外科学教学课件：腹部损伤和腹膜炎

AcuteSuppurativeperitonitisWelcome！Mainpoints！（1）

Anatomy&physiology（2）

Acutediffuseperitonitis

a、Etiology b、Pathophysiology

c、Clinicalmanifestation d、Auxiliaryexamination e、Diagnosis f、Treatment（3）AbdominalAbscess（4）Abdominalcompartmentsyndrome（ACS）Acuteperitonitis InflammationofperitoneumClassificationEtiology:PrimaryorSecondaryRegion：LocalizedorDiffuseClinicalcourse：AcuteorChronicCause：SepticorAsepticPeritonitisMostsurgicalperitonitisissecondarytobacterialcontaminationfromthegastrointestinaltract.Secondaryperitonitis腹内脏器损伤胃肠道穿孔胆囊坏死穿孔外伤腹内脏器炎症扩散阑尾炎胰腺炎女性生殖器官化脓性感染手术腹腔污染瘘/漏腹壁感染Etiology致病菌：胃肠道内常驻菌群大肠埃希菌Forsecondaryperitonitis:Appendicitis(inflammationoftheappendix)StomachulcersTornortwistedintestine

Severelyinflamedgallbladder

DamagetothepancreasInflammatoryboweldisease,suchasCrohn'sdiseaseorulcerativecolitis

Atwistedintestinethatcancauseobstruction

InjurycausedbyanoperationContinuousambulatoryperitonealdialysis(CAPD)–aprocedureusedforpeoplewithend-stagerenaldisease

Trauma

RiskFactors

预后取决于以下2个因素全身、腹膜局部防御能力污染细菌性质、数量、作用时间肠内容物细菌、产物充血水肿浆液性渗出炎症反应坏死脓液脱水电解质紊乱休克MODSPathophysiologyPathophysiologyPathophysiologyDiagnosisDiagnosisHistoryClinicalfeaturesDREDP/LAuxiliaryExaminationHistoryOnset(acutevs.chronic)DurationofpainLocationRadiationQualityandseverityAssociatedsymptomsAlleviatingoraggravatingfactorsPastmedical/surgicalhistoryIsthereahistoryofpredisposingfactors?recentabdominalsurgery,pepticulcerdisease,diverticulosis,Crohn'sdisease,gastrointestinalmalignancy,pancreatitisDiagnosisSymptomsAcuteAbdominalpainSuddenandsevereincaseofrupturedviscusConstant&unendurable,Unmovable,IncreasedwithmovementDullandpoorlylocalizedlocalizeddiffuseNausea&VomitingGIirritationorparalysis(flatus,constipation)Fever,rapidpulseInfectivetoxicsymptoms：septicshockClinicalmanifestation

SignsGeneralSignscompulsivepositionPatienttendstoliestill,supine,kneesflexedInvoluntaryguardingofabdomenFever,Tachycardia,hypotensionAbdominalSignsPeritonealirritationLocalizedormildtenderness,rigidity,rebound

tendernessBoard-likerigidityofabdomenAbsentbowelsoundsHypoactivebowelsounds,EnteoparalysisPercussionpain,ShiftingdullnesspositiveDigitalrectalexamination（DRE）ClinicalmanifestationPhysicalexamination

Vitalsigns ConstitutionalfindingsAbdomenInspection,auscultation,percussion,palpationPelvicexaminationRectalexaminationCardiac/respiratoryexaminationAcompletephysicalexaminationisimportantDigitalRectalexaminationVaginalandbimanualexaminationinfemalepatientsDiagnosisDigitalrectalexamination（DRE）Anus：HemorrhoidsoranalfissuresRectum：GrowthsProstate：enlarge,tenderness,Rectalfossa：plumpfeeling&tendernessAnteriorrectalwall：tenderness,volatilesenseGlovedfinger：bloodClinicalmanifestationSummarySymptomsAcuteabdominalpainNausea&VomitingFever,rapidpulseInfectivetoxicsymptomsAbdominalSignsPeritonealirritation（tenderness,rigidity,rebound）Absentbowelsounds,shiftingdullnessDigitalrectalexamination（DRE）ClinicalmanifestationSummary实验室检查白细胞↑、中性粒细胞

↑腹部立卧位平片肠麻痹、膈肌抬高膈下游离气体B超、CT、血管造影腹腔穿刺&腹腔灌洗DPL根据抽液性质判断病因AuxiliaryexaminationParalyticileuswithAir-fluidlevelsSubphrenicfreeairAuxiliaryexaminationX-RayLiverabscessGallstone,afterPTGBDAuxiliaryexaminationX-RayLiverabscessPelvicabscessAuxiliaryexaminationB-ultrasoundAuxiliaryexaminationPerforationofappendix↑

Necrosisofintestin↑ DiagnosticParacentesis&PeritonealLavage(DPL)

诊断性腹穿或腹腔灌洗术

Puncturepoint:

脐与髂前上棘连线中外1/3交界点

脐水平线与腋前线交界点Auxiliaryexamination

腹腔灌洗术PeritonealLavage阳性指标不凝血、胆汁、胃肠内容物、尿液

镜下RBC＞100×109/L，WBC＞0.5×109/L

淀粉酶大于100U/L，镜下找到细菌DPLAdvantagesRapidAidsoperativedecision-makingGoodfordetectinghollowviscusinjuryDisadvantagesSamplesonlyperitonealcavityInvasive,intestineperforationFalsepositiveorFalsenegativeNon-specificDPLPeritonealfluid

Paracentesis,aspirationofabdominalfluidcollectionsIntraoperativeperitonealfluidculturesEvaluatethesampleforpH,glucose,protein,lactatedehydrogenase(LDH),cellcount,Gramstain,andaerobicandanaerobiccultures.AmylaseanalysisifpancreatitisorpancreaticleakissuspectedBilirubinanalysiswhenabiliaryleakissuspectedEvaluatethefluidcreatininelevelwhenaurinaryleakis

suspectedPeritonealfluidtests腹腔穿刺胃十二指肠穿孔黄色浊液含胆汁或食物急性阑尾炎穿孔浓稠脓液带臭味绞窄性肠梗阻暗红色腥臭血性液坏死性胰腺炎淡红色液、淀粉酶升高结核性腹膜炎草绿色腹水PeritonealfluidtestsDiagnosisprocedureHistoryClinicalfeaturesAuxiliaryExaminationDPLPeritonitisPrimaryperitonitisSecondaryperitonitisAppendicitisCholecystitisPancreatitisDiverticulitisPerforationObstructionAcuteischemiaEctopicprenancyRuptureaorticaneurysmnephrolithiasisGeneralprinciples

(1)tocontroltheinfectioussource(2)topurgebacteriaandtoxins(3)tomaintainorgansystemfunction(4)tocontroltheinflammatoryprocess

Medical,interventional,andoperativetreatmentoptionsarecomplimentary,notcompetitive,inthetreatmentofperitonealinfections.TreatmentNon-operativetherapy早期（24h）、轻型、体征减轻or无法耐受手术体位（半坐卧位）禁食、胃肠减压纠正水、电解质紊乱（抗休克）抗生素（混合感染）补充热量及营养支持（3000~4000kcal/d）对症支持：镇静、止痛、吸氧TreatmentCarefully!!!Antibiotictherapy

Primaryperitonitis ▪Initiatewithathird-generationcephalosporinandthentailortherapyaccordingtothecultureresults. ▪Thetraditionaldurationoftherapyis10daysSecondaryperitonitis ▪Asecond-orthird-generationcephalosporin ▪Tripleantibiotictherapyintravenously,providingaerobic,gramnegativeandanaerobiccoverage ▪DurationdependedontheresponseTreatmentOperativetherapy手术适应证保守治疗无缓解或加重（6~8h）原发病严重（穿孔、破裂、绞窄、漏）腹腔炎症重、大量积液（肠麻痹、休克）

病因不明确，无局限趋势Treatment手术原则全麻处理原发病彻底清洁腹腔充分引流腹腔引流管放置指征病灶及坏死组织未能彻底清除预防渗漏术野渗液或渗血较多已形成局限性脓肿拔管指征＜10ml、非脓性、无发热腹胀、无腹膜炎体征OperativetherapyProcedureofsurgeryAnesthesiamethods

General,epidural,localIncisionselection

Para-medianormidlineTotalexplorationOperativetherapyOperativetherapyPrognosiswilldependon

ThecauseofperitonitisTheNature,quantity,durationoftheinfectionTheResistanceofthepatienttheindividualpatient'spreviousstateofhealthpre-existingconditionsThetimebetweentheonsetoftheperitonitisanddiagnosis&treatmentPrognosisHypovolemiaSepsis,progressingtosepticshockOrganfailure(kidneys,liver)AcuterespiratorydistresssyndromeAbscessformationComplications病理生理急性化脓性腹膜炎抵抗力强病菌毒力弱治疗及时渗出物吸收炎症消退痊愈局限性脓肿抵抗力弱病菌毒力强病变严重脱水电解质紊乱休克MODS循环衰竭死亡TakeappendicitisforexampleImaginethedifferenttimeafterthestartofthedisease2-3hours1-2days3-4days2-3weaksSymptomandsignsPhysicalexaminationAuxiliaryexaminationsTreatmentWhatarethekey-pointstothesequestionsQuestionslistSymptomsSignsAuxiliaryexaminationtreatment2-3hours1-2days3-4days2-3weaksQuestionslistSymptomsSignsAuxiliaryexaminationtreatment2-3hours腹痛恶心、呕吐发热、脉速感染中毒全身表现腹部体征腹膜炎肠鸣音体位移动浊音直肠指检双合诊DPLLabtestX-rayB-usCTAngiographNon-opoperation1-2days3-4days2-3weaks学习要点！急性弥漫性腹膜炎

a、病因

b、病理生理

c、临床表现

d、辅助检查

e、诊断

f、治疗原则Acuteperitonitis解剖&生理原发性腹膜炎腹腔脓肿Abdominalcompartmentsyndrome（ACS）

腹腔间隔室综合征Take-homemessagesPeritoneum(2layers)parietalperitoneumvisceral

peritoneum2cavityPeritonealcavityOmentalbursaCommunicatethroughWinslowforamen(Epiploicforamen)2OmentumOmentummajus&minusAnatomy腹膜壁腹膜脏腹膜腹膜腔（2部分）大腹腔（腹膜腔）小腹腔（网膜囊）两者经网膜孔相通（Winslow孔）解剖&生理Omentummajusthegreater(gastrocolic)

omentumOmentumminusthelesser

(gastrohepatic)

omentumAnatomyFunctionsoftheperitoneumProvidesafrictionlesssurfaceoverwhichtheabdominalvisceracanfreelymove

50-100mlofclear,straw-coloredfluid

Servesasabidirectionaldialysismembrane

¤

Isotonicsalinesolution30to35mlperhour ¤

Hypertonicfluid300to500mlperhour ¤

Blood,airandgasesareabsorbedataslowerratePhysiology神经支配壁腹膜

肋间和腰神经支配定位准确痛觉敏感脏腹膜

交感及迷走神经支配定位差钝痛腹膜生理扁平间皮细胞双向半透性膜解剖&生理EtiologySpontaneousbacterialperitonitis（SBP） Anasciticfluidinfectionwithoutanevidentofintraabdominalsource

G+

&G-organismsBacteriainvasionpathways：Hematogenousdissemination：infant,childrenUplinkinfection：femaleDirectextensionPerforativeinfection:GIwallPrimaryperitonitis原发性腹膜炎

多见于儿童、营养差或免疫低下者血行播散上呼吸道或泌尿系感染上行性感染女性生殖道细菌淋菌性腹膜炎直接扩散泌尿系感染透壁性感染肠腔内细菌移位腹水、肾病、猩红热致病菌：溶血性链球菌肺炎双球菌大肠埃希菌PrimaryperitonitisForprimaryperitonitis:Liverdisease(cirrhosis)KidneydamageFluidintheabdomenCompromisedimmunesystem

PelvicinflammatorydiseaseRiskFactors常见分类（按部位）膈下脓肿盆腔脓肿肠间脓肿腹腔脓肿

脓液在腹腔内集聚，由腹内脏器、网膜、肠系膜等黏连包围，与游离腹腔隔离，形成腹腔脓肿。SubphrenicabscessPathologylowestposition(supineposition)Invasion(portalvein&lymphaticsystem)ClinicalmanifestationSystemicsymptomsLocalsymptomsDiagnosis&DifferentialdiagnosisTreatmentPercutaneouscatheterdrainageIncisiondrainageAbdominalAbscess解剖&病理脓液集聚在膈肌下与横结肠及其系膜的间隙内易长期感染、局部刺激重、易形成内瘘临床表现全身症状发热：弛张热、高热感染消耗症状

局部症状腹痛：持续钝痛、肋缘下或剑突下呃逆胸膜、肺反应季肋区叩痛膈下脓肿膈下脓肿诊断病史症状、体征辅助检查X线：膈肌抬高、胸膜反应B超、CT：明确诊断治疗支持治疗：补液、输血、营养、抗生素经皮穿刺置管引流术（B超引导下）切开引流术（肋缘下切口、后腰部切口）AbdominalAbscessPelvicabscessClinicalfeaturesDiagnosisTreatment：non-operative,drainageInterloopabscessPathophysiology：AdhesiveileusDiagnosisTreatment：non-operative,laparotomy盆腔脓肿临床表现及诊断直肠、膀胱刺激征直肠指检：触痛、波动感B超可协助诊断治疗支持治疗：抗生素、物理热透、灌肠切开引流经直肠前壁经后穹窿肠间脓肿脓肿包围在肠管、系膜、网膜间常为多发易广泛黏连导致肠梗阻B超、CT可协助诊断治疗非手术治疗：抗生素、物理热透手术治疗：解除梗阻、清除脓液、引流AbdominalAbscessAbdominalcompartmentsyndromePathophysiologyIntra-abdominalhypertension Intra-abdominalpressure（IAP）＞20mmHgHypotensionRespiratoryinsufficiencyRenalinsufficiencyVisceralischemiaACSMODS腹内压＞20mmHg下腔静脉受压回心血量↓肠系膜血流↓肠道缺血门静脉血流↓肝脏缺血循环阻力增大心排减少肾灌注↓肾小球滤过率↓膈肌抬高胸腔压力增高呼吸衰竭腹内压升高＞20mmHg，并伴有腹腔高压相关脏器功能衰竭病理生理腹膜腔间隔室综合症MODSDiagnosisCausesofintra-abdominalhypertensionClinicalfeaturesDistension&RigidityHypotensionafterfluidresuscitationHypoxemiaElevatedCVP&PCWPOliguriaoranuriaIAPdetection：TransvesicalpressureTreatmentIndication：IAP＞25-30mmHgLaparotomy：decompression,drainage,wallrepairACS诊断腹腔高压病因（腹壁因素&腹腔因素）临床表现腹部，呼吸，高碳酸血症，少尿、无尿、氮质血症呼吸功能衰竭低心排出量综合征膀胱测压CT治疗非手术治疗、穿刺手术治疗：IAP＞25mmHg，腹腔开放术腹膜腔间隔室综合症AbdominalInjuriesZhangKunSong,M.D.&Ph.D.DepartmentofPancreatobiliarySurgeryTheFirstAffiliatedHospitalSunYat-SenUniversityWelcome！Mainpoints！（1）

ClassificationandtheEtiologyofabdominalinjury（2）

Clinicalmanifestation（3）

Keypointsofdiagnosis a、Openinjuries;Penetratingtrauma b、Closedinjuries;Blunttrauma（顿挫伤）（4）

Principles

of

management（5）

CharacteristicsandtreatmentofcommonvisceralinjuriesAbdominalInjuriesTakethiscaseforexampleMale，42yoldFallenoffasteeltowerfrom5mheightComplainofanabdominalpainanddrymouthWhathappenedWhattodonextWhatisthemostimportantthingStartwiththesequestions?Why?QuestionslistWhatdoUalreadyknow

WhatwouldUwanttoknow

QuestionslistWhatdoUknowWhatwouldUwanttoknowWhyRemarkWhathappenedWhattodonextWhatisthemostimportantthing“Comeon,Ithinkit’stimeforabreak.”Abdominalinjuryreferstothehistologicaldamageanddysfunction（组织损伤和功能障碍）causedbydifferentkindsofinjuriesWhatisabdominalinjuryClassification

Openinjury开放性： Penetrating（穿透性）

Tubularwound盲管伤

perforatinginjury贯通伤

Non-penetrating

Closedinjury闭合性（Blunttrauma） Abdominalwallinjuries Visceralinjuries

开放性：穿透性

盲管伤

贯通伤非穿透性闭合性：腹壁损伤

内脏损伤医源性损伤

Classification

开放性：投射物，刀、子弹伤闭合性：钝性暴力，撞击、挤压、坠落

常见内脏损伤易难程度开放性：肝、小肠、胃、结肠、大血管闭合性：脾、肾、小肠、肝、肠系膜较难：胰、十二指肠、膈、直肠EtiologyOpeninginjury

directinjuryBlunttrauma: Compressionforces

压缩力 ¤tearsandsubcapsularhematomastothesolid viscera ¤deformholloworgansandtransientlyincrease intraluminalpressure,resultinginrupture Decelerationforces

减速力 ¤rupturesupportingstructuresatthejunctionbetweenfreeandfixedsegmentsMechanismsofinjuryCompressionforcesDecelerationforcesAbdominalwall： localswollen&pain、tenderness、bruise&ecchymosis

Visceralinjuries内脏损伤：TwoPoints

Internalhaemorrhage内出血：Hemorrhagicshock

（Parenchymaorgan实质脏器：spleen、liver、kidney）

Peritonitis腹膜炎：peritonealirritation腹膜刺激征、 abdominalpain、infection

（holloworgan空腔脏器：Gastrointestinal、biliarytract、bladder）Clinicalmanifestation

Hemorrhage出血

面色苍白、脉搏细速、失血性休克

腹痛及腹膜炎表现轻

腹胀、腹部包块、移动性浊音、血尿

Peritonitis腹膜炎

Peritonealirritation腹膜刺激征 （强弱依次：胰液、胆汁、胃肠液、血液、尿液） Gastro-intestinalsymptoms胃肠道症状 systemicinfection全身性感染

、septicshockClinicalmanifestationClinicalmanifestationRetroperitonealPeritonitisHemorrhageLiverStomachDuodenumKidneyBladderSmallintestineSpleenPancreasColonRectumPelvicFractureClosedinjury：4steps 1、Isthereavisceralinjury? 2、Whichorgan? 3、Aretheremultipleinjuries 4、IfdifficulttodiagnoseDiagnoseAbdominalinjury?Viscerainvolved?Whatkindoforgans?Multipleinjuries?IfdifficultdiagnosisWhichorgan?Diagnosisprocedure1、Isthereavisceralinjury?1）受伤史：时间、地点、致伤条件、伤情等2）监测全身情况：生命体征、休克征象3）体格检查：全面而有重点，腹部+腹外伤道，DRE4）实验室检查：三大常规、淀粉酶ClosedinjuryJudgeIndexofabdominalvisceralorganinjuries！（1）早期出现休克（出血性）（2）持续性、进行性腹部剧痛伴恶心、呕吐（3）明显腹膜刺激征（4）气腹征（5）移动性浊音（6）便血、呕血或尿血（7）直肠指检前壁压痛、波动感、指套血染ClosedinjuryAbdominalinjury?Viscerainvolved?Whatkindoforgans?Multipleinjuries?MakedifficultdiagnosisWhichorgan?Diagnosisprocedure2、WhichorganParenchyma实质脏器

orHollow空腔脏器ClosedinjuryClinicalmanifestationRetroperitonealPeritonitisHemorrhageLiverStomachDuodenumKidneyBladderSmallintestineSpleenPancreasColonRectumPelvicFractureWhichorganwasinjured?恶心、呕吐、便血、气腹→胃肠道排尿困难、血尿、外阴或会阴牵涉痛→泌尿系膈面腹膜刺激、同侧肩背牵涉痛→上腹下位肋骨骨折→肝、脾骨盆骨折→下腹、盆腔ClosedinjurySummaryDependontheinjuredorgansIntraperitonealbleeding---solidvisceraPeritonitis---holloworgans,bileductandpancreasTraumaishighlyvariableinpresentation,extentofinjury,andexaminationEasytolosesightoftheforestforthetrees.ClinicalmanifestationAbdominalinjury?Viscerainvolved?Whatkindoforgans?Multipleinjuries?MakedifficultdiagnosisWhichorgan?Diagnosisprocedure3、Aretheremultipleinjuries避免漏诊可

1）同一脏器有多处破裂能

2）一个以上脏器受损伤存

3）合并腹外损伤在

4）腹外损伤累及腹内脏器ClosedinjuryAbdominalinjury?Viscerainvolved?Whatkindoforgans?Multipleinjuries?MakedifficultdiagnosisWhichorgan?Diagnosisprocedure4、IFdifficulttodiagnose1）Auxiliaryexamination

辅助检查2）Close

observation&monitoring

严密观察3）Laparotomy

必要时剖腹探查Closedinjury1）Auxiliary

examination DiagnosticParacentesis&PeritonealLavage(DPL)

诊断性腹穿或腹腔灌洗术

DifficultDiagnosis腹腔穿刺胃十二指肠穿孔黄色浊液含胆汁或食物急性阑尾炎穿孔浓稠脓液带臭味绞窄性肠梗阻暗红色腥臭血性液坏死性胰腺炎淡红色液、淀粉酶升高结核性腹膜炎草绿色腹水AbdominalX-ray

膈下积气

胃肠穿孔、破裂

腹膜后积气十二指肠、结直肠穿孔

膈肌抬高、肋骨骨折肝脾破裂B-ultrasound,CT,Angiography

肝、脾破裂或血肿Auxiliary

examinationX-RayX-RayUltrasonographyDifficultDiagnosis脾破裂肝破裂胰腺断裂肾破裂四-4进一步确诊Angiography2）Close

observation&monitoring生命体征：P、R、BP，15’-30’腹部体征：腹膜炎程度和范围的变化，30’血常规的变化：30’-60’重复腹穿或灌洗术注意：减少搬动、慎用止痛、禁食支持治疗：抗休克、抗感染、胃肠减压DifficultDiagnosisDuringtheobservationIntravenousinfusionofcrystalloidinfusionorbloodproductsSystemicadministrationofantibioticsGastrointestinaldecompressionNomovement,Nofood,LestanalgesicDifficultDiagnosis3）Laparotomy！(Indications)全身情况有恶化趋势，RBC进行性下降腹痛和腹膜刺激征进行性加重肠鸣减弱、消失或明显腹胀膈下游离气体抗休克未见好转或继续恶化消化道出血腹穿有气体、不凝血、胆汁或胃内容物直肠指诊明显触痛DifficultDiagnosisAbdominalinjury?Viscerainvolved?Whatkindoforgans?Multipleinjuries?MakedifficultdiagnosisCloseobservationWhichorgan?DiagnosisprocedureAuxiliary

examinationLaparotomyPrinciplesofmanagement1）内脏损伤：做好术前准备，力争及早手术2）伴发腹外损伤： 权衡轻重 先处理对生命危害最大的损伤3）积极抗休克治疗、抗感染治疗4）尽早剖腹探查Management“theabdomenshouldneitherbeignored

northesolefocusofthephysicians”SequenceoftreatmentCPR(cardiopulmonaryresuscitation)ControlexternalbleedingControlopenandtensionpneumothoraxManagementofshockCraniocerebraltraumaAbdominalinjuryCombineinjuriesManagementofshockisakeytotreatmentHemodynamicallystable

furtherexaminationHemodynamicallyunstablewithintraperitonealbleeding TransfusionBP90mmHgoperationHemodynamicallyunstableafterappropriatetreatment OperationimmediatelyHolloworganinjury OperationaftermanagementofshockSepticshock OperationandsystemicantibioticsShockManagement剖腹探查腹腔探查顺序先受伤脏器、血凝块集中处肝、脾、膈、胃十二指肠、空肠、回肠、大肠先止血后处理破裂出血性损伤→重污染穿透性损伤→轻污染清洗、引流Laparotomy广州勇警飞身擒贼遭车撞抢救无效光荣牺牲2007年7月6日，广州越秀区公安分局便衣陈世豪在广州大道上追捕抢劫疑犯时，被疾驶而来的汽车撞倒后，经抢救无效，于凌晨3时光荣牺牲。生死营救5小时

5日22：00，送到医院。

22：30，送入手术室。6日01：30，手术进行了3小时。主治医生出来称陈世豪的肾脏破裂，肋骨、盆骨等多处断裂，失血严重，20余名各科专家正在集体进行手术，尽全力抢救，并找来体外循环专家，准备进行体外循环。

03：05，由于陈世豪从脑到胸到盆腔均有裂伤，多器官破损，虽然心跳一度回来，但由于出血速度太快，4条管道供血仍来不及，最终宣告不治。输血量超过2万ml。腹部损伤Threatentolife¤Majorbleedingcausedbybrokensolidorgansorlargevessels¤SevereintraperitonealinfectioncausedbybrokenholloworgansKey:reducethemortality¤Earlycorrectdiagnosis¤AppropriatemanagementSeverityandpatternofinjurydependon¤Intensity,velocity,positionanddirectionoftheviolenceimpartedthebody¤Localanatomycharacteristics¤PreexistingpathologicconditionSummaryAlgorithmTakethiscaseforexampleMale，42yoldFallenoffasteeltowerfrom5mheightComplainofanabdominalpainanddrymouthWhathappenedWhattodonextWhatisthemostimportantthingStartwiththesequestions?Why?QuestionslistWhatdoUknowWhatwouldUwanttoknowWhyRemarkWhathappenedWhattodonextWhatisthemostimportantthingHistoryPhysicalexaminationVitalSignsDiagnosticParacentesisAuxiliaryExaminationCaseBoy,7yold,HitbyamotorbikeVitalsignsstable,mildabdominalpainatleftupperquadrantoftheabdomenPhysicalexamination:someScratchatthemiddleandleftupperquadrantoftheabdomen,slighttendernessofleftupperquadrantDiagnosticParacentesis:refusedCase21hrlater,vomit,showedasignofperitonitisatleftabXray:SubphrenicfreeairB-ultrasound:NegativeTearandperforationofgreatergastriccurvatureWhy?History:Justhadlunch腹部闭合性损伤学习要点！（1）分类，病因，机制（2）临床表现：2points（3）诊断要点：4step（4）处理原则AbdominalInjuriesDiagnosisofOpenInjuryLaparotomyCommonvisceralInjuriesLiverruptureSplenicrupturePancreaticinjuryGastricinjury&DuodenalinjuryDamagecontrolsurgery（DCS）Pre-hospitalcareTake-homemessages

受伤史、体征、必要的治疗

开放性损伤注意点：

要点：是否为穿透伤！ 1）出、入口可能不在腹部 2）未穿透腹膜亦可能有内脏损伤 3）出、入口与伤道不一定是直线 4）伤口大小与伤重程度不成正比OpeninjuriesOpeninjuriesGeneralanesthesiaIncisionchoiceneartheinjuryConvenientforexplorationPrincipleStopmajorbleedingFirst!LaparotomyExplorationSequencePre-operationdiagnosis ConcentrationofbloodclotHemostasisfirst,thenruptureSystematicexplorationLiver,spleen,diaphragmStomach,duodenum,Jejunum,ileum,colon,mesenteryOmentalbursa,posteriorgastricwall,pancreas2-4partofduodenumLaparotomyExplorationCommonvisceralInjuriesLiverruptureSplenicrupturePancreaticinjuryGastricinjury&DuodenalinjurySmallintestineruptureColonruptureRectalinjuryRetroperitonealhematomaHistoryClinicalmanifestationDiagnosisManagement

病史临床表现诊断治疗脾脏破裂下肋骨折出血休克腹穿有血脾切除肝脏破裂

下肋骨折出血+腹膜炎腹穿血+胆汁肝修补、切除胰腺损伤上腹挤压腹膜炎重淀粉酶止血清创切除吻合十二指肠同上腹膜炎腹膜后气修补减压小肠破裂打击刀伤腹膜炎气腹修