Abdominal major vascular injury

　　First, etiology

　　More than 90% of abdominal aortic injuries are caused by penetrating trauma, the most common being gunshot wounds (accounting for the majority) and stab wounds, with a small part caused by blunt trauma; most of the injuries to the inferior vena cava and some of the abdominal aorta injuries are caused by abdominal blunt trauma, such as traffic accidents and falls from a height. Especially the sagittal injury of the liver, which is cut in half, is most prone to injury to the inferior vena cava, with some injuries to the inferior vena cava caused by sharp penetrating trauma or iatrogenic injury.

　　Second, pathogenesis

　　Blunt injury to the abdominal aorta often causes vertebral fracture displacement, or the blunt injury factor in front of the lumbar spine compresses the abdominal aorta between them, resulting in vascular wall damage, aortic occlusion, thrombosis, traumatic aneurysm formation, and massive hemorrhage around the abdominal aorta. Penetrating injury of the abdominal aorta due to massive hemorrhage forms a hematoma, and the hematoma above the renal artery is generally limited, while the hematoma below the renal artery is not easy to limit, with blood flooding into the abdominal cavity to form a large hematoma, often reaching the anterior abdominal wall. Injuries to the inferior vena cava are common in penetrating injuries, stab wounds, and lacerations, resulting in severe hemorrhage, hematoma, and thrombosis.

　　1. Shock:It is a severe hemorrhagic shock with a dangerous condition.

　　2. Abdominal distension, abdominal pain, and hemorrhage:Acute abdominal trauma stimulation, the occurrence of peritonitis and abdominal distension, and abdominal pain can all cause abdominal pain, but the nature and severity are different. Open wounds can bleed大量 blood, with bright red arterial blood that may pulsate. It is worth noting that in some cases, the injury to major abdominal blood vessels can lead to retroperitoneal hemorrhage, which may be concealed, with little blood accumulation in the abdominal cavity.

　　3. Injury to abdominal major blood vessels:Injuries often accompany injuries to the small intestine, liver, pancreas, colon, kidneys, and the occurrence of spinal fracture displacement. In addition to the above symptoms, acute peritonitis, hematuria, anuria, hematemesis, fecal hemorrhage, and dysfunction of the nervous system may also occur.

　　First, symptoms

　　1. Shock:It is a severe hemorrhagic shock with a dangerous condition, which is a common cause of early death.

　　2. Abdominal distension, abdominal pain, and hemorrhage:Acute abdominal trauma stimulation can cause abdominal pain, accompanied by peritonitis and abdominal distension, but the nature and severity are different. Open wounds can bleed大量 blood, with bright red arterial blood that may pulsate. It is worth noting that in some cases, the injury to major abdominal blood vessels can lead to retroperitoneal hemorrhage, which may be concealed, with little blood accumulation in the abdominal cavity. A typical example is a stab wound to the lumbar and dorsal region, where the blade pierces from the lower two ribs.

　　3. Injury to major abdominal blood vessels:Accompanied by injuries to the small intestine, liver, pancreas, colon, kidneys, and the occurrence of spinal fracture displacement, in addition to the above symptoms, acute peritonitis, hematuria, anuria, hematemesis, fecal hemorrhage, and dysfunction of the nervous system may also occur.

　　Second: Signs

　　Patients due to massive blood loss generally have poor general condition, sudden drop in blood pressure or cannot be measured, rapid and weak pulse to the touch, or shallow breathing, confusion of consciousness, pale complexion, cold extremities, etc. Abdominal distension, sharp injury bleeding from the wound. If there is concomitant injury to the digestive system, the contents of the digestive tract or digestive juices flowing into the abdominal cavity can cause tenderness, rebound pain, muscle tension, and other peritoneal stimulation signs, positive shifting dullness, weak or absent bowel sounds on auscultation.

　　2. Do not eat too much salty and spicy food, do not eat overheated, cold, expired, and deteriorated food; for the elderly, the weak, or those with certain genetic predisposition to diseases, eat some anti-cancer foods and alkaline foods with high alkalinity in moderation to maintain a good mental state.

　　1. Develop good living habits, quit smoking and limit alcohol. The World Health Organization predicts that if people stop smoking, the world's cancer rate will decrease by 1/3 in 5 years; secondly, do not drink heavily. Tobacco and alcohol are highly acidic substances, and people who smoke and drink for a long time are prone to acidic constitution.

　　First: Emergency blood routine, blood type, urine routine, blood urine amylase and other laboratory tests.

　　Second: Peritoneal fluid detectionThe blood-like peritoneal fluid generally should be examined by smear and the amylase content measured to exclude the possibility of gastrointestinal injury. It should be performed in an emergency state and requires rapid and comprehensive action.

　　Third: Abdominal puncturePercutaneous abdominal paracentesis is particularly applicable to abdominal closed injuries, and it has diagnostic significance for judging whether there is injury to abdominal internal organs and which organ is injured. If there is injury to a large abdominal blood vessel, it is easy to draw out unclotted blood. The blood-like fluid extracted generally needs to be examined by smear and its amylase content measured to determine whether there is injury to other organs. In some cases, peritoneal puncture may not reach fluid, but it does not exclude the possibility of injury to abdominal blood vessels and organs.

　　Fourth: X-ray examination

　　1. Thoracoabdominal X-ray examination:Subdiaphragmatic air, fluid in the thoracic and abdominal cavities, and changes in the size, shape, and position of certain organs can be seen. When there is a hematoma behind the peritoneum, the shadow of the psoas muscle can disappear.

　　2. Angiography:If the patient's condition allows, abdominal aorta and inferior vena cava angiography should be performed to determine the location, extent, and degree of vascular injury, especially for patients with great vessel injury caused by blunt abdominal trauma. At the same time, it can be checked whether there is injury to the branch vessels.

　　3. CT and MRI:It is of great help in the diagnosis of abdominal great vessel injury.

　　4. Ultrasound examination:Ultrasound can detect the presence of fluid in the thoracic and abdominal cavities, the shape, size of certain organs, the evolution of hematomas in solid organs, and in addition, Doppler ultrasound can detect the rupture and obstruction of traumatic abdominal aorta.

　　5. Others:When there is a suspicion of renal vascular injury (especially in cases of abdominal blunt trauma), renal parenchymal injury and hematuria, intravenous pyelography and CT renal scan should be performed. If there is renal dysfunction or the kidney does not show up, renal arteriography should be performed.

　　First: Dietetic recipes after abdominal great vessel injury surgery

　　1. Boiled pumpkin with red dates and brown sugar

　　[Ingredients] 500g of fresh pumpkin, 20g of jujube, and an appropriate amount of brown sugar.

　　[Preparation] Peel the pumpkin, cut it into small cubes, add jujube and brown sugar, and cook in water until done.

　　[Usage] Take as a side dish with meals, and it is better to eat on an empty stomach.

　　[Applicable] Suitable for postoperative deficiency of both Qi and blood and weak physique.

　　2. Black sesame bean milk

　　[Ingredients] 30g of black sesame seeds, 40g of soybean powder.

　　[Preparation] Roast black sesame seeds over low heat until they are cooked, grind them into fine powder and set aside. Put soybean powder in a pot, add an appropriate amount of water, mix well to form a thin paste, soak for 30 minutes, simmer over low heat until it boils, filter the soy milk with a cloth, add it back to the pot, and simmer over low heat until it boils again. Then, add the black sesame powder and mix well.

　　[Usage] Take in the morning and evening, and add brown sugar as needed when taking.

　　[Applicable] Suitable for postoperative deficiency of both Qi and blood, and deficiency of liver blood.

　　3. Astragalus perch soup

　　[Ingredients] 1 perch (200g), 30g of Astragalus, 30g of Chinese yam, 6g of tangerine peel, and 4 slices of ginger.

　　[Preparation] Clean and cut the perch into pieces. Wash Astragalus, Chinese yam, and tangerine peel, and put all the ingredients in a pot. Add an appropriate amount of water, bring to a boil over high heat, and then simmer over low heat for 1 hour.

　　[Usage] Drink the soup and eat the meat.

　　[Applicable] Strengthen the spleen and Qi, improve appetite, and benefit the middle, especially suitable for postoperative patients recovering their physique.

　　4. Dried red bean and rabbit meat stew

　　[Ingredients] 60g of jujube, 250g of rabbit meat.

　　[Preparation] Wash the rabbit meat, blanch it in a pot of boiling water, remove it and cut it into small pieces, then put it in a pot with mung beans and红枣. Add an appropriate amount of water, bring to a boil over high heat, add cooking wine, and then simmer over low heat for 40 minutes. After the rabbit meat is cooked, add chopped green onions, ginger, salt, monosodium glutamate, and five-spice powder, mix well, bring to a boil again, and then add sesame oil to finish.

　　[Usage] Take as a side dish with meals, and take freely.

　　[Applicable] Tonify both Qi and blood, restore physical and mental strength after surgery.

　　Second, what foods are good for the body after abdominal major vascular injury surgery

　　1. Provide easily digestible and absorbable protein foods, such as milk, eggs, fish, and soy products.

　　2. Eat more foods with blood-building properties, such as jujube and longan.

　　3. Eat fresh cooked vegetables and fruits, and eat more mushrooms, sunflower seeds, asparagus, tomatoes, carrots, and so on.

　　Third, what foods should be avoided after abdominal major vascular injury

　　1. Avoid animal fats and greasy foods.

　　2. Avoid smoking, alcohol, and spicy刺激性 foods.

　　3. Avoid moldy, fried, smoked, and salted foods.

　　4. Avoid hard, sticky, and indigestible foods.

　　First, abdominal aortic injury

　　1. Indications for surgery:①The patient rapidly develops hypovolemic shock, and even after rapid administration of 2000ml of crystalloid solution or plasma substitute, there is no improvement. In such cases, the presence of abdominal aortic injury should be considered, and immediate laparotomy exploration is required. ②There is a drop in blood pressure, symptoms of peritoneal irritation, and the abdominal circumference rapidly increases in a short period of time. If non-clotting blood is aspirated from the abdominal cavity by puncture, and other solid organ injuries are excluded, abdominal aortic injury should be suspected, and laparotomy exploration is also required. ③If there is obvious shock or the blood pressure recovers after resuscitation, and the condition is stable, if retroperitoneal hematoma, pseudo-aneurysm, or aortocaval fistula is found through non-invasive examinations such as ultrasound and angiography, surgical treatment is needed.

　　2. Anesthesia:General anesthesia is used.

　　3. Surgical method:The incision can be selected according to the condition of the injury, such as a median abdominal incision, a thoracoabdominal incision, and an incision along the lateral border of the rectus abdominis muscle. The exposure at the foramen of the diaphragm of the aorta is generally performed using a thoracoabdominal incision, while the exposure of the aorta below the level of the celiac trunk and renal artery is generally performed using a median abdominal incision. Before finding the proximal and distal ends of the injured vessel, hemostasis can be achieved by using methods such as compressing with gauze, finger compression, instrument compression, and balloon catheter occlusion inside the lumen. For minor lateral wall injuries or penetrating injuries, side repair or artificial patch缝合 can be performed. When the injury area is large, the damaged part can be resected and replaced with a人造血管. For patients with associated gastrointestinal injuries and severe peritoneal contamination, due to the high risk of infection and even anastomotic breakdown and bleeding in artificial blood vessels, artificial blood vessel transplantation should be avoided, and bilateral axillary-femoral bypass surgery should be performed if necessary.

　　4. Postoperative management:

　　(1) Monitoring of vital signs: Postoperative patients should be monitored in the ICU, with close observation of blood pressure, pulse, respiration, hourly urine output, and central venous pressure.

　　(2) Monitoring of coagulation mechanism: The administration of a large amount of stored blood during treatment can lead to coagulation disorder, so close monitoring is required. When coagulation disorders occur, fresh blood, plasma, or platelet concentrate should be administered, and vitamin K+, Ca2+, and antifibrinolytic agents should be supplemented.

　　(3) Protect renal function and treat acute renal failure: Low blood volume shock has resulted in insufficient renal blood supply. To control bleeding and repair trauma, when blocking the superior mesenteric artery above the abdominal aorta, renal ischemia becomes more severe, and prolonged ischemia time can lead to acute glomerular necrosis. In the event of acute renal failure after surgery, mild renal dysfunction can be improved by appropriately controlling the volume of intravenous fluid administration, administering mannitol or sorbitol as osmotic diuretics, which can increase urine output and improve renal function. For patients with severe renal failure, significantly increased blood urea nitrogen and potassium levels, dialysis therapy is recommended.

　　(4) Improve respiratory function and prevent pulmonary complications: Keep the respiratory tract unobstructed, administer oxygen, and maintain normal oxygen partial pressure in the blood. Strengthen nursing care to prevent complications such as atelectasis and pulmonary consolidation. For patients with closed chest drainage, maintain the patency of the drainage and remove the drainage tube in a timely manner.

　　(5) Continue to reasonably select the use of antibiotics for 2 weeks after surgery. If incisional infection or residual abscess in the peritoneal cavity has occurred, timely drainage should be performed.

　　II. Injury to the inferior vena cava

　　1. Indications for surgery:In the event of massive intraperitoneal hemorrhage and shock, once diagnosed with liver rupture and suspected injury to the inferior vena cava or hepatic veins behind the liver, immediate laparotomy exploration and surgical hemostasis should be performed.

　　2. Anesthesia and position:General anesthesia is usually adopted, with the patient in a supine position. If a right thoracoabdominal incision is performed, the patient can be in a left lateral position.

　　3. Surgical steps:The incision initially adopts a median abdominal incision, and after opening the abdomen, a comprehensive exploration of important organs such as the liver, spleen, and intestines is conducted to check for any associated injuries. If there is liver rupture, the blood flow at the hilum of the liver can be blocked using a fine rubber tube or a non-traumatic vascular clamp. If there is still dark blood, it can be confirmed that there is an injury to the inferior vena cava or hepatic veins behind the liver, and the incision can be quickly expanded using the following two methods:

　　(1) Thoracoabdominal incision: Extend the median abdominal incision upwards to the right above and cut through the fifth or sixth intercostal space to open the thoracic cavity, cut through the diaphragm to the inferior vena cava orifice at the top of the liver, and expose the superior and posterior inferior vena cava.

　　(2) Thoracoabdominal incision: Extend the median abdominal incision upwards to the right above and cut through the fifth or sixth intercostal space to open the thoracic cavity, cut through the diaphragm to the inferior vena cava orifice at the top of the liver, and expose the superior and posterior inferior vena cava. If the condition allows during surgery, the inferior vena cava internal shunt technique should be adopted. In an emergency situation, the first hepatic portal, superior and inferior vena cava, and even the abdominal aorta can be directly blocked. At this time, the first hepatic portal and abdominal aorta clamps should be released every 10 minutes to maintain liver blood supply. The repair of the posterior inferior vena cava should be determined according to the specific situation. Generally speaking, it is necessary to resect the right half of the liver to expose the inferior vena cava before repair. The repair can be performed with 4-0 nylon suture for continuous or结节缝合. The First Affiliated Hospital of China Medical University once encountered a 15-year-old male patient with liver injury, who underwent simple liver suture in a hospital outside. After 15 days, he developed abdominal distension and abdominal mass, and color Doppler showed that the inferior vena cava injury orifice was connected with the hematoma formed. The second operation adopted the bloodless resection of the right half of the liver, and it was found that the posterior inferior vena cava orifice was 2 cm long, and it was cured after performing side wall continuous suture. If the injury is located below the inferior vena cava and above the renal vein, an artificial vascular interposition technique can be used. If the injury is located below the renal vein, ligation of the inferior vena cava or inferior vena cava-right atrium shunt technique can be performed.

　　It is noteworthy that if the inferior vena cava is a penetrating injury, attention should be paid to the repair of the posterior wall injury and not to omit it.

　　4. Postoperative management:

　　(1) After surgery, ensure adequate drainage of the liver wound, pay attention to the patency and observe the amount of drainage.

　　(2) After surgery, expand the volume in large quantities, prevent lower limb venous stasis, tie the affected limb with an elastic bandage, and raise it appropriately for one week.

　　(3) Use glucose, vitamins, etc. to protect liver function.

　　(4) Monitor vital signs: respiration, blood pressure, pulse, etc.

　　(5) Maintain circulatory stability: supplement blood volume, monitor central venous pressure, urine volume, etc.

　　(6) Maintain water and electrolyte balance and acid-base balance.

　　(7) Prevent renal failure and treat multi-organ failure.

　　(8) Improve respiratory function and prevent pulmonary complications.

　　(9) Use antibiotics.