H6I NGHI KHOA HOC U N TM VII. HOI TIET NIEU - THAN HOC VIST NAM (VUNA)
truong h(7p. Tap ch{ Y hgc Vift Nam.
Chuyen Si Ni?u-Th$n hpc, 8-2005, tfp 313, tr 49-58.
Nguyen Kh3c L9I: Nghien cuu chan doan va di6u tri phSu thuat h?p khuc noi be than - ni?u quin a ngu^i Idn tuoi tai b?nh vi?n Vi?t Dilc - Lujn van tot nghi?p b4c sT chuyen khoa II. 4/2000.
Nguyin Xuan Thu - Nguyin Danh Tinh:
Cac di dang phSn tren duang tifit ni?u. Sinh hoat ky ni?m 60 nam thanh lap DHYK, 1992.
Johnston JH, Evans JP, Glassberg KI Pelvic hydronephrosis in children: a review of 219 personal cases. J Urol 1977 Jan;
117(1): 97-101 [Medline].
BLfdC DAU DANH GIA KET QUA P H A U THUAT NOI SOI SAU PHUC MAC LAY SOI B^ T H A N
TAI BENH VIEN HUTU NGH! VIET NAM - CUBA DONG H 6 |
Hoang v a n Cong', Nguyen Van Phuc', Bui Due Thao', Ha Thien Tan', Nguyen Thj My Ha'
TOM TAT:
Muc tieu: BUdc dau danh gia ket qua phau thuat npi sol sau phuc mac lay sol be than tai Benh vien Hu\l Nghj Viet Nam - Cu Ba.
eol tUdng va phu'dng phap; Nghien ciru mo ta tien atu tren 24 benh nhan difdc phau thuat no! soi sau phuc mac lay sol tir thang 7 nam 2011 den thang 9 nam 2012 tai benh vien Hihj nghi Viet Nam - Cuba Dong Hdi.
Ket qua: Tuoi trung binh cua benh nhan 54,79±14,78 tuoi (33-82); 91,6 % sol be than, 8,4
% sol tie than va dai ducfi. Ty le thanh cong mo noi soi la 95,83%, ty le sach s6i la 91,6%. Kich thudc sol trung binh (20,54±3,74mm)x(17,95±4,34 mm). Thdi gian mo trung binh 65,83±25,30 phut (35 - 120 phut).
Thdi gian nam vien trung binh 6,08 ± 3,10 ngay (4 - 1 5 ngay).
Ket luan; Phau thuat noi sol sau phuc mac lay soi be than la lu^ chpn an toan, hieu qua.
Tir khoa: phau thuat npi soi sau phuc mac lav soi be than.
: Benh vi?n Hini Nghi Vi?t Nam - Cu Ba, Quang Binh.
Phan bien Idioa hoc; PGS.TS. Tran Van Hinh
SUMMARY
INITIAL RESULTS OF RETROPERITONEAL LAPAROSCOPIC PYELOLITHOTOMY IN
VIETNAM-CUBA HOSPITAL Objective; To assess the initial results of the efficacy of retroperitoneal laparoscopic pyelolithotomy for treating stone In the renal pelvis.
Patients and methods; A prospective study from July 2011 to September 2012 in the Vietnam-Cuba Dong Hoi friendship hospital was performed.
Results; 24 patients undenwent retroperitoneal laparoscopic pyelolithotomy. The mean age was 54.79 ± 14.78 age (range 33 - 82). 91.6 % of the patients has stone In the pelvic, 8.4 % of them has stone In the pelvic and renal calix infenor. Successful rate was 95.83 %.
Stone-free rate was 91.6 %. The mean stone size was (20.54±3.74mm)x(17.95±4.34 mm).
Y HOC VI^T NAM THANG 8 - S6 D A C B I £ T / 2013 Average time of operation was 65.83 ± 25.3
minutes (range 35 - 120). Mean hospital stay was 6.08±3.10 days (range 4 - 15).
C o n c l u s i o n : Retroperitioneal laparoscopic pyelolithotomy was safe and effective alternative.
K e y w o r d s : Retroperitioneal laparoscopic pyelolithotomy.
I- Dfyl V A N OE
Soi than la b?nh ly thuong g^p, hay tai phat do su ket thach cua mot so thanh phan trong nuoc tieu 6 duong tiet nieu tren, trong nhiing dieu kien ly hoa nhSt dinh. Soi gay t3c duong tiet nieu, gay nhiem khuan va suy than, gay nguy hai den sue khoe, tinh mang nguoi benh.
Hien nay, nhieu ky thuat ngoai khoa it xam Ian dieu tri soi than kich thuoc nho va trung binh co nhieu uu diem vu(?t trpi nhu:
tan soi ngoai co the, tan soi than qua da, lay soi than qua npi soi ngugc dong, phau thuat npi soi lay soi..., phau thuat mo da dugc thu hep pham vi chi dinh [4]. Matlaga va Assimos bao cao trong 986 truong hop dieu tri \ky soi than tu nam 1998 - 2001 chi ap dung 0,7% m6 mo [4],[5].
Tai Viet Nam, do thieu trang thiet bi nen phuong phap phlu thuat mo dang ap dung phan Ion. Nhuprc diem cua phuong phap mo mo g6m: dau nhiku, thoi gian nSm vien dai ngay, thai gian tro lai lao dong dai, yeu to tham my cua vet mo, chi phi cao... Trong dieu kien co so kien thieu phuong tien, viec ap dung ky thuat it xam Ian phau thuat npi soi sau phiic mac lay soi than la can thiet.
Nam 2010, Trin Chi Thanh, Vu Nguyen Khai Ca bao cao 24 b?nh nhan dugc phau thuat n6i soi sau phuc mac lay soi be than tai benh Viet Due Ha Noi cho ty le thanh cong la 92,9%, ty 1? hit soi la 100%, an toan va hieu qua [3].
Tir thang 7 nam 2011, chiing toi tiln hanh phau thuat npi soi sau phiic mac lay soi be than tai benh vi?n hini nghi Viet Nam - Cuba Dong Hoi. Chiing toi nghien ciiu vkn de nay vol muc tieu "Danh gia ket qua birdc dau phu'dng phap phau thuat npi soi sau phuc mac lay soi be than tai Benh vien Hfru Nghj Viet Nam - Cu Ba".
II- 06\ TUONG VA PHUONG PHAP NGHIEN CCrU
2.1. Doi tuong nghien cmi: Tat ca cac benh nhan (BN) dugc phau thuat npi soi sau phiic mac lay soi be than tai benh vien Huu nghi Viet Nam - Cuba Dong Hoi tir thang 7/2011 d6n 9/2012.
2.2. Phuong phap nghien CUD: tien cuu mo ta
2.3. Tieu chuan chon benh nhan: Soi be than tren BN co be than ngoai xoang, trung gian.
2.4. Tieu chuan loai trir: BN co tien sir mo sau phuc mac, di dang duong bai xuat tren, soi be than trong xoang, BN co chong chi dinh ve ph^u thuat noi soi.
2.5. Phirong tien: Bp phau thu$t npi soi:
dung cu phlu thuat, he thong camera va phuong tien ph§u thuat npi soi (Laparoscopy)...
2.6. Cac bu-6-c tiln hanh phau thuat n()i soi sau phiic mac lay soi be th^n.
- Gay me npi khi quan.
Tu th§ BN va v; tri kip mo: BN nam nghieng nhu mo mo lay soi than, co don g6i o hong va gap ban.
- D5t 3 trocar theo phuong phap dung kim veress hoac mo deu dugc. Vj tri rach da dku tien a hong lung 1 cm. Dat va bom bong d^ tao khoang thao tac sau phiic mac, bom hoi ap luc 12 cm H2O, diing optic dk ven phuc mac vao trong tao khoang hoat dong
HQI NGHj KHOA HpC L^N THiJ VII, HQI TlgY NigU - T H A N HQC VI$T NAM (VUNA)
sau phiic mac; dSt cac trocar theo huong dan cua camera [1].
Tim ni?u qu^n 1/3 tren va bpc Ip be th^: Bom b6ng tao khoang thao tdc sau phtic mac da tot va BN khong qud b^o phi thi co the nhin thay ni$u qudn ngay khi dat may soi.
Neu c6 dat thdng ni$u qu^n tru6c phau thuat thi di chuyen thong se nhin thay ngay ni?u quan. Co Psoap la moc quan trpng can phai djnh vj dugc dau tien. Bat d^u tim ni$u quan bang each xe can gerota ngay tren co psoap va md rong khoang nay. Bpc Ip be than bang pince cat dot ven to chiic mO ij be than.
- Xe be than: cd the xe dpc be than hoac xe chQ- V (Gilvemet), chiing toi thuang x6 bk than hinh chij V; dung cu xe b^ than la dao nong
- Lay soi bk th|in: Diing Spartule nay soi soi de lay soi ra, pince gap soi nay soi dk lay soi ra khoi bk than,
- Kiem tra be than - nieu quan Dat thong nong nieu quan xu6ng duoi soi dk kiim tra mire dp thong thuong cua nieu qudn. Dat thong nong nieu quan hogc dat thong JJ tiiy danh gia ciia phau thuat vien.
- May be than: bang chi vicryl 4.0 khau mui vat hoSc mui rai tren thong nong ni?u quan. Riit 6ng thong nong hoac dk lai sonde JJ ni?u quan.
- Dat dan luu sau phiic mac va d6ng cac vet trocar: dan luu viing sau phiic mac khong nen dat 6 vi tri 16 trocar 6 phia sau, vi khi BN nam ong dan luu co the gap lam k^m hi?u qua.
- Cham soc hgu phau: khuyen BN nen van dpng som, cho an bang mi?ng som. Thoi gian dat ong dan luu sau phiic mac thuang la 2 den 10 ngay tiiy tinh trang ro, xi nude tidu.
2.7. Theo doi bien chiing ciia ngi soi sau phuc mac lay soi be than
- Tran khi duai da: do chan trocar rpng qua, CO th^ gay tran khi duoi da nhung thuong nhe va tu hk.
Ty mau duoi da: do chay mau thanh bung d chan trocar, nhe va tu het.
- Xi ro nu6c ti^u: do vk khau bk than khong dii kin, thuong se het trong vong 10 ngay. Neu r6 lau hon nen soi nieu quan dat thong JJ.
2.8. cac chi tieu nghien ciru:
Tuoi, gioi, chan doan ben t h ^ co soi, kich thucrc soi, muc dp ur nuoc, thai^ian mo trung binh, thdi gian phyc hoi luu thong rupt sau mo, thoi gian nit dan luu ho mo, thdi gian hau phau. bien chung sau mo.
2.9. Xir 1> so lieu: Theo phucmg phap thong ke.
Ill- KET QOA NGHIEN CCTU
1. Dae diem chung ve cac doi ttrQng:
- Tu6i trung binh: 54,79 ± 14,78 tu6i (33 - 82 tu6i).
- Gioi: Nam 10 BN (41,66%), Ntr 14 BN (58,33%)
2. Dae diem vc soi than
- Soi than dugc can thiep: Soi than phai:
12 BN (50%), soi than trai 12 BN (50%); co i truong hgp soi than trai kk hop soi nieu quan phai, co 1 truong hgp soi than phai kit hgp veo cot song.
- Kich thudc soi trung binh: chilu dai 20,54 ± 3.74 mm (14 - 3Imm), chilu ngang 17,95 ±4,34 mm (10-27mm).
- Mire dg u nude tren sieu am: Dg 1: 07 truong hgp (29,16%); dp 2: 14 trucmg hgp (58,33%), dg 3: 3 (12,5%).
Ure mau trung binh: 5,94 ± 2,19 mmol/1 (3,5-12,5 mmol/1)
Creatinin mau trung binh: 88,87 ^ 37,17Mmol/I(46-208^mol/l).
3. Qua trinh mo
- Thdi gian md trung binh: 65,83 ± 25, 30 phut (35-120 phut).
20
Y HOC VIET NAM T H A N G 6 - SO OAC Blgl / 2013
- Cac bien chung trong md: khong co trudng hgp nao chay mau, thimg phuc mgc.
- Chuyen mo md: 01 trudng hgp (4,1%), ly do tut ong thong nong.
- So BN c6 d^t sonde JJ nieu quan trong md: 04 trudng hgp.
4. Dieu tri sau mo
- Thdi gian riit dan luu hd md trung binh: 3,37 ± 3,22 ngay ( 2 - 1 5 ngay).
- Cac bien chimg sau md:
Tran khi duoi da: 03 trudng hgp, it. ty het sau 3 ngay
Xi rd nude tieu keo dai phai dat stent JJ nieu quan; 03 trudng hgp (12,5%).
- Thdi gian nam vien trung binh; 6,08 ± 3,10 ngay (4-15 ngay)
- Ty le thanh cdng 95,83%, ty le sach soi sau md 91,16%, co 2 trudng hgp soi soi dai duoi sue rira khong sach, chiing toi dat dng thong JJ nieu quan va dieu tri bang tan soi ngoai CO the khi BN tai kham sau 1 thang.
Ket qua sach soi sau tan soi Ian 2.
IV- BAN LUAN
1. Ve ap dung phirorng phap phau thuat noi soi lay soi than
Budc tien sir dung phuong phap phau thuat npi soi lay soi than da dugc cac nha nifu khoa thuc hien vdi nhung each thiic khac nhau de han che md md. Moi loai phuong phap lAy soi bang phlu thuat npi soi da dugc bao cao (Raboy va cong sy 1992, Winfield va cong sy 1993, Ruckle va Segura 1994, Vancangh va cong su 1995, Harmon va cong sy 1996, Deger va cong sir 2004).
Tuy nhien, phuong phap phau thuat npi soi nen dugc xem xet chi khi ket qua ciia phuong phap tan soi ngoai co the, npi soi ngugc dong lay soi la ngheo nan [4].
Nhimg trudng hgp ap dung phau thuat noi soi dugc xem la hgp ly la: md be than toi
thieu lay soi, chirc nSng than giam, sdi be than cd kich thudc Idn, kha nang lay sdi qua npi soi ngugc dong that bai [4].
O cac nude phat trien, viec ap dung phau thuat npi soi lay sdi 6 miic dp han che do dSy dii phuong tien ky thuat lay sdi hi?n dai nhu lay sdi than qua da, qua ngi soi ngugc dong.
Theo Desai va Assimos (2008), chi cd 1%
cac trudng hgp sdi than dugc ap dung. Trong do chi dinh thong thuong nhat la sdi d vi tri khiic noi be than nieu quan [4].
CJ dieu ki?n b?nh vien chiing toi con thieu nhieu phuong ti?n de trien khai ky thuat lay sdi than qua da, thieu phuang tien tan sdi (laser, sieu am), thieu phuong tien soi mem... viec lya chpn ky thuat it xam nhap de lay sdi than, dam bao riit ngan thdi gian dieu tri, dam bao tham my, tra lai thdi gian lao dpng sdm cho BN la dieu can thiet.
Chiing toi chi chpn nhiing BN sdi be than tren BN cd be than ngoai xoang, be t h ^ trung gian de thuc hien ky thuat phau thuat npi soi sau phuc mac lay be than.
Chiing toi khong chpn BN cd tien sir md sau phiic mac, di dang dudng bai xuat tren, sdi be than trong xoang, BN c6 chong chi dinh ve phau thuat npi soi.
2. Ve ky thuat mo:
Sau khi tao khoang boat dpng sau phiic mac chung toi bp Id than va nieu quan doan ndi bk than, bgc Ip be than mat sau bang cat ddt cac to chirc mo xung quanh be than.
Md bk than: Chung toi thudng md be than theo hinh chir V sau khi bpc Id be than rgng dk \iy sdi. Sau khi lay sdi, chiing tdi siic rira bk than bang d^t dng hut so 16 Fr ludn qua trocar vao be than de siic rira.
Dat dng thong nieu quan de kiem tra luu thong nieu quan ben dudi, va lam nong dk khau hk than, nieu quan, dng thdng dugc nit sau khi khau hk than. Chiing tdi khdng d§t
H$l NGHI KHOA HpC L A N THCf VII, Hpi TIET NigU - THAN HQC VigT NAM (VUNA)
Iim 6ng thong ni$u qu^n nhu t^c gia Tran Chi Thanh [3]. vi ly do chung toi da tien h^nh thanh thao ley phau thu§t npi soi lay s6i ni?u q u ^ truoc khi triSn khai ky thuat nay nen khi khau noi ni?u qudn chung toi deu lam chii dugc ky thuat. Nhihig trudng hgp khd nSng cdn soi hoac be than miin, chiing toi deu d3t sonde JJ ni?u qudn.
Thin gian mo cua chung toi trung binh 14: 65,83 ± 25,30 phiil, thdi gian nhanh nhjl 35 phiit, d4i nh^t: 120 phiit. Thdi gian ve sau c4ng ngin do mile dg thdnh thao ngay cang dugc nang cao. T4c gia Tran Chi Thanh 133,8 phut, nhanh nhat 90 phiit, cham nhat 180 phiit [3]. Bui Van Chi6n 70,6 phiit, nhanh nhdt 45 phiit, cham nhat 120 phiit [2].
Mau chdy trong qua trinh m6 la khong dang kS chi tham udt I meches nho. Qua trinh phau thuat khong xay ra thiing rach phiie mac, khong co trucmg hgp nao khong bpc Ig dugc bd than do dinh. Trong khi do tac gia Bill Van ChiSn phau thuat cho 80 BN CO 3 BN khong bgc Ig dugc bk than, 1 trudng hgp thung phiic mac[2].
Kjt qui thanh cong la 95,83%, ty le sach sdi la 91,16%. Co 5 trudng hgp co djt sonde JJ trong md, trong do cd 2 trudng hgp soi dai dudi vien nho, siic nla khong ra, chiing toi dat ong thong JJ sau do tan sdi ngoai co thS thanh cong. 3 trudng hgp cdn lai do b^ than mun liic lay sdi chiing toi dat sonde JJ. Ty le thanh cong ciia chiing toi tuong duong vdi tie gia Trin Chi Thanh, Vu Nguyen Khai Ca d B?nh vi$n Vi$t Diic (2010); 95,9%, va tac gia Bui Van ChiSn, Le Quang Hiing d B?nh vi?n Viet Tiep Hai Phdng (2010): 92,5%
[3,2].
Cd 01 BN phai chuyen md md la do khi dat ong thong xudng nieu quta d6 khau bS than do so y dS tut dng thong vao ni$u quan, chiing tdi chuyen md md.
3. Vc thoi gian hau phSu.
Thdi gian nit dan luu hd md trung binh ciia chiing tdi la: 3,37 ± 3,22 ngay, giong vdi tac gia Biii Van Chien 3,2 ngay [2].
Cd 3 trudng hgp bi rd nude tieu keo dai ngay thii" 7 sau md, trong dd cd 1 trudng hgp khdng d$t sonde JJ trong md chiing tdi ti^n hanh dat sonde JJ, rd nude tieu het ngay sau dd. 02 trudng hgp rd nude tieu sau md d BN CO dat sonde JJ do be than miin liic lly sdi. 2 trudng hgp nay t\r het sau 7 - 1 5 ngay h^u phau.
Thdi gian njm vien trung binh ciia chiing tdi: 6,08 ± 3,10 ngay, so vdi tac gia Triin Chi Thanh la 7,3 ngay [3], Biii Van Chi6nla5,l ngay [2].
Khdng cd trudng hgp nao nhiem khudn nieu, trong khi do tac gia Biii Van Chian la 8,7% [2], cd Ig sd lieu cua chiing tdi cdn it.
IV- KET LUAN
Phau thuat ngi soi sau phiic mac lly soi be than la phau thuat an toan, it xam h^i, tham my cao, cd the ap dung rpng rai trong dieu kien thieu phucmg tien ky thuat it xam nh$p khac.
TAI LIEU THAM KHAO
1. Nguyen Hoang BSc, Nguyen Hoang Dire, Tran Le Linh Phinmg (2006), "Tao khoang thao tac trong ngi soi sau phiic mac, Ky thu^t npi soi sau phuc mac lay sdi nieu quan", Phau Thvgt il xam hgi Irong lie! nifu, NXB Y hpc, Tr 72 - 94.
2. Bill VSn Chien, Le Quang Hiing, Nguylo Cong Binh, Nguyen Manh ThSng (2010),
"K6t qua phau thuat npi soi sau phuc mac lay soi be than tai benh vien Vi$t Ti$p Hai Phong", Tap chi Y hpc Vi?t Nam, tjp 375, tr 354-357.
3. Tran^Chi Thanh, Vu Nguyin Khai Ca, Nguyin Thanh Long, Phjm The Anh 22
Y HOC V1$T NAM T H A N G 8 - S 6 D A C BigT / 2013 (2010), "Ket qua phuang phap npi soi 6 byng
sau phiic m^c md be than lay sdi be th§n".
Tap chi Y hpc Viet Nam, tr 240-244.
Brian R.Matlaga MD, MPH. James E.
Lingeman, MD (2012) "Surgical
Management of upper Urinary Tract Calculi"
CambeU's Urology, CD ROM.
James E. Lingeman, MD, David A.
Lifshitz, MD Andrew P. Evan (2007),
"Surgical management of urinary lithiasis", CambeU's Urology, CD ROM.
KET QUA P H A U T H U A T NQI SOI SAU PHUC MAC
LAY SOI NIEU Q U A N DOAN TREN TAI BENH VIEN 103
Tran van Hinh', Thieu Ban Trang', Dao Dang Linh'
TOM T A T :
Muc tieu: Danh gia ket qua gan cua phau thuat noi soi (PTNS) sau phuc mac lay soi nieu quan (SNQ) doan 1/3 tren va mot so yeu to co lien quan den ket qua p h l u thuat. Doi tu'tfng va phu'dng phap: nghien cCru tien ciili, mo ta cat ngang thiTc hien tren 70 benh nhan (BN) du'cJc PTNS sau phuc mac lay SNQ doan tren tai Benh vien 103 t i r thang 6/2008 den thang 6/2011. Ket qua: Tuoi trung binh la 44,5 ± 12,8 (tiT 18 - 79 tuoi), ty le nam/nij* la 5:2. Kich thu'cfc doc trung binh cua soi la 15,62 mm (tir 9 - 2 7 mm). 100%
BN bj gian dai be than ben co SNQ, nhuYig khong CO tru'dng hdp nao gian dp IV. 71,43% chOrc nang than con dam bao, 28,57% chiTc nang than kem. PTNS thanh cong tren 63 BN, 7 tru'dng hdp phai chuyen mo md. Thdi gian mo trung binh la 82,8 phut. Tai bien trong mo chiem 22,8%. Thdi gian nam vien sau mo trung binh la 6,8 ngay va rut dan lu'u ho mo trung binh sau 3 ngay. Bien chiihg sau mo bao gom ro nu'dc tieu, sot, dai mau, nhiem khuan chan trocar chiem 16%. Ket Juan: PTNS sau phiic mac lay SNQ doan tren la phu'dng phap tu'dng doi hieu qua va an toan, co the thay the mo m d , giup giam thdi gian nam vien va cac bien chLTng sau mo.
' Bp mon Ngoai TiS't Ni^u, Hpc Vi?n Quan Y Phan bifn khoa hgc: PGS.TS. Va Nguyin Khai Ca
TlT Ithoa: Soi nieu quan, phau thuat npi soi, phau thuat npi soi sau phuc mac.
S U M M A R Y
RESULTAS RETROPERITONEAL LAPAROSCOPIC URETEROLITHOTOMY FOR UPPER URETER STONES AT 1 0 3 HOSPITAL Objective: Assess near results and relative factors of retroperitoneal laparoscopic for treatment stone upper 1/3 ureter stones.
P a t i e n t s and methods: A prospective study was performed on 70 patients with upper ureteral stone, treated by retroperitoneal lapanascopic ureterolithotomy for upper ureter stones at 103 Hospital between June 2008 and June 2011. Results: The mean age was 44.5 ± 12.8 years (range 18 - 79) and the male to female ratio was 5:2. The mean longitudinal size of those stones was 15.62 mm (range 9 - 27).
100% patients had hydronephrosis but none had four degree hydronephrosis. 71.43% renal function was good and 28.57% bad. Total 7 of 70 cases were converted to open surgery. The mean operative duration was 82.8 min.
Complications in surgery was 22.7%. The mean
