HOI NGHj KHOA HOC LAN THLf IV • HOI TIET NIEU - THAN HOC VIET NAM
KET QUA CAT THAN MAT CHUTC NANG B A N G P H A U THUAT NOI SOI TAI BENH VIEN VIET DUfC NHAN 86 TRlTONG HOP
D6 Trucmg Thanh, Le Nguyen Vu, Vu Nguyen Khai Ca, Hoang Long, Nguyen Quang(*)
TOMTAT
Muc tieu: Trong giai doan 2005-2010 khoa phau thuat tiet nieu benh vien Viet Diic da thUc hien BP rudng hgp cat than mat chu'c nang bang phau thuat ngi soi. Nghien ciiu ciia chiing tdi nham muc dich danh gia tinh hieu qua, miic do an toan va nhCi'ng kinh nghiem tii 85 benh nhan nay, de cd the phat trien ky thuat nay rgng hdn trong dieu trj cac benh ly ciia than.
TU lieu va phUdng phap: Tii thang 1/2005 den thang 6/2010, 86 BN dUdc chan doan va dieu tn phau thuat than benh ly lanh tinh mat chiic nang do cac nguyen nhan: 63 Bn sdi tiet nieu soi than, be than nieu quan gay than uT nUdc mat chiic nang, 6 Bn hep khuc ndi be than nieu quan than mat chifc nang, 25 Bn teo than, 2 Bn hep nieu quan 1/3 dUdi sau md.
Ket qua: Trong 86 trUdng hdp cat than ngi soi qua phiic mac (61), va sau phiic mac (25) chung tdi khdng cd bien chu'ng nao trong va sau md. Thdi gian md trung binh la 83 phut (ddi vdi phlu thuat sau phuc mac) va 95 phut vdi phau thuat trong d bung. Thdi gian nam vien tii 3 den 6 ngay, trung binh la 3,9 ngay.
Ket luan: Phau thuat cat than ngi soi la phUdng phap an toan, hieu qua, giup benh nhan hoi phuc sdm sau md.
Tii khoa : Phau thuat ngi soi cat than mat chiic nang.
SUMMARY:
Objective: During the period 2005 - 2010, the urology department of Viet Due Hospital has
carried out 86 cases of simple laparoscopic nephrectomy. Our study aims at evaluating the efficiency, the safe degree and with drawing first results in order on the treatment of kidney diseases.
Material and method: From fanuary 2005 to fune 2010, 85 patients are selected and surgically treated with diagnosis: benign nonfunction kidney disease due to:
+ Urologic calculus, renal and ureteral calculus causing hydronephrosis 53 cases.
+ Nonfunction kidney due to obstruction of the pel vi-ureteric junction : 6 cases
+ Atrophic kidney: 25 cases
+ Postoperatire restriction of ureter at 1/3 lower section: 2 cases.
- Results/ Among 85 cases of laparoscopic nephrectomy transperitoneal (51) and retroperitoneal(25). There were no peroperative and postoperative complications. Arerage operating time is 83 minutes (with extraperitoneal operation) and 95 minuter (with intra abdominal operation). Hospitalizing time is from 3 to 6 days; 3,9 days on average.
Conclusion: The laparoscopic nephrectomy is a safe efflective method, helping patient to restore soon in post operative time.
Keyword: Simple laparoscopic nephrectomy.
I.
OAT VANof
cdt than la mdt trong nhiing phau thuat nieu khoa dugc ap dung phuong phap ngi soi
Y HOC VIET NAM THANG 11 - SO 2/2010
dau tien. Nam 1991, Clayman [4] la ngudi dau tien thuc hien cdt than phai ndi soi bang duong qua d bung. Ciing nam dd Ferry thuc hien cat than trai ndi soi qua d bung. Hai nam sau 1993, Gaur thuc hien cat than bang ducmg sau phiic mac [5]. Ciing tir thdi dilm nay, phau thuat ndi soi qua thanh bung dugc phat trien mdt each vugt bac. ,
Nam 2002 Hdi nieu khoa chau Au (EAU) [5] sau khi danh gia ket qua tren gan 1500 ca cat than ndi soi, da chap nhan img dung phau thuat ndi soi trong nhiing trudng hgp cat than benh ly lanh tinh mat chiic nang.
Tai Viet Nam, vdi su phat trien ciia phau thuat ndi soi, hau bet cac thao tac md md trong nieu khoa deu cd the thuc hien dugc qua phau thuat ndi soi d bung.
Tir thang 1/2005 din thang 6/2010 tai khoa phau thuat tiet nieu benh vien Viet Diic Ha Ndi da thuc hien cat than bang phau thuat ngi soi cho 86 BN. Vdi ket qua thu dugc tir 86 trudng hgp nay, chiing tdi xin dugc ddng gdp mgt phan kinh nghiem, de ban che nhiing bien chiing ciing nhu tang them dugc nhung lgi diem cua phuong phap phau thuat nay.
II. OOI TUONG VA PHUdNG PHAP NGHIEN CQU
Chung tdi nghien ciiu hdi ciiu nhirng trudng hgp phau thuat cat than mat chiic nang bang phuong phap ndi soi sau phiic mac va trong phiic mac tir thang 1/2005 din thang 6/2010 tai khoa phau thuat tiet nieu benh vien Viet Diic Ha Ndi.
1. Dac diem chung • .' ' Tuoi vd gi&i ; .^' .• . •, . Do tudi trung binh : 49,74± 11,18 ""'' BN it tudi nhat la 20 tudi, ngudi nhilu tudi nhat la 75 tudi.
Nam cd 17 BN, nii cd 69 chilm, ty Ie nu/
nam la 4/1
2. Can lam sang
Tat ca cac BN khi vao vien deu dugc tien hanh xet nghiem he thdng de kilm tra cac chi sd sinh hoa va mau trudc md. :' ,
2.1 Sd luang hong cau, bach cdu deu trong gidi han binh thudng
2.2 Nong dp ure vd creatinin mdu tru&c mo trong gi&i han binh thudng
2.3 Cdc phuang phdp thdm khdm chdn dodn hinh dnh 2.3.1 Chup he tiet nieu khong chudn bi
Vi tri cua sdi qua chup he tiet nieu khdng chuan bi
Vi tri cua soi Sdi NQ ciing ben
Sdi be than Khdng thay sdi
Tonq sd
SolUdng 61 15 10 86
Tv le o/o 70,93%
17,44%
11,53%
100%
Sdi nieu quan chiem ty Ie cao 70,93%).
2.3.2 Kit qud sieu dm: Chan doan hinh thi than, miic do than li nudc. ' ' •
2.3.3 Kit qud chup UIV (Chup nieu do tinh mach)
- 16/86 (18,60%) than bai tilt rdt kem
hinh anh DBT khdng rd.
- 74,41%) than khdng bai tilt khdng thdy hinh DBT.
- 6 benh nhan hep khiic ndi bl than- nieu quan, chup tilp UIV thdi dilm 120' vdn khdng thay hmh DBT (than khdng ngdm thudc).
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HOI NGHj KHOA HOC LAN THLf IV • HOI TIET NIEU - THAN HOC VIET NAM
2.3.4 Ket qud chdn dodn hinh dnh than li nudc CLVT (chup cdt ldp vi tinh) - DVPX (chup ddng vi phdng xa).
Chup CLVT chi dinh bd sung trong cac trudng hgp benh nhan cd tien sir benh than da can thiep ngoai khoa va sieu am chan doan than li nudc do hep khuc ndi BT-NQ va chup DVPX de xac dinh chirc nang than.
3. Chan doan nguyen nhan gay benh ly than mat chuc nang
63 benh nhan sdi tiet nieu, be than nieu quan gay than li nudc mat chirc nang. 6 Hep khuc noi be than nieu quan than mat chiic
nang. 15 Teo than. 2 trudng hgp hep nieu j quan sau md viing tieu khung
III. KET QUA NGHIEN CCfU 3.1. Ket qua trong mo
- Tat ca benh nhan deu dugc thuc hien \ gay me toan than (86/86)
- 21 benh nhan dugc cat than bang ducmg j sau phuc mac, 65 benh nhan duoc cat than !
bang duong trong d bung. i - 25 benh nhan cat than phai, 61 benh '
nhan cat than trai. • -Thod gian phau thuat va dien bien trong mo :
Thdi gian md Rdi loan HA Truyen mau Chuyen mo md
Cat than sau phiic mac 83 phut (70'-90')
0 0 1
3.2 Ket qua sau mo
Cat than qua phuc mac 95 phut (70'-130')
0 0 0
^ ^ ' • \ r •:..-' • - - ^ . , _ ^ , . ,
Dien bien sau mo Chay mau sau md
Phuc hoi lUu thong tieu hoa
NK vet md Ngay nam vien TB
Cat than sau phuc mac 0
1 ngay
0 4 ngay
Cat than qua phuc mac 0
1 ngay
0 5 ngay
3.3 Giai phau benh : Cac benh pham dugc xet nghiem vi the ket luan viem dai be than, j
viem than ke man tinh khdng thay cd hinh anh ac tinh. !
IV. BAN LUAN
Ndi soi qua thanh bung trong tiet nieu bat dau bang phau thuat nao hach, tinh hoan lac cho va gian tinh mach tinh.
Cat than don thuan chi dinh cho nhimg trudng hgp than mat chiic nang va than teo.
Nguyen nhan cua nhiing trudng hgp nay la:
viem than be than man tinh, tac nghen, benh
Iy sdi, chan thuong than, xo hoa than nieu quan, trao ngugc bang quang than, teo than bam sinh. Cat than don thuan ciing chi dinh cho nhiing trudng hgp cao huyet ap nguyen nhan mach mau than va than da nang cd bien chiing. Cac benh nhan trong nghien ciiu cua chiing tdi deu nam trong nhung chi dinh nay.
Trong nghien ciiu nay da sd cac trudng hgp thuc hien bang dudng trong phiic mac
=it\J -M-i Y HOC VIET NAM THANG 11 - SO 2/2010 i ; j t '
(70,9%o). Sd dl chiing tdi sir dung dudng trong d bung la vi da so benh nhan than u nudc d miic do nang. Than gian rat to. Vdi dudng mo trong d bung cd trudng md rdng, giup quan sat va bdc tach than de dang hon.
Theo kinh nghiem cua chiing tdi, vdi nhiing trudng than ir nudc gian to neu sir dung dudng vao sau phiic mac thuc hien phau thuat se rat khd khan vi than to da choan hit viing md. Neu chge hiit cho than nhd lai thi gd dinh than ciing gap khd khan vi khi dd nhu mo than rat mun, khd bdc tach ra khdi td chiic xung quanh, khi phau tich rat de Iam raeh nhu md than, gay chay mau (mac dii khdng nhieu) nhung se lam trudng md tdi, khdng quan sat dugc rd rang. Va dac biet tdi thi phau tich vao cudng than cang khd khan, de gay bien chiing.
Dudng sau phiic mac cd uu diem la tiep can nhanh va true tiep vao cudng than. Ciing ..la dudng md thdng thudng cua phau thuat
mo md. Tuy nhien dudng md nay cd khoang phau thuat hep, hap thu anh sang nen quan sat trong md ban che hon so vdi dudng trong phiic mac. Chiing tdi sir dung chu yeu de cat than teo va than li nudc mat chiic nang, than unudcdd2,3.
Ty le phai chuyen md md la 3-9,4%o [5].
Dudng nhu dudng sau phiic mac thdi gian phau thuat nhanh hon. Ket qua cua chiing tdi thdi gian md trung binh 83 phiit vdi dudng sau phiic mac va 95 phiit vdi dudng trong d bung. Tuy nhien nhung trudng hgp md trong 6 bung dugc chiing tdi tien lugng trudc la phiic tap hon.
Keeley [5] ciing cd ket qua tuong tu vdi 100 benh nhan cat than bang dudng qua phuc mac, d 20 benh nhan sau cimg thdi gian md giam tir 204 phut xudng cdn 108 phut. Biln
chiing phau thuat dudng nhu hay gap d 20 trudng hgp dau tien.
Bien chiing phau thuat cat than ndi soi theo thdng ke vdi sd Iugng Idn benh nhan la:
2,8-37%, ty le chuyin md md la 2,8-10,3%
[5]. Trong nhdm benh nhan cua chiing tdi cd 1 benh nhan phai chuyen md md, dd la trudng hgp teo than do viem than bl than.
Khi phau tich than chay mau Iam tdi trudng md, phai chuyen md md de cat than.
Gill [4] va cdng su thdng ke tren nhieu trung tam thay ty Ie bien chimg la: 16%) va ty le chuyen md md la 6%.
Phau thuat cat than ndi soi dugc coi la mdt phau thuat khd vdi nguy co ldn ve chay mau, ddi hdi ky nang phau thuat phai thanh thao. Thdi gian de hgc va Iam quen vdi phau thuat nay ddi hdi phai keo dai hon.
Theo Wendy Tabor [5] phau thuat cat than ndi soi mang lai nhieu uu diem cho benh nhan: it mat mau, it dau sau md, giam thdi gian nam vien va chi phi cugc md. Sau md benh nhan hdi phuc sdm va trd lai sdm cac boat ddng xa hdi. Cac benh nhan cua chung tdi deu cd thoi gian nam vien ngan (4-5 ngay), thdi gian binh phuc sau md nhanh va khdng cd bien chiing gi dang ke trong va sau md.
IV. KET LUAN
Qua kinh nghiem 86 trudng hgp phau thuat cat than quan NSOB, chiing tdi nhan thay day la mdt phuong tien dieu tri hieu qua va an toan trong nhung trudng hgp than mat chiic nang. Vdi nhung trudng hgp than ii nudc gian to thi dudng qua d phiic mac se de thuc hien phau thuat hon. Dudng sau phiic mac tiep can than nhanh hon nhung trudng md hep khd phau thuat cho nhiing trudng hgp than to nhieu, nhung lai rat hieu qua vdi than teo nhd.
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HQI NGHj KHOA HOC LAN THLT IV • HOI TIET NIEU - THAN HOC VIET NAM
TAI LIEU THAM KHAO
1. Vu Le Chuyen va cong su: Nhung kinh nghiem qua 40 trudng hgp cat than benh ly qua ngi soi 6 bung, Y hoc Viet Nam 8-2005, pp 33-38. • •'^- ' - 2. Nguyen Phuc Cam Hoang, Vfl Le Chuyen,
Nguyen Van An, Nguyen Te Kha, Ngo Dai Hai, Tran Thugng Phong, Tran Quang Phiic: Cat than noi soi sau phuc mac trong than mat chiic nang do benh ly than lanh tfnh: kinh nghiem ban dau qua 24 truong hgp, Y hoc Viet Nam 8-2005, pp 39-47.
3. Hoang Long, Tran Binh Giang, Vu Nguyen Khai Ca, Nguyen Diic Tien, Le Viet Khanh, Nguyen Quang: Cat than ngi soi qua phuc mac nhan 15 truong hgp mo tai
benh vien Viet Dire, Y hgc Viet Nam 8- j 2005, pp 25-30.
4. Gill L S, Clayman R. V, Retroperitoneal and j pelvic extraperitoneal laparoseopy : an | international perspective. Urology, 1998 ; 52 1
: 566-571. -:•••>; "• j 5. Philippe SEBE, Alexandre de la TAILLE, ;
Andreas HOZNEK, Dominique CHOPIN, i Clement-Claude ABBOU, Laurent i SALOMON, Ngphrectomie simple par j laparoscopie rgtropgritongale, Progrls en i
Urologie (2003), 13, pp 577-580 j 6. Phillips N. Urologic Surgery. In: Beny & \
Kohn's Operating Room Technique. 1 Ith ed. St. \ Louis, MO: Mosby Elsevier; 2007: 728-758. \
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