PHAU THUAT NOI SOI DIEU TR! B U dU GIAP TAI BENH VIEN BINH DAN H6 Nam", NguySn Ba Minh Nhat', Ho Khanh Due*, Nguyin Van Viet Thanh*
TOM T A T
Dat van de: PhSu thuat ft xam lan hien nay dugc sir dung rong rai trong dieu tri birou giap.
Muc dich cua phau thuat noi soi la giai quyet dirge van de ve tham my, Bn khdng co seo rao a CO. BV Binh Dan da thirc hien phau thuat ngi soi trong dieu tri benh ly tuyen giap tiJ 2006.
Muc tieu: Mo ta ky thuat m6 va danh gia kit qua di^u tri
Phircmg phap nghien ciru: Tien cuu mo ta tat ca cac truong hgp buou giap dugc phau thuat ngi soi tai BV Binh Dan tu 6/2007 - 6/2009.
Kit qua: Trong 2 nam, 76 truang hgp buau giap dugc phlu thuat ngi soi tai BV Binh Dan (8 nam - 68 nu) va dugc theo doi it nhat 3 thang. Do tuoi trung binh la 32 (16 - 63 tuoi). Buou giap don nhan 62 TH (82%); buou giap da nhan I thuy 4 TH (5%); buau giap da nhan 2 thuy 5 TH (6,5%); Basedow 6n 5 TH (6,5%). K giap qua FNA truoc m6 0%. Ki'ch thuoc buou trung binh a moi thuy qua sieu am la 3cm (2-5). Khoang thao tac vung co dugc tao bSng d6t dien don cue voi khi C 0 2 ap lire 8-lOmmHg. Buou dugc dt bing dao sieu am.Thcri gian phau thuat trung binh 100 phiit (60-180). 2 benh nhan phai m6 ha lai do chay mau sau m6. 2 TH bj khan tieng nhe va hoi phuc sau 3 thang. 2 TH te tay tam thoi sau mo. Khong TH nao bi nhiem triing vet md. Tat ca Bn sau mo deu hai long ve ti'nh tham my, khong co cam giac nuot vuong sau mo giong phau thuat ha.
Ket luan: Day la ky thuat mo an toan va hieu qua d6i voi nhimg phlu thuat vien co kinh nghiem trong mo ngi soi va mo ha buau giap. Lgi i'ch 1cm nhat doi voi Bn la mang tfnh tham my eao. Ky thuat co the ap dung trong dieu trj buou giap dan nhan to han va buou giap 2 thuy.
Tu khoa: Ph&u thuat ngi soi buou giap SUMMARY
ENDOSCOPIC THYROIDECTOMY FOR THE TREATMENT OF GOITER AT BINH DAN HOSPITAL
Introduction: Minimally invasive surgery is widely employed for the treatment of goiter. The greatest benefits of this procedure is better cosmetic results, no scarring at the neck. We have performed endoscopic thyroidectomy since 2(K)6
Objectives: In this study, we have described our technique and evaluated the feasibiUty and efficacy of this procedure.
Materials and Methods: Descriptive study - all patients have the goiter treated by endosopic thyroidectomy from 6/ 2007 to 6/2009
Results: In 2 years, 76 eases of endoscopic thyroidectomy were done with a 3 month follow- up at our center in 8 male and 68 female patients. Mean age was 32 (range 16 to 63). 62 solitary nodular goiter (82%); 4 multinodular at one lobe (5%); 5 multinodular at two lobes (6.5%) and 5 Basedow (6.5%) underwent near-total lobectomy or thyroidectomy. No malignant tumor was detected by FNA.The mean diameter of one lobe is 3 cm (range 2 to 5 cm) under ultrasound diagnostic. The working space for adequate visualization was created by pneumoinsufflation with carbon dioxide (CO 2) and a continuous pressure of 8 to 10 mmHg was maintained The thyroid lobectomy was realized by harmonic scapel. The mean operating time was 100 min (range 60-180 min). 2 patients required conversion to open cervicotomy for cervico-hematoma postoperative. 2 cases recurrent laryngeal nerve palsies and only 2 cases postoperative tetany occurred. No infection of the chest wail scar. All patients were satisfied with the cosmetic results.
* Khoa Ngogi Ldng Nguc- Mgch mdu BV Binh Ddn
Dia chi lien lac: BS. H6 Khdnh Diic DT: 0958924262 Email: [email protected]
Conclusions: It is a safe and effective technique in the hands of an appropnately trained surgeon. The patients get a cosmetic benefit. It is possible to remove large nodules and perform as well as total thyroidectomies using our endoscopic approach.
Key word: Endoscopic thyroidectomy
DATVANDE , _ . Buau giap la mgt benh ly ph6 bien d Viet Nam. Hang nam, tai BV Binh Dan cbung toi mo hon 1000 truang hgp buau giap. Sau phau thuat benh nhanco v6t seo a co, gay m5t tham my, anh huang dSn sinh hoat, giao ti6p cua nguoi benh. Phau thuat ngi soi la phucmg phfip m6 ft xam lan, khong da lai seo x§u va la xu huimg phat trien ciia thi gidi. Tai Viet Nam, tu nam 2004, BV Ndi ti8t Trung Uong Ha Noi, BV Nhan Dan Gia Dinh Tp HCM da budc diu tiin hanh p h k thuat buou giap qua noi soi. Tai BV Binh Dan, ehung tpi da thue hien cac TH cit budu giap vdi duong md nhd qua ho trg cua ngi soi tu 2(X)4. Phlu thuat cat tuyen gidp hoan toan qua ndi soi dugc ehung toi thuc hien tir 2006. Muc tieu cua nghien cuu la mo ta ky thuat md va danh gia ket qua sdm qua 76 trudng hgp trong 2 nam.
Muc tieu nghien cuu
Ap dung ky thuat md ngi soi trong dieu tri budu giap
• Danh gia tinh hieu qua cua pp nay qua ket qua dieu tri PHUONG PHAP NGHIEN CLfU
Thiet ke nghien ciiu
- Ti6n cim md ta cac TH buou giap dugc phlu thuat ndi soi tir 6/2007-6/2009 tai BV Binh Dan. Theo ddi tai kham sau 3 thang
Chi dinh md ngi soi
- Cae TH budu giap co dudng kfnh mdi thuy qua sieu am < 4cm.
- Binh giap tren lam sang va XN chiie nang tuyen giap - Benh nhan ddng y phlu thuat ngi soi
- Loai trir cdc TH ung thu tuyen giap da cd chan doan qua FNA, cac TH budu tai phdt.
Phuang phap phlu thuat ngi soi budu giap
Benh nhan dugc gay me NKQ. Tu the nam ngua, dat gdi dudi vai de ngua co. Man hinh ngi soi dat ve phfa trai hoac phai tijy timg phau thuat vien (PTV), phfa tren dau ngudi benh. PTV cd the dung cung b6n hoac doi ben vdi buou, ngudi phu dung ddi hin. Rach da dudng 5mm d 2 ben quang vU, dung kelly boc tach lap dudi da. Dat 2 trocar 5 hucrng ve hom lie. Ong kinh 5 dat qua mgt trong hai trocar 5. Rach da 10mm dudng hdm nach cimg ben PTV chfnh va dat trocar 10 hudng vi hom ire. Dung ddt dien don cue tao khoang cd. Dimg khf C02 vdi ap lire tir 8-lOmmHg. Dung ddt dien don cue boc tach dudng giOa khdi co trudc tuyen giap. Bdc Id budu, diing dao cat ddt sieu am de cit gan trgn thijy tuyen giap. Chii ^ cam mau ky. Lay budu qua nga dat trocar 10 d hdm nach. Dat dng dan luu qua trocar 10. Bang €p viing cd. Dan luu se duoc nit vao ngay thu 2.
KET QUA
Tir 6/2007- 6/2009, chiing tdi da thuc hien 76 Uudng hgp phau thuat ngi soi c5t thiiy tuyln giap cho cae tnrdng hgp buou giap don nhan, da nhan va Basedow.
Gidi tfnh: Nir: 68TH (90%) Nam: 8 TH (10%) Tudi trung binh: 32 (19 - 63 ) Chan doan
<• BG don nhan: 62 (82%)
• BG da nhan 1 thiiy: 4 (5%)
• BG da nhan 2 thuy: 5 (6,5%)
• Basedow dn: 5 (6,5%) Phuang phap md
Cat gan trgn thiiy; 66 (86%) c a t gin hk tuyen giap: 10 (14%) Dat din luu: 100%
Giai phlu benh
Trudc md (FNA): 100% buau lanh tinh Sau md
+ Budu lanh: 75 (98,5%) H-Carcinoma dang nhu: 1 (1,5%) Ket qua phau thuat
Mau mit trong liic md: 25ml (10-50ml) Thdi gian mo trung binh: 100 phiit (60-180 phiit) Bien ehiing:
+ Chuyen md hd do chay mau sau md: 2 (2,5%) -I- Khan ti6ng tam thdi: 2 (2,5%)
-I- Te tay tam thdi sau md: 2 (2,5%) -I- Hematoma nhe d thanh ngue: 1 (0,12%) -I- Bam mau nhe d cd va thanh ngue: 5 (6,5%) + Khdng trudng hgp nao bi tran khf dudi da nang Benh nhan dugc xuat vien vao ngay hau phau thii 2
Tdi kham sau 1 thang, 3 thdng: eae vit seo d thanh nguc lanh tdt, khdng trudng hgp nao bi nhiem trung vet md. Tat ca cac TH md ndi soi hoan toan deu hai long vi khdng cd seo d cd, khdng cam giac nudt vudng.
B A N LUAN
Nam 952 sau Cdng nguyen, Moolish, bac sT ngudi Ba Tu thuc hien ca phlu thuat budu gidp dau tien tren the gidi.Theodor Kocher, phau thuat viSn ngudi Thuy ST dugc xem nhu ngudi khai sdng cho nin phlu thuat budu gidp thdi hien dai. Dudng mo kinh diln la rach da dudng ngang cd, chieu dai dudng md tiiy thude vao kfch thude budu. Sau md benh nhan cd vet seo dai d cd, anh hudng den tinh tham my, nhat la ddi vdi cac benh nhan nii. Ngoai ra rit nhieu Bn than phiin earn gidc nudt vudng.
Phlu thuat ngi soi vdi cac dudng md nhd d thanh ngue, ed the dau trong do da dap ung dugc nhu cSu ve tham my. Gagner Id ngudi dau tiin thue hien phau thuat cat tuyen can gidp qua ngi soi bang tao khoang d cd, bom khf CO2 trong trudng hgp cudng tuyen can giap nam 1996 va da dat duge ti'nh hieu qua ve mat ldm sang va tfnh tham my' '. Huscher la ngudi dau tien thuc hien cat thiiy phai tuyen gidp hodn toan qua noi soi nam 1997*'. Ngay nay phau thuat ndi soi viing ed de dieu tri benh ly tuyen gidp da trd ndn phd bien vdi mue dfch tham my. Co nhieu phucmg phap de tiep can khoang cd va tuyen gidp da duge dp dung nhu: dudng md nhd d cd tren hdm lie vdi su ho trg cua ndi soi, dudng dudi xuong ddn, dudng hdm nach va quing vii. Cac dudng md nay deu co uu va khuyet diem'^*.
Tai Viet Nam phuang phap md ndi soi cat tuyen gidp eung da bude diu dp dung d mgt sd benh vien d Ha Ndi va TPHCM tir nam 2004'^'. BV Binh Dan, da dp dung phau thuat cat tuyen gidp don nhan vdi dudng md nhd d cd tren hom uc vdi su hd trg cua ndi soi tir nam 2004. Tir nam 2006 ehiing tdi bat dau thuc hien phlu thuat cit tuyln giap hoan toan qua ndi soi.
Ve chi dinh md, da sd cac tac gia nude ngoai khuyen nen md ddi vdi cde trudng hgp budu gidp don nhan nhd <4cm, vi viang cd co kieh thudc han che va phau thuat dcm gian han vdi budu cd kfch thudc nhd"""^'. Mdt sd tdc gia nude ngoai da bao cao phlu thuat cdt budu
>4cm, tham chi Uem va cat gan het tuyen gidp, ngay ca ddi vdi ung thu*'^'. Thdi gian diu, chiing toi chl chgn cac TH budu dcm nhan, kfch thudc < 4em qua si6u am va lanh tinh qua FNA. Nam 2009, chiing tdi da bit diu phlu thuat ede TH budu giap da nhan 2 ben va
Basedow dn. Cac TH nay, budu mdi ben thuy ddu cd kfch thudc < 4cm. Khdng cd TH nao phai chuyen md hd. , , ^ .;
Vl vi tri dat Trocar, mdt so tdc gia chgn dudng md d ndeh, d quing vii de giau seo md'^*. Trong giai doan diu ehiing tdi sii dung 4 trocar voi 1 trocar 7mm dat d dudi hom lie 5 cm dl dat camera 5, 2 trocar 5mm dudi xuong ddn cung ben budu dl dat dung eu phau tieh, 1 trocar 5mm dudi xuang ddn ddi ben ddt dung cu d l ngudi phu nim giir co hoac budu. Cdc dudng md nay phii hgp vdi cdc loai trocar thdng thudng vi khoang each den viing cd ngan.
Tuy nhien Bn vin cd seo d viing thanh nguc trudc cung anh hudng den vin d l tham mf.
Chiing tdi cd sang chl 2 loai trocar 5 dai d l cd thi di tir quang vii den hdm lie, mdt farabeuf ndi soi dl ven eo. Sau nay chiing tdi chgn cac dudng vao hocar la d 2 ben quing vii de dat trocar 5 va d hom nach dat trocar 10. Budu se duge liy qua trocar 10. Cac lo trocar nay bao dam tfnh tham my cao.
\ ' ! iri Trocar Dung cu tu che
Khi tao khoang d cd, cd 2 each Id diing khung ndng hoac bom khf C 0 2 vdi dp luc 8- lOmmHg*^^'. Chiing tdi chgn cdch bom khf CO2. Vdi dp luc khoang 1 OmmHg dam bao cho Chung tdi ed mdt khdang uong tdt dl thao tdc va trdnh dugc bien chiing tang CO2 mdu, toan hda mdu vd tran khi dudi da'"**. Trong giai doan dau chiing tdi ed chgn each dung khung nang, nhung doi vdi chiing toi pp nay cd nhilu bat lgi nhu tao khoang trdng khdng tdt va khd vudng dung cu thao tac.
Cac tac gia nude ngoai khuyen nen tim day thdn kinh quat nguge thanh quan va tuyen can giap dl bao ve ehung*'*'. Chiing tdi diing ddt dien don cue de tao khoang cd va bde Id budu, diing dao cat sieu Sm de cit budu nham tranh lam tdn thuemg md lan can dac biet Id than kinh quat ngugc thanh quan va tuyen can giap. Chung tdi chgn pp eat gan trgn thuy tuyen gidp va chira lai mgt phan mat sau tuyen gidp vdi muc dfch an toan khdng xam pham than kinh quat ngugc thanh quan vd tuyln can giap. Tat ca cac TH md ngi soi deu cd chan dodn trudc md qua sieu am la budu don nhan hodc da nhan nhd va lanh tfnh qua FNA, do dd each md nay an toan cung nhu bao dam dugc hieu qua dieu tri, Cd mdt TH ung thu gidp phdt hien sau md khdng phu hgp vdi ket qua FNA. Day la carcinoma dang nhii, vdi cdch cat gan trgn thuy nhu vay la chua dat theo nguyen tac dieu tri ung thu. TH nay dugc theo ddi sdt va cd hda tri bd tiic. Cd 2 TH bi khdn tieng tam thdi va hdi phuc sau 3 thang. Cd 2 TH bi te tay tam thdi sau md va hdi phue vdi thudc calci.
Sau md chiing tdi deu dat dng din luu kfn khoang cd qua mdt vi tri ddt trocar 10 d hdm nach va riit vao hau phlu ngdy 2. Tuy nhien, cd 2 TH chay mdu phai md lai va md hd.
Mdt trudng hop bi mdu tu to d ed, phai md Iai sau 6 gid. Mdt trudng hgp chay mdu nhieu qua dng dan luu, md lai ngay sau 1 gid. Mot trudng hgp hematoma nhe d thanh nguc va dieu tri khdi bang bang ep va thuoc. Mdt sd trudng hgp bam nhe d viing ed. Day la cae TH dau tien ehiing tdi thuc hien va sii dung dao dot dien ludng cue. Khuyet diem ciia dao ddt luong cue Id phau tnrdng tdi do khdi vd cim mau khong tdt, mit thdi gian. Vdi dao cat sieu am, khi cdt se lam hda hai td chiie, vira cat vira cam mdu, do dd da khde phuc dugc cdc nhugc diem tren.
Sau md da sd cac benh nhan ed tran khf nhe d viing cd vd nguc va tu khdi d hau phlu ngay 1, khdng ghi nhan TH nao tran khf dudi da nans va lan tda keo ddi.
Thdi gian md cd keo dai hem so vdi md hd kinh dien. Trung binh mdt ca md ndi soi keo dai tir 90 - 120 phiit. Trong khi md hd la trung binh 30 - 45 phiit. Lugng mdu mit trung binh khoang 30ml la chip nhan dugc. tit ea benh nhdn deu dugc xuit vien ngay thii 2 hau phau sau khi nit din luu. Benh nhan tai kham sau 1 va 3 thang, khdng cd TH ndo bi nhiem triing vet md (khdng sir dung khang sinh) va hai long vi khdng ed seo d ed. Khdng benh nhan nao than phien vl di cam d cd, eam giac nudt vudng (nhiing khd chiu hay gap d cac benh nhdn md hd kinh dien). Hai bn bi khan tien sau md da hdi phuc hoan todn gigng ndi sau 3 thang.
Thdi gian dau, chiing tdi chgn budu don nhan, kfch thudc nhd. Khi ky thuat da thuan thuc, ehiing tdi da budc dau thuc hien cac TH budu gidp da nhan hai thiiy vd Basedow dn.
Cac TH nay deu cd budu mdi thuy nhd hon 5 cm. Chiing toi cdt gin trgn tuyln giap. Sau 3 thang kiem tra, ddi vdi cac TH Basedow, khdng cd TH nao bi suy gidp sau md va tai phat.
Bn sau md KET LUAN
Phlu thuat ndi soi cat budu giap qua nga thanh ngue trudc cd nhieu thuan lgi nhu dudng md nhd, thay ro eau triie giai phau qua dng kinh camera, an todn vd hieu qua. Cac phlu thuat vien cd kinh nghiem ve md ndi soi cd the thuc hien, bao dam dugc hieu qua dilu tri lam sang va ddc biet Id mang tfnh tham my cao. Benh nhan cd the hdi phue nhanh, nhanh chdng trd lai ldm viee, giam mae cam khi khdng cd seo d cd. Day la lgi diem ldn nhat eua phuang phdp nay. Ky thuat da cd the ap dung cho cac TH budu to, budu da nhan va dac biet la Basedow.
TAI LIEU THAM K H A O
1. Gagner M. Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg I996;83:875
2. Huscher CS, Chiodini S, Napolitano C, Recher A. Endoscopic right thyroid lobectomy.
Surg Endosc 1997;11:877.
3. Palazzo FF, Sebag F, Henry JF. Endocrine surgical technique: Endoscopic thyroidectomy via the lateral approach. Surg Endosc 2006 ;20; 3 3 9-42
4. Puntambekar Shailesh P ; Endoscopic thyroidectomy: Our technique, Joumal of minimal access surgery: 2007, volume 3, 91-97
5. Trinh Minh Tranh, Tran Thanh Vy - Sii dung khung nang da trong phau thuat ndi soi tuyln giap tai BV Nhan Dan Gia Dinh - Hgi nghi phlu thuat ndi soi toan qudc Idn I Ha Ndi 2006.