Y Hpc TP. Hb Chi Minh * Tap 18 * So 1 * 2014 Nghien ciru Y hpc
CAT RUOT THI/A N O I SOI MOT DlJOfNG MO VOI 2 TROCAR Nguyen Tliaidi Phong*
T O M TAT
Md ddu: Ngdy nay, cat ruot thiea qua mi soi d'bung dugc diuc hiai dw hau hei cdc trudng hap vidn ruot thira cap tqi cdc benh vien. Co mot so'nghieii dm su dung 1 lo trocar ron decat mot thiea idiimg Irnii hS cdc nghien ciru ndy ddi sir dung mot trocar ran co nhieu kenh thao tdc vd dung cu phau thuat diuyen biet Idiong hien CO tqi cdc binh vien. Chiing toi gidi tiiieu phteaiig phdp cat mot thiea qim nga noi soi d'bung, sie dung 2 trocar qua 1 dudng rqdi da a ron vdi nhieng dung cu ph&u thuat noi soi thudng dung decdl ruot thiea liodn todn tiong o bung nham ddtdt gid tinh khd thi ciia phitong phdp ndy.
Muc tieu nghien cihi: Budc dau ddrdi gid tinh an todn vd hiiu qua dm pliau thuat ngi soi cat ruot thiea 1 diedng rach da qua rm vdi 2 trocar trong dieu tii -dim mot thira cap khdng biai diung.
Boi tiwng- Phuangphdp: Tir thdng 9/2010 ddi thdng 8/2012, chiing toi thuc luen 196 trudng hap cat mot thiea qua ngd noi soi vdi 2 trocar qual ducmg rach dad roh. Chung toi sie dung 1 trocar Smm vdi trocar 10mm dgt qua duang radi da nay, diing kinh soi phau thudt Smm vd dung cu phdu thudt ngi soi thudng dung tai benh viin. Ruot thira dugc xir ly hodn todn trong obung. Sau do mot thiea dugc keo ra ngodi qua 16 10mm.
Kei qua: 196 trudng hap cat mgt thiea qua nga noi soi vai 2 tiocar, tuoi tmng binh 34. thdi gian mo20±8 phut. Thdi gian nam vien sau mo trung bhih 3 ngdy. Tat cd ddi thuc hiin vdi 1 diedng mo qua roil, Ididng co truimg hap ndo them trocar hoac diuydi mo'md. Co 4 (2%) TH nhiim trung vi ti-l trocar ran, 1 (0,5%) TH tu dich ho chau pliai nhiem triing. Chung toi Idiong gap tai bidi hay tu inrng. Trong thdi gian theo doi tif 1 tuan dai 1 thdng, diung toi cUng khdng gap bai ky biai diung ndo lien quan dai cuoc mo viim ruot thiia.
Kei luan: Cdt niSt thiea qua ngd ngi soi vdi 1 ducmg rack da quanh ron, sie dung cdc dung cu phdu thuat ngi soi thudng ddng tqi binh vien vd xu ly ruot thiea trong d'bung Id an todn. hiiu qud vd Id mdt chgn lua khde cho phau thuat bung khong co sea mo.
THT khoa: cat ruot thiea qua ngi soi, 2 tiocar, 1 dudng rach da a rmi.
SUMMARY
LAPAROSCOPIC APPENDECTOMY USING TWO TROCARS VHTH A SINGLE- INCISION PERUMBIUCAL
Nguyen Thanh Phong * Y Hoc TP. Ho Chi Minh * Vol. 18 - No 1 - 2014: 83 - 88 Backgoimd: L^rosccfpic appendedomy is used for almost aatte appendiatis at liospitals. Single- port laparoscopic appaidedomy was applied in some liospdals but they had to be used a spedfied port and laparoscopic mstnimaits. We report our experience in hiparoscopic appaidedomy using tuK) ti-ocars with a single- indsion perumbdical and common laparoscopic iiistrumaits; die appendix was removed completely intra-dbdomiiially.
The aim ofthe study: to evaluate thefeasibUity and safety of this technique.
Method: From September 2010 to August 2012, we paprmed 1% laparoscopic appaidedomies using tivo trocars with a single- incision pemmbilical. Tim trocars: 5 mm and 10 mm wa-e inserted through this indsion, using Smm telescope with usually hiparoscopic iiistrumaits such as scissor and grasper ... into the abdomai. The appendedomy was perfermed completely intra-abdominally then witlidrawn through tlie 10 mm tiocar.
» BV Dai hoc V Du^c
Tac gid lien lac PGS.TS.Ngu}'ln Thanh Phong DT: 0903643310 Email phongy89(Syahoo.com
Hpi Nghi Khoa Hpc Ky thuat BV. Binh Dan 2014
Nghien ctru Y hpc Y Hpc TP. Ho Chi M i n h * Tap 18 * So 1 * 2014
Results: one hundred nighty six cases of a single- indsion pemmbilical laparoscopic appendedomy liave beai performed. The median age was 34 years {range, 13-82). Tlie average opa-ating time was 20 minutes (range, 15-60) and the median hospital stay was 3 days. All patiaits u>ere operated with a single- indsion perumbilical;
ndther conversion nor additional tiocar ivas necessary. 4 patients (2%) had supafidal umbilical port site uxiund infection, 1 (0.5%) intra-abdominal fluid infections. Tliere liave been no deatlis During 1 week to 1 month follmo up, no problems related to tlie appaidedomy have been reported.
Ccmclusions: Laparoscopic appaidedomy using tioo tiocars zoith a single- indsion pa-umbilical idth common laparoscopic iiistrumaits and intra-abdominal removal completely of appaidix zoas safe andfeasiUe and would be another option for scarless abdominal surgery.
Keywords: Laparoscopic appendectomy, tioo trocars, single- indsion pemmbilical D A T V A N D E
Ngay nay, cat mpt thua qua nga npi soi 6 bung la phuong phap hieu qua thirong dung de dieu tri viem rupt thiia cap khong bien ehung tai cac benh vien"-"'. Mot trong nhung ben bp trong phau thuat noi soi dupe chap nhan hi^n nay la phau thuat noi soi mot trocar hay mpt duong mo. Ve CO ban la dira ta't ca dung cu phSu thu^t noi soi vao 6 byng qua mot duong mo 6 ron qua mpt dung cu goi la TriPortP-^'^^-'i. Tuy nhien phuong phap nay can phid co nhimg dung cy chuyen biet khong thuong co tai cac benh vi^n hi?n nay.
Vai tning tam phau ttiuat npi soi trong nuoc dang nghien cmi cat rupt thua npi soi qua 1 duong rach da quanh ron dimg 3 trocar de cat rupt thua.
Tuy nhien kho khan ehung nhat khi ap dimg cac phuong phap nay la phau truang tam giac quen thupc cua cac bac si phau thuat npi soi khong con, h ^ che su linh hoat cua cac dung cv npi soi va nguoi cam camera, dimg cy npi soi \'a kinh soi phai thao tac trong phau truong ben trong va ben ngoai han che, viec di chuyen cua camera co the lam di chuyen vo y oia dung cu npi soi nam sat ben, dieu nay co the lam tang kho khan khi tieh hanh cac thao tac tuong doi don gian nhu can phai quan sat cac cau tnic hay tang lan can khi tien hanh cSt rupt thua.
Nham myc dich cai thien hon niia nhimg lpi diem cua mo cat ruot thira npi soi mot duong mo va nhiing han che neu tren, chiing toi thuc hien
phuong phap cat rupt tfiira qua npi soi mpt duong mo qua ron voi 2 trocar.
Myc tieu nghien curu
Buac dau danh gia tinh an toan va hi?u qua Clia phau thuat noi soi cat rupt thira 1 duong rach da qua ron voi 2 trocar trong dieu tri viem rupt thua cap khong bieh chiing.
P H L T O N G P H A P NGHIEN CUtJ Nghien cuu tien cuu thuc nghiem lam sang khong nhom chiing, thuc hien tai khoa hoi sue cap cuu 1 bfnh vien Binh Dan. Thai gian nghien ohi til thang 9/2010 den thang 8/2012.
Doi tupng nghien curu Tieu chuan chon benh nhdn
- Benh nhan dupe chan doan viem rupt thira cap khong bien chiing.
- Khong CO nhiing chong chi dinh cua phau thuat npi soi.
Diingcu
- Dung cu phau thuat npi soi thong thuong de cit rupt thira tai benh vien.
- Kinh noi soi 5mm, 45".
Cdc budc tieii hdnh
Kham b|nh, chan doan, lam benh an mlu, xet nghiem tien phlu.
Ky thuat mo: gom 5 budc.
Suoc 1: bo tri phong mo: man hinh, nguon sang, bom hoi va dot dien ben phai ban mo.
Phau thuEit vien ben trai va phu mo ben phai ban mo.
84 Hpi Nghi Khoa Hpc Ky thuat BV. Binh Dan 2014
Y Hpc TP. Ho Chi Minh * Tap 18 * So 1 * Nghien cuu Y hpc
Buoc 2: duong rach da qua ron dai 2 cm. Tat ca 2 trocar dupe dat qua duong rach da nay.
Buoc 3: dat trocar: trocar ^ u tien 10mm bom hoi khi C O voi ap lyc 10 -15 mm Hg. Trocar 5 mm canh trocar 10mm dau tien, voi su quan sat Clia kinh soi de giam nguy co ton thuong tang trong phuc mac.
Buoc 4: cat rupt thira: buoc Sau tien la tree rupt thira len thanh bung 6 ho chau P. Day la thao lac kha quan trpng: dimg kim Vicryl 1. Uon thanh kim thang, vi la kim to nen xuyen qua da se de dang, sau do dam ngupc ra ngoai da tao thanh mpt niit that 6 ho chau phai de treo toan bp ruot thira va mac treo, keo chi cang rupt thira nhe nhang thuan lpi cho viec gjai phong mac treo dieu nay se tranh cat diit rupt thira.
Boc tach mac treo ruot thira, khi boc tach chii y dpng mach mac treo rupt thira va manh trang.
K?p 2 clip sat goc dpng mach mac treo rupt thua.
est dot mac treo sat rupt thira, khi cat dot chu y den goc rupt thira.
Neil rupt thira qua dai co the noi long vong that va treo tiep phan rupt thira con lai sau khi da cat dot mac treo. Dimg 2 dip de kep goc rupt thira va 1 clip de kep phan xa goc ruot thira.
CSt ruot thira va lay ra ngoai qua trocar lOnun. Co the bo rupt tiiira vao bao trong truong hpp rupt thira to hoai tii co nguy co vo khi lay ra ngoai.
Lau ky ho chau phai la quan trpng de ngira bien chirng tu dich nhiem trimg sau cat rupt thira. Khong can dat dan liru.
Buoc 5: dong vet mo. Dong vet mo tiii don gian, dimg 1 miii khau vicryl 1 dong 16 trocar 10 mm. May da.
Theo doi hau phau bang lam sang, va sieu am.
Theo doi tai kham khi benh nhan xuat vien.
Ghi nhan cac thong tin can nghien aiu vao b^nh an mau.
Thu thap va xir ly so lieu voi chuong trinh SPSS 16.0.
KETQUA
Tir thang 9/2010 den thang 8/2012 tai benh vien Binh Dan, ehung toi thuc hien cat rupt thira qua npi soi 6 bung sir dung 1 duong rach da qua ron voi 2 trocar va cac dung cu phau thuat npi soi dimg de cat rupt Ihira tai benh vien cho 196 tnrdng hop viem rupt thira cap.
Co 57 nam (29,1%) va 139 nu (70,9%), trung binh la 34 tuoi (13-82), tat ca rupt thira sau mo deu dupe giri giai phau benh
Bdng 1: Thai gian phdu thuat vd thai gian mm vien Then" gian
Phlu thuat (phut) Nam vien (ngay)
Tmng binh 20
3
Ngin nhat 15
1 UunhSt
60 7 Bang 2: Thuemg tmi rudt thiea trong khi mo
Thwynqton
^lem rijdtthi>3 sung huyet iTiem njpt thira mu
^lem mot thi>a hoai ti>
Benh nhan 77 103 16
•ni#(%) 39,3 52.6 8.1 Bdng 3: Vi tri rudt thiea trang khi md'
Vitri Ho chau phai Sau manh trang
Tfku khung Sau hoi trang
Bfnh nhan 158
25 2 11
Tilf(%) 80.6 12,7 1 5.7 Co 2 (1%) truong hop co thai 12 tuan va 20 tuan khi mo.
Co 4 (2%) truong hpp rupt thira hoai hi co nguy eo vo phai bo vao bao de lay ra khoi bung
Khong CO trucmg hpp nao chuyen mo ha, them trocar hay dat dan luu
Co 4 (2%) TH nhiem trimg vi tri trocar ron Co 1 (03%) TH tu dich sau mo dupe dieu tri npi on dinh.
Khong CO tir vong.
BAN LUAN Lpi ich
Nhiing tien ich aia phau thuat cat rupt thira npi soi da dupe ehiing minh, truoc tien la viec tham sat 6 bung dupe thirc hien thuan lpi va ky cang,. eho phep chan doan phan biet vol nhiing benh khac lien quan trong \'ung chau va ho chau phai ding nhu de dang danh gia nhiing truong
Hpi Nghi Khoa Hpc Ky thuat BV. Binh Dan 2014
Nghien curu Y hpc Y Hpc TP. Ho Chi M i n h * Tap 18 * So 1 * 2014
hop rupt thira kho hay nhiing trucmg hop ruot thira o vi tri bat thuang. Co 25 (12,7%) TH ruot tfiira sau manh trang, 2 (1%) TH rupt thira 6 tieu khung va 11 (5,7%) TH rupt thira sau hoi trang.
Da so nhimg ky thuat cat rupt thira npi soi hien nay ap dung tai hau het benh vien la dimg 3 trocar. De giam chi phi dieu tri va ti le nhiem trimg vet mo cung nhu tang tinh tham my, ky thuat c^t rupt thira npi soi ven 1 trcKrar va duong rach da toi thieu dirpc mo ta.
Chpn durnig vao 6 byng qua 1 duong rach da ron
Phau thuat npi soi cat rupt thira qua 1 duong raeh da la ky thuat moi, qua mpt duong rach da nay cac trocar va dijng cu npi soi dupe dua vao 6 bung de cat rupt thira, chiing toi chon duong vao 6 bung qua ron \a:
- La 16 tu nhien ciia co the^ noi mong nhat de vac 6 bung va khong thay s?o mo.
-Tranh dupe nhimg bieh chiing do ton thuang dpng mach thupng vj duoi hole cac nhanh khac cap mau cho thanh bung va ton thuong bang quang neu dat trocar vimg ha vi.
- Co the mo rpng vet mo de lay rupt thira trong truong hop kho voi it nguy co chay mau va ton thuong thanh bung nhat.
Chpn dung cu - Kinh npi soi 5nmi, 45°.
- Dung cu npi soi thuong dimg de cat rupt thiia tgi benh vien.
Thao tac thuc hanh
Khau treo rupt thira len thanli bung ho chau phai: day la thao tac quan trong quyet dmh thanh cong aia cupc mo, chiing toi thuc hien thao tac nhu mo ta tren va chua co truong hpp nao bl diit ruot thira dupe ghi nhan. Vi tri treo ruot thira tiiy thupc vao vi tri oia goc mot tiiira trong 6 bung, tuy nhien chiing toi tiiuong chpn v\ tri tai diem Mae Bumey, dieu nay ciing phii lipp voi vi tri mot thira tiiuong gap 6 ho chau phai nhu trong nghien ciiu aia chiing toi co 108 (76,1%) TH cung tuong tu cac tac gia khad-'?'.
Xii ly mac treo rupt thiia:
+ Sau khi kep 2 clip sat goc dpng mach, mac treo rupt thira dupe cat do't sat mot thiia nham muc didi lam nho rupt thira toi thieu, giiip de lay mpt thira qua trocar 10mm va it bi chay mau trong khi cat dot.
+ Dimg dot dien don eye (monopolar) de cat dot mac treo rupt thira.
+ Co gang thuc hien dot va cat 1 Ian tranh xay ra tut mach rupt thira, vi xii iy tai bieh neu co trong mo rat kho khan.
+ Chiing toi ghi nhan nhieu tac gja tren the gioi xii ly mac treo rupt thira o ngoai o bung, hau het la a tre em(*'">. Co le mpt thira tre em di dpng hem nguoi lan nen de keo ruot thira ra ngoai 6 byng hon. Tren the gioi ehung toi da tim thay 1 cong trinh nghien ciiu tree rupt thira len thanh byng trong mo 1 16 trocar tuong tu nhu ehiing toi'^'. Trong nuoc co 1 cong trinh nghien ciiu cua Nguyen Tan Cuong voi 47 truong hpp cat rupt thiia qua nga noi soi vdi 116 trocar roh tuy nhien phai dimg dyng cy npi soi dat biet va phai co dung cu mo npi soi dai 450mm thay vi 330niin nhu thong thuongt^l.
Xir ly goc rupt thira: goc rupt thira dupe kep bang 3 chp, 2 clip sat goc rupt thira va 1 clip 6 phan xa. Dimg keo nhiing betadin cit goc mpt thira. Chiing toi chua gap tai bien nao lien quan den tyt clip goc rupt thira.
Thoi gian mo Bdng 4: Tlidi gian mo
Thd'i gian (phiit) Pelosi'"
Rosso™
Esposito'^'
Valla""
Nguyin Tan
C L F O - n g ' ^ '
Chung loi
Cach mo 1 trocar co kinh
thao tac 1 tnacar co kenh
thao tac 1 trocar r6n c6 kenh+cat rt ben
ngoai 3 trocar tbn 1 trocar r6n c6 kSnh
thao tac 2 trocar r6n
Trung binh
7 43,5
25
15 27,6 20
Ngan nhit 5 25 12
10 15 15
nhit 45 65 45
90 85 60 Thoi gian mo ciia ehung toi co ngan hon cac
86 Hgi Nghi Khoa Hoc Ky thu|t BV. Binh Dan 2014
Y Hpc TP. Ho Chl Minh * Tap 18 * So 1 * 2014 Nghien cuoi Y hpc
tac gia khac do chiing toi chi sii dung co 2 trocar, phau thuat vien ciing la nguoi cam camera nen tranh dupe nhiing h ^ che do sir dung 3 trocar nhu:
Phau thuat vien duoc thao tac trong phlu truong quen thupc.
Dung cu npi soi va kinh soi dupe thao tac trong phlu truong ben trong va ben ngoai kh6ng han che.
Camera di chuyen theo y muon ciia phau thuat vien.
Khong con viec dyng cham cua dyng cu npi soi, giiia phau thuat vien va nguoi phu mo.
Thoi gjan nam vien Bdng 5: Thdi gian nam viai
Thoi gian (ngay) Rispoi^^' Rosso'^"' Esposito''''
V a l l a " "
Nguyen Tan Ci/cmg'^*
Chung t&i
C d c h m d 1 trocar ron co kenh+cit rt b&n ngoai
1 trocar r6n 1 trocar ron co kenh+cat rt ben ngoai
3 trocar r6n 1 trocar r6n co kenh
2 trocar rAn Trung
binh 2
2,6 2
2 2.1 3
Ngan nhat 1
1 1
1 1 1
Dai n h i t 4
7 4
22 5
7
Thoi gian nam vi^n phu thupc vao nhieu yeu to khach quan nhu: tinh trang mpt thira, tinh chat cupc mo, tai bien, bien chiing sau mo, hoan canh gia dinh, yeu to tam ly va hoan canh dia K'<'^>. Thai gian n&n vien cua chiing toi ding tuong ty voi cac tac gia khac.
Than my
Nhirng lpi ich mang lai cho benh nhan la dang ke^ ve tham my phau thuat cat rupt thira mpt duong m6' la m6t hen bp Ion khi phuong phap nay mang den cho benh nhan phau thuat khong thay seo mo. Mot duong mo ding co nghia la it dau sau mo, giam nguy co nhilm trimg vet mo va thai gian binh phuc nhanh hem.
Dang ke hon la benh nhan phau tiiugt m6t duong mo CO thoi gian nim vien ngan hon, benh nhan c6 the xuat vien b-ong ngay hay ngay h6m
saij(is,9.iD.ii),
Tat ca cac benh nhan trong nghien ciiu oia chiing toi deu hai long ve vet mo, benh nhan hoan toan kh6ng thay seo hoac seo rat nho kho nhan thay 6 ron.
Tai bien, bien ehung 5 6; Bidi chimg
Tac gia P^OSl""
Esposito'-'' Rispoh""
Rosso*'"' V a l l a ' " ' N g u y i n Tan C u ^ g ' ^ '
Chung toi Tai bien
0 0 0 0 0 0 0
Bien ehung s o m
0 0 1 1 %
0 5%
0 2%
Bien chiing muon
0 0 0 0 3,5%
0 0,5%
Trong nghien ciiu cua chiing toi kh6ng co tai bien va bieh ehiing nhiem trimg trocar ron la 2%, 1 (0,5%) TH tu dich nhiem trimg ho chau phai ngay h^u phau thii 8 duoe dieu trj npi on dmh.
Co 2 (1,6%) truong hpp co thai dupe mo, chiing to phuong phap nay an toan, hieu qua. Tuy nhien, vi thai gian theo doi con ngan nen chting toi chi CO the ket luan phau thuat nay co tinh kha thi cao doi vol viem rupt thira chua co bien chiing va duoc tiiuc hien boi nhung phau thuat vien CO kinh nghiem mo npi soi tai b^nh vien.
KETLUAN
Cat mpt thira n6i soi bang 2 trocar voi 1 duang rach da qua ron, sir dung cac dyng cy phau thuat npi soi thuang dimg tai benh vien va xii ly m6t thira trong 6" byng la an toan, hieu qua va la mpt chpn lua khac cho phau thuat bung kh6ng CO sec mo.
TAI LIEU THAM KHAO
1 De Matos P, Lugwig K (1999), Laparoscopic appendedomy, iflfiisof^nrastopirsiir^m/.CurrailmediciMi', {2)18'320-3M 2. Esposito C (1998) One-trocar appendectomy in pediatne
surgery Surgaidosc, 12.177-178.
3 Fad\'en B. Wolfe B, et al (1992), Laparoscope management of the acute abdomen, appendix and small and large bowel Surg Oiti North Am, 75 (5)-1169-1182
4 Hin C (1997) One-puncture laparoscopic appendectoiry SurgKo! laparoscopjc & £iidosa;7K,7(l};22-24 5 Nguyen Tan Cuong, Do Hmi Liet, Le I r a n DVK. Tin (20CS)
c a t ruot thiia nra soi \'6i 1 trocar IOT, Y HOT TP mChiMmh Tap 12 phii to" flirt so"^ 126-130
6 Oguz A, Gulce H (2007) Smgle-port laparoscopic appendectomy conducted intra-corporeally ivith the a d of a
Hpi Nghi Khoa Hpc Ky thual BV. Binh Dan 2014
Nghien cmi Y hpc V Hoc TP. Ho Chi M i n h * Tap 18 * So 1 * 2014 •
transabdomonal sling suture, /ouriol c^ pediatric an umbilical one-trocar technique. Swiss Surg, 4:7-9 surgerTi,42.1071-l(S7i H Valla J. Ordonca-Hores R, Ste)'aeit H, Menot (1999) 7 Palanivelu C Rangarajan \i, John S (2007), Laparoscopic Umbmcal one-puncture laparoscopic-asated appendectomy
appendectomy for appendicitis m uncommon sihiahons: the in children Surgendosc.UiSi^.
advantages of a Imlored a(^)roa<ii.Sn?giJfwre Med j . 48 (8) 737-
P d o a M (1992) UparosoDpic appendectomy tisng a angle Ngdy nlian hdi bdo: 01/10/2013 umbilical puncture, loumal cf reproducti^ wedicme, 38(7) ]\Joau nhdn bien nhdn xct bdi bdo. 05/12/2013 588-594 & :>r • .
Rispoli G, Atmdlino MF, Esposito C (2002) One trocar Ngay bai bdo duac diing: 20/02/2014 appendectomy Siif^ endosc, 833-835
Rosso RD, Wettstan M, Btuttm M M q w A (1998) Initial expenence with laparoscopic assisted appendicectomy, u a n g
Hpi Nghi Khoa Hpc Ky thuat BV. Binh Dan 2014
