穿孔性溃疡（图文演示）

10.手术结束
•原则

腹腔灌洗是这种手术的重要步骤。在曝露之后立即进行以迅速移除大多数污染液。在缝合之后继续进行。

•灌洗

使用加压抽吸灌洗装置，以温生理溶液（4到6 L）进行腹膜灌洗，直到变为清澈流出液为止。通常需要改变手术台位置或者稍微摇晃病患，以便液体可以更完整的分布于腹膜内。所有的残余液体必须抽掉。

•引流

使用硅胶（大小为12到18 French）引流管进行腹膜腔的常规引流。
依照腹膜炎的严重度，使用1到3根引流管：一根通过位于右腹部套管引流缝合的溃疡伤口，一根通过位于左腹部的套管引流直肠泌尿道穿孔处，一根通过剑突下套管位置进行左膈下引流。以垂头仰卧位进行引流。

•关闭

逐一移除套管且确认套管位置的止血。肌膜平面（musculo-aponeurotic plane）仅在10/11 mm套管位置关闭。使用吻合器或者缝线关闭皮肤。

11.术后处置
静脉注射H2受体拮抗剂或者一旦停止输液，给予口服质子泵抑制剂（proton pump inhibitor）。
一旦每天流出液体小于100mL，可移除引流管，条件是不再流出不洁、血水或化脓物质。
一旦蠕动恢复且（ a clamping test）夹胃管测试成功之后，可以移除鼻胃管。之后进行水溶性胃食道显影剂检查，以确认闭合的整体性，以及确保没有出现幽门十二指肠狭窄。之后恢复进食。
当缝合有困难或者肠道功能较晚恢复，胃管可以留在原处久一点。
依照溃疡的严重度维持静脉注射抗生素治疗，至少到获得手术时取得的脓液的细菌培养结果为止。如果培养是阳性，首先继续静脉注射抗生素治疗10天，之后在恢复肠道功能和进食之后给予口服药物。
在手术后四到六周进行追踪胃镜（gastroscopy）检查。

12.Reference
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