Nghien cihi Y hoc Y Hoc TP. Ho Chi Minh * Tap 18 * So 1 * 2014
KET QUA DIEU TR} VIEM RUOT THl/A CAP BANG PHAU THUAT NQI SOI MOT VET MO QUA RON TAI BENH VIEN 198
Phan Sy Thanh Hd', Trdn Minh D^o*
TOM TAT
Dat van de: Plidu thuat ngi soi mot vci mo'qua roil dieu tii viem ruot thim Id mot phuang plidp mdi.
Muc tieu: Ele tdi nhhn ddnh gid tinh an todn, hieu qua vd kel qud cua phau thuat ngi soi mgt vii cat ruot thira.
Phuong phdp lighten ciiu: Nghiai cuu tidi dru mo td trai 33 BN viem mgt thiea duac phdu thudt noi soi mgt vii mo tai Badi men 198 tir 10 thdng 6 ndm 2011 ddi 31 thdng 12 ndm 2013.
Kii qua. Co 90,9%> i-uoi thiea n&m d vi tii bmh thieang, viem ruot thiea mu chidn uu thi'81.8%. Mot benh nhdn mdn phuc mqc todn thi'chiem ty li 3%. Ty li 0 than cong: co 2 benh nhdn chidn ty le 6%. Khong co trudng hap ndo phai chuydi qua monoi soi truydi thdiig. Thdi gian phau thuat trung binh 45.7 phut. Nhiim triing vel mo chiem ty lc3%. Thdi gian dieu tii ti-ung binh 4.8 ngdy. Kei qud dieu tri t^: 97%.
Ke't ludm Phau thuat ngi soi mgt vii mo cdt ruot thim Id an todn, hieu qud mang tinh tliShi my cao, co thcap dung toi cho vidn ruot thiea co chua co bidi diung. Vdi kii qud toi 97%>.
Titklwa- Plidu thudt ngi soi mgt vel md'qua ron dieu trj viem nigt thua.
ABSTKACT
SINGLE INCISON LAPAROSCOPIC SURGERY TREATMENT OFAPPENDICTUS AT 198 HOPITAL Phan Sy Thanh Ha, Tran Minh Dao
* Y Hoc TP. Ho Chi Minh * Vol. 18 - No 1 - 2014:70 - 74 Background: Single indson laparoscopic surgery (SILS) treatmait ofappatdidtis is a new method Objectives: Subject evaluate the safety, effidaicy and the results ofa SILS appendidtis.
Methods, prospective stiidy. 33 patients with appendidtis is SILS at 19.8 hospital 10 June 2011 to 30 December 2013.
Results: Tha-e were 90.9% located in the appaidix normal, appaididtis pus dominant 81.8%. One patient with perioiiitis overall ocaipancy rate of3%>. Patient put tivo port account for 6%. The average surgicd time 45.7 minutes. Wound infection rate accounted for 3%. The average duration oftieatinait 4.8 days. Good tieatments rcsuls 97%.
Conclusions- SILS treatmaits appaididtis is safe, ejfedive high aesthetic There may well apply for appendidtis without complication. YJith 97% good results.
Keywords: Single indson laparoscopic surgery (SILS) treatma^ of appaididtis.
DAT VAN DE nguyen ly co ban ciia phlu thu^t npi soi tmyen
I
Viem mot thua cap la mpt cap cuu ngoai thong, cac phau thuat vien va cac nha san xuat khoa hay gap nhat, chiem 60-70% trong cap aiu , .'*°"« " ^ ^ " ^ ^ "™ ^ ' ' ' ^ " ' ' ' " ' " ^ ^ bung va xay ra o moi liia tuffiM. Dya tren ' ' ' ™ P " " * " ^ ' " * ' " " ' '^ 1 " ^ *^'"' * ^
• Khoa ngoai tong hop - Benh vien 198, Bg Cong an - Ha Noi.
mgii l,i„ he ThS.Bs. Phan Sy Thanh Ha DT. 0982882033 Ema,l drhal98@t!mail.com
'" Hpi Nghi Khoa Hpc Ky thuat BV. Binh Dan 2014
Y Hpc TP. Hb Chi Minh * Tap 18 * So 1 * 2014 Nghien cmi Y hpc nhap toi t h i ^ ngay cang tia nen it tham nhap
hon niia voi viec sir dung cac dung cu phSu thuat CO kich thuoc nho hon (mini- laparoscopy)t^» sii dung it cong thao tac hon va lua chon duong mo theo 16 tu nhien ciia ca the voi muc dich khong de lai seo va giam thieii bien ehung do phau thuat gay nen. Nam 1992, Pelosi la nguoi dau tien cat nipt thua \'iem mpt cong duy nhat b&ig single - port tu chei^'-*'. Ngay 18/6/2009 hgi nghj phau thuat noi soi chau Au Ian thii 17 to diuc tai Thuy Sy da cong nhan ky thuat mo khong s?o nayP). Cho deh nay cat mot tfiua viem bang phau thuat npi soi qua mpt vet mo da dupe trieh khai tren the gioi va 6 Viet Nam nhung no duoc tien hanh vdi nhieu ky thuat va dung cu khac nhauP^i. Van de trang bi dung cu chuyen dung nhu Multripor va cac dung cu phau thuat co khop xoay... cho phuong phap phau thuat nay con kho khan. Chung toi buoc dau tien hanh cat mot thiia viem qua mpt vet mo a ron bSng dung cu phau thuat npi soi thong thtrong nham tim hieu chi dinh, danh gia ket qua cua ky thuat nay.
DdlTUpNG-ffll/ONGHIAPNGHIENCUU Doi tirong nghien cmi
Gom 33 BN duoc chah doan la viem nipt thiia cap co hoac khong co bien ehung dugc phau thugt ngi soi cat mot thua viem qua mpt vet mo tai Khoa Ngoai Tong hpp - Benh V i ^ 198. Tu 10 thang 6 nam 2011 den 31 thang 12 nam 2012.
Fhutmg phap nghien cmi Nghien ciiu mo ta tien cihi.
Phuong phap phau thu^t
Dyng cy; sii dung dung cu phau thuat npi soi thong thuong, optic 30° qua trocar 10mm.
Phuong phap vo cam: me ngi khi quan.
Vi tri aia kip phau thu$t va tu the BN va dan may mo npi soi giong nhu phau fhuat ngi soi thong thuang.
Cac buac tien hanh ky thuat chiing toi rach da theo vong tron ciia ron 2,5-3cm vao mpt
trpcar 10mm 6 gjua \a 2 trocar 5mm hai ben.
Mac treo mgt thua dupe dot b ^ g dao dien don cue, goc mgt thiia dupe that bang no chi Roeder dua tu ngoai vao. Benh phain dixoc lay qua bao cao su co buoc sgi day chi dai vao vanh bao cao su qua trocar 10mm \"a keo spi chi nit bap ra (benh pham) ra duai huong dan ciia camera. Khau vet mo.
Cac chi tieu nghien cmi - Dac diem ehung. gioi, tuoi.
- Tim hieu ve chi dinh.
- Dac diein phau thuat ehi dinh phau tiiuat, tai bien chiing trong va sau mo, thdi gian phau thuat, dau sau mo, thoi gian tnmg tien, thoi gian nam vien.
Danh gia ket qua som sau mo*^
- Tot Dien bien trong va sau mo tot khong sol, dau vet mo it, tnjng tien som, hoi phuc nhanh vet mo kho va khong eo eae bien ehung sau mo.
- Trung binh: Dien bien trong va sau mo tot CO sot sau mo keo dai 2 - 3 ngay, dau vet mo nhieu, vet mo tu mau, li dich hay nhiem trimg va dieu tri ngi khoa dap ling khong mo lai.
- Xau: Gom nhiing truong hpp bi tai bi&i trong mo nhu thuang ton maeh mau Ion, thuemg ton rupt vk cae bieh chiing: buc mom mpt thira, ro manh trang ap xe ton du, ap xe thanh bung, tac rupt
KETQUA D|ic d i ^ d i u n g Bdng 3.1 Dac didn ve tuoi
Tuoi
Gtcri
Nhom tu6)
< 20 tuoi 2 1 - 4 0 luoi 4 1 - 6 0 t u e i
> 60 tuoi Tong
Nam Ni>
So benh nhan
3 19 11 0 33 19 14
T y l e % 9.1 57,6 33,3 0 100%
57,6 42,4
Hpi N g h i Khoa Hpc Ky thu?t BV. Binh Dan 2014
Nghien cmi Y hpc
- Tuoi thap nhat 18, tuoi cao nhat: 56, tuoi trung binh; 29,5 tuoi
- Ty le nam nhieu hon nii. Ty le Nam/Nii
=1,36.
D^c diem trong va sau phau thuat - Vi tri mpt thua:
+ Ho chau phai: 30/33 chiem ty Ie 90,9%.
+ Sau manh trang 3/33 chiem ty le 9,1%
- Ton thuong mot thiia khi mo:
+ Ruot thua sung huyet 4/33 ehiem ty le 12,1%.
+ Ruot thiia mii: 27/33 chiem ty le 81,8%.
+ Ruot thiia hoai tii 2/33 chiem ty 1^ 6,1%.
- Co mgt benh nhan viem phtic mac toan the chiem ty le 3%
- Ty 1| dat them cong{trocar) 6 vi tri khae: Co 2 BN (6%) phai dat them trocar: 1 BN dat trocar ha vi do CO u nang buong tning chiem ty 1? va 1 BN viem phiic mac toan the dat trocar ho chau phai de lau nia, dat dan luu 6 bung. Khong eo truong hgp nao phai chuyen qua mo ngi soi tmyen thong.
- Thoi gian phau thuat: nhanh nhat 28 phtit, lau nhat 90 phut thoi gian phau thuat trung binh 45,7 phiit
- Tai bien va bieh chiing: Nhiem triing vet mo: 1/33 chiem ty le 3%. Khong co b?nh nhan nao tii vong.
- Thoi gian tmng ti^n sau mo: som nhat 12 gio, lau nhat 48 gio, trung binh 24,5 gio.
- Thoi gian dieu tri trung binh 4,7 ngay. Thoi gian dieu tri tiia'p nhat 3 ngay. Thai gian dieu tri cao nhat 7 ngay.
Danh gia ket qua dieu tri + Tot97%(32/33BN).
+ Trung binh: 3% {1/33 BN).
BAN LUAN
Dac diem ehung va chi dinh phau thuat.
Trong nghien ciiu cua chiing toi co 19 nam
Y Hpc TP. Ho Chi Minh * Tap 18 '^ So 1 * 2 0 1 ^
va 14 nii tuoi trung binh la 29,5 tuoi. Nam chiem ty le 57,6%, nii chiem ty 1| 42,4%. Ty 1^ Nam/Nu
=1,36.
Phlu thuat npi soi dieu tri viem rupt thiia da tro thanh thuong quy a cac benh vien co phlu thuat ngi spi. So vai mo ma thi phlu thuat npi soi mang lai nhieu lpi diem nhu: thoi gian nim vi|n ngin, it dau sau mo va dac bi^t mang lai tham my cao'^'. Noi soi 6 bung de cat mpt thiia lan dau tien dugc thuc hien bai bac si San khoa nguai Diic Kurt Semm''*) thuc hi|n nam 1983. Den nam 1992 lan dau Hen Pelosi da thuc hi?n thanh cong 25 truong hgp viem mpt thua qua mgt vet mo bang Sigle-port tir che(3-''*>. Cho den nay phau thuat npi soi cit mgt thua qua mgt vet mo hay phau thu|t khong seo da dugc ihifc hien bang nhieu ky thuat khac nhau nhu sii dung mpt trocar chuyen dung, sii dung multriport hoac 2-3 trocar qua mot vet mo 6 ron'-'^'^'*'. Va nhieu tac gia da thuc hien noi soi mot vet mo de cat tiii mat, cat lach, cat nang gan... nhung do eae bao cao cae tae gia dimg nhiing dung cu phau thuat va phuang phap khac nhau nen chua di den thong nhat ve ehi dinh ciia phuong phap phau thuat ngi soi mpt vet mo nay. Theo Hong T.H ehi dinh trong truong hgp viem rupt thira chua CO bien chiing viem phiic mac va BN khong CO b^nh ly tim phoi nang kem theo'*'.
Tuang tu nhu vay, Nguyen Tan CuongP', Nguyen Thanh Phong<^> ciing chi dinh cho viem ruot thua chua c6 bien chiing. Ngugc lai, Kim J.H, Lee S.Y«J, Kossi )('> chi dinh cho rupt thiia viem co bien chiing lan chua co bien chiing, cho ca tre em lan nguai lan. Trong nghien cuu ciia chiing toi eo 1/33 BN viem phiic mac toan thC ket qua dieu tri tot. Nhung chiing toi mat nhieu thoi gian (90 phiit), g|p kho khan trong viec lau riia o bung, chpn vj tri va dat dan luu. Nhiing truang hpp viem mpt thua CO bien chiing nhu viem phiic mac, theo chiing toi nen chuyen sang mo ngi soi truyen thong hoac mo mo de nit ngin thai gian phau , thuat va dam bao an toan eho BN.
Hpi Nghi Khoa Hpc Ky thuat BV. Binh Dan 2014
Y Hpc TP. Ho Chi Minh * Tap 18 * So 1 * 2014 Nghien cuu Y hpc
Vi tri, miic do ton thirong rupt thira, kho khan, ty le dat them trocar trong mo.
Co 90,9% mgt thua nam 6 vi tri binh fhutmg va 9,1% mgt thua sau manh trang. Viem rupt tfiua mu diiem uu the 81,8%. Ben canh nhiing uu diem ma phau thuat npi soi tmyen thong da chiing minh dupe thi phSu thuat ngi soi mgt vet mo con CO uu diem'^'^i; mgt vet mo 2,5-3cm 6 ron: ron la noi mong nhat de vao 6 byng. Tranh ton thuong dgng mach thupng vi duoi, bang quang khi ehpc trocar ha vi, giam nguy eo nhiem trung vet mo, khi can thiet co the mo rpng vet mp de lay benh pham, seo mo nho 6 ron nen tinh tham my toi da, su hai long eiia BN cao. Do dieu kien trang bi dung cu phau thuat npi soi chuyen dung nhu cac multriport, cac dung cu co khop xoay con kho khan chiing toi da tien hanh cat mpt thua ngi soi qua mot vet mo voi cac trocar chgc qua can thanh bung 6 ron. Chung toi gap mpt so kho khan; ro ri khi COs trong khi mo, mat tam giac ^ a o tac trong phau thuat ngi soi tmyen thong, cae dung cu hay va cham va xung khic vao nhau. Ross SB**' nhan xet ve lihiing ha che Clia phau thuat ngi soi mpt vet mo:
- Vong ron nho rach da rpng gay bieh dang vong tron ciia ron
- Chi so BMI Ion, thanh byng day anh hucrng den viec sii dung mpt so triport nhu SISL.
- Cac multnport khong phai vien nao eiing sSn CO, gia thanh cao. Dung cu khong dii dai de thao tae 6 cac vimg xa ron 6 trong 6 bung, mat tam giac thao tac trong phau thuat npi soi tmyen thphg ro ri CO: trong Iiic mo.
- Byng CO seo mo cu kho tmy cap vao khoang phiic mac do dinh.
Trong phau thuat npi spi mgt vet mp dii CP dii 3 kenh, nhung dii it hay nhieu ding anh huong toi thao tac ciia phau thuat vien, nhat la trong nhiing truong hop rupt thira nam sau manh trang, viem phiic mac phai lau nia nhieu. Nhihig b-uang hpp nhu vay chiing ta nen dat mot cong (trocar) niia la can thiet nhung khong xem do la that bai ciia phau
thuat. Pham Anh vii c6 1/20 benh nhan can dat them 1 congi-". Trong nghien ciiu aia chiing toi CO 2/33 BN dat them mgt cong khac: 1 BN d ha vi vi phau thu|t boc ung nang buong tning ket hgp va 1 BN viem phiic mac toan the dat trocar ho chau phai de lau nia, dat dan luu 6 byng. Khong co truang hop nao phai chuyen sang phau thuat npi soi truj'en thong.
Thoi gian phSu thua^ thai gian trung t i ^ thoi gian nam v i ^
Thai gian phau thuat phu thuoc nhieu yeu to nhu: ro ri khi CO: trong khi mo, mat tam giac thao tac trong phau thuat ngi soi truyen thong, cac dyng cy hay va ch^m va xung khac vao nhau va bien ehiing ciia viem ruot thira.
Chinh nhiing van de nay da lam cho thoi gian phau thuat cua chiing toi keo dai, nhung dan dan van de ky thuat mo ding dugc lam quen va tro nen thanh thao. Thoi gian phau thuat trung binh eiia ehiing toi la 45,7 phiit Hong T.H CO thai gian mo trung binh la 40,8 phiit, Pham Anh Vu khi mo bang cong single-port cua SILS 12nnm Covidien co thoi gian phau thuat trung binh 40 phiif*', Nguyen T&i CuongP' khi cat rupt thira bang trocar ehuyen dung CO thai gian phau thuat trung btnh la 27,6 phut. Nguyin Thanh PhongP'la 25 phiit Thai gian trung tien trong nghien eiiu aia ehiing toi la 24,5 gio. Thoi gian nam vien trung binh Clia chiing toi la 4,7 ngay trong do benh nhan viem phiie mac co thoi gian nam vien dai nhat 7 ngay. Nguyen Thanh Phong^^' 2 ngay, Nguyen Tan Cu6ngP> la 2,1 ngay. Thai gian nam \ien tmng binh phu thuoc vao tinh trang mgt thiia, tinh chat cupc mp, tai bien, bien ehung sau mo va do day la buoc dau trien khai phau thuat moi.
Tai b i ^ bieh chiing va ket qua.
Tai bien va bien chiing eua phau thuat npi soi mpt vet mp cat rupt thira: chiing toi co mgt truong hgp nhiem trimg vet mo chiem ty le 3%.
Con Stallfil A.B ghi nhan co 14,6°<> bieh chiing sau mo. Hong T.H co 9% bien chiing sau mo
Hpi Nghi Khoa Hpc Ky thuat BV. Binh Dan 2014
Nghien cuu Y hpc
gom 2 ap xe ton du va mgt ap xe vet m&^^\ Con cac tac giaf^'-^' khong co tai bien \'a bien chiing sau mo. Nhiing Ipi ich mang Iai eho BN la dang ke, ve tiiaim my cat mpt thira mgt duang mo la tien bg Idn khi phuong phap nay mang den cho BN phau thuat khong thay seo. Ket qua dieu tri tot chiem 97%, bimg binh: 3%.
KETLUAN
Ph3u thuat ngi soi mpt vet mp cat mpt thira la an toan, hieu qua mang tinh tham my eao eo the ap dyng tot cho viem mot thira co chua co bien chiing. Vdi ket qua tot 97%.
TAI LIEU THAM KHAO
1 Kosa J and Luostannoi M (2010) "Iiubal Expenertv of the Feaabilitv of Smgle-Inasion Lapaiocopc Appendietomy in Different Clinical Conditions". K a g n Ther Erdosn 2D10:
240260 Doi 10-1155/2(110/240260
2. Nguyen Twi Cirong D6 Hiiu Liet Le Tran Diiu Tin (2008)
"Cat rupt thua npi soi vai mpt trocar rrai". Hpi n g h Ngo?]
khoa va p h l u thu^t npi soi toan QuSc n i m 2008 Y Hiu: TP Ho
Y Hpc TP. Ho Chi Minh * Tap 18 * So 1 * 2014
Chi Minh - T^p 12'Phv ban so 4 Tr 126-129.
Nguven Thanh Phong, Nguyin Dang Pha'n (2011) "Cat nipt thira n ^ SOI mot duong m o qua ron v<n 2 trocar" Ngoji khoa so d ^ b i ^ so'^5,6 - D ^ hgi phau thuat ngi soi Chau a - Tliai Binh Duong(ELSA) lan thii l a Tr 96-102.
Fham Anh Vii, Hiam N h u Hiep, P h s m Minh Ehk c o i l ) "Ket qua binic dau irng d i ^ g phau Ihulit n ^ soi mpt craig". T^p cH y hpc thyc hanh so 5(765): Tr 142-144.
Phan Sy Thanh Ha, Tran M n h Dao (2011), "Nhan xet 54 trucmg hpp v i e n phiic mac mpt thua dui^c dieu tri bang phau thugt rpi soi". Tap chi Y hpc quan su. So 267, Thang 9-10. Tr 39-41
Ross SB, Oaric CW, Morton C A and Rosemurgy AS (201C5
"Access for LaparoseOfric smgle site suigety". CNa^iotics and Therapeuhc Endoscopy Volume 2010 Ajlicle ID 943091, 7 pages. Do] 101155/2010/943091
Tri?u Tneu Duong, H o Hiiu An, Nguyen Manh Chung (2011)
"ling dyng phirong phap m o n ^ soi mpt lo qua real dieu UJ b | n h viem tui m|it t4ii Benh vien T W { ^ 108" T?p chi Y - Dupe hpc quan sv so chuyen de ngoai bung Tr44-50.
Ngdy nhdn bdi bdo: 03/10/2013 Ngdy phdn bien nhan xet bdi bdo: 01/12/2013 Ngdy bdi boo duac Sang. 20/02/2014
^
Hoi Nghi Khoa Hoc Ky thuat BV. Binh Dan 2014
