86 TCYHTH&B so 1 - 2012
S d DUNG VAT DA CO THANG TRONG Oi^U TRj BENH NHAN BflNG SAU VUNG C A M Cfl DO DONG DIEN CAO THfi
(Thdng bao lam sang)
Ting Thanh Hii, VO Quang Vinh, VQ Trpng Tiin, L§ Nim Vi$n Bdng Qudc gia
T6M TAT
Bdng ddng diin cao thd toin bd viing cd tnrirc vi dwdi cdm li cdp ciru It gip trong tai nan bdng. Tdn thuang siu ring vung cdm cd do ddng diin li tdn thuang phirc tap, nguy ca tdn thuang nghiim trcng dc ca quan giy hoai tir Id kht quin, ddng mach mit, Id xirang him dirdi, tdn tht/ang khdng cimg miic Cd nguy ca tir vong cao do chiy miu thir phit (chdy miu mudn: tdn thuang mach hidu irng due id), suy hdhdpdo tdn thuang khi qudn vi trin miu vio di/dng hd hdpf^'^^. Viic che phii sdm vi cung cdp dinh dir&ng sd gdp phdn Urn giim nguy ca tif vong, ciru sdng bdnh nhirP'^. ChOng tdi di sir dung vat da ca thang dang ddo che phd thinh cdng cho mdt bdnh nhin bdng diin vimg cd trvdc, kinh nghiim lim sing si duac md ti trong bio cio niy.
SUMMARY
Injury caused by high voltage electnc bum at anterior neck is tiii challenged of piastic surgeons These damages usually deep and large, structure tissues below are destroyed such as muscle, main artery, exposed tracheal...and these defect need to be coverage as soon as possible to avoid secondary hemorrhage, tracheal and mandible necrosis. In this paper, we report a case bum caused high voltage electric was covered by trapezius muculocutaneous flap. The result and technique will be discussed In this paper.
I. DAT VAN oe t h i bi 10 gSy chiy m4u muOn nhi/ chSy mSu VOng cam, c6 tru'de \i noi c6 nhiiu ca '">"S '^^^^ "'^^- S'^P trang trSn thjm chl niu quan quan trpng * qua khi quin. tuyin du'di '*'^*"9 <="= P*"^ 5*"" ^*'' *^°^' "* ^^^ '''"'3 him, tuyin giSp, ding tlnh msch mSt, SC/ng '"'<=•' ' * " "''"' '^"^ ^'°"^' '^'*' " 9 ° * ' ^'^"^
m?ch canh chung, dCing msch canh ngoai, "•'^"p.'^s* * * ' * " ° " 9 '™"9 '•"*' 3'^"
aOng m$ch giap trang trSn, day thin kinh X, " 9 * "
xu'ong ham, cac khii c o " " . . . Khi bi bing do C6 rit nhiiu phuong phap tir don gian tac dOng cua dSng diin cao thi t i n thuong din phi>c t$p dS diiu tri cho nh&ng binh nhan do hai CO chi chlnh gay ra: co chi sinh nhlit nhu' nSy nhung cac phuong phap d i cin ci cac m6, t i ChCrc c6 di^n t r i cao, t i n thuong nhO'ng nhuoc diim chua khic phuc duoc nhiJ thuftng khing ciing mCfC tao ra hoai tu sSu, ghap da trung blnh kJ thu$t don gian, nhanh, ngic ngach. nham nhi. va khi quan sgn giap nhung nin tin thuong ph^i c i t i chuc hgt dep nhin nim ngay d u i i da d i h09i tu v i gay va cin thii gian chuin bi nin ghip lau, sau khi suy h i hip; va hi^u ung dgc l i gay tin khii d i l$i di Chung co kio njng n^'\ Cac thuong cac thanh mach mau nguy co gay v?t da can ngiu nhiin va vat cuing mgch vCing hogi tu va Thim nOa. cac mgch mau l i n c i lan cin nhu vgt thuong din, vgt nhinh xuyfin
TCYHTH&Bsol -2012 87
aOng mgch vii trong, chim c6 vai, chim c6 licng,.. thLPb-ng chl che phu du'g'c nhO'ng tiiLTong t6n kicti thudc trung blnh,
Cic vgt da co tM" do n6i vi phliu ntiLf: vgt da c3n - da co thdng bi,ing, vgt da cdn-da cdn CO lirng rQng, vgt da cdn co thang, vgt da cdn - da CO m6ng Ib-n, vgt da cSn- da CCT thing dCji ngoSi'^'^'^,... CDng khd ip dyng do mgch miu nhan thu'b'ng bj t6n thuang do tdc dOng cua ddng di$n nSn 6h gdy tic mgch sau m6, phiu thu^l vi6n phii c6 ky thu$t cao, vd thi-i gian phiu thu^t fc^o ddi.
Do vdy, trong bdi bdo ndy chCing tdi thdng bdo mdt ca di^u trj t6n thu-ong bong sdu todn bd vung c6 tru'de bing vgt da co- thang Ky thu$t, kinh nghidm su dyng vgt da ndy se du'p'C md t l ky trong bdi bdo ndy.
II. CA BENH NHAN THONG BAO
B$nh nhdn Nguyin Trpng S, nam, 23 tuoi, so BA 9225 dup'C di^u trj tgi khog bong Ngudi ldn VBQG. Chin dodn: Bong di0n cao the 9%(9%) dd IV, V cdm co smh dye vd hai chdn.
B$nh sir: BN dang sua dieu hda dudi dudng di$n cao th^ 35kV, bit ngd phdng di$n gdy bdng dug-c sa d p cuu vd vdo vi$n bong gid thu 8 dd dup'C dieu trj tich cyc tgi khoa H6I si>c tich cyc: BN bj hogi tu khd d6t vung elm c6 trudc, khd v$n ddng ch. khd tha dup'C h6i SCPC ch6ng s6c tich cyc, rgch hogi to giai phdng ch6n dp c6, md khi quan, duac phiu thu$t ba lln cit lpc hcgi tu vung d m c6, sinh dye vd hai chdn, trong qud trinh dieu trj b$nh nhdn dd chgy mdu ddng mgch gidp trgng trfin ngdy thu 20 dup'C d p cO-u, xu tri kip thdi.
Sau cdc tin phiu thu$t tlnh trgng cua b$nh nhdn hogi tu da cdn, ca vCing cdm Id xuang hdm dudi, thdt ddng mgch mdt trdi, nguy ca Id ddng mgch m$t phii vd xuang mdng, hogi tu da cdn mdt phin ca vung ch trudc, nguy ca hogi tu bd mgch cinh chung, vd chay mdu ddng mgch cinh chung vd ngodi'"'
Bdnh nhdn dup-c phiu thu$t ngdy thd 23 tiln hdnh d t Ipc phin ldn hogl tu d m c6, d t mdp vlt thuang, tfin khuyit phin mim kIch thudc 22x12cm, 1/2 chu vl c6, tu cdm(giCpa xuang hdm dudi) din bd trdn hdm dc(xuang i>c)[1,2,6,7]. Thilt k l vgt da ca thang bdn phai 22x12cm, su dyng dgng dao cu6ng Id ddng mgch ngyc lung vd nhdnh dOng mgch c6 ndng, vgt bdc tdch liy mdt phin ca tuang duang vgt dpc theo tryc dOng mgch, thiy hinh Inh mgch chgy tryc tilp dudi ca[6,7], kilm tra xdc dinh bing sidu dm doppler, dudc bdc trin bd mgch xoay khoang 150° che phu c6, d^t din luu, ddng kin da thua, kilm tra h6i luu tuin hodn vd ddng kin vCing cho vat 1 lln. Theo ddi vgt tien triin ngdy diu sau m6 thu$n ldi vgt hing Im, vgt n l bd mdp cdng, djch qua sonde ddn luu lOOmL djch hong, thim ngodi bd mdp vCpa; sgu 5 ngdy giam ne, rut sonde, vgt tien triin tit, bd mdp khd dan lien tit, mdu sic da vgt din v l nhu vung da ldnh; sgu 1 thdng vgt liln hodn todn, mdu sic da nhu dg Idnh, vCing cho vgt liln dup'C, b$nh nhdn v$n ddng c6 tit, khdng co kdo, cdc chCcc ndng hd hip, ndi blnh thudng, hgn chl nhg g5p c6, gigm lyc kdo lln trdn cua tay phii.
TCYHTH&Bso 1 -2012
0^
Hinh 1: Tru-6-c phau thu$t: cdn n h i l u ho^i lu' nham nho* ngoc ngacti, lp xu'O'ng ham dirdi, 1$
khi quan, co to chii'c hat xen ke do ne;
Hinh 2 Thiet ke vat: dong mach nhanh xuong co nong nuoi co* thang, dpng mach lung vai, vat dpc
theo dpng m^ch kich thud'c 22 x 12cm;
DSA(dorsal scapular artery); CSA (cervical scapular artery)
Hinh 3. Boc tach v?t, chuyen v^t len viing cam Hinh 4; Ngay thLK 8 sau phau t h u | t : vat hong, mau CO sac da nhu cu, bo- mep lien, v^i day
TCYHTH&B s6 1 -2012 89
Hinh 5: Sau 1 thang, chLre nang va vung cho v^t;
vgt dpp, mau sic binh thuong, bcr mep Ii4n t6t, diy III. BAN LUAN
Bong dien viing co trudc thudng la bong s^u gdy hoai t u cdc to chuc quan trgng gdy lp khi quan, cac bd mach Idn ddi hoi phai che phu sdm'^'*' Do vay, c h i t lieu tao hinh ddi hoi phai c6 du kich thudc, du dd ddy. Do ca c h l tdc ddng cua ddng dien cac mach mdu Idn cgn ton khuyet thudng bi ton thuang t u dai the den vi the. Do vdy, dp dung cdc vat tai chd va vat tu do gap nhieu khd khdn'^' Cac vat co cuong mach Id mdt uu the, tuy nhien viec lua chgn vat da ndo cd du dd day. kich thudc rOng va duac cap mdu tot v i n la thdch thuc cua cac phiu thuat vien tao hinh'^^'^'.
Trong bong didn cao the vung co trudc khi quan co nguy c a hoai t u khi de h d do d | c diem giai phdu gom cdc cung sun vd Idp ca mong dang b| ton thuang can dup'C che phu vd phai dup'C nudi d u d n g mdt trudc bdi nguon mach ddng tin cdy giup phyc hoi khi quan, hoai ti> sau ngdc ngdch giua cdc khoi ca nguy ca
^> I*
Hinh 6: Vung l^y vgt lien tot
gdy ton thuong cdc bd mach quan trgng, ddng tTnh mach canh chung, canh ndng, giap trang khi dugc che phu sdm giup lanh vet thuang, duac nudi dudng Idm giam yeu to nguy ca gay chay mau'''*'^'- Do do trong qud trinh dieu tn chung toi cung han che cdt Igc hoai t u khi dieu kien chua cho ph^p de tao hinh che phu Benh nhdn cua chung tdi ton khuyet sdu, nhieu 6 hoai tu, cdc mach mau Idn co nguy ca lp Do vdy, trong trudng hap ndy vat da ca thang Id chi dmh phii hap do do vat du rdng vd ddy de che phu ton khuyet, kha ndng tudi mdu tot se lam giam nguy ca nhiem trung tai chd, giup su phuc hoi ton thuang tai chd tot han[6,7]
Vung cap mdu vat, dam bao do tin cay cao, vat ndy d u a c cap chinh mau bdi nh^nh xuong dgng mach vai lung vd dgng mach co ndng cd the lay d u g c kich thudc Idn dam bac dd tin cdy, chay dudi ca thang dpc theo vd song song cdt s6ng{dudng hen gai sau), vat cd the m d rdng kich thudc vat bdng cdch lay rdng ca thang, ddng mach co ndng tuang ddi h i n g
90 TCYHTH&Bsol -2012
djnh chgy trong bao c a , ngay d u d i ca, phdn nhdnh nudi c a vd nudi da, dd ddy cCig vgt tiy 3cm d i n 5 c m ' ^ " ' ' ' do dd vgt ndy sau khi d u d c che phu s i du khd ndng l i p d i y nhOng k h o i n g t r i n g vd ngdc ngdch vung c l ngay, sau Idnh v l t thuang cho d c vCing xung quanh cijg c a d$c bi$t Id khi qudn, ddy Id u u d i l m mgnh cdc vgt ca, ndn thudng dudC ung dyng trong p h i u thu$t khuyit h i n g Id x u a n g , cd vidm x u a n g , vd lodt t h i l u d u d n g , lodt xg trj ..VCing cho vgt dudC ddng kin ngay trong p h i u thudt v l l i l n t i t vgt dup'C l i y c u i n g s i u dgt d u d c t h i m m?
vung l i y vgt d a ' " ' '
Thdnh cdng trong d i l u trj BN cua chOng tdi gdp p h i n k h i n g djnh giup cho cdc p h i u thu$t vifin cd thfim nhOrg kinh nghifim trong ung dyng vgt da c a thang d l d i l u trj cdc khuyit h i n g p h i n m i m vung d i u vd c6, ngyc vd vai vd cdn cd t h l s u dyng n h u mdt vgt t y do n l i mgch vi p h i u .
IV. TAI LI$U THAM KHAO
1. Di Xudn Hpp; Gidi phdu nguin; Nhd xu^t bin y hpc;
1971
2 Nguyfin Huy Phan. K^ thu^t vi phiu m^ch miu-lhln kinh, thi/c nghidm vd i>ng dvng lfim sdng, Nhd xudt bdn khoa hpc vd k^ thufit, 1999
3 16 Thd Trung, Bdng vfi nh&ng kiln thirc chuydn ngdnh; Nhd xu&t bdn y hpc, 2005.
4. Hugh M. Gloster, Jr., MD; Complicalions in Cutaneous Surgery; Springer; 2008
5 Frank H Netler, MD Atlas gidi phiu ngirfri; Nhd xu^t bdn y hpc; 2001.
6 Stephen J.Malhas, MD vd Foad Nahai, MD, Clinical Aplications For Muscle and Musculocustaneuos Flaps; The C V Mosby Company; 1982 7, Stephen J Mathas; MD vd Foad Nahai, MD, Clinical
Atlas of Muscle and Musculocustaneuos Raps, The C V Mosby Company, 1979.
