JHVI surgery

JHVI surgery is used for surgical treatment of liver trauma. Near hepatic vein injury refers to the damage of the main hepatic vein and the posterior inferior vena cava. Due to the special anatomical location of the posterior hepatic region, it is difficult to treat. So far, hepatic vein injury is still one of the most difficult problems in the field of liver surgery. Near hepatic vein injury accounts for only 10% of liver trauma, but its mortality rate is high. Despite the progress of pre-hospital treatment, more and more critically ill patients can enter the emergency room, but the mortality rate of near-hepatic vein injury is still as high as 60% to 100% (average 83%), and has not been in the past 20 years. Significant improvement. Near hepatic vein injury can cause fatal bleeding. These large vein walls are thin, and some of them are surrounded by liver tissue. It is difficult to perform surgery and repair. In addition, the anatomical position after the liver is not easy to show. The operation causes more severe bleeding and there is a risk of air embolism; if blind bleeding is performed, the damage can be aggravated. In Western countries, except for gunshot wounds, the mortality rate of blunt liver injury is higher than that of liver penetrating injury, mainly due to blunt liver injury accompanied by near hepatic vein injury. It is not uncommon for patients with severe blunt liver injury in China to have near hepatic vein injury. According to data analysis, the right hepatic vein injury accounted for 85%, followed by the middle hepatic vein, and the incidence of left hepatic vein injury was small. Simple intrahepatic venous injury is rare, and more combined with right hepatic or left hepatic vein injury. Post-hepatic inferior vena cava damage is often caused by laceration of the main hepatic vein. Treating diseases: liver trauma Indication When the hepatic vein is damaged, such as the patient's shock is not easy to correct, in the surgical exploration, the partial compression or hepatic occlusion of the gauze pad can not control the hemorrhage of the liver wound, suggesting that the hepatic vein trunk or the posterior inferior vena cava tear. Then we should take appropriate measures. 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 Choose anesthesia based on the presence or absence of shock and injury. If the injury site is the outer and upper part of the liver, a combined chest and abdomen incision is required, and tracheal intubation and intravenous anesthesia should be performed. If the injury site is suitable for transabdominal surgery or if the liver injury is not serious, it is advisable to use an epidural anesthesia. If you have a shock, you can use local infiltration or endotracheal intubation and intravenous anesthesia. Generally take the supine position, such as taking the chest and abdomen combined incision can use the left semi-recumbent position. 1. Suture repair at the injury site It is a simple and effective method for the treatment of near hepatic vein injury. Intraoperative hemorrhage occurs immediately if hepatic hemostasis is ineffective or the liver is pulled up and down. This suggests a near-hepatic vein injury. At this point, the liver is first filled with hemostasis, but the large bleeding is not effective. It is only for the auxiliary hemostasis before the other operations. Immediately use the chest and abdomen combined incision, cut the diaphragm to the inferior vena cava, fully reveal the second hepatic hilar and hepatic naked area, control the large vessel cleft under direct vision, clamp the vena cava tear with the heart ear clamp, suture the cleft, accompanied by liver If the leaf is severely contused, the corresponding liver lobe can be removed. Finger pressure can also be used to control vascular ruptures and repair. In recent years, the right inferior costal incision was used, and the acupressure was used to control the vascular cleft and repaired successfully. Perihepatic vascular isolation and vena cava shunt For patients with direct repair failure, perivascular vascular isolation (full hepatic vascular exclusion) and vena cava shunt should be used. Whole hepatic blood flow block is to block 4 parts of blood at room temperature, first block the infraorbital abdominal aorta, then use the block to control the liver pedicle, then block the inferior vena cava at the level of the renal vein, and finally cut Happy bag, block the superior and inferior vena cava, the blocking time is 30min, no adverse consequences. There are three ways to transfer the vena cava blood flow through the vena cava: 1 through the right atrial cannula to the inferior vena cava, using a 32 or 34Fr silicone tube to connect the diverting pump, ligation of the inferior vena cava and renal vein in the pericardial cavity. Upper inferior vena cava. Control the hepatic hilum and then repair the venous injury; 2 intubation through the inferior vena cava, and then repair the vena cava injury; 3 intubation at the junction of the femoral and saphenous veins: a polyethylene shunt with a length of about 66 cm (28Fr) The top latex balloon is 9cm, which is inserted from the junction of the femoral and saphenous veins. After the balloon is filled with water, the vena cava segment from the diaphragm to the lower edge of the liver can be completely blocked. The lateral hole on the catheter facilitates blood shunt. After the shunt is completed, repair the damage.