探讨外伤性肝破裂的个体化治疗方法。

回顾性分析2011年4月至2013年12月在武警四川省总队医院接受诊治的58例外伤性肝破裂患者临床资料。所有患者均签署知情同意书，符合医学伦理学规定。其中男31例，女27例；年龄2～76岁，中位年龄44岁；美国创伤外科协会（AAST）肝损伤分级Ⅱ级33例，Ⅲ级16例，Ⅳ级9例。患者入院后行常规腹部检查，闭合性肝破裂行腹腔穿刺术检查，急诊行血常规、凝血功能、肝肾功能、腹部超声、CT检查，了解肝破裂位置、裂口大小和深浅、失血量、基础疾病、复合损伤等情况。根据患者AAST肝损伤分级及综合情况制订个体化治疗方案，包括非手术治疗、手术治疗。

24例患者采用非手术治疗，其中9例3～7 d后行超声、CT检查见腹腔积液明显增多，遂行腹腔镜探查，术中发现5例仍有少量渗血，使用电刀、超声吸引刀或钛夹止血成功，4例见肝脏破裂口出血停止。2例2～3周后复查CT示肝右叶旁包裹性积液；1例肝肾隐窝积液，均在CT定位下穿刺引流治愈。34例患者行急诊剖腹探查术，其中25例清除失活肝组织，缝合创面；6例行规则性肝叶（段）切除术；2例行肝动脉分支结扎及创口缝合；1例行大网膜填塞缝合。1例术后发生肝周脓肿，穿刺引流后治愈。58例患者均治愈出院，其中45例获随访1～6个月，无再出血、胆漏、感染、肝功能不全等并发症发生。

外伤性肝破裂可采取个体化治疗方案，对于裂口较小、较浅的肝破裂患者可在严密观察下行非手术治疗，对于生命体征不稳定、肝破裂处进行性出血患者则行手术治疗，两种方法均可取得良好疗效。

To investigate the individualized treatment for traumatic liver rupture.

Clinical data of 58 patients with traumatic liver rupture diagnosed and treated in the CAPF Sichuan Provincial Corps Hospital between April 2011 and December 2013 were retrospectively studied. The informed consents of all patients were obtained and the local ethical committee approval had been received. Among the 58 patients, 31 were males and 27 were females with the age ranging from 2 to 76 years old and the median of 44 years old. According to the American Association for the Surgery of Trauma (AAST) grading for liver injury, 33 patients were with Grade Ⅱ liver injury, 16 with Grade Ⅲ liver injury and 9 with Grade Ⅳ liver injury. After admission, all patients underwent routine abdominal examination and abdominocentesis for the closed liver rupture. In addition, blood routine, coagulation function, hepatic and renal function, abdominal ultrasound and computer tomography (CT) were also examined emergently to know about the location, size and depth of liver rupture, blood loss, underlying diseases and combined injuries. The individualized treatments, including non-surgical treatment and surgical treatment were performed according to the AAST grading criteria for liver injury and the comprehensive conditions of patients.

Non-surgical treatment was given to 24 patients in which 9 cases were found having obviously increased ascites by ultrasound and CT examination 3-7 d after treatment. Laparoscopic exploration was then performed on the 9 patients. During the operation, 5 were found with mild bleeding and the bleeding was stopped successfully with electrotome, cavitron ultrasonic surgical aspirator or titanium clip. And the rupture bleeding of the other 4 cases were found stopped. Two patients received CT scan 2-3 weeks after treatment and were found with encapsulated effusion near the right liver lobe and 1 case with effusion in hepatic and renal recesses. All these 3 patients underwent CT-guided puncture drainage and were cured. A total of 34 patients underwent emergency exploratory laparotomy. Among these patients, 25 underwent debridement of devitalized liver tissues and wound suture, 6 underwent regular segmental hepatectomy or hepatic lobectomy, 2 underwent hepatic artery branch ligation and wound suture, and 1 underwent greater omentum filling and suture. After the treatment, 1 patient developed perihepatic abscess and was cured after puncture drainage. All 58 patients recovered and were discharged. Forty-five patients were followed up for 1-6 months. No recurrence of bleeding, bile leakage, infection, hepatic insufficiency and other complications were observed.

Individualized treatment can be applied for traumatic liver rupture. Patients with small and shallow liver rupture may receive non-surgical treatment under a close observation and patient with unstable vital signs and progressive bleeding at the liver rupture may receive surgical treatment. Both treatments can achieve good curative effects.