BAI HOI HOI NGOAI KHOA VN LAN THU Xll VA HQl NGHj KHOA HOC NGOAI KHOA TOAN QUOC LAN XIV
VAT THEN, TONG QUAN VA tiUG DUNG TRONG TAO HINH AM DAO
Nguyen Thu Hang', Tran Thiet Son ^
T O M TAT
Vat then du'dc mo ta lan dau tien de tao hinh am dao vao nam 1989 bdi Wee va Joseph sau khi nghien ciiu ve cap mau cua vat tren xac.
Trong nghien cifu nay chung tdi nhac lai co sd giai phau va nhii'ng phat hien mdi ve cap mau ciia vat then cung nhU iing dung vat then trong tao hinh am dao. 7 benh nhan khdng am dao du'dc tao hinh am dao bang vat then 2 ben trong vdng 18 thang. 5 benh nhan dUdc danh gia ket qua sau tir 3 den 15 thang. 1/7 benh nhan hoai til" hoan toan vat, 1 benh nhan bj hoai tir dau xa CLia vat nhu'ng sau d d vat lien tdt va v i n dam bao do dai ciia khoang am dao. 2/5 benh nhan cd Idng moc trong khoang am dao mdi. Ket qua cho thay vat then cd do tin cay cao, ki thuat bdc tach khdng phiic tap, ciing vdi hieu biet mdi ve cap mau ciia vat se lam giam bien chiTng hoai t d dau xa ciia vat.
T& khoa: vat then, khong am dao, pudendal thigh flap, Singapore flap, vaginal agenesis.
S U M M A R Y
Pudendal thigh flap first described by Wee and Joseph for reconstruction a new vagina in 1989 after they studied the blood supply of upper thigh skin in cadavers. I n our study, we reviewed the anatomical basic and the new studies for vascular and applied the pudendal thigh flap for creating a new vagina. 7 cases of vaginal agenesis have been reconstructed with pudendal thigh flaps in a period of 18 months. 5 patients were observed for 3 months to 15 months
following the operation and the incidence of flap loss occurred in 1/7 patient, 1 case had necrosis of the distal flaps which healed spontaneously, Hair grew in the vagina in two cases. The result showed that the flap is good flap reliability, the technique is simply, minimal donor-site morbility and the currents studies provided the anatomic basis for techniques to maximize its survival.
Key word: pudendal thigh flap, Singapore flap, vaginal agenesis, vaginoplasty.
I. TONG QUAN 1. Ljch %\£
Vat then (pudendal flap) lan dau tien dugc md ta va sii dung vao nam 1989 de tao hinh am dao bdi 2 tac gia Wee va Joseph ngudi Singapo. Chinh vi vay vat cdn cd ten ggi la vat Singapo [9].
2. C a so giai phau [6,9]
La vat da can than kinh. Gidi han: phia tren trong ciia diii, canh mdi ldn va nep ben.
Vat bat dau chay tir cue dudi ciia day chau Ien den ngang miie mu, giua mdi Idn va mat trudc trong cua dui, tren nep lln ben.
Kich thudc tdi da ciia vat: 15x6 cm. Vat cd the dugc lay d 1 hoac ca 2 ben.
Ngudn cap mau:
Kinh dien, theo nghien ciixi ciia Wee va Joseph, vat dugc cap mau bdi 3 nhanh mach la ddng mach then trong, ddng mach then ngoai va nhanh ciia ddng mach bit trong do nhan manh den vai trd cua ddng mach then trong la ddng maeh sinh ra true ti§p tir nhanh trudc ciia ddng mach chau trong, la 1 trong
^ Khoa phau thuat tao hinh ham mat benh vien Viet D&c Ha Noi
^. Khoa phau thuat tao hinh benh vien Xanh Ron, Ha Ngi; Bo mon phau thuat tao hinh tr&dng dai hgc Y Ha Ngi
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NGOAI KHOA SO OAC BIET 1,2,3/2012
nh&ng nhanh tan. Ddng mach chay xuyen qua can sau. O ngang miic day chau, ddng mach cho cac nhanh cho da vimg hau mdn, va ca that hau mdn ngoai rdi tiep tuc chay va ddi ten thanh ddng mach mdi/biu sau cho 2 den 3 nhanh cap mau cho mdi Idn d nif va biu d nam. Nhanh dgng mach mdi/biu sau cd vdng ndi cap mau cho da viing day chau vdi
nhanh sau cua ddng mach then ngoai va nhanh trudc ciia ddng mach bit.
Tuy nhien, trong nghien ciiu mdi day cua Tham va cdng su [8] cho thay 3 ddng mach mdi/biu sau, ddng mach mdi trudc (la nhanh tan cua ddng mach then ngoai) va cac nhanh ciia ddng mach bit cung cap mau eho vat va chay rat gan vdi dudng giira cua vat.
Vat then la vat 3 khu vuc cap mau.
Hinh 2: X quang viing day chau sau khi tiem thudc can quang: mau da cam la viing cap mau ciia ddng mach then ngoai, mau xanh la viing cap mau ciia cac nhanh ddng mach bit, mau dd tim la viing cap mau ciia ddng mach then trong. Cham den cd miii ten ehi la vj tri noi ddng mach xuyen rada.
l/u d\km cua vat la mdng, co gian tdt, ki thuat liy vat khdng phiic tap, noi cho vat seo dep va kin dao
3. lfng dung vat then trong dieu tri phau thu^t di tat khdng am dao
Nhiing uu didm ciia vat then phii hgp vdi tieu chi tao hinh 1 dng am dao (do day vira phai, co gian tdt, nai lay td chiic it anh hudng dkn chiic nang va tham my). Vi vay tir thang 5/2008 chung tdi tign hanh phau thuat tao hinh am dao cho benh nhan khong am dao bang vat then.
II. o6l TU0NG VA PHUONG P H A P NGHIEN CCTU Tir thang 5/2008 ddn thang 10/2009, 7 benh nhan khdng am dao dugc tien hanh phlu thuat tao hinh am dao bang vat then. 6 trong sd 7 benh nhan khdng cd am dao hoan
toan, 1 benh nhan am dao kich thudc 3 cm. 2 benh nhan dugc chan doan hdi chiing tinh hoan nii tinh hda, 5 benh nhan la hdi chiing Mayer-Rokitansky-Kuster-Hauser.
KT thuat: vat then dugc thiet ke cd hinh simg, lay d ca 2 ben nep lan diii. Dem trudc ngay phSu thuat, benh nhan nhin an, thut thao. Tu thg phhi thuat ia tu the san khoa, benh nhan dugc dat thdng tieu. Tien hanh bdc tach khoang am dao, la khoang giiia bang quang va true trang, khoang bdc tach dai khoang 10 den 12cm. Sau khi bdc tach khoang am dao, tien hanh bdc tach vat theo dudng thilt ke. Rach da bat dau tii phia tren ngoai ciia vat, rach Idp dudi da den Idp can sau, khdng rach phan dudi vat liic nay. rach da vimg dudi cua vat den lap dudi da vdi do day khoang 1 cm (d viing nay lop dudi da 411
DAI Hpi HQI NGOAI KHOA VN LAN THJ Xll VA H O I NGH! KHOA HOC NGOAI KHOA TOAN QUOC LAN XIV
thudng day). Bdc tach vat d ngang mirc nay.
Lam nhu vay vdi ben ddi dien. Tao dudng ham d ngang miic mdi ldn. Xoay vat, dua vat qua dudng ham. Khau ndi 2 vat, cd the cd dinh vat hoae khdng. Ddng noi cho vat va dat dan luu.
III. KET QUA
7 benh nhan dugc tao hinh am dao tir thang 5/2008 ddn thang 10/2009. Tudi trung binh trong nhdm benh nhan la 29,7 tudi, benh nhan nhieu tudi nhat la 35 tudi, benh nhan it
tudi nhat la 23 tudi. Tat ca cac benh nhan dlu cd hinh the ngoai day du la nu, vdi day dit cac CO quan sinh due thii phat bao gdm tuyIn vii, am hd am dao, mdi Idn mdi nhd. Vat then dugc lay d ca hai ben. Kich thudc trung binh ciia vat da sir dung la: 12x 6 cm, vat nhd nhit la: 11 X 5.5 cm. vat ldn nhat la: 13x6 cm. Tdt ca 7 benh nhan vung lay vat deu ddng true ti6p.
Sau md, noi cho vat seo lien tdt. Cd 1 benhnMn vat bi hoai tu hoan toan va bong ra khdi khoang am dao mdi, 1 benh nhan vat hoai tu 1 phan phia mep vat, sau do vat vin lien tdt.
Bdng 1: Ket qua sau phau thuat STT
1 2 3 4 5 6 7
Tuoi 35 24 26 34 23 32 34
Chan doan tinh hoan nu" tinh hda
Khonq am dao Khonq am dao Khonq am dao Khdnq am dao Khonq am dao Tinh hoan nii tinh hda
Ndi nhan vat Tdt Tdt Tdt Tdt Tdt Vat hoai tii Hoai tir dau vat
KichthifdcAD tru'dc p h l u thuat khdng am dao khonq am dao khonq am dao khdnq am dao khdnq am dao khdnq am dao khdng am dao
Kfch thu'dc AD sau phau thuat 7,5 cm 7 cm 6 cm khdnq co thonq tin khdnq cd thdnq tin 2 cm 6 cm
Sau 3 thang, chiing tdi kham lai dugc cho 5 benh nhan. T^i noi cho vat, cac benh nhan deu khdng gSp khd khan khi di lai va van ddng giang khep chan. Cd 4 benh nhan seo md, lien tdt va trimg vdi nep tu nhien, 1 benh nhan seo co keo vung tang sinh mdn va cd 1 diem rd. Tai noi nhan vat, kich thudc trung binh cua am dao dat khoang 6,5 cm. Be mat am dao mem mai, cd lugng djch vira phai, cd kha nang co gian. 2 benh nhan cd Idng moc ben trong khoang am dao.
Sau phlu thuat 6 thang, qua kham true tiep va ggi qua dien thoai, cd 3 benh nhan da quan he tinh due, 2 benh nhan khdng cd
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thdng tin, 2 benh nhan dang dung dung cu nong thudng xuyen.
IV. BAN LUAN
Nam 1989 khi Wee va Josept \kn din tien md ta va iing dung vat then trong tao hinh am dao [9]. Vat then da cho thdy nhiSu uu diem, do la qua trinh phau thuat khdng phiic tap, thdi gian thuc hien ngSn, do tin c|y cao, am dao dat dugc kich thudc can thiet.
Trong nghien ciiu cua chiing tdi, chi co 1 benh nhan vat bi hoai tii hoan toan. Nguyen nhan ciing cd the do benh nhan da quan he tinh due qua sdm, ngay sau phau thuat 2 tuin. Ngoai ra 1 benh nhan vEit bi hoai tir 1
NGOAI KHOASODAC BIET 1,2,3/2012
phan d dau vat nhung sau dd vat vSn dam bao do dai cua khoang am dao. Hoai tii dau vat la 1 trong nhiing nhugc diem ciia vat, ngay trong nghien cihi ciia Joseph [3] cung cho ket qua 2 benh nhan tren 12 benh nhan CO hoai tu dau vat, trong nghien ciin cua Giraldo 1/12 bSnh nhan [1,2], ciia Karacaoglan 3/24 [4]. Mdt sd nghien ciiu khac cd ti le thanh cdng 100% nhung sd lugng benh nhan thudng it, tir 1 ddn 6 benh nhan. Kich thudc trung binh cua vat la 12x6 cm. Kich thudc vat ve chieu dai tuong duong vdi kich thuoc vat trong nghien ciiu ciia Khazanchi (12,5 cm) [5] va Giraldo (12 cm) [1] nhung Idn hon ve chieu rdng 6 cm so vdi 5 va 3,5 cm. Kich thudc vat cua chiing tdi nho hon cua Monstrey (kich thudc tir 14,5 x 5 cm den 16,5 x 6 cm) [7]. Chiing tdi thay ring viec ddng vet md true tiep khi lay 6 cm la khdng khd khan va khdng gay co keo td chirc xung quanh, seo van triing vao nep tu nhien. Cd 2/5 benh nhan cua ehiing tdi cd hi?n tugng mgc ldng trong khoang am dao, day ciing la nhugc diem cua vat da dugc Karacaoglan de cap den trong nghien ciiu cua minh [4]. Tuy nhien day khdng phai la nhugc diem ldn va cd thd cai thien bang each triet long hudc phau thuat [ 1,2]
V. KET LUAN
Qua nghien cihi, chiing tdi thky vat then CO dp tin cay cao, kT thuat bdc tach vat khdng qua phiic tap va thdi gian phau thuat ngan, rat phii hgp de tao hinh am dao va che phu khuydt hdng viing day chau. Ciing vdi hieu biet ngay cang tdt han ve cap mau cua vat se lam giam nguy c a hoai tii dau vat.
TAI LIEU THAM KHAO
1. Giraldo Fr. Cutaneous neovaginoplasty using the Malaga Flap (vulvoperineal fasciocutaneous flap): A 12-year follow-up.
Plastic reconstructive surgery 2003: 111;
1249-56.
2. Giraldo F, Solano A, Mora MJ et al. Hair growth in the vagina after reconstruction with pudendal thigh flaps in congenital vaginal agenesis (letter). Plast. Reconstr. Surg. 1998:
102;924.
3. Joseph VT. Pudendal thigh flap vaginoplasty in the reconstruction of genital anomalies. J. Pediatric Surg. 1997: 32; 62 - 5.
4. Karacaoglan, N., Velidedeoglu, H., Sahin, U., et al. Reconstmction of vaginal agenesis by Singapore flap. Eur. J. Plast. Surg, 1994;
17; 283.
5. Khazanchi R., Takkar M'. Vaginal depth following reconstruction with pudendal thigh flaps in congenital vagina atresls. Plast.
Reconstr. Surg. 1997: 99; 592-593.
6. Mathes Stephen J. Nahai Foad.
Reconstructive surgery: principles, anatomy and technique. Volume Two.
7. Monstrey S, Blondeel Ph, Landuyt K, Verpaele A, Tonnard P, Matton G. The versatility of the pudendal thigh fasciocutaneous flap used as an island flap.
Plast reconstr surg 2002: 107; 719-25.
8. Tham Nicole LY, Pan WR. The pudendal thigh flap for vaginal reconstruction:
optimizing flap survival. J. Plast, reconstr &
aesthetic Surg. 2010: 63; 826 - 31.
9. Wee JT, Joseph VT. A new technique of vaginal reconstruction using neurovascular pudendal-thigh flaps: a preliminary report.
Plast Reconstr Surg. 1989: 83; 701-709.
10. Woods JE, Alter G. Experience with vaginal reconstruction utilizing the modified Singapore flap. Plast Reconstr Surg. 1992:
90; 270 -74.
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