Sedative Meds

Abdominal injury treatment

Patients with abdominal injuries, both penetrating and non-penetrating conductive subject to surgical treatment. Exceptions are power metal hnostnye stab wounds prescription abdominal wall over 24 hours already infected. These wounds are not subjected to a primary surgical treatment of classical and treated with an antiseptic solution, ukry vayut bandage for the injured state is performed on the active observance over the next 48 hours. The appearance of signs of intra-abdominal hemorrhage or peritonitis is an indication for laparotomy. With a closed abdominal injury, tactics are more differentiated. Conservative treatment is required for victims with contusions of the abdominal wall, with those intraorgan hematomas of parenchymal organs that do not tend to increase, with small and stable subcapsular hematomas.

 The beginning of the modern history of conservative management of injured parenchymal organs was laid by M.R. Kagr et al (1983), published by The investigations dovanie discontinuities healing process without liver surgery in 117 children. The authors found that the post-traumatic process takes from 3 to 4 months and proceeds in four stages: in the first stage, blood resorption occurs, in the second – rupture of the rupture, in the third – reduction of the size of the defect and in the fourth – complete restoration of the homogeneous structure of the liver. However, most surgeons IME were significant objections to conservative tactics. Firstly, the presence of blood in the abdominal cavity require laparotomy, irrespective of the stable NOSTA or hemodynamic instability. Second, without a visual inspection of chi rurgi could not assess the damage, life-threatening. And that the most essential but, for the non-surgical treatment is necessary with absolute precision excluded chit other intra-abdominal injuries.

These problems have been resolved after the widespread introduction into practice of ency- variables diagnostic and therapeutic technologies as ultrasound, CT and angiography. These methods allow accurately visualize morphology and degree cha severity of liver damage, spleen and pancreas, quantitatively determined share haemoperitoneum volume and the rate of its increase, and give full infor mation about the presence or absence of damage to other organs of the abdominal cavity and retroperitoneal space.

Experience has shown that often enough (up to 80% of cases) with closed grass IU liver during laparotomy surgeons ascertain the blood flow has stopped chenie. Therefore, some authors consider that the indication for emergency laparotomy is is achieved not haemoperitoneum volume (blood may be less than 500 or more than 500 ml), and hemodynamic instability prolonged despite blood transfusion 2-3 doses.

Subcapsular hematoma and central parenchymal organs at first did not much increase in volume, and then gradually dissolve. Some spe ists believe that damage to the liver and spleen I and II severity treated conservatively with stable haemodynamics. According to them, con conservatively treatment requires the exclusion of intra-intensive krovotech Niya, careful follow-up with ultrasound or CT scan.

Indeed, the decision to conduct conservatively victim with an established diagnosis of parenchymal organ damage confers on the surgeon more from responsibility. According to the statistics of foreign literature in recent years, conservative management of closed injury of the liver with the right selection patsien comrade was effective in 94% of cases. At the same time, cases of two-stage ruptures of subcapsular and central hematomas in late terms after an injury are known from practice. According Multicenter Research Association surgeons grass matologov United States, the frequency of failure in conservative treatment reaches 20 %. We believe that such a high failure rate due to the lack of strict crit riev selection of patients in the initial period of implementation of the new tactics. In addition, pro -caking tendency of American colleagues write victims of stationary Nara for 3-4 hours, without assessing the dynamics of the traumatic process in the parenchyma of Pec or, without a thorough analysis morfofunktsinalnyh changes, using only a single CT examinations, without all of the complex radiation techniques, including Ultrasound, ultrasound, and according to indications – and angiography. Indicative in this respect, the words EEMoore (Denver, USA), who in 1995 called on their colleagues to reconsider zitsii and against US and begin widespread introduction of this method, “as is done in most developed countries.”   

 Conservative treatment in cases specified by ultrasound and CT, closed parenchymal injury abdominal display but under the following conditions: 1) stable haemodynamics; 2) stable hemoglobin and hematocrit; 3) the absence of damage to other organs of the abdominal cavity and retroperitoneal space requiring operator proliferative treatment; 4) the availability of appropriate medical equip Bani and staff for day and night surveillance.

The decisive factors determining the effectiveness of conservative Nogo therapy, are, firstly, the correct selection of patients, and secondly, – the repeated and frequent their examination during the first 2-3 days after the injury.

The ultrasound is currently used as a screening method allowing conductive identify morphological organ changes and track their dynamics Coy. Since ultrasound is not very informative in patients with extensive emphysema of soft tissues, an emergency CT scan is used in such cases.

Negative dynamics revealed by these methods is yet zaniem to use Doppler (Doppler ultrasound) and angiography, the latter is not only diagnostic but therapeutic procedure allows the hemostasis endovascular techniques.

 Endovascular methods of hemostasis are based on the introduction of sclerotizing substances, emboli, cylinders, spirals into a damaged vessel, creating a mechanical obstruction to blood flow with subsequent thrombosis, which leads to occlusion of the lumen of this vessel for a certain length. After the invention in 1975 of G. Gianturco et al., Elastic steel spirals up to 5 cm long and less than 1 mm in diameter, many modifications of these artificial emboli have been proposed. Most widespread roub of them are steel minispirali interweaving with Teflon or Tay ( “Trufill”, “Tornado”).

Modern endovascular equipment and developed technology that enable you to successfully use the methods of endovascular hemostasis in trauma Pec any and spleen, especially in cases where there are contraindications to surgery Ceska method of treatment or in the postoperative period, when a so-called secondary hemorrhage as a result of false arterial GOVERNMENTAL aneurysms, arteriovenous fistulas and hemobilia when surgical treatment is associated with a high risk.

There are different points of view on contraindications to perform endovasku lar hemostasis, but the authors are unanimous in considering the most serious anti indication only expressed intolerance of iodine preparations. At the same BPE on me it should be recognized that the technique of endovascular hemostasis, in addition to sophisticated equipment, requires the highest skill of the surgeon, radiologist.  

 Conservative treatment includes replenishment of blood loss, anti-shock measures, the introduction of hemostatic agents, hemodesis, vasopressors.

After removing the victim from shock carry out activities aimed at combating paresis of the gastrointestinal tract: noseejunal intubation, intravenous administration of solutions containing ka ly, hypertonic enemas. The paranephral novocaine blockades used in the past are currently abandoned due to inefficiency.

The presence of obvious signs of intra-abdominal bleeding Build gave a closed abdominal trauma is an absolute indication for immediate surgery, regardless of the severity of the condition postradavshe th and hemodynamic parameters. 

The victim with a clinical picture of a rupture of a hollow organ should also be immediately subjected to surgery. However, in the case of late for NTRY when there is detailed clinical picture of intoxication with peritonitis, electrolyte disturbances and unstable hemodynamic Mika, it needs to be short (no more than one and a half to two hours), but intensive preoperative preparation. Its basis is infusion-transfusion therapy.

Finally, if a patient with severe concomitant injury, finding schegosya in a state of traumatic shock, found a gap urine Vågå bubble, the operation on the subject may be delayed until I will bring Nia will suffer from shock.

When clear evidence of a penetrating wound of the abdomen surgery CPA Dhu start with a midline laparotomy. In all other cases, perform initial debridement, whose task is to by not only the removal of devitalized tissue, hemostasis and suturing, but the final establishment of the nature of injury: whether it is a penetrating or not. 

When an extended wound channel, especially in patients with ozhire Niemi, this task often presents certain labor Nost. Performing vulnerografii permissible, but it is not always re results of untrue and negative data vulnerogra phy surgeon has over the next 24-48 hours to carry out the state of the patient’s careful follow-up.

Typically, vulnerografiyu operate with stab wounds on the boundary with the stomach regions (lumbar, groin, buttocks), the absence of clinical manifestations intraperitoneal disaster. It should be remembered that with injuries of the abdomen, any doubt is decided in favor of the operation. 

Therefore, there is a rule – the wound of the anterior abdominal wall should be treated so that the surgeon can clearly see the bottom of the wound channel, if it does not reach the sheet of the peritoneum. If the wound channel reaches preperitoneal fat, the surgeon must sa by direct carefully explore the surrounding areas of the peritoneum in order not to miss the slightest flaw it. In such SLN teas help skin wound size comparison with the size of the wound channel stratified its dissection: if the size of soft tissue wounds quickly reduced, so wounding weapon was pointless end (configuration of an ordinary knife blade) and the length of the channel is small. If the size of the wound channel in the course of processing times remain equal dermal wounds measures, The presence of a peritoneal defect is an indication for a wide median laparotomy.  

Given that before closure the primary surgical treatment is impossible can make a judgment about the necessity laparotomy, which performs dissolved under endotracheal anesthesia with muscle relaxants, following the treatment of wounds is also performed under endotracheal anesthesia with muscle relaxants. Firstly, in these cases the problem is removed during expansion wound lane between primary surgical treatment (if this is required). Secondly, in cases where a laparotomy is indicated, there is no need to switch from local anesthesia to general anesthesia.

Victim with a closed abdominal trauma or injury to the abdomen ne ed anesthesia compulsorily administered gavage, and after the introduction of anesthesia produce bladder catheterization.

Surgical treatment principle in the stomach damage consists camping that all complex surgical procedures consist of not how many steps, the sequence of which must be strictly Observed give. Derogation from these principles can be the cause of vozniknove Nia complications during surgery, postoperative complications, and in some cases, death of the victim.

Treatment of evented organs. The precipitated outwardly loop ki shechnika and wound under general anesthesia washed with warm sterile nym isotonic sodium chloride solution, and then – a solution of anti septic tank. If the intestine is not damaged, it is inserted into the abdominal cavity, and the wound is temporarily tamped with a sterile napkin. Fault loop wrap a napkin and left temporarily on the anterior abdominal wall, which is carefully treated with an antiseptic solution, then you suppl laparotomy. The further course of the operation depends on the damage found during the audit. The precipitated strand gland anyway ne revyazyvayut and cut without imbedding into the abdominal cavity, the wound covering was napkin. 

Access. In all cases, a median laparotomy should be performed extending from the xiphoid process and 4 cm below the navel (the length of the wound should be at least 20 cm). The need for such a broad Internet access is pa dictated by the fact that patients with profuse intraperitoneal bleeding surgeon can never anticipate the volume and location of damage. 

Performing limited verhnesredinnoy laparotomy (sword from a prominent ridge before reaching 2 cm to the navel) is a frequent and rough so cal error. Through small access, a full audit and free intervention on the organs is impossible, and in such cases the surgeon has to spend time expanding the access down. However, and with broad access midline laparotomy sometimes necessary during opera tion extend obliquely upward from the umbilicus toward the costal arch (those nical difficulties in suturing discontinuities right liver lobe at spleen injury).   

Temporary hemostasis and blood evacuation. At the moment of opening the abdominal cavity bleeding from damaged vessels is enhanced by reducing Nia intraabdominal pressure. In this regard, the anesthesiologist takes measures to maintain the hemodynamics, the surgeon performs a fast temporary stop bleeding, and the assistant performs the evacuation of blood from bryush body cavity. In this case, the blood must be collected in a sterile container, so that then, after ascertaining the nature of damage, try faiths pull the it into the bloodstream of the victim, that is, subject to reinfusion. 

Sources bleeding surgeon discovers when he sees pulsating boiling jet of blood or blood by doing a characteristic hissing from the vessel in Glu bin wounds, moves the blood, already izlivshuyusya into the abdominal cavity.

The most simple method of temporary hemostasis is survived TII bleeding vessel fingers. This is easy to do with bleeding from the vessels of the mesentery of the small and large intestine. Temporary hemostasis for damage to the liver and spleen is achieved by clamping the hepatic-duodenal ligament or spleen leg. In order to stay novit bleeding from aorta, it retroperitoneal vistseral spaced arms that iliac arteries and inferior vena cava and its branches, the wound must first press a finger or the whole hand to the bone (spine, pelvic bones, etc.) , and then select the vessels proximal and distal to the wound. Once in the selected areas of a large CRO venosnogo vessel will be imposed turnstiles of the tape or elastic plastic tubes or soft vascular clamps, the bleeding is stopped safely and the surgeon, in a calm atmosphere, can continued to live operation. The same turnstiles are placed on the hepatoduodenal ligament, on the leg of the spleen or kidney.

In cases where the above-mentioned methods is insufficient ef ciency and the bleeding continues, it should be handed to the pin on zvonochniku aorta immediately below the diaphragm. At the same time, it is more convenient to use a special aortic “plug”, however, when using it, one must not allow the interposition of pancreatic tissue.

Revision of the abdominal organs. Convinced Time to Foot hemostasis and collecting blood from the abdomen, the surgeon proceeds to a thorough audit bodies. Revision is better to start with hollow bodies, the fact that the detection of lesions of hollow organs, firstly, allow to take measures for insulation fault location and, therefore, to stop the permanent infection of the abdominal cavity, and, secondly, to decide GPs grew up on the admissibility of blood reinfusion, collected from the abdominal cavity. 

Prior revision is necessary to make the abdomen novocaine blockade root mesentery, transverse colon and whitefish movidnoy intestines (200 ml of 0.25% novocaine solution). Revision begins with the stomach. At the same time, the small and large curvatures and the area of ​​the hepatoduodenal ligament, in which there may be a large hematoma due to damage to large vessels, are carefully checked.   

When any damage to the anterior wall of the stomach, dvenadtsatiperst hydrochloric colon or pancreas should be widely cut gastrointestinal ligament and inspect the rear wall of the stomach, podzheludoch hydrochloric gland and duodenum.

Damage to the duodenum are recognized by bile staining and the presence of gas bubbles in the retroperitoneal space stve. Diagnosis of duodenal damage can be alleviated by administration during surgery gavage ra alignment methylene blue. The appearance of blue staining of tissues in about domain duodenum suggests rupture of its wall. When Nali PIR injury duodenum its rear wall must be carefully inspected after bowel mobilization of Kocher: a vertical prefecture direction along the lateral edges dissect the peritoneum gut and release duodenum blunt by using the cotton swab from its bed. In this case, care must be taken not to damage the inferior vena cava lying directly under the intestine. 

An audit of the small intestine begins with the first loop, located at the root of the mesentery of the transverse colon to the left of several vertebrate ka (area Treitz ligament); then the loops of the small intestine are sequentially removed, examined and immersed in the abdominal cavity. The detection of even minor injuries of the small intestine during late (after 12-24 hours) surgery is facilitated due to the presence of inflammatory infiltration in the lesion area. Blood clots fixed to the bowel wall can cover the wound. Large subserous hematomas should be opened to exclude the message of the hematoma to the intestinal lumen. Especially Atte tion should be inspected mesenteric intestine region, where the hematoma is often hides the perforation site. Damage detection point, the chief account the loop cloth or conducting thread-taped by the mesentery.   

Revision of the colon begins with the ileocecal angle. When the suspect SRI to injury retroperitoneal department colon dissected Bru bus on the outer edge of the ulcer over the 15-20 cm indication for the mobilization of the fixed parts of the colon are:. Detect voltage petechial hemorrhages, hematomas, bruises on the back sheet of the peritoneum, as well as injured when the direction of the wound channel indicates the possibility of damage to the retroperitoneal part of the colon. 

If difficulty detecting holes in the gut due to its small di ametra should squeeze intestine above and below the site of injury and to monitor the stepping gas and intestinal contents. Insulating tampons are temporarily brought to the place of detected damages.

Revision of hollow organs ends examination of the rectum and urinary Vågå bubble. During the audit, organ defects should not be sutured, since the need for resection of this organ may be revealed.  

Excluding hollow organ damage, the surgeon gives instructions to start reinfusion of blood and continues to audit further evaluating of stated failures parenchymal organs. 

Audit of the liver is carried out visually and by palpation. After inspection and palpation localization injury to inspect the diaphragmatic surface of the liver is necessary to perform the mobilization svya dressing device – it allows greater access to the diaphragmatic surface. For the mobilization of the left lobe of the liver from her huddled down and to the right, cross the left triangular ligament and part’ve finite bundles. In bundles, in some cases are small bile proto ki, so they must be pre-cast clamps and ne revyazyvat catgut. Similarly, but pulling the liver down and to the left behind the right lobe, they intersect the right triangular ligament to mobilize the right lobe of the liver. Technically, the intersection of the crescent ligament is easier, but it must be borne in mind that in the case of portal hypertension, large vessels can pass in it, the damage of which is accompanied by intense bleeding. According to this ligation sickle ligament is mandatory. 

In case of trauma to the inferior surface of the liver, it is necessary to cross the hepatic-renal ligament. To do this, lift the liver up in the results those that bundle is stretched and becomes available for dissection. Sosa rows it contains.

In severe bleeding from the liver if the clamping hepatoduodenal bunch proved to be ineffective, the time of Noah clamping of the inferior vena cava in order to completely turn off the liver from the circulation. The inferior vena cava is pinched above and below the liver with the help of turnstiles. For clamping of the vena cava below the liver of the right gib colon mobilized medially and drawn off, after which the exposing etsya free approach to the inferior vena cava above the renal vessels. Pe rezhatie inferior vena cava above the liver requires torakofrenolaparotomii. Taken taped aperture edge widely bred and anteriorly pushing the liver, via the turnstile dissector fed wok pyr this short portion of the inferior vena cava. Full off ne Cheney from the circulation may for a period not longer than 20 minutes.

Diverting mirror left abdominal wall and thus, pulling zhelu docking right visually and by palpation possible to inspect the spleen. Nali Chie clots in the body indicates damage. For exposing the Niya vascular spleen legs open distal parts of the gland howling bags, dissecting gastro ligament close to the cross-about zling intestine. A turnstile is placed around the vascular pedicle using a dissector or a soft vascular clamp is applied to the artery and vein, which ensures the cessation of blood flow.

For an overview of the pancreas commonly dissect gastrointestinal about zling bunch with ligation of vessels in its dlinniku. In order not to break   

blood supply to the stomach, dissection is carried out between the gastrointestinal arteries and the colon. Lifting up the stomach, and by closely down the transverse colon, the pancreas reveal the climb all over.

Retroperitoneal hematoma is subject to revision at any wound (ho lodnym weapons or firearms). In a closed abdominal trauma retroperitoneal hematoma not reveal if palpation kidney integrity is not in doubt, the hematoma does not grow on the eyes and it is obvious prichi to – fracture of the pelvis or spine. 

Rapid growth of the hematoma, bleeding in the free abdominal cavity, suspected kidney rupture are an indication for its revision.

After upward traction ileocecal angle and move aside loops tone Coy intestine over hematoma dissect the peritoneum and rear sheet to bleed profusely (pulsating jet) superimposed receptacles krovoosta navlivayuschie clamps. Venous and capillary bleeding is temporarily stopped by tight tamponade.

Blood reinfusion. An indication for blood reinfusion is blood loss of more than 500 ml. Blood streamed out into the abdominal cavity, even after 24 hours is suitable for reinfusion of zhiz nennym indications. 

 Blood is collected using a special device for reinfusion. In its absence Corollary different pumps are used and standard bottles for transfusion. In the latter case the plug sterile 500 ml bottle containing 30-40 ml of a 4% sodium citrate treated antiseptics and pierce two degrees -sterile needles for blood transfusion. A tube from the tip is attached to a long needle, and a tube going to the electric suction pump to a short needle. If it is impossible Nala dit similar system collect blood from the cavity sterile cup or ladle into a sterile metal cup 500-1000 ml capacity, containing 50-100 ml of a 4% sodium citrate solution (ratio blood preservative and 10: 1) and covered with eight layers of cheesecloth dampened sterile 4% sodium citrate solution or TSOLIPK-76 preservative. Blood collected in some way, to meet the sterility transmitted personnel that after the test on hemolysis pours it into the vein suffered Shem through the system for blood transfusions, provided with an appropriate filter.

Reinfusion of blood in comparison with transfusion of donor blood and its components has significant advantages, which consist in the rapid use of blood without determining the group and individual compatibility; in vascular blood returning to the channel involved in the transfer of oxygen and containing enzymes and immune bodies present on the suffering that increases resistance in the early post operative period; as well as in the absence of the risk of transmission of viral diseases and the risk of individual intolerance.

Contraindications to reinfusion of blood is the concomitant damage to hollow organs, long, longer than 24 hours, the period proshed shy after trauma and expressed hemolysis.

If nevertheless occurred unintentional reinfusion contaminated blood (eg damaged hollow organ unnoticed initially), then the affected postoperative be desig chit massive antibiotic therapy, which usually fast! Ro leads to disappearance of bacteremia and sepsis without developing smiling. At the same time, the desire to sanitize reinfused blood by adding antibiotics directly to it is very dangerous, because Snack paradise death of microorganisms in such a case would lead to a massive sps dew endotoxins and endotoxic shock.

Surgery on damaged organs

The nature of surgical intervention in the abdominal injury for hanging on its type and the damaged organ.

Liver. With small linear wounds, U-shaped sutures are used to perform hemostasis, which should be applied in the transverse direction with respect to the vessels and bile ducts of the liver. For suturing the liver parenchyma, it is necessary to use vicryl or catgut No. 4 on an atraumatic needle. In the absence of material atravmatichesksgo possible to use a circular needle thread 4 or № № 6. Apply nonabsorbable suture material on Proposition stitches in liver tissue is impossible, because in this case watching Xia prolonged inflammatory reaction often abstsedirovaiie, which requires re-operation and removal suture yavlyayusche Gosia foreign body.   

 With blind gunshot wounds in the liver tissue at different depths are bullets, fragments, fragments, shots, etc. Easily accessible foreign bodies are best removed, however if very traumatic access is required to remove them, the foreign bodies are left in place, while all non-viable tissues are removed and the damage area is reliably drained.

In the presence of torn and gunshot wounds operate excised liver of edges and removal of devitalized tissue sections and then both sides of the hemostatic defect superposed U-shaped seams. Sutures must impose, departing from the wound edge is not less than 0.5 cm. After reaching zhelchestaza hemo- and bring together the edges of the defect layer by layer superposition continuous or U-shaped nodal joints, whether for entering NIJ hemostatic joints and using them to reduce the load on friable liver tissue. When eruptive hemostatic sutures, synthetic absorbable films are placed under them. At impossibility Nosta convergence wound edges or teething seams defect tissue there ponir gland strand and tie knots on top of this strand. In the presence of wounds in the crescent ligament defect can hide mobiles Call falciform ligament.     

 With a closed injury, a wide variety of liver injuries are observed – from small sizes of rupture of the free edge to the separation of the organ into fragments (with varying degrees of viability). The most frequently encountered the incorrect hydrochloric shape ruptures the capsules and expiration parenchyma with blood and bile (60-70%). The softening of several segments, on the contrary, occurs in only 1-2% of cases. Often when closed abdominal trauma surgeon encounters great subcapsular heme volumes representing parenchyma preserved gap with the capsule (15-20%). Subcapsular hematoma looks like a fluctuating flat formation of dark color, located under the Glisson capsule. In view of the high probability of a two-stage rupture, such hematomas should be emptied by hemostasis using one of the above methods. A special form of closed liver injury is intrahepatic hematoma, which is difficult to diagnose even during laparotomy, since the appearance of the liver may not change (10-12%). Indirect when signs of hematoma may be intrahepatic hemorrhage portion of dark color or a small crack stellate capsules. In any case, intrahepatic hematoma is subject to conservative treatment and dynamic monitoring.   

In the presence of liver large and deep cracks without major damage suck rows must use gepatopeksiyu to create an isolated closed vannogo space. Gepatopeksiya by Hiari-Alfyorov-Nikolaev also shows the presence of wounds or gaps in the diaphragmatic or nizhnedorzalnoy poverhnos five liver. The operation consists in fixing the free edge of the corresponding lobe of the liver from a round to a triangular ligament to the diaphragm along the line of its attachment to   

chest wall (with ruptures of the diaphragmatic surface of the liver) or to the posterior sheet of the parietal peritoneum (in the presence of trauma on the lower surface). After such operation artificially creates a closed slot-shaped space emkos Tew 15-25 cm , wherein a seam lines in or subdiaphragmatic subhepatic pro space for outflow of wound drainage is fed Double lumen.

When rupture of the liver, accompanied by profuse bleeding, outlined GOVERNMENTAL above methods is not always possible to achieve complete hemostasis, especially in the extensive destruction of its parenchyma and the presence hemobilia. In such cases, if the cross-clamping time hepatocellular ligament has sufficiently precise hemostatic effect, you can try to perform intraoperative embolization, but this is not possible the hepatic artery sling vayut. To this end, the upper edge of the dissector hepatoduodenal a connected ki perform allocation of its own common hepatic, liver and gallbladder ar Theurillat. Own hepatic artery is ligated distal to the place of discharge of the cystic artery with silk No. 4 (otherwise, development of necrosis of the walls of the gallbladder is possible and cholecystectomy will be required). Podcherye need to whip that ligation of the hepatic artery in itself leads to 20-25% of cases of lethal outcomes due to the development of multiple small segmental necrosis, and so this technique should be used when absolutely necessary.

In patients with extensive breaks in some cases, the liver parenchyma before put the individual fragments, which have contact with each other only vascular secretory legs. Removal of these fragments is not difficult pos le ligation separate vessels and bile ducts. In such cases, the wound surface of the liver is covered with a lock of a large omentum, fixing it to the capsule of the liver with separate sutures.    

Injured areas of the liver with dubious viability must be removed starting from the depth of the gap. Thus fingers bluntly separated TCA portions nor stringing sensing blood vessels and bile ducts (this technique is called etsya digitoklaziey), and then pierced and ligated lavsan vessels and ducts.

With deep and bleeding breaks, in order to achieve hemostasis, a partial separation of the liver along the portal slots should be used. To do this, the assistant carefully spreads the edge of the liver, and the surgeon with the fingers of the left hand gradually releases the vessels and bile ducts in the parenchyma in the damage zone, walking along the vascular-secretory bundle. Finding the source of bleeding, the vessel together with the adjacent portion of the parenchyma ne Cheney sewn or twining round vicryl suture catgut on atraumatic needle.

After the final stop of bleeding, the turnstile is gradually weakened from the hepatoduodenal ligament, and within 10-15 minutes it is necessary to observe a change in the color of the liver. The appearance of dark purple or gray color indicates a violation of the blood supply, and requires the removal of the corresponding guide segment. However, with large blood loss, unstable hemodynamics, this technically complex and traumatic intervention should be postponed for 2-3 days until the condition stabilizes or until the victim is taken to a specialized hospital. It must be remembered that the implementation of such extended interventions leads to a sharp increase in mortality (up to 60-80%).

If it is impossible to isolate vascular secretory legs and continued bleeding, as an exception, it is possible to apply a tight wound tamponade using 5-6 gauze swabs, which are removed through contraception in the right hypochondrium. 

With severe damage to both lobes of the liver and profuse bleeding against the background of multiple and combined injuries, a tight tamponade with gauze swabs is also performed. In all cases of severe liver injury, including at tight tamponade, shows double-lumen silicone drainage tube E subdiaphragmatic and subhepatic mandatory decompression spaces and Sia biliary tract by external drainage of the common bile duct Keru or overlay holetsis  

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