Y Hpc VigT NAM THANG 9 - SO'EJIC BlgT/2012
DANH GIA K i T QUA BlTOfC D A U DIEU TRj VIENI RUOT THUTA VA VIEIVI PHUC MAC RUOT THUTA B A N G P H A U THUAT NOI SOI TAI BENH VIEN NHI THANH HOA
Ta Van T6ng, Dodn Nam Hung, Phiing Dii-c Todn vd CS (*)
TOM TAT
Muc tieu: {)anh gia ket qua butfic dau dieu tri viem njot thu& va viem phuc mac ruot thula bSng phau thuat npi soi tal Benh vien Nhi Thanh Hoa.
Oo! tu'dng vd phu'dng phdp: TLT thang 10/2008 den thang 6/2011, 550 benh nhdn viem rupt thij^ va viem phuc mac rupt thCTa du'dc dieu tri bSng phu'dng phap ph§u thuat npi soi tai khoa Ngoai tong hop, B#nh vien Nhi Thanh Hoa.
Ket qua: Trong tong so 550 benh nhan co 384 (69,8%) benh nhan viem mpt thiTa cap, 166 (30,2%) benh nhan viem phuc mac ru6t thu^, ty 1^ nam/ ni? la 1,2/1; ty le chuyen mo md 1,8% d nhom viem phuc mac mot thuci, ty le nhiem trijng vet mo 2,5%, Phau thuat cSt rupt thij:a bang phudng phap npi soi co nhieu ulj diem nhu':
D u ^ ^ mo nho, benh nhan 'A dau sau mo va co tfnh tham my cao. Thdi gian nSm vien du'dc mt ngan, sdm trd lai sinh hoat binh thudng. Giam ti le nhiem tnjng vS mo mot each dang ke. Onhijhg benh nhan beo phi phudng phap nay b^nh phai sir dung du'dng mo Idn.
Ket lu$n: Hien nay mo viem rupt thu^, ke ca viem ruot thCte co bien chuhg bSng phudng phap n^ s(» la mpt phudng phap an toan va hieu qua.
ABSTRACT
TO EVALUATE PREUMINARY RESULTS OF LAPAROSCOPIC SURGERY IN TREATING
APPENDICTIS AND APPNEDICULAR PERITONITIS AT THANH HOA PEDIATRIC
HOSPITAL
Objective: To evaluate preliminary results {*J Benh vien Nhi Thanh Hoa
of laparoscopic surgery in treating appendicitis and appendicular peritonitis at Thanh Hoa Pediatric Hospital Method: From 10/2008 to 6/2011, 550 appendicits and appendicular peritonitis were treated by laparoscopic at Thanh Hoa Pediatric Hospital.
Results of 550 patients: There was 384 (69.8%) patients with acute appendicitis, 166 (30.2%) patients with appendicular peritonitis, the rate of male/female was 1.2/1; conversion rate to open surgery was 1.8% In the appendicular peritonitis group, wound infection was 2.5%, laparoscopic had many advantages such as: Incision was small, postoperative pain was reduced, cosmetic was considerable.
Hospital stay was shorter, earlier return to normal activities, wound infection rates was decreased significantly. In obese patients this appnDach avoided using a large incision.
Conclusion: Currently treatment appendicitis and appendicular peritonitis by laparoscopic is safe and effective.
I. O^T V A N OE
Viem rupt thua cap Id cap cuu ngoai khoa xdy ra cr mpi liia tuoi, gdp hang ngdy 6 mpi ca sa y te, chiem ty le 60 - 70% cdc tnrdng hop cap cuu ve bung.
Viem rugt thira c6 benh cdnh da dsing, khdng CO trieu chung lam sang vd c|in lam sdng dac hieu. Do vay, viec chdn dodn VRT van Id mgt thu thach Idn doi vdi cdc thdy thuoc. Ngdy nay, tuy hieu biet ve viem ruot
C H U Y £ N el: Hpl NGHI KHOA HQC N B A N H NHI KHOA T O A N QUO'C LAN THIJ IX
thCra vi cdc phuong ti$n chan dodn ngiy ctog hoan thi?n nhung ty 1§ viem phiic m ^ do viSm ruOt thiia 6 nude ta v5n c6n r^t cao.
Chjn do4n mu0n vi khong di^u trj kip th6i 14 nguyen nhSn chinh dSn din tinh tr^g viSm phuc miic, ti* cing nh6 thi vi?c chin doin cing kh6 khan vi ty i? viem philc mac cing 16n.
Thing 9. 1889. Ivic Bumey, da g6p phAn quan trpng trong vi^c de ra ky thujt cit rupt thira bing dufmg mo Mc Bumey. TCr d6 din nay, dudng mo b\mg kinh dien niy dupc xem nhu li mpt tieu chuin ving vh m$t ky thu§t de dieu trj viem ru$t th£ia cap.
Phlu thu?t cit ru0t thira npi soi (PTNS RT) dupc Kurt Semm m^t bic sy sin khoa nguM Dire thvc hi?n nSm 1983. Nim 1987 Schreiber da cit mpt truong hpp vi6m ruOt thira qua npi soi. Tir id dSn nay, PTNS RT khong ngimg dupc hoin thi?n vi m6 rpng, din din da di vao thuonag qui.
Tai Viet Nam cung co nhiSu c6ng trinh nghien ciiu ap dung phau thu^t npi soi dieu tri viem rupt thira nhu cua Le Diing Tri, Ph^m Nhu Hiep va cpng su (1999 - 2006) tjii Bpnh vi?n Trung uong Hue, Vu Thanh Minh (2001 - 2003), Phimg Dire Toin (2010) tji Benh vipn Nhi Trung uong.
Tai Khoa Ngo^i tong hpp, B?nh vipn Nhi Thanh Hoa, chung toi bit diu ip dyng rpng Tii md rudt thira viem bing phuong phap npi soi 6 phuc m^c tit thing 10 nim 2008 cho dta nay di frd thinh thudng qui, chinh vi vay de tai dupc th\rc hi?n nhim muc dich dinh gii ket qua cua phau thuat vi rut kinh nghifm qua 550 trudng hpp.
II. Odl TU0NG VA PHUONG PHAP NGHIEN CClU 2.1. Doi tiTQUg nghien clhi:
Gdm 550 bpnh nhan dupc chan doin li viem rupt thira cip vi viem rupt thira cd biSn chiing cd chi dinh phau thu^t bing phuong phip
n0i soi 6 byng t^ii B^nh vi?n Nhi Thanh Hoi Thdi gian tir 8/2008 din 6/2011.
2.2. Phuong phip nghiSn cihi:
Li m^t nghiSn cdu lim sing h6i cim md ti.
2.2.1. Tiiu chuin chfn b4nh nhin : Bpnh nhin viSm ru0t thira cip, viem nipt thCra cd biin chimg viem philc mac khdng cd chIng chi djnh trong phlu thu|t n^i soi 6 byng.
2.2.2. Tiiu chuin lofi trit:
B?nh nhin cd tien sir m6 byng dudng giOa trSn dudi r6n, b$nh ly tim m?ch vi b ^ ly ve phii njng, suy gan, ting ip l\rc tinh m^ch cira, cd rii l o ^ chitc ning ddng miu.
* ChuSn bj bfnh nhSn :
- B$nh nhan dupc mo cip cira d\ra tiSn thim khim lim sing, \tt nglii^m vi si3u im chin doin. Trong trudng hpp khd bpnh nhan dupc chyp CT. Scanner d byng.
- Khing sinh trudc mo : Cephalosporin thi h^ 111 + Metronidazol, doi vdi viem phuc mac rupt thira cd them Amikacin.
* Phuong tien phau thu^t:
- Din miy phau thujt hing Karl - Storz.
- Ap I\rc CO2 d phuc m^c 6- 12nmiHg.
* Phuong phip vo cim: Gay me npi khi quin.
* Ky thu jt mo
- Tu thi b^nh nhan: nim ngijra, diu hoi thip vi nghiSng trii.
- Vi tri phau thu^t vi6n: Phau thu|it viSn chinh dirng ben trii b^nh nhan dii di^n vdi ming hinh, phau tht4t vien ph\i dumg ciing bSn vi bSn phii phiu thu^t viSn chinh, dvng cy viSn dirng doi di^n vdi pliau thu$t vien ph\i.
- Vj tri d^t trocar: mpt troca 10 mm djt ngay vj tri ron, mpt trocar 5 imn hi ch^u phii vi mpt troca 5 mm hi ch^u trii.
- Ky thuft ml: Sau khi d|it trocar 10 nun ngay vj tri rdn theo phuong pliap md Hasson, bom hoi (CO2) vio I phiic mac tir 6 - 12 mmHg, lim lupng 41/p. Sau khi tlidm sit I
10
Y HQC VigT NAM T H A N G 9 - SO 0 ^ 0 BlgT/2012
phiic m^c va quan sat ru^t thira, chgn vi tri thuan Igi dg d^t m^t troca 5 mm d h6 chfiu phdi vd d^t mgt trocar 5 mm ho chgu trdi.
Tim rugt thira, b6c tdch g& dinh n^u rugt thira viem dinh voi cdc t^ing xung quanh. D6t di?n mac treo ru^t thiia bdng dao dien, opt g6c rugt thira bdng hai na chi (dupc 1dm tir ngodi dua vdo 6 b\mg), cdt ru0t thira bdng k6o, ddt niem m^c g6c ru$t thira bdng dao di^n. Doi v6i rugt thira c6 kfch thuac < 10 mm dua rugt thira qua trocar vj tri r6n, neu rugt thira c6 kich thu6c > 10 mm thi b6vdo tui nylon de trdnh vay nhiem vd dua qua vel mo 6 ron. Trong trudng hgp mu lan tod thi djch 6 b\mg dugc l^y nuoi cay, dinh danh vi khuan lam khdng sinh do, 6 byng dugc rira s^ch bdng dung djch NaCI 9%o. D^t dan luu 6 bung khi can thiet.
Kiem tra todn bg 6 bung de phdt hi$n cdc bfnh 1^ kem theo nhu viem tui thira Meckel, viing tieu khung d6i vai tre gdi. Dong lai cdc lo troca.
- Tdt cd rugt thira cdt b5 d6u dirge Iam gidi phau b^nh.
- Giam dau sau mo bdng Paracetamol d^t hau mon.
- B?nh nhan dugc dn u6ng khi co nhu d$ng rugt tra lai.
- B?nh nhan dui^c xuit vi?n khi hk s6t va dn udng binh thuang.
- S6 lugng, gidi tinh, tu6i b?nh nhdn, tinh trang giai phau bfinh rugt thira, phuang phap phau thugt, s6 lo?ii biin chirng, thai gian phliu thuat va qua trinh diiu trj dugc phan tich dua trdn phdn mhm EPI-INFO 6.04.
III. KET QuA NGHIEN c a u
Tir thdng 8/2008 din thdng 6/2011, chiing toi da tiin hanh m6 550 trudng hgp viSm ruOt thira vd viem phiic mac rugt thira
theo phuang phdp mo n0i soi c6 kit qud nhu sau:
- 550 benh nhan (nam 301, 249 ntt), tu6i trung binh 8,9 tu6i.
- 10 tnrdng h(;rp (1,7%) phdi chuyen tir phau thuat ngi soi sang mo md g|p d nhdm benh nhan viem phiic mac rugt thira.
- 124 benh nhdn (22,5%) bi viem phiic mac rugt thira dugc ddt dan luu 6 b\mg, cd 42 b$nh nhdn viem phuc mac rugt thira nhung kh6ng can thiet phdi ddt dan luu.
- Khong CO bien churng trong phau thuat, kh6ng c6 benh nhdn tur vong.
- Bien chijmg sau phlu thudt ngi soi: 15 trudng hgp (2,7%) trong do:
+ 14 b6nh nhdn c6 nhilm trCmg trocar vi tri ron chi cdn diiu tri ngi khoa.
+ 01 benh nhan co biSu hien dau bung can, non, Xquang 6 bung khSng co hinh dnh miic nirdc miic hai trong 6 bung. Trudng hgp ndy diiu tri ndi khoa on dinh.
+ Khong gap trudng hgp ndo c6 dp xe tin du.
- Khong cd bien chiing sau phau thu|it la 535 b?nh nhan (97,3%).
- Thdi gian phau thugt: tCt 20 - 180 phut (trung binh 65 phiit). Thdi gian phau thu^t phu thugc vdo tinh trang rugt thira nhu rugt thira tham nhilm, dp xe, ddm quanh va kinh nghiem cua phau thudt vien.
- Gidm dau sau phau thuat chi dugc dirng trong 24 - 48 gid dau.
- Benh nhan dugc an long sau 24 gid, nhung trudng hgp co viem phiic mac, b?nh nhan dugc an sau 48 gid.
- Benh nhan dugc xudt vien sau 4 - 8 ngdy (trung binh 5,5 ngay) tuy thuSc vdo the trang benh nhan va loai viem rugt thira.
C H U Y E N e g : Hpl NGHI KHOA HQC N G A N H NHI KHOA T O A N QUO'C L A N THI? IX
IV. BAN L U A N
- Phau thuit nOi soi cd uu dilm li mpt phiu thu§t it xam lin, vlt ml thinh b\mg nhd, it dau sau phiu thu§t, hii phyc nhanh hon, thim my tit hon vi it biin chimg sau phiu thu§t. Do dd, phau thu§t cit ruOt thira viem da trd thinh phiu thuit thudng quy cho ci tre em vi ngudi Idn.
- Phit hi$n vi cd chi djnh phlu thu?t dii vdi viem rupt thira cip 6 tr4 em li rit khd khin ngay ci vdi phiu thuit vien cd kinh nghidm. Phiu thuit ndi soi gidp chin doin vi giii quylt mpt cich de ding nlu phit hi?n tin thuong.
- Trong nghien cim cua chdng tdi, nhOng b?nh nhin cd tri?u chung dien hinh dupc mo cip ciiru. Nhihig b?nh nhin cd tri?u chung chua ro ring dupc theo ddi vii gid. Trong thdi gian theo doi, bfnh nhin dupc lim cic xet nghidm vi sieu am, trudng hpp khd dupc lim CT. scanner d bung de cd quylt dinh phai phau thuat hay khdng.
- Phau thuat npi soi dupc thvc hien cho tit ca cic benh nhan, khdng phu thupc tuli, gidi tinh, tinh trang rupt thira viem.
- Trong nghien cim ciia chiing tdi tit ci cac trudng hpp diu chi sir dung 3 trocar, khong phii sir dung them trocar thil 4.
- Phiu thuit npi soi cdn cd uu dilm li cd thi cit rupt thira de ding khi vj tri rupt thira bat thudng nhu d tieu khung, sau manh tring, dudi gan.
- Phiu thuat npi soi cd thi quan sit dupc toin bp d byng, die bi?t nd cd y nghla kilm soit duoc viing tieu khung ddi vdi trd gii.
Trong nghien ciiu cua chung tdi khdng g^p tre gii nio cd nang budng trdng phii hpp.
Phau thuat npi soi cit rupt thira cdn nhilu y kiln chua thong nhit, d^c bi$t ttong viem phiic mac rupt thia. Trong nghien cim ciia chiing tdi cd 166 tre bj viem phdc m^ic
ruOt thiia, phlu thu^t ndi soi giiip cit raOt thira dl ding hon, din luu mil vi rira I bung tit hon.
- Thdi gian phlu thu^t n^i soi cimg dupc tranh luin trong m^t si nghien cuu. Mpt so tic gii cho ring phlu thuit nOi soi mit thdi gian nhilu hon so vdi ml md. Trong nghien cira cua chung tdi, thdi gian phlu thuat npi soi ngin hon so vdi ml md, bdi vi cic b|nh nhin cua chdng tdi dupc phlu thujt vdi phiu thu^t vien cd kinh nghidm Ai dupc dio t^o ve phlu thuit n$i soi I bung tai Bfnh vifn Nhi Trung uong vi Bfnh vifn Vift Due, chi cd 10 trudng hpp phdi chuyin sang mo md vi bfnh nhin din mudn, ruft thira viem hoai td, 0 byng diy dinh nhieu khd bdc tdch. Rupt thira viem cd biin chimg nhu ip xe, thim nhilm quanh ru0t thira, rupt thira vifm vS mil, the tich 6 byng giim, vj tri bit thudng cua rupt thira Id nhiing nguyfn nhin din din keo dai thdi gian phiu thuit. McKinlay vi cpng sy da chiing minh khdng cd sy klidc bift cd y nghia thing ke giiia ip xe tin du sau phau thuit npi soi vi ml md d trf em.
Trong nghien cdu ciia chiing tdi, vifc lau nia sach I byng vi dan luu I mit tot da lim giim rd rft cic biin chung sau phlu thu|t. Chiing tdi chi gap cd 14 bfnh nhin nhiem trirng trocar vj tri rdn, 1 bfnh nhin cd bilu hifn tic rupt, cic bfnh nhin niy chi cin diiu tri ndi khoa In djnh, die bift khdng gjp trudng hpp nio cd ip xe ton du.
- Nhiing uu dilm khic cua phlu thuat npi soi gom: Thdi gian nim vifn ngin, benh nhin binh phyc nhanh hon, thdi gian dau sau phlu thuit ngin hon vd cin liiu giim dau it hon. Trong nghifn ciiu cua chiing tdi, gidm dau chi dupc sur dung trong 24 - 48 gid diu sau phlu thu^t. Hiu hit bfnh nhin cua chiing tdi dupc dirng giam dau chdng viem nhdm Nonsteroid. Bfnh nhan dupc xuit vifn sdm.
Y HQC VigT NAM THANG 9 - s6 B^C BlgT/2012 dieu nay dd 1dm gidm sir lo lang cho gia dinh
bfnh nhan.
V. KET LUAN
1. Phau thu|t ngi soi cdt rugt thira dugc thuc hifn tai Benh vifn Nhi Thanh Hod Id rdt an toan va hif u qud, kl cd viem rugt thira c6 bien chiing.
2. Phau thu|it ngi soi nSn dugc triln khai rong rai cho tdt cd tr6 em bj vi6m rugt thira.
TAI UEU THAM KHAO
1. Tran Binh Giang (2002), Phdu ihugt n0i soi 6 byng, Nhd xudt bdn y hgc.
2. Pham Dire HuSn (2005), "Cap ciiu ngo^i khoa tieu hod", Viem rugt thira, pp.91 -101.
3. Nguyen Thanh Liem (2000), "Vi£m ruft thira cap tinh", Ptiau thugt tiiu hod rre em, Nhd xuat bdn y hpc, pp. 205 - 216.
4. Vu Thanh Minh (2003), "Nghien ciiu iing dyng cdt rupt thijra ngi soi tre em t^i Bfnh vien Nhi Trung uong", Ludn vdn tot nghi?p Bdc sicimyen idioa cdp II. Tnrdng Dgi hgc Y HdNgi.
5. Le D0ng Tri, Ph^m Nhir ffigp, L€ Loc vd CS (2006), "Phlu thuat nfi soi cdt ruft thiJra
viem d tre em: Kinh nghifm qua 500 trucmg hgp t^ii BVTW Hue", Tgp chi y HQC th\tc hdnh.
6. Phiing Dd-c Todn (2010), "Nghifin cuu d§c diem lam sang, c$n lam sdng vd ket qud dieu trj phau thudt nfi soi viem phuc mgc rugt thiJra 6 tre em tgi Bfnh vifn Nhi Trung ucmg", Lu^n vdn tdt nghi?p Thgc sp chuyin ngdnh ngogikhoa, Trudng Dgi hgc YHa Ngi.
1. McKinlay R, Neeleman S, Klein R, et al.
Intraabdominal abscess following open and laparoscopic appendectomy in the pediatric population. Surg Endosc. 2003;17:730-733 8. Kara E Hennelly, Richard G Bachur.
(2009), "Pediatrics, Appendicitis", Emedicine.
9. Thambidorai CR, Aman Fuad Y. (2008),
"Laparoscopic appendicectomy for complicated appendicitis in children", Singapore Med J. 49(12), pp. 994.
10. Wojciech Korlacki, Jo zef Dzielicki.
(2008), "Laparoscopic Appendectomy for Simple and Complicated Appendicitis in Children—Safe or Risky Procedure", Surg Laparosc Endosc Percutan Tech, 18(1), pp.
29-32.