair C, et al. Venovenous bypass for major hepatic and caval trauma. J Trauma 1995; 39:671.
  35. Heuer M, Kaiser GM, Lendemans S, et al. Transplantation after blunt trauma to the liver: a valuable option or just a "waste of organs"? Eur J Med Res 2010; 15:169.
  36. Kaltenborn A, Reichert B, Bourg CM, et al. Long-term outcome analysis of liver transplantation for severe hepatic trauma. J Trauma Acute Care Surg 2013; 75:864.
  37. Ball CG, Dente CJ, Shaz B, et al. The impact of a massive transfusion protocol (1:1:1) on major hepatic injuries: does it increase abdominal wall closure rates? Can J Surg 2013; 56:E128.
  38. Noyes LD, Doyle DJ, McSwain NE Jr. Septic complications associated with the use of peritoneal drains in liver trauma. J Trauma 1988; 28:337.
  39. Kozar RA, Moore FA, Cothren CC, et al. Risk factors for hepatic morbidity following nonoperative management: multicenter study. Arch Surg 2006; 141:451.
  40. Asensio JA, Demetriades D, Chahwan S, et al. Approach to the management of complex hepatic injuries. J Trauma 2000; 48:66.
  41. Singh V, Narasimhan KL, Verma GR, Singh G. Endoscopic management of traumatic hepatobiliary injuries. J Gastroenterol Hepatol 2007; 22:1205.
  42. Kozar RA, Moore JB, Niles SE, et al. Complications of nonoperative management of high-grade blunt hepatic injuries. J Trauma 2005; 59:1066.
  43. Dabbs DN, Stein DM, Scalea TM. Major hepatic necrosis: a common complication after angioembolization for treatment of high-grade liver injuries. J Trauma 2009; 66:621.
  44. Peitzman AB, Richardson JD. Surgical treatment of injuries to the solid abdominal organs: a 50-year perspective from the Journal of Trauma. J Trauma 2010; 69:1011.
  45. Polanco P, Leon S, Pineda J, et al. Hepatic resection in the management of complex injury to the liver. J Trauma 2008; 65:1264.
  46. Piper GL, Peitzman AB. Current management of hepatic trauma. Surg Clin North Am 2010; 90:775.
  47. Ordoñez CA, Parra MW, Salamea JC, et al. A comprehensive five-step surgical management approach to penetrating liver injuries that require complex repair. J Trauma Acute Care Surg 2013; 75:207.