DANH GIA KET QUA CAT TUI MAT NOI SOI
AP DUNG BUOC NO TRONG CO THE VA CAM MAU DONG MACH TUI MAT BANG DOT DIEN L U O N G Cl/C
« Tran Bao Long
• Trddng Dai hgc Y Ha Ndi
Muc tieu: dinh gii Hnh kha thi vi bleu qua cua phuang phip dt tui mat ndi soi ap dung ky thual lam na trong ca the bugc d'ng cd till mat vi cim miu dgng mach tui mat bing ddt dien lUdng cUc. Doi tUgng va phuang pbap ngbien ciifu: so benh nhan nghien edu Hin cdu can thiep duac tic gii tht/c hien phau thuat td 1/2005 - 4/2009. Kit qua: 140 BN bj sdi tdi mat hay polip tiii mat cd tnSu chdng hay biin chdng cap Hnh dugc dt tui mat ndi soi ip dung ky thuit lim na trong ca the bugc dng cd tui mat vi cim miu dgng mach tui mat bing ddt dien ludng cUc, kit qui khdi ra vien 100%o, nhiem khuin vet troca viing rdn chiim 3,92%.
Thdi gian md trung binh 47,75 ± 17,74 phut (dao ddng td 25 -155 phut). Thdi gian nim vien sau md:
2,28 ± 1,07 ngiy (dao ddng td 1 - 7 ngiy). Kit luan: cat tui mat ndi soi ip dung ky thuat budc na trong ca the vi cim miu ddng mach till mat bing ddt dien ludng cdc, khdng sd dung clip li phuang phap an toan, cd hieu qua.
Tur khoa: c^t tiii mat noi soi, bupc nd trong ccf the, cam mau bang ddi di?n lUdng cUc
I. DAT VAN DE
Benh iy sdi tiii mat ri't phd bien tren the gidi cung nhif d Viet Nam, ty le ttf 5 - 10% d i n sd [ 1 , 3]. Cat tiii mat noi soi ngay cang dtfpc phd bie'n rpng rai do nhufng iiU die'm vifpt trdi nhtf: ft dau sau md, hdi phuc nhanh, thdi gian nam vien ngan, dat yeu cau tham mT cao [ 1 , 4 ] . . . Cd the cd bien ehifng: clip di chuyen vao trong dtfdng mat tao sdi mat (sdi mat meo)... [3].
Nghien cifu I p dung phifong phap cat tiii mat noi soi vdi ky thuat budc dng cd tiii mat bang e l c h lam no trong cd the va cam mau ddng mach ttii mat bang dot dien lu'dng ctfc, khong sd dung clip nham muc tieu:
Danb gia tinh kha thi va hieu qua diiu tri cua ky thuit vdi trang thiit bi sin co d tat ca cac ca sd tbUc hien phiu tbuat ngi soi hien nay (chi tieu tdng hap, cim mau ddt dien lu&ng cUc).
II. DOI TUONG VA PHGONG PHAP NGHIEN CLfu
1. Dd^i tuong nghien cdu
140 benh n h i n (BN) nam, ntf tudi > 16, chan d o l n sdi tui mat, pd lip tiii mat, dtfdc md phien hay c i p cifu do mpt p h i u t h u i t vien thtfc hien,cat tiii mat npi soi ap dung buoc dng cd tiii mat bang ky thuat budc nd trong cd the va cam m l u dpng mach tui mat bang phUOng p b l p ddt dien lddng cifc, khdng sd dung clip tai khoa p h i u thuat gan mat - benh vien Viet Dife, khoa dieu trj ttf nguyen - benh vien Viet Dife, khoa Ngoai - benh vien Dai hpc Y H I N p i , khoa Ngoai - benh vien da khoa Bac N i n h , khoa Ngoai - benh vien da khoa khu vtfc Bai Chay - tinh Q u i n g N i n h , ttf t h i n g 1 2/2005 de'n t h i n g 4/2009.
2. PhUdng phap nghien cu'u: nghien cifu tie'n cifu can thiep.
- Ti't ca c i c BN thuoc ddi tUOng nghien cifu dupc chuan bj trUdc md thtfdng qui cho c l e trifdng hdp md cat tiii m i t npi soi, chap n h i n p h i u thuat.
- Ky thuat; gay me theo phuong phap npi khf q u i n , BN nam ngufa theo ttf the 2 c h i n khep.
P h i u t h u i t vien va phu m d difng ben trai, dung cu vien ddng ben sau p h i i cua p h i u thuat vien, man hinh va dan may chie'u sang, m i y bom khf CO2 d ben ddi di$n. M d nhd t h i n h bgng tren hay dtfdi rdn cho troca 10 m m dau tien vao de dat camera, d i n h gia tinh trang d bgng. Dat tiep theo;
1 troca d phfa miii ifc de sd dung phau tfch bang mde (hook) va ddt dien Itfdng ctfc. 1 - 2 troca tie'p dtfdc dat de bpc 16 tiii mat va budc chi. Ong cd tiii mat va dong mach tiii mat dtfpc bdc lo ro sau khi
- Ke't q u i dieu trj; ke't q u i sdm (liic ra vien);
chia l l m 3 mifc do; tdt (dien bie'n tdt, khdng cd bien ehifng), trung binh (didn bien td't, cd bie'n ehifng n h i i m khuan 16 troca), Xi'u (khi p h i i chuyen md md hay cd bien ehifng trong hoac sau md p h i i can thiep lai). Ke't q u i xa (theo doi sau ra vien td 1 t h i n g trd len) gdm 4 mifc do; Tdt (tinh trang t o l n t h i n tdt, khong dau vting gan, kh6ng bj roi loan tieu hoa khi an md, trtfng, khdng p h i i dieu trj). K h i (tinh trang t o l n t h i n tdt, cd rdi loan tieu h o i keo dai dtfdi 1 tuan khi an md, trifng, khdng p h i i vao vien dieu trj). Trung binh (tlnh trang toan than tdt, cd rdi loan tieu hoa khi an md, trdng keo dai > 1 tuan hoac cd nhidm khuan vet trocart p h i i thay bang, khdng p h i i vao vi$n dieu trj). Xau ( p h i i vao vien dieu trj vi c i c roi loan CO nang sau cat tiii mat).
IILKETQUA
140 BN cd tudi trung binh: 50,82 + 13,32 (dao dpng ttf 20 - 90). Gidii nO: 93 BN, nam: 47 BN , ty le nti/nam: 1,98. Nghe nghiep: lam rudng; 40 BN, can bp cdng chdc; 74, nghe khac: 26 BN.
p h i u tfch I I tru'dc v l I I sau cua phuc mac trong tam giac Calot, dting pince dUa chi tieu tdng hdp 2/0 v i o d bung, qua tam g i l c Calot da bpc Ip rd dng cd, 1 pince khac dtfa qua troca 5 mm ddn dau sdi chi va lam nut buoc trong co the sit vdi dng m | t chu, sau dd cat chi va ll'y chi tbda qua troca 5 m m . Doan chi cdn lai difOc sd dung de buoc tiep phan dng cd tiij mat se li'y bd. Dpng mach tiii mat dUOc cam mau bang ddt dien Itfdng cifc. Tiii mat difdc cat ngifdc ddng va lay qua Id 10 m m .
1. Dac diem b?nh ly: tien sd; benh noi khoa;
d i i t h i o dddng: 5BN, tang huye't | p ; 19 BN, Loet h i n h t l trang; 3 BN, Xul't huye't g i l m tieu cau;
1 BN, viem cau than; 1 BN, xd gan Child B; 3 BN. 2 BN cd kem benh thd 3 (thoai hoa cpt sdng cd kem loet hanh t l trang, tang huyet I p kem viem cau than). Benh ngoai khoa; 31 BN cd tien sd p h i u t h u i t d bung (20,44%%),trong dd cd 4 BN cd tien sd md cat 2/3 da day, 2 BN cd tien sd md vet thddng thi'u bung, ,4 BN cd so lan md 2 lan (2 BN md de 2 lan, 2 BN m d d ^ 1 lan va m d rd nieu q u i n 1 lan), 1 BN cd tien sd md viem phuc mac rupt tbda, 2 BN cd tien sd md viem rupt tbda, 18 BN cd tien sd m d dd. Benh ly; ta't ca cac BN deu cd tien sd dau ha sifdn p h i i , 20 BN cd tien sd cd nhdng dot sd't p h i i dieu trj k h l n g sinh, khong cd trtfdng hop nao bj vang da vang mat.
Thdi gian cd trieu chdng tdi khi vao vien de p b l u t h u i t :17,35 -1- 27,78 t h i n g (dao ddng td 1 - 120 t h i n g ) . Dac diem khi vao vien; dau vung dUdi sudn p h i i : 14 BN, dau vung dUdi sUdn p h i i kem sdt; 4 BN, dau vung dtfdi stfdn p h i i kem sdt va cd p h l n dng thanh bung vung dUdi sUdn p h i i ; 4 BN.
2. Hoan canh md, tdn thUdng trong md
Md phien; 136 BN (97,14%), md cap cdu; 4 BN (2,86%). sd dung 3 troca; 112 BN (80%), 4 troca: 27 BN (19,29%). 115 BN cd tui mat viem day (82,14%), trong do 29 BN tui mat bj viem dfnh bdi mac ndi ldn va c i c tang l l n can (20,71%), 7 BN cd tdi mat viem teo, 5 BN bj tui mat viem phti ne xung huye't d l rich va d l chly mlu khi kep pince, 3 BN bj viem tui mat hoai td.
3 BN cd gan xo phdi hpp vdi sdi tui mat. Thdi gian md trung binh 47,75 ± 1 7,74 phut (dao dpng td25 -155 phut).
3. Ket qua dieu trj
Ket qui sdm; ti't c l c i c BN khdi v l ra vien, khdng cd tru'dng hdp nao bj bie'n chdng phii can thiep lai, khdng cd trtfdng hdp nio bi td vong. Ke't qui sdm dat ket qui td't chiem 97,86%, ket qui trung binh; 2,14%. Thdi gian nam vien sau md;
2,28 ± 1,07 ngly (dao ddng td 1 - 7 ngly). Ket qui xa; tdt; 47 BN (92,16%), k h i ; 2 BN (3,92), trung binh; 2 BN chiem 3,92 % , xiu; khong cd trUdng hpp nio.
IV. BAN LUAN
Cat tiii mat npi soi cd nhieu UU diem vtfdt trpi nhif; ft dau, hdi phuc sau md sdm, d i m bio tham my, thdi gian nam vien ngan, gilm chi phf dieu tri va sdm trd lai cupc sdng lao dpng binh thifdng [1, 2, 4]... Phtfdng phap cam mlu va cam mat d dng cd tui m i t dUdc I p dung nhieu cho tdi nay II sd dung clip titanium kep dpng mach va dng cd tui mat [1, 2, 3, 7]..., sd lUpng clip sd dung tdi thieu cho mpt ca phiu thuat la 6 chiec, g i l thanh khoing 79,81 euro [4]. G i l clip hien nay d thj trtfdng nifdc ta td 16 000 ddng de'n 56 000 ddng/
chiec. Sd dung clfp tieu hay chi budc san endoloop do gil thanh cao nen viec I p dung v i n khdng phd bien. Ton thifdng trong md; chung toi gap 115 BN cd tui mat viem day (82,14%), ty le tiii mat bi viem dfnh bdi tang l l n can chiem
20,71%, 7 BN cd tui mat viem teo, 5 BN bj tui mat viem phu ne xung huyet d l rach va d l chly mau khi kep pince, 3 BN bj viem tui mat hoai td.
3 BN cd gan xo phdi hdp vdi sdi tui mat. Ti't c l cac BN deu dUdc thUc hien cat tui mat npi soi thinh cong, khdng cd bie'n chdng trong v l sau md. Sd troca dUpc sd dung td 3 - 4 chiec, trong dd 1 troca 10 rhm cho camera va 2 trocart 5 mm cho pince va keo, mde. G i l m bdt kich thu'dc cua Id troca la mpt trong nhdng UU diem cua phu'dng pblp cat tui mat npi soi ap dung ky thuit buoc dng cd tui mat bang cich lam no trong cd the, va ddt dien Itfdng cdc cam m l u dpng mach tui mat, khong sd dung clfp. Troca dUdng kfnh 10 mm dat d gan mui dc de cho kep clip vao, da khdng can sd dung tdi. Do viy, chung tdi thay the bang troca dudng kfnh 5mm. Thdi gian md trung binh: 47,75
± 17,74 phut (dao dpng td 25 -155 phut). BN cd thdi gian md l l u nhl't do bj viem tui mat hoai td, trong tien sd da md viem phuc mac rupt thda, do viem tui mat cap gly dfnh v l de chly mlu khd xac djnh ranh gidi cua tui mat vdi cac thanh phan cua cudng gan. So vdi y van thdng bao; thdi gian cat tui m|t cd cap clfp trung binh theo Nguyen Dinh Hdi (giai doan 1996 - 2000, tren 2589 benh nhin) td 70 - 80 phut [1], cua Pham Duy Hien II 57,5 phut [2]. Cam m l u dpng mach tui mat bang dot dien lu'dng cUc cho phep chung tdi thUc hien nhanh hdn cle thao t i c buoc chi cua Sir Kumar [4], ky thuit dam bio an toan va d l thUc hien.
Theo Capelluto.E , Champault.G [5], phUdng phip ddt dien cam mau lddng cUc an toln vi d dd d cleh vj trf ddt 5 cm chi cd chenh nhiet dp 3°C so vdi dd't dien ddn cdc len tdi 29°C va 0,3°C ddi vdi cam mlu bang sieu i m , do v i y khi phiu tfch d gan du'dng mat hay d'ng tieu hoi, viec sd dung cam mlu bang ddt dien lifdng cdc hay sieu I m la khuynh hddng dddc lUa chon. H i u q u i do clfp tao nen m l y van da thong bio nhif; clip di chuyen vao difdng mat tao sdi dng mat chu, di chuyen vao d I p xe dtfdi hoanh, gay hinh anh g i l u dUdng
mat tren phim chup cong htfdng td dUdng mat sau md cat tui mat noi soi [3, 7] da difdc loai trd. Chi phf cupc md npi soi giam vi BN khdng p h i i sd dung clip. PhUdng phap nay chi sd dung nhdng dung cu s i n co d tl't c l cac cd sd ngoai khoa cd the md npi soi (chi tieu tdng hop, ddt dien cam m l u Itfdng cdc, pince), ky t h u i t khdng qua phdc tap.
Ke't q u i sdm; tl't c l c i c BN deu khdi va ra vien, 96,08% sd BN dat ke't q u i tdt, khong cd trtfdng hdp nao p h i i chuyen md md v l cung khdng cd trUdng hop nao c h l y m l u p h i i truyen m l u , khong cd trifdng hop nao bj bie'n chdng p h i i can thiep lai cung nhtf khong cd trtfdng hpp n i o bi td vong. Ty le n h i i m khuan vet troca d ro'n chiem 3,92% (2 BN) cao hon n h i i m khuan Id troca d rdn cua Champaulc.A (1,8%) [4] va thi'p hdn ty le n h i i m khuan vet md d ro'n cua Pham Duy Hien (6,43%) [2]. Thdi gian nam vien sau md: ngan hdn nghien cdu cua N g u y i n Dinh Hdi va Pham Duy Hien thdng bao (3 - 5,3 ngay) [ 1 , 2] va tifong difOng vdi ke't qua nghien cdu cda Champaulc.A (55,8 gid) [4]. Ket q u i xa: da sd c l e trtfdng hdp (92,85%) dat ket q u i tdt. 6 BN dat ke't q u i k h i chie'm 4,28%, 4 BN dat ke't qua trung binh chiem 2,87%, khong cd trUdng hdp nao phai v i o vien dieu trj do rdi loan cd nang sau md cat tiii mat.
V. KETLUAN
C i t tiii mat npi soi I p dung ky thuat buoc dng cd tiii mat bang c i c h lam no trong co the bang chl tieu tdng hdp, phdi hdp vdi ddt dien Itfdng cUc cam m l u dpng mach tui mat, khong dung clfp la phifong p b l p an toan, cd hieu qua cao trong dieu trj.
Ky thuat cat tui mat ndi soi khdng sd dung clip
khdng q u i phdc tap, ft tdn kem, cd the I p dung d c i c cd sd thuc hien p h i u thuat cat tui mat npi soi vdi c i c trang bj san cd hien nay.
TAI LIEU THAM KHAO
1. Nguyin Dinh Hoi, Nguyin Hoang Bac, Nguyin Tan Cu'dng va cpng sU (2001), "Cat tui mat bang phSu t h u i t npi soi", Ngoai khoa XLV, 1 , t r 7 - 14.
2. Pham Duy Hien, Bui Trung (1999), "Ket qua bddc dau dieu tri viem tui mat do sdi bang p b l u t h u i t npi soi", Dai hpi ngoai khoa Viet Nam lan thd X, Ha Npi 1999, 96 - 102.
3. Angel R, Abisambra N, Marin J.C (2004),
" c h o l e d o c h o l i t h i a s i s a f t e r l a p a r o s c o p i c cholecystectomy". Endoscopy, 3 6 , 2 5 1 .
4. Champaulc.A, Von.C, Dagher.l et al (2002), low cost laparoscopic cholecystectomy, British Journal of surgery, 89, 1602 - 1607.
5. Capelluto.E , Champault.G (2000),
"Variations de la temperature intraperitoneale a u ' cours de la cholecystectomie laparoscopique", Annales de Chirurgie , Volume 125, Issue 3, Pages 2 5 9 - 2 6 2 .
6. Sisir Kumar Saha (2000), "Ligating the cystic d u c t in l a p a r o s c o p i c c h o l e c y s t e c t o m y " , Ame.J.Surg, 1 79, 494 - 496.
7. Vuji Watanabe, Masako Dohke, Takayoshi Ishimori, Yoshiki Amoh^ Akira Okumura, Kazushige Oda, Shinji Koike, and Yoshihiro Dodo, (1999), "Diagnostic Pitfalls of MR Cholangiopan- creatography in the Evaluation of the Biliary Tract and Gallbladder", Radiographics. 1 9 : 4 1 5 - 4 2 9 . Summary
EVALUATION OF THE LAPAROSCOPIC CHOLECYSTECTOMY WITH INTRACOPOREAL LIGATION AND BIPOLAR COAGULATION
Purpose: evaluation of the practicability and of the effect of the laparoscopic cholecystectomy w i t h the intracorporeal ligation and bipolar coagulation. Methods: a perspective interventional study performed by
the author during 1/2005 - 4/2009. Results: 140 patients with the symtomatic gallbladder stones or acute complication and w i t h gallbladder, polyps were performed the laparoscopic cholecystectomy with intracorporeal ligation and bipolar coagulation. All of the patients were discharged on the 1st - 7 r d post operative day, a infection of the umbilical incision represent 3.92%, the average operating times was 47.75 ± 17.74 minutes (25 - 155minutes), the post operative hospitalization was 2.28 ± 1.07 days (1 - 7 days). Conclusion: the laparoscopic cholecystectomy with intracorporeal ligation and bipolar coagulation's a safe, effective. ,.!:•':,,,• ,
Keywords: laparoscopic cholecystectomy, intracorporeal ligation, bipolar coagulation
KHAO SAT TY LE BENH LY CAU THAN VA
• • • T I M HIEU CHLfC N A N G THAN NGU^CJl TRU^^NG T H A N H
TRONG C O N G DONG TAI TINH BAC GIANG
Dinh Thi Kim D u n g \ D6 Gia Tuyen^ Le Danh Vinh^
^Benh vien Bach Mai, ^Trddng Dai hoc Y Ha Noi
Nghien cdu dich tS bdnh ly than Hit nieu da dugc Hin hinh d nhieu nUdc tren thi gidi nhim xic dinh rd md hinh nhdrfi benh niy de xay dt/ng ke hoach dif phdng vi ap dung cac bidn phip diiu trj thich hgp nhim ngan ngda sU Hin trien vi biin chdng ciia bdnh. Muc tieu: xic djnh ty le bdnh ly cau than ngUdi trudng thinh trong cgng dong tai Bic Giang vi dinh gii chdc nang than d nhdng bdnh nhan neu tren. Doi tugng va phuang phap nghien ciiu: Hen cdu, md ta dt ngang sing Igc tai cgng dong vdi sd luang 961 ngUdi, d 3 huyen cua dnh Bic Giang. Kit qua: ty le mic benh ciu than tai BSc Giang li 5,7% va khdng khac bi$t vi ty Id mic benh cau than gida 2 gidi. Mde Igc'cau than (MLCT) trung binh d nhdm cd protein nidu duang tinh li 67,10 ± 21,4 ml/ph. Sd ngUdi cd protein nidu duang Hnh bj giam chdc nang thin chiem 34,6%. u nhdm protein nidu duang Hnh cd THA thi MLCT trung binh la < 60ml/ph, xu hUdng tha'p hah nhdm khdng THA. Kit luan: d Hnh Bac Giang, ty le mic bdnh cau thin vi sd ngUdi cd protein nidu duang Hnh vi giam chdc nSng than la khi cao. Viec phit bidn sdm benh ly ciu than trong cgng dong thong qua vide phat hien sang lgc protein nieu vi cic da'u hieu di kem la bet sdc quan trgng nham cd nhdng ki hoach theo ddi va diiu trj liu dii cho nhdng ddi tugng nay.
Tii khoa: suy than, nghien cdu sang Ipc, b^nh If cau than ^
I. DAT VAN DE ntfdc dang p h l t trien [ 1 , 2, 5, 6, 7, 8, 10].
Hien nay md hinh benh t i t tren the gidi da cd Tai nUdc cd nen kinh te phat trien, ty le suy nhieu thay ddi, xul't hien nhieu benh cd lien quan than giai doan cudi do benh tieu dtfdng va tang de'n dieu kien sdng cung nhif thdi quen trong sinh huyet I p ddng hang dau [2, 9, 10]. Trong khi dd, boat nhd; tang huye't I p , tieu durdng va benh t h i n d nhdng ntfdc cd nen kinh te chu'a p h l t trien, man tfnh Dieu nay da va dang trd thanh c i c van benh n h i n suy t h i n giai doan cudi (hay benh de ldn mang tfnh xa hoi ma c i c ntfdc dang p h i i t h i n giai doan cudi) do benh ly cau t h i n va do ddi mat, ke c l c i c ntfdc phat trien cung nhU cac n h i i m trung chien ty le cao nha't. Nghien cdu
