Przyczyną większości uszkodzeń mechanicznych wątroby jest tępy uraz brzucha. Z uwagi na cechy budowy anatomicznej narząd ten jest szczególnie narażony na jakiekolwiek urazy. Dlatego tak ważne jest wykonanie odpowiednich badań u każdego pacjenta po urazie jamy brzusznej.
Decyzja o zabiegu operacyjnym zawsze powinna być podjęta na podstawie przede wszystkim oceny stabilności układu krążenia. W przypadku wystąpienia krwawienia wewnętrznego, a także pacjentów niestabilnych hemodynamicznie kwalifikuje się do laparotomii zwiadowczej, in. diagnostycznej. W niektórych przypadkach wykonuje się ją nawet przed ukończeniem pełnej diagnostyki obrazowej.
Siła urazu a obrażenia narządu
Dzięki laparotomii możliwa jest diagnostyka pod kątem obecności krwiaka śródmiąższowego oraz podtorebkowego, który może zajmować różną powierzchnię wątroby, przerwania torebki Glissona z rozerwaniem miąższu sięgającym różnych głębokości czy uszkodzenia naczyń krwionośnych i dróg żółciowych.
Podczas operacji ważne jest opanowanie krwawienia, zabezpieczenie dużych naczyń, a także usunięcie uszkodzonych tkanek. Niekiedy w ograniczeniu krwawienia niezbędne będzie czasowe zaciśnięcie więzadła wątrobowo-dwunastniczego na maksymalnie 15-20 minut. Jest to tzw. manewr Pringle’a. Co szczególnie ważne, czas niedokrwienia miąższu powinien być przedzielony kilkuminutowym przywróceniem krążenia.
Znaczenie zastosowania tamponady w przypadku urazu wątroby
Niekiedy ciężki stan pacjenta, towarzyszące mu rozległe obrażenia wątroby, długotrwałe preparowanie tkanek wątroby czy więzadła wątrobowo dwunastniczego prowadzi do wzrostu ryzyka zbyt dużej utraty krwi, a nawet śmierci. Dlatego jeżeli jest to konieczne, należy wykonać tamponadę, czyli tzw. packing. Polega ona na uciśnięciu chustami z gazy wszystkich powierzchni wątroby.
Tamponadę wykonuje się również, jeżeli z różnych przyczyn nie jesteśmy w stanie właściwie docelowo zaopatrzyć uszkodzonego miąższu. Dzięki tej metodzie możliwe jest wówczas ustabilizowanie stanu hemodynamicznego i bezpieczne przygotowanie pacjenta na transport do ośrodka, który specjalizuje się w chirurgii wątroby.
Aby ostatecznie zaopatrzyć uszkodzony narząd, po 24-48 godzinach wykonuje się relaparotomię, czyli ponowne otwarcie jamy brzusznej. Należy pamiętać również o maksymalnym czasie utrzymywania tamponady, który wynosi 72 godziny. Jest to szczególnie istotne w kontekście wystąpienia ewentualnych powikłań infekcyjnych.
Źródło: Głuszek S., Chirurgia podstawy, Wydanie II uaktualnione i rozszerzone, Warszawa 2019, s. 327
Przeczytaj także: „O wynikach leczenia ran oparzeniowych decydują pierwsze godziny po wypadku” – rozmowa z mgr Beatą Śpiewak
Bardzo cenne informację, muszę doczytać resztę w książce dr Głuszka
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