DANH GIA P H A U THUAT N O I SOI TRONG DIEU TRj
VIEM R U O T T H L / A C A P T A I KHOA NGOAI BENH VIEN BACH MAI
Tran Hie'u Hoc
Bg mon Ngoai - Tnfdng Dal hgc Y Ha Ngi
Phiu thuit ndi soi dang ngay cang phd biin vi dugc ip dung nhiiu trong diiu trj viSm rudt thda cap.
Myc tiSu: dinh gia kit qua ciia phau thuat dt rudt thda viem qua ndi soi d bung nhim nhan xet nhdng Uu diim vi vai trd ciia phiu thuit ndi sol trong phit hiSn, xd ly cic tdn thuang phdi hgp vi chin doan viSm rudt thda khd. Bdi tUgng va pbuang phap ngbien cdfu: hoi cdu 307 benh nhin viSm rudt thda dp duge dieu trj bing phiu thuat ndi soi tai khoa ngoai benh viSn Bach Mai trong nam 2007. Kit qua: 307 benh nhan gom
150 nam vi 157 nd, tudi tha'p nhai 12, cao nha't 82 sau khi phiu thuat va theo ddi cho thay: thdi gian md trung binh 66 ± 24,9 phiit, thdi gian HSt rugt sau md 21,5 ± 13,9 gid; thdi gian dau sau md 1,6 ± 1,4 ngiy;
thdi gian nim vien 2,8 ± 1,9 ngiy, ty IS bien chdng thap: nhiim khuan vit md 0,3%o, khdng cd td vong phiu thuii cd Hnh tham my cao. Kit luan: phiu thuat.ndi soi ed the duge ip dung thudng quy trong diiu trj vISm rudt thda dp d cic ca sd y te, dac b/ef cd gii trj trong trudng hgp chan doan khd va phit hien dc tdn thuang phd'i hgp nhu u nang budng trdng, viSm phan phu...
Tit khda: phau thuat noi soi, viem ruot thifa cap
L D A T V A N D E
Viem rupt thfla I I mpt c i p ct'fu thfldng gap n h i t trong sd d c benh ly c i p cflu ve bung vdi t'y"
le gan 50%. Trong n h i i u nam cho tdi thap ki 80, p h i u t h u | t md kinh dien cat rupt thfla viem qua dfldng rach hd chau p h i i v l n I I phflpng p h i p dflpc Ifla chpn. Ke tfl khi K. Semm rdi Schrieber thtfc hien cat rupt thfla qua ndi soi va dae biet la sau trfldng hdp eat tui mat qua npi soi cd video hd trp cua P.Mourret thi p h i u thuat cat rupt thfla qua npi soi d bpng da dflpc nhieu ngfldi chu y. Phflpng p h i p cat rupt thfla qua npi soi d bpng da td ra cd n h i i u flu diem vfldt trpi so vdi p h i u thuat md md kinh dien [7, 8, 9, 10].
0 nfldc ta, p h i u thuat npi soi dieu trj viem rupt thfla c i p da dflpc I p dung k h i phd bie'n d nhieu cPsd y t e [ 1 , 2, 3, 5, 6]. Tai khoa ngoai benh vien Bach mai Ha npi, p h i u thuat npi soi d bung cat tui mat dflpc thflc hien tfl 1993 va I p dung eho dieu trj viem rupt thfla c i p tfl 1996. Chung tdi thtfc hien nghien cflu nay vdi muc tieu:
Danb gia kit qua ciia phau thuat cat rugt thda viSm qua ngi soi d bung; Nhan xet vai tro cua phau tbuat ngi soi trong pbat hien, xd ly cac tdn thuang phdi bap va chan doan viem rugt
tbda kho.
II. DOI TU'ONG VA P H U O N G PHAP NGHIEN CL/U
1. Ddi tuong nghien cu'u
Tat c l cac benh nhan cd c h i n d o l n sau md I I viem rupt thfla cap dflpc dieu trj bang phau thuat npi soi tai khoa Ngoai benh vien Bach Mai trong nam 2007. Loai trfl khdi nghien cflu n l y nhflng benh nhan v i e m rupt thfla c i p nhflng khdng md bang phflpng p h i p npi soi hoac c h i n doan trfldc md I I v i e m rupt thfla cl'p dflpc md bang phflpng p h i p npi soi nhflng c h i n doan sau
md I I benh ly khac. ' 2. PhUOng phap nghien cu'u
Nghien cflu hdi cflu md ta va phan tfch hd so benh an dfla vao cac chi sd sau:
+ Tudi, gidi, cic trieu chflng lam sang va can lam s i n g de chan doan I I viem rupt thfla c i p . Chu y tien sfl md cu d bung.
-1- Trong md d i n h g i l tinh trang rupt thfla viem, cae tdn thflpng phd'i hdp k h l c v l c l e h thflc xfl ly.
+ Sau md theo ddi de p h l t hien e l e bie'n chflng nhfl d c trfldng hdp md bung thdng thfldng.
3. Xfl ly sd lieu
sd lieu thu thap dflpc xfl ly bang thd'ng ke y sinh hpc.
I I I . K E T Q U A 1. Dac diem chung
Tudi va gidi: trong 1 nam tfl t h i n g 1/2007 den het t h i n g 12/2007 cd 307 benh nhan dfldc d i i u trj viem rudt thfla c i p bang p h i u thuat npi soi bao gdm 1 50 nam va 1 57 nfl, tudi t h i p n h i t la 1 2, tudi cao n h i t la 82. Phan chia nhdm tudi dfloc ghi nhan trong b l n g 1.
Bang 1. Pban chia nhom tudi
Nhom tudi n (%)
1 2 - 2 0 21 - 30 31 - 4 0 41 - 5 0 51 - 6 0 61 - 70 71 - 72
> 8 0
62 9 6 . 58 37 40 9 4 1
(20,2) (31,3) (18,9) (12,1) (13,0) (2,9) (1,3) (0,3)
Tdng sd
307 (100,0)Kit qua eho thay benh viem rugt tbda cap cd the gap d mgi Ida tudi va khdng cd sd khac nhau gida hai gidi.
2. Lam sang
- Dau bung: cd 146 benh n h i n (47,6%) t h i y dau khdi d i u d hd chau phai, 1 28 benh n h i n dau
tfl vung khac (thflpng v i , quanh rdn, ha sfldn p h i i ) rdi khu tru hd chau p h i i v l ed 33 trfldng hpp dau d vj tri ngoli hd chau phai.
Hau het d c benh nhan d i u dau lien tuc (267 BN chiem 86,9%), va mflc dp dau am i (297 BN chiem 96,7%).
- Da sd benh nhan cd sdt, nhiet dp trung binh 37,5 ± 0 , 7 .
- Thdi gian tfl luc dau bung den khi dfldc md trung binh 25,6 ± 14,8 (sdm n h i t I I 8 gid v l cham n h i t 100 gid).
- Chan d o l n trfldc md dfldc ghi nhan trong b l n g 2.
Bang 2. Chan doan trUdc md
Chan doan trUdc mo Viem rupt thfla c i p Nghi viem rupt thfla U nang budng trflng xoan Viem phuc mac khu Viem phuc mac toan
tru thd
n 275 18 2 5 7
(%)
(89,6) (5,9) (0,6)
• (1,6) (2,3)
3. Danh gia trong md
- So'trocars sfl dung: ed 304 trfldng hdp dung 3 trocars (99,0%) va 3 trfldng hdp dung 4 trocar.
- Tinh trang d bung dflpc md ta trong b l n g 3.
Bang 3. Tinb trang d bung
Tinh trang d Khd
Djch trong Dieh due
but ig n
212 63 32
(%)
(69,1) (20,1) (10,8) - Tlnh trang rudt dfnh do v i e m : da sd d c trfldng hop khdng dinh (205 benh nhan chiem 66,8%), cd dfnh it 77 trfldng hpp va dfnh nhieu 25 trfldng hdp.
- Vi trf rudt thfla: 254 trfldng hdp rupt thfla d vj tri binh thfldng (82,7%), sau manh trang 33 va vj
trf khac 20 trfldng hdp (dtfdi gan, trong tieu khung). ,.:i
- Cac tdn thtfong khac t h i y dfloc trong khi md:
-I- Cd u nang budng trflng: 3.
-I- Nang budng trflng c h l y m l u : 1.
+ Vd nang De Graff: 2. .. , + Viem phan php: 4.
+ Viem rupt thfla d benh nhan cd xoan trung trang: 1. ' • .
+ U rupt non: 1. "' •' '•
- Cat rupt thfla.
+ Xfl ly mac treo: chu ye'u bang ddt dien (294 trfldng hpp chiem 96,7%), budc chl 12 trifdng hdp va dflng stapler 1 trfldng hpp. , . ; , , , , ,H
+ Cat rupt thtfa xudi ddng 292 trtfdng hdp (95,1 %) va c i t ngtfpc ddng 1 5 trfldng hdp.
+ Xfl ly gd'c rupt thfla: chu yeu la that gd'c b l n g endo - loop tfl tao hoac clips, gan d l y chung tdi cd dung Hem - o - lok.
+ L i y rupt thfla trflc tiep qua trocar 281 trifdng hpp va cho rupt thfla vao tfli nylon de l i y d 36 benh nhan.
- Tai bien trong md: cd 3 trfldng hdp bj chay m l u tfl dpng maeh rupt thfla dflpc xfl ly bang clip hoac dd't dien, ngoai ra khdng cd tai bien k h l c .
- Rt'fa d bpng va dan Itfu.
+ Tie'n hanh rfla d bung cho 40 trtfdng hdp va khdng rt'fa 267 trtfdng hpp.
+ Dan lflu d bung thtfc hien d 36 trtfdng hpp.
- Chuyen md md: 5 trifdng hpp, trong dd 4 trfldng hop vl dfnh rupt va 1 trtfdng hpp do het CO2 gifla cupc md.
- Tdn thifpng g i i i p h i u benh ly:
- Thdi gian p h i u thuat trung binh 66,5 + 24,9 phut (nhanh n h i t 30 phut va lau nhat 180 phut).
Bang 4. Tdn thuang giai phau benh
Ton thUdng giai Xung huyet Viem mu Hoai tfl Thung
phau benh n 131 145 14 17
(%) (42,6) (47,2) (4,6) (5,6)
4. Dien bie'n sau md
- Thdi gian benh nhan nhu ddng rupt trd lai trung binh 21,5 ± 13,9 gid (sdm n h i t la 8 gid va cham n h i t I I 72 gid).
- Thdi gian benh nhan cd dau sau md trung binh 1,6 ± 1,5 ngay (ngan n h i t 1 ngay va dai n h i t la 4 ngay).
- Thdi gian nam vien trung binh 2,8 ± 1,9 ngay (nhanh n h i t 1 ngay va lau nhat I I 10 ngay).
- Nhiein trung vet md: 1 trfldng hop.
- Tfl vong: khdng cd trtfdng hdp nao. '•• '• , .;
IV. BAN LUAN
1 . Vai trd cua noi soi d bung trong viec phat hien va xu' ly cac tdn thUdng phdi hdp hay cac bat thudng trong md va chan doan viem ruot thfla kho
Do tfnh phflc tap va da dang ve benh d n h lam s i n g cua viem rupt thfla ma d c t i c g i l trifdc day da gpi la " d c benh viem rupt thfla". N h i i u trfldng hpp chan doan khd mac du cd sfl hd trd cua d c phtfong tien hien dai, ngtfdi t h l y thude p h i i chpn lfla eh! dinh md hay khdng md vdi mpc dfch g i l m ty le md n h i m nhflng cung tranh d e bien cht'fng neu de mupn. Trong trfldng hdp nay p h i u t h u | t npi soi cd tfu diem la ed the x l c dinh c h i n d o l n rupt thifa viem hay p h l t hien tdn thtfong k h l c , dac biet n h i t la dd'i vdi nhflng phu nfl d dp tudi sinh de. Trong thdng ke nay cd 11 trfldng hdp cd benh phdi hpp thi 10 benh nhan la phu nfl tudi sinh de gdm: nang budng trflng 3; vd
nang DeGraff 2; nang budng trflng e h l y m l u 1;
viem p h l n phu 4. T i t d c l e trfldng hdp nay d i u dtfdc xfl ly bang p h i u thuat npi soi mdt d c h thuan tien m l khdng p h i i chuyen difdng md hay keo d i i dtfdng md nhfl trong md md. Cd 32 trfldng hdp cd djch due hoac mu trong d phue mac da difpc rfla sach k h i de dang.
Vdi vai trd chan d o l n , npi soi d bung md rpng khai niem "ndi soi c h i n doan" trong d c trtfdng hop nghi ngd benh ly bpng ngoai khoa ndi chung va nghi viem rupt thfla ndi rieng [3]. Chung tdi cd 20 trfldng hdp c h i n doan trfldc md nghi viem rudt thfla, npi soi phat hien 2 trifdng hdp u nang budng trflng va 3 trfldng hpp viem p h i n php.
2. Tinh tham m-y va dp an toan ciia phau thuat
»ngi soi
Vdi vet md thdng thfldng trong viem rupt thfla difpc thay the bang d c vet rach nhd de dat trocar d nhflng vj tri khd p h l t hien mang lai tlnh t h i m my tdt, n h i t la nhflng trfldng hpp md khd hay ed tdn thflong phd'i hdp e i n p h i i md rdng dfldng md.
T i t d cac nghien cflu deu khang djnh tfu diem nay cua phau thuat npi soi [ 1 , 2, 5, 6, 7, 9, 10].
Mpt sd'tac g i l edn I p dpng phau thuat npi soi eho d c trifdng hdp viem rupt thfla d phu nfl cd thai va da chflng minh tfnh hieu q u i va an toan cua nd [1]. Trong nghien cflu nay khdng cd trfldng hdp nao dflpc tien hanh d php nfl cd thai, chung tdi se I p dpng va thdng b l o ke't q u i d mpt b l o c l o sau.
3. Ke't qua ciia phau thuat
- Tai bien trong md: cd 3 trtfdng hdp bj c h l y mau trong khi md dflpc xfl ly ngay. Hai trfldng hdp bj c h l y m l u tfl thanh bung ndi dat trocar l O m m , mpt dtfdc xfl ly bang ddt dien va mpt bang khau e l m m l u . Mot trfldng hdp c h l y m l u tfl ddng mach rupt thfla dtfpc cam mau bang ddt dien.
H l u het d c benh nhan cua chung tdi dtfpc xfl ly mac treo rupt thfla bang ddt dien nhfl n h i i u t i c g i l I p dung [2, 3, 5]. Chung tdi khdng gap c l e tai
bien khac trong sd 307 benh nhan md nam 2007, cd the do p h i u thuat nay da dtfpc thflc hien thfldng quy va d c p h i u thuat vien ttfdng dd'i ed kinh nghiem.
- Thdi gian md phu thupc vao tinh phflc tap eua benh ly va trinh dp cua p h i u thuat vien [ 1 , 2, 3, 5, 7, 8, 10). Thdi gian md cua chung tdi trung binh la 66,5 ± 24,9 phut ttfdng tfl nhfl cua mpt sd t i c g i l : N g u y i n T i n Cifdng 66 phflt [1], Phan K h i n h Viet 43 phut [6], Kum 43 phut [9].
- T'y- le chuyen md md: chung tdi ed 5 trtfdng hdp p h i i chuyen md md (1,6%) trong dd cd 4 benh nhan bj dfnh rupt nhieu khdng the tien h i n h npi soi difpc. Trong 25 benh n h i n dtfpc ghi nhan ed dfnh rupt chl cd 4 trfldng hdp dfnh nhieu mdi p h i i chuyen md md. Mpt trfldng hpp d i n g tiec p h i i chuyen md md vi ly do he't khf CO2 khi dang md gifla chflng. N h i i u t i c g i l cung nhan xet va cd t'y- le chuyen md md tfl 3 den tren 5% [1, 5 , 6 ] . - Nhiein trung vet md: c l e vet md nhd 10mm va 5mm ch! tiep xuc vdi trocar lam g i l m nguy cd nhiem trung tai chd. D l y cung la mpt iiLi diem cua phau thuat npi soi. Chflng tdi ch! gap 1 bien chflng nhiem trung vet md, cung ttfpng tif ket q u i cua c i c t i c g i l k h l c : Tran Binh Giang 0,6% [5], Nguyin T i n Cfldng 2,3% [1], Grandjean 2,3% [8].
- Thdi gian liet rupt va dau sau md
D l y cung la tieu chuan quan trpng d i n h g i l tfu the cua phau thuat npi soi. Thtfc te cho t h i y benh nhan d i u t h i y t h o l i mai va de chiu sau md vi dau It va cd trung tien sdm. Thdi gian cd trung tien trong nghien cflu nay trung binh la 21,5 gid, sdm n h i t I I 8 gid va chain n h i t la 72 gid (benh n h i n nay bj viem rupt thfla va cd dj t | t x o l n trung trlng).. Thdi gian dau, mt'fc dp dau sau md nhin ehung ft hon so vdi md md, trung binh trong nghien ct'fu I I 1,6 ± 1,4 ngay. Ke't q u i nay cung tflong tfl nhfl nhan xet cua n h i i u tac gia k h l c [2, 5, 6, 7].
V . K E T L U A N
P h i u thuat cat rudt thifa viem qua ndi soi d bpng ngay c l n g dflpc ap dung phd bien v l chflng td tinh tfu viet so vdi md md kinh dien. Trong nam 2007 tai khoa Ngoai benh vien Bach mai cd 307 trtfdng hpp viem rupt thfla dflpc d i i u trj bang phau thuat npi soi. Phtfpng p h i p nay cd tfnh an t o l n cao, rut ngan thdi gian hdi phuc sau md va nam vien, ty le bien chflng t h i p v l ed the I p dpng trong c i p cflu thifdng quy.
Phiu thuat npi soi d bung cd flu diem Idn trong viec p h l t hien, xfl ly d c tdn thifong phdi hpp va c h i n d o l n viem rupt thfla khd.
TAI LIEU THAM KHAO
1. Nguyen Tan CUdng, Nguyen Hoang Bac (2001), D i n h gia mflc dp an toan va hieu q u i cua cat rupt thfla npi soi. Tap chf Ngoai khoa, (4), t r 6 - 10.
2. Cao Viet Dung, Tran Ho Nhi (2004). P h i u thuat cat rudt thfla qua ndi soi d bung tai khoa Ngoai tdng q u i t benh vien tlnh K h i n h Hda, Y hpc thflc hanh, 4 9 1 , tr 21 7 - 2 2 1 .
3. D6 Minh Dai va cong sif (2004). P h i u thuat npi soi d i i u tri viem phuc mac rupt thifa. Y hpc thflc hanh, 4 9 1 , tr 227 - 230.
4. Nguyen Hoang Djnh, Nguyen Tan Cudng
(1997), P h i u thuat e l t rudt thfla qua ndi soi d bung. Y hpc TP H C M 4 (1), tr 1 6 - 24.
5. Tran Binh Giang, Le Viet Khanh, Nguyen thj HUdng (2004). Ddi chieu ket qua sdm phtfdng phap p h i u thuat npi soi d bung va md bung kinh dien dieu trj viem rupt thfla c i p . Y hpc thtfc hanh, 4 9 1 , tr 249 - 2 5 5 .
6. Phan Khanh Viet (1998). So s i n h p h i u thuat kinh dien va p h i u t h u | t npi soi d bung trong eat rupt thfla viem c i p . Luan van thae sT Y khoa, Trfldng Dai hpc Y H I Npi.
7. Cristalli B. et al (1991). " Appendicectomie intraperitoneale par coelioscopie: resultats preliminaire d'une nouvelle technique", J. Chir, (128), p 302 - 305.
8. Grandjean J.P, Arefiev A. (1999)
"L'appendieectomie par voie coelioscopie:
reflexions a partir d'une serie homogene de 906 cas", Ann Chir, 53 (4), p 280 - 284.
9. Kum C K . et al (1993) "Randomized controlled trial comparing laparoscopic and open appendectomy". Br.J.Surg, 80, pp 1596 - 1600.
10. Palanivclu C, Rangarajan M , John S J, Senthilkumar R, Madhankumar MV. (2007)
"Laparoscopic appendectomy for appendicitis in uncommon situations: the advantages of a tailored approach", Singapore Med J, 48 (8), pp 737 - 740.
Summary
EVALUATION OF OUTCOMES OF LAPAROSCOPIC APPENDECTOMY FOR ACUTE AP- PENDICITIS AT BACHMAI HOSPITAL
The study was performed in 307 patients with acute appendicitis treated by laparoscopic opperation at Surgical Department of Bachmai Hospital from January to December 2007. The results showed that the laparoscopic operation had several advantages: few complications (infection 0.3%; none death); duration of intestinal paralysation was 21.5 ± 13.9h; pain duration was 1.6 ± 1.4 day; hospital stay was 2.8 ± 1.9 day;
perfect aestheticism. This method was valuable for appendicitis with difficult diagnosis and easy to detect the combinative injury. The laparoscopic operation for acute appendicitis is appicable generally.
Keywords: laparoscopic surgery, acute appendicitis
