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Emergency Vascular Surgery A Practical Guide - part 4

Nó là cần thiết để có kinh nghiệm trong phẫu thuật gan thành công hoàn thành "tổng" kiểm soát của tổn thương gan, và trung gian luân chuyển nội tạng động mạch chủ suprarenal và tiếp xúc với mạch chủ cũng có thể rất khó khăn nếu không có kinh nghiệm. | 56 Chapter 5 It is necessary to have previous experience in liver surgery to successfully accomplish total control of liver injuries and the medial visceral rotation for suprarenal aortic and cava exposure may also be very difficult without experience. Retrohepatic Injuries. Particularly cumbersome is control of injuries to the retrohepatic vena cava. This type of exposure is difficult because the liver covers the entire anterior surface of the vena cava. The low number of patients surviving long enough to arrive at the hospital with this type of injury also makes it hard for most surgeons to gather experience with it. The special problems encountered concern the difficult access because as stated the liver covers the vena cava and the reduced blood volume returning to the heart when the vena cava is clamped. A number of methods have been suggested for control. One example is atriocaval shunting by inserting a large tube into the vena cava through a hole in right atrium s appendage. In the Technical Tips box the technique for total clamping and control directly without adjunctive measures is described because we feel this may occasionally be a practical approach for controlling unmanageable bleeding from this area. For immediate control during the exploratory procedure for total control clamping the aorta the infrarenal vena cava and the suprahepatic vena cava and doing the Pringle maneuver the liver is compressed dorsally against the spine manually and by using lap pads. Control of bleeding by direct pressure is facilitated by dividing the falciform ligament and tilting the liver downward. However it is reasonable to refrain from attempting to repair injuries to the retrohe-patic vena cava and instead as the only measure taken pack the liver to reduce the bleeding. NOTE It is rarely sensible to try to repair retro-hepatic vena cava injuries in unstable patients. Superior Mesenteric Artery Injuries. SMA injuries can also be quite difficult to expose and control. .