Reed R L, Merrell R C, Meyers W C, Fischer R P
Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710.
Ann Surg. 1992 Nov;216(5):524-38. doi: 10.1097/00000658-199211000-00002.
Surgical and radiologic techniques from computed tomography (CT) scanning and embolization to temporary gauze packing and mesh hepatorrhaphy have been developed to make the management of severe liver injuries more effective. Surgical approaches for severe liver trauma have been oriented to two major consequences of these injuries: hemorrhage and infection. Early attempts at hemorrhagic control found benefit only in temporary intrahepatic gauze packing. The subsequent recognition of complications after liver injury blamed the practice of packing, which then remained unused for more than 30 years. Yet more aggressive attempts at controlling hemorrhage without temporary packing failed to improve results. Temporary perihepatic gauze packing therefore has been reintroduced, but this is probably an imperfect solution. Mesh hepatorrhaphy may control bleeding without many of the adverse effects of packing. Fourteen patients are reported with severe liver injuries who have undergone mesh hepatorrhaphy, bringing the current reported experience with mesh hepatorrhaphy to 24, with a combined mortality rate of 37.5%. Thus far, it appears that only juxtacaval injuries fail to have their hemorrhage controlled with mesh hepatorrhaphy, but many believe that these injuries may be controlled by perihepatic packing. Prophylactic drainage of severe liver injuries is a concept for which there is little evidence of benefit. Furthermore, recent radiologic developments appear capable of draining those collections that do occasionally develop in the postoperative period. The ultimate challenge of liver transplantation for trauma has been attempted, but the experience is thus far very limited.
从计算机断层扫描（CT）扫描、栓塞到临时纱布填塞和网状肝缝合术等外科和放射技术已经得到发展，以使严重肝损伤的处理更加有效。严重肝外伤的手术方法主要针对这些损伤的两个主要后果：出血和感染。早期控制出血的尝试发现，仅临时肝内纱布填塞有益。随后对肝损伤后并发症的认识归咎于填塞做法，因此该方法停用了30多年。然而，在不进行临时填塞的情况下更积极地控制出血的尝试未能改善结果。因此，临时肝周纱布填塞术再次被采用，但这可能是一个不完美的解决方案。网状肝缝合术可以控制出血，且没有填塞的许多不良反应。报告了14例接受网状肝缝合术的严重肝损伤患者，使目前报告的网状肝缝合术经验达到24例，总死亡率为37.5%。到目前为止，似乎只有腔静脉旁损伤不能通过网状肝缝合术控制出血，但许多人认为这些损伤可以通过肝周填塞来控制。严重肝损伤的预防性引流是一个几乎没有证据表明有益的概念。此外，最近的放射学进展似乎能够引流术后偶尔出现的积液。创伤性肝移植的最终挑战已经有人尝试，但迄今为止经验非常有限。
