CAT TUI MAT NOI SOI DIEU TRj VIEM TUI MAT CAP
T6M TAT
D^t vin de Tmng thdi ky diu cOa kj nguyin dt tlii mdt qua ndi soi i bi^ng, vidm tdl m$t cip (VTMC) dwgc xem Id chdng chl dinh cho phiu thudt dt tOi mdt ndi soi (CTMNS). Tuy nhidn, vdi kinh nghidm ngdy cdng nhiiu. mdt sd bdo cdo cho thiy VTMC khdng cdn Id chdng ch! dinh nO-a Tai Vidt Nam, cdn It cdng trinh nghidn cdu vd CTMNS di diiu trj viim tdi m$t cip (VTMC). Tmng bdi bdo niy chiing tdl trinh bdy kit qud CTMNS tmng diiu tn VTMC t^i BVDK Cin Tha. Phwong phip nghidn cdv: hdi cdu, md ti dt ngang. Kit qud: Td thdng 6- 2002 din thing 7- 2004. Cd 42 bdnh nhdn VTMC dugc phiu thudt ndi SOI. Cd 7 bdnh nhdn (16,7%) phii chuydn md hd.
Thdi gian md tmng binh li 94 phOt. Khdng cd tai biin tmng md. Bidn chimg sau md: 1 ca tu djch nhg dwdi gan vi 2 ca nhiim tmng vit tmcarrdn vd cd 3 ca diu dwgc diiu tri ndt khoa. Khdng cd trwdng hgp tw vong.
Thdi gian nim vidn tmng binh Id 3.2 ngdy. Kit lu$n Phau thuat CTMNS di diiu trj VTMC Id phiu thuit an toin vdi thdt gian nim vidn ngin.
Tip khdamdi soi d bung, vidm tui mit cip SUMMARY
Background: In the earty days of the ' lapamscopic cholecystectomy em", acute cholecystitis was considemd a contmindication to the lapamscopic approach. However, with increasing experience, a number of reports show that this is no longer the case Till now, in Vietnam, very few studies on laparoscopic cholecystectomy for acute cholecystitis wem published. This study reviews the expenence of lapamscopic cholecystectomy for acute cholecystitis in Can Tho General Hospital.
Methods: Retmspective and descriptive study Results: A total of 42 patients who had acute calculous cholecystitis underwent lapamscopic surgery between June 2002 and July 2004.
Conversion to open cholecystectomy was required in 7patients (16.7%). The mean operation time was 94 minutes. There was no intraopemtive complication.
Postoperative complications consisted of 2 mild infections of umbilical port and 1 mild subhepatic fluid collection. Three these cases wem tmated medically.
There was no mortality. The mean hospital stay wem 3.2 days
Conclusions Laparoscopic cholecystectomy to treat acute calculous cholecystitis was safe procedure with short hospital stay
Keywords: laparoscopic cholecystectomy em OAT V A N o e
Sdi lui mat la mdt trong nhirng bdnh thudng g$p nhdt cua dudng tigu hda tai cgc nudc phuong Tay.
Khoang 10% dan s l bi benh soi tui mat. Tuy nhien.
N G U Y I N V A N Q U I , PHAM V A N N A N G Trwdng D^i hgc Y Dtpgv Cin Tha trong sd nay ed tdi 80% sdi tCii mgt khdng ed tri^u chCrng. Vidm tCii m^t e l p ed x u l t dd tCr 1-3% trong s6 nhO'ng bgnh nhan bj sdi tCil mdt cd trigu chu'ng [9],
Tgi Vigt Nam, tuy chua ed thdng kg d i y dCi v l soi tui mat, nhung sd b$nh nhan ddn d i l u trj ngay cgng nhidu. H l u hdt cgc bgnh vidn Idn trong cd nudc fflu thyc hi$n d u y c p h l u thudt c i t tCii mat ndi sol d l dilu trj bdnh sdi tCii mdt. Cd kha nhidu cdng trinh bgo cio vd p h l u thu$t e l t tCii mgt ndi soi d l d i l u trj sdf tui m§t [2,3.4,5,6]. Tuy nhign. s i bgo cao vd p h l u thugt cit tCii mdt ndi sot didu tn vidm tui mat edp do sot cdn kha ll [7,8]. Chung tdi thyc hign nghidn eCru nay d l danh gia k i t q u i bude d l u cua p h l u thudt e l t tdi mgt nOi soi trong didu tri vigm tui mdt edp vdi cgc mgc t i ^ chuygn bidt gdm dd an loan, ty lg chuyin m l hdva bidn chCrng sau md
DOl T U V N G VA PHU-ONG P H A P NGHiEN CCfU 1- Ddi t u y n g nghign c f r u :
T i t eg bgnh nhan cd ehi ^ n h m l c^t tiii mgt n^
soi trong khi md ghi nhan dgi t h i la vigm tiii mdt cip vg gtai p h l u b$nh cd kdt qua id vigm tiJi mdt d p ho3c dyt cap trdn ndn vidm mgn tinh duyc dua vgo io nghten eCru,
2- P h u u n g phgp nghien c u u : Hdi cuu md t l e l t ngang.
3- Phiro-ng phgp t h d n g kg:
Phan tieh sd Ndu dya theo p h i n mdm SPSS 11,5 K t T QUA
TCr 15 thdng 6 ndm 2002 ddn 30 thang 7 nSm 2004, cd 42 bgnh nhan vl6m tOi mdt cdp cd chi iJinh md cat tilt mat ndi soi.
1- Tudi: TCr 35 den 78 tudi, tmng binh la 56,4.
2- Gidi: cd 34 ca lg nCr (chidm 81%) vg namiafl ca(19%).
3- Ly do vao vien: Oau hg sudn phai lg l!^ do chinh cua 41 bdnh nhgn (97,6%) vg chi cd 1 b^iiti nhgn cd ly do vgo vien ig dau thuyng vj.
4- Sdt: 11 bdnh nhan ed sdt (26,2%) vg 31 b^nti nhan khdng sdt (73.8%)
5- Bgeh c l u tang trdn 18 bgnh nhan, chilm 42,9% vg khdng tang trdn 24 bdnh nhan (57,1%).
6- Thanh tCil mat day tCr 3mm trd lgn g^p trong 35 benh nhan (83,3%). chi cd 7 bdnh nhgn thgnh tti mat khdng dgy (16,7%).
7- Chl djnh md trong 42 bdnh nhdn cd 20 b6nh nhgn d u y c chi dinh md d p eCru vg 22 ca mo phign(52,4%)
8- Thdi gian mo thdi gian mo n g i n nhit IS 50 phut va dai nhat la 130 phCit, trung binh la 94 philt
9- Cd 13 ca (37,1%) phai chpc hut djch, miJW mat trudc khi p h i u tich tam giac Calot.
10- Tinh trgng dinh cua tOi mat vdt cae tgng nlw mgc ndi, ta trang, dgi trang ngang,,. gap trong25
Y H Q C THV'C HANH (872) - SO 60113
tm-dng hyp (59,5%).
11- Cd 31 ca (73.8%) ed sdi kgt cd tCii mgt, 12-Cd 2 phuong phgp e l t tdi mat ndi sol: e l t tu' day tOi mat (7 ca, ehilm 20%) va e l t tCr c l tOi mat (28 ca, ehilm 80%).
13-Cd 22 ca dng tCiI mat viem nhg ngn sir dyng clip d l kgp dng tCil mgt, edn lai 13 ea phai dung ehi vicryl, cdt no Roeder d l xi> ly dng tCii mgt
14- Sau c i t tOi mgt vg rua vOng dudi gan, ed 5 ca phai d i n luu dudi gan.
15-Trung tign sdm nhdt x u l t hign sau md 14 gid vg eham n h l l la 72 gid, trung binh la 40,7 gid,
16- Tai b i l n trong md vi b i l n chCrng sau md: ed 1 ca tu djch dudi gan (2.8%) va 2 ea nhilm trOng nhg v i t trocar rdn. Tat c l d l u khdi sau d i l u In ndi khoa,
17- Giai p h i u bdnh: 6 ca vigm tut mgt hogi t u , 18 ca vidm tui mgt d p (57,1%) vg 18 ca lg dyt vigm d p trgn n i n viem xo mgn tinh.
18- Thdi gian ra vidn trung binh ta 3,2 nggy, Sdm nhit lg 2 nggy va mudn nhdt lg 5 nggy
19-T9 lg chuydn md h d la 16,7% (7 ca), Ly do chuydn m l hd eho t i t ca 7 trudng hyp la do tinh trgng viSm dinh r l t nhilu, khdng nhan dinh duyc rd cgc d u true giai p h l u lidn quan.
B A N LUAN
Trong hon 2 nam, cd 42 ca vidm tCii mgt d p duuc chi djnh m l ndi soi tai BVDK Can Tho. Dgy la eon sd chua d i y du v l sd ea vidm tCil mgt d p duyc d i l u In phiu thugt vi ngogi sd ca duoe m i ndi sol, cdn nhCrng trudng hop khgc duuc md hd do chua ed dO phiu thugt vidn not sot trong cgc tua tryc d p cCru.
Viem tui mgt d p do sdi cOng nhu sdt lui mat ndi chung, gidi nO' ehidm da so.
T i t ca cge bgnh nhan viem tCii mgt d p do sdi deu vgo vign vi dau bpng, trong dd chu ydu lg dau ha sudn phai.
S l bdnh nhgn cd sdt ehi chiem 26,2%, trong nghien eu'u eua V5 Qudc Togn, tae gia cQng ghi nhgn sdlehigap10,1%[8].
Trgn sigu gm. thgnh tui mat day tCr 3mm tru lgn gap trong 35 b$nh nhan (83,3%), chi cd 7 bgnh nhan thgnh tCii mat khdng day (16,7%).
Thdi gian md' thdi gian md n g i n nhdt la 50 phCit va dai nhit la 130 phut, tmng binh la 94 phut. Thdi gian md tmng binh trong nghign eCru cua Dd Trpng HII va Vd Qude Toan theo thCr l y la 107 phut va 83,7 phOt [5,8].
Jrong vidm tCii mat d p vide kgp giO- tui mgt 3d phau lieh thu'dng r l t khd. Trong id nghign cuu eua ehung tdi, 37,1% cgc trudng hyp phai chgc hCit djch, mO tui mat Inrdc kht p h l u tich lam gigc Calot Con sd nay eua Vd Quoc Toan lg 26,4%.
Tinh trang dinh cDa tCii mat vdi cae tgng nhu mac ndi, la trgng, dai trgng ngang, gap Irong 59,5% cgc Inrdng hyp. Vd Qudc Toan ghi n h i n dinh kha nhidu vd rat dinh trong 56,8% cgc trudng hyp,
Sdi kgt dng ICii mat va cd tCii mgt la nguyen nhan chlnh cua vigm tOi mat cap, chCing ldi gap 73,8%, Theo tdng k i t cua Indar vg Beckingham la trgn 90%
eae trudng hyp VTMC [ 9]. Sdi to kgt e l lOi mat eung la nguygn nhgn Igm eho eudc md khd khan hon logi sdi trong Idng tui mat vl p h i u tich tam gigc Calot khd khan hon nhdt lg khi vign sdi ggy viem dinh chat vgo dng gan chung
cae trudng hyp p h i u tich vg x u ly duyc dng tCii mgt vg ddng mgch tCii mgt lg duong nhidn cudc md trd ngn thugn lyl. 80% cgc trudng hyp chung tdi d t tCr ed tOi mat, Tuy nhign, trong 20% cgc trudng hyp edn lai do sdi to kgt ed tCil mat va do vidm dinh phu n l nhilu ehung tdi khdng thd phgu tieh duyc tam gigc Calot. ChOng tdi phai d t tu* day tCil mat, sau dd dung ehi vicryl s l 1 dd cdt dng tCil mgt, Trong nghign eCru cOa VO Qudc Togn, ehi ed 3.2% phai d t tCr dgy[8].
Cd 22 ca I n g tCii mgt vigm nhg ngn sd dyng clip dd kgp dng lOi mgt, edn lgi 13 ca phai dung ehi vicryl, cdt nu Roeder dng tCii mgt do ehCing tdi khdng cd nhidu cd clip khgc nhau d l xd ly dng tCil mat.
Sau d t tOi mgt vg rCra vung dudi_gan, cd 5 ca phal d i n luu dudi gan Chu ydu, dgt dgn luu 3d theo ddi vg Igm phgu thugt viSn ygn tam Khdng cd ca ngo rd mat sau m l
Tai b i l n trong luc md- tdn thuung dudng mgt chlnh la tai b i l n dang so n h l l trong PTCTMNS Trong VTMC tai b i l n nay thudng cd xult dd cao hon do tinh trang vigm dinh vg phu ne vCing tam gigc Calot Nguygn Hoang B i c vg But An Thg khao sgt tren 1082 ca d t tuii mat ndi sol, ghi nhgn 1 % cd tdn thuong dudng mgt chinh [1]. Cgc tac gia chia t i n thuong dudng mgt chlnh igm 5 logi vg khuyin ego cgch phdng ngCra. R l t may man. trong Id nghign eu'u ngy, chCing tdt khdng ggp tai bidn ngy Lj/ do cd the do s u than trgng trong quydt ^ n h chuyin mo hd ddi vdi nhii'ng trudng hyp qug khd Thung tCil mgt trong ICic mo khdng p h l i la tai biln nghiem trgng. Kht ggp tai bidn nay chiing tdi hut vd rua sgch va sau dd bd tCil mat va sdi vgo mdt tCil nhua trudc khi l l y ra khdi xoang bung
Bien ehCrng sau m l : cd 1 ca tu djch dudi gan (2,8%) va 2 ca nhidm trting nhe v i t trocar rdn. Tat ca deu khdi sau dilu tri ndi khoa, Trong nghien eCru eua v a Qudc Togn, tu dich dudi gan ed xudt dd 4% [8],
Ly do chuydn m l hd cho tat ca 7 trudng hyp cua chung ldi eOng gilng nhu cgc nghien cCru khgc la do tinh trgng vidm dinh rat nhidu, khdng nhan dinh duyc rd cgc cau true gial p h l u lidn quan [5.7,8] Ngoai ra, t;^ |g chuyen md hd se giam khi PTV cd nhieu kinh nghiem.
T^c gia Nquy^n T^n Cudnq
Pham Duy Hign e6 Trong Hai, Nqu^ln Tu^n Nguygn H Bac,
V5 Q Togn Graham, Flowers,
Scott, Zucker ChLinq t6i
T6ng s6 ca VTMC
6 20 50 128 992 42
Ty 1$ chuydn m6 33,3 55,0 8,0 3,0 22,0 16,7
Y HQC THVC HANH (872) - SO 6/2013
K^T L U A N
1- Cd t h i thyc hign an logn p h i u thugt d l tCii mat ndi soi d l d i l u In vidm tui mgt c i p do sdi.
2- Ty Id chuydn md hd edn cao.
3- Khdng cd b i l n ehCrng nghigm trgng trong vg sau md.
T A I LIEU THAM K H A O
1- Nguyen Hogng Ble vg cs: Tdn thuung dudng mgt chinh trong phiu thugt d t tui mgt qua ndi soi, Ngogi khoa 1998,2 : Tgp XXXIII [38-45],
2- Nguyen Tdn Cudng, Dilu In sdi tCii mgt bang phlu thugt d t tui mgt qua soi i byng, Lugn gn Phd tiln sT khoa hpc y duyc DHYD TP HCM, 1997,
3- Lg Van NghTa, Lg Quang Nghia, Vgn Tin- Cit tCii mgt qua ndi soi I byng nhgn 474 trudng hyp. Bgo ego khoa hgc, HNNK Vigt Nam lln X, 1999.109-112
4- Trin Binh Giang: Phau thugt ndi soi tgi bgnh vign Vigt Due. HNNK Vigt Nam lln X, 1999, 93-95
5- Dfl Trpng Hai, Nguyin Tuan: Y l u td dy dogn kh6 khan cua d t tCii mgt ndi soi trong vigm tui mgt d p d^
sdi, Tgp san HNKHKT DHYD TP HCM l l n 21:14-17 '^
6- Nguydn Minh Hogng: Danh gig p h i u thugt cIttOl mgt qua ndi sol I byng. Lugn vgn t i t nghigp bac sT chuygn khoa d p II. 2000,
7- Phgm Duy Hiln: Ket qua budc d l u cua dieu tn vigm tui mgt d p do sdi bing phau thugt ngi soi, HNNK Vigt Nam l l n X, 1999. 96-102.
8- VO Quic Togn, Phau thugt ndi soi dilu tn viem tui mgt e l p do sdi. Lugn vgn t i t nghigp bgc sT chuyfin khoa II, 2002.
9- Adrian A Indar. lan J Beckingham: Acute cholecystitis, BMJ 2002.325639-643.
10- Steven A. Ahrendt, Henry A. Pitt; Acute calculous cholecystitis Sabiston Textbook of surgeiy, 16'^Ed,2001. 1086-89,
PHAT TRIEN CHlATNG TRINH GIAO DUC Y HOC DjNH HOfrNG NGHE NGHIEP:
THUC TRANG, THACH THUTC VA GIAI PHAP
THl/C TRANG P H A T T R I E N CHUONG TRJNH GlAO DUC Y HQC
Ngh! quydt 14/2005/NQ-CP nggy 2/11/005 eCia Chinh phu ve d l i mdi eo ban va togn dien Gigo dye dai hpc Vidt Nam giai dogn 2006-2020 da dat ra myc ligu phin dau d i n ngm 2020 phai c d " 70-80% tdng s l sinh vien theo hpc cac chuong trinh nghd nghiep - Crng dung.."
De dgt duyc mue tidu trdn, Bd Gido due vg Dgo tgo ddi hdi cgc eo sd gigo due dgi hge phai khdi d l u qua trinh phgt tndn chuong trinh dgo tao b i n g vi$c xgc
^ n h chudn d l u ra, ti>c la xac cSnh nhCrng nang Iyc cy the ma gidi tuyin dung yeu d u nhu'ng ngudl hpc phai ed duyc sau khi hogn thanh khda hpc. Ydu cdu ngy duyc t h i hign r l t rd rang qua Luat Giao dye, Bd tidu chuan, lidu chl kiem dmh c h i t luyng eo sd glgo dye, cae edng van ydu d u , hudng d i n xgy dyng chuin d l u ra. Theo xu the chuyen ddi trilt ly giao dye ICr gigo due tinh hoa sang gigo dye dai chCing, t y hpc tap suit ddi cua UNESCO, Bd Gigo dye va Dao tgo cDng khuyen khich cgc trudng dgi hoe cung d p cho ngudi hpc cgc chuong trinh dgo tgo phu hyp vg ed llnh ung dung cao trong thuc t i l n . khuyen khich giam tinh hgn lam vg tgng ty le thyc hgnh trong cgc chuong Irinh dao tgo. Trong may nam g i n day, cudc each mgng "
dao tgo dya trgn nhu d u xa hdi" da duyc tnen khai rdng rai d tdl ca cae eo sd gigo dye dgi hpc cua ea nude, Tuy nhign vdi nhung nganh nghd dgo tag dac thu nhu nganh Y chlnh nhirng nhg quan \y cua da Bp la Bd Y td - Bd GD-DT - Bd Tgi chinh vg Bd Lao ddng - thuong binh xa hdi-., va mdt sd uy ban ldn cua Dang va nha nudc ddu chua cd nhidu thao lugn mang tinh
BUI MY HANH
TT. phat trien chwong trinh ddo tao nhdn Itfcyti- Dai hgc YHd Ndi
khoa hpc b i n g chCmg dd dua ra nhO'ng quydt ngh] pHQ hyp. v i n de t y ehu theo Nghj i^nh 43 eua ehinh pHu ICr nam 2006 eCing khiln ege bdnh vien thue hgnh, trudng y ddng thdi roi vao tinh trgng khd khSn Ck bgnh vidn la nhOng don vj cd thu vg vdi sy bit cgn flii giO'a cung-du trong dd cung lgi t h l p hon cau nhir hidn nay thi s y qua tdi (b$nh nhan ddng) Igi lg gar*
nang "mong mudn" eCia nhO'ng nggnh djch vg 'dSc bidt" nhu nggnh Y. Mdt s y van hgnh theo xu thi '(Kp Crng nhu d u ° cgc co sd dgo tgo ao gt xin tang chlS^u, md rdng logi hlnh dgo tao trong khi thye chit phli Ok\
100% eae chuong trinh dgo tgo tnjydn thing (ehirakl ddn cac loai hinh dao tgo lidn thdng, ehuyen tu, cif tuyin) nhu dao tgo bae sy da khoa (vdn duoe coi la quy cd nhll) edn ehua ed mdt ban ttiilt k l ehireng trinh dao tgo theo dCing chuin ndi dung, hlnh thi>cva dgc bi§t chua ed mdt ban bao eao giai trinh ehinh thi>c nao duyc cdng bd v l danh gia nang Iyc eua ngiwi duyc dgo tgo dd hgnh nghd y tCr cgc co sd dgo t g ^ v l phuong phgp day hoc, mgc dO Nghi q ^ 14/2005/NQ-CP chi rd cac tnrdng dai hgc Viet Nam phai nhanh ehdng lhay ddi tCr each dgy hoc thuyet giang Imydn thdng qua phuong phap dgy hpc lay ngudi hge iam tmng tam. nhdn mgnh nS luc ti/ hpc cua ngudi hgc. Nhung ed Id s y lhay doi nay cung kti6 thyc thi vi cd mdt khoang trdng rat ldn ve nSng \^
ph'ai tridn ehuong trinh (d|e bidt Id triln khai c^c phuung phgp dgy hge dya trdn chudn nang Iyc ilau ra). Dieu nay cQng dd hieu vi mudn thay ddi phirong phgp ti>c la phai thay doi t u duy, thay ddi i l i suy r#j da thanh thdi quen rat lau d^c bidl vdi nhung Ui^VjJ vdn la nhO'ng thay thude r l t gidi. Ngay ea viec clflp
Y HOC THVC HANH (872) - SO fi