HOI NGH! KHOA HOC LAN THLf IV • HOl TIET NIEU - THAN HOC VIET NAM
PHAU THUAT NOI SOI 6 BUNG TRONG SA SAN CHAU
G A Y T O N THLfONG N A N G HE TIET NIEU
• • •
D6 Nguyen Phuong*, Tran Quang Phuc **, Nguygn Thi Nga**
Chau Quy Thuan***, Tr^n Trong Tri***, Tran Ngoc Sinh*** va cs.
TOMTAT
Dat van de: Sa sinh due (SSD) la benh kha phd bien d benh nhan Idn tudi, man kinh, sanh nhieu ian Benh gay nhieu phieu toai trong sinh hcc .dng ngay ciia benh nhan cung nhu* cac bien chu'ng tai cho hay tren du'dng tieu hda, tiet nieu.
Phu'dng phap nghien cii'u: Nghien cii'u md ta, cat dpc, tien ciiu.
Ket qua: TiC thang 04/2004 den 04/2010, tai Benh vien Chd Ray va Benh vien Da Khoa Kien Giang cd 34 TH SSD the nang du'dc phau thuat npi soi cd dinh san chau vao mdm nhd xu'dng ciing bang lddi. Trong dd, sa tiT cung dp III CO 14 TH, sa t i i cung dp IV cd 14 TH va sa vom am dao cd 6 TH. Tudi trung binh 67,03 (48- 88), thdi gian mo trung binh 234,2 phiit (115- 400), tai bien trong mo 1 TH (2,9%), bien chiing sdm sau md 1 TH (2,9%), thdi gian nam vien trung binh 7,76 ngay (4-25), khdng cd TH nao chuyen md md, khdng TH nao that bai hay tai phat.
Ket luan: Phau thuat npi soi o bung cd dinh san chau vao mdm nhd xu'dng ciing dieu tn SSD the nang la phau thuat an toan, hieu qua.
SUMMARY
LAPAROSCOPIC SURGERY FOR PELVIC FLOOR PROLAPSE SEVERERY AFFECTING
THE URINARY SYSTEM
Background: Genital prolapse is quite common among older, menopausal, multiparous women. The disease hampeas the patients daily activities and causes local or gastrointestinal.
* Khoa Ngogi BVDK tinh Ddng Thdp,
* * Khoa sdn phu va Khoa Ngogi B V DK tinh Kien Giang,
*'"'-Khoa Tiit Nieu B VCR
urinary complications.
Methods: Descriptive, cross- sectional, prospective study.
Results: From April 2004 to April 2010, at the CHO RAY HOSPTFAL and KIEN GIANG GENERAL HOSPFTAL, the mesh laparoscopic promontofixations were performed on 34 women with severe genital prolapse. The cases included 14 grade I I I , 14 grade IV uterine prolapses and 6 vaginal vault prolapses. The average age was 67.03 (48- 88); the average operative time 234,2 minutes (115- 400). There were one intra- operative accident (2,9%) and one post- operative complication (2,9%). The mean hospital stay was 7,76 days (4- 25). There were no referals for open sugery, no failures or recurrences.
Conclusion: The mesh laparoscopic promotofixation for severe genital prolapse is both safe and effective.
I. OAT VAN OE
Benh SSD cd thi gap d mpi lua tuli.
Tuy nhien, benh thudng gap d phu nii ldn tudi, man kinh va sanh nhieu con. Beilh gay nhieu phien toai cho berth nhan trong sinh boat hang ngay. Nam 1991, Wattiez A. thuc hien phau thuat npi soi cd dinh tu cung vao mdm nhd xuong cung bang ludi de dieu tri sa tu cung va bang quang dau tien [6]. Den nay, phau thuat nay da dugc phd bien rdng rai tren toan the gidi vdi ket qua tdt. CJ Viet Nam, da cd vai tac gia bao cao ve phau thuat nay. Tuy nhien, cac bao cao vdi sd lugng benh nhan
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Y HOC VIET NAM THANG 11 - SO 2/2010
cdn ban che va phdu thuat cd ca ngudi tre tudi va ngudi gia bi SDD miic do tu nhe din nang. De danh gia ket qua cua phdu thuat chi d ngudi ldn tudi cd SSD thi nang va vdi sd lieu ldn hon, chiing tdi thuc hien dl tai nghien ciiu nay. .': •: , - . ^ >:i;
Muc tieu nghien cihi
1. Danh gia tinh an toan ciia phau thuat dua theo: ti le tai bien va bien chiing ciia phdu thuat.
2. Danh gia tinh hieu qua ciia phdu thuat dua theo: miic dp cai thien khdi sa, cai thien cac trieu chiing tai chd, rdi loan tilu, su li dpng nudc tieu, tai phat.
3. Cac yeu td lam sang anh hudng len ket qua cua phdu thuat.
I I . PHU'ONG PHAP NGHIEN CLtU 1. Thiet ke nghien cmi: Nghien ciiu cdt dpc, md ta, tien ciiu.
2. Tieu chuan chon benh: Benh nhan SSD dp m, IV. Benh nhan ddng y phau thuat npi soi.
3. Tieu chuan loai trir: Dang nhilm tning tieu nang, suy than nang, benh ket hgp nang. 3.jv>u:? fi,* :.••...: . -
4. Phuong tien va ky thuat
4.1. Phuang tiin: May ndi soi, dung cu phau thaut ndi soi, bom khi CO2, cat ddt don cue, ludng cue, cat ddt sieu am, ludi polypropylen.
4.2. Ky thugt: Benh nhan nam dau thap 30°. Xii dung 3 hoac 4 trocar: rdn 10 mm, 2 trocar hd chau 5 mm, tren xuong mu 5 mm.
Cac budc tien hanh: tao khoang trdng vung tieu khung. Bdc tach thanh sau am dao, dua ludi khau dinh vao co nang hau mdn hai ben, thanh sau am dao va day chang tu cung cung.
Bdc tach phiic mac tao dudng hdm tu mdm nhd din tiii cung Douglas. Bdc tach thanh trudc am dao. Dat ludi khau dinh mdt ddu vao thanh trudc am dao. Dua ludi len khau cd dinh vao mdm nhd xuong cung.
I I I . KET QUA NGHIEN CU'U
Tu thang 04 nam 2004 din 04 nam 2010, tai Benh vien Chg Ray va Benh vien Da Khoa Kien Giang cd 34 TH SSD thi nang dugc phau thuat ndi soi cd dinh san chau vao mdm nhd xuong cung bang ludi: sa tii cung dp III cd 14 TH, dp IV cd 14 TH va sa vdm am dao cd 6 TH.
Dac diem dan so mau (bang I).
Bang 1: Dac diem dan sd mau
Tudi:
Sd lan sanh: < 2 con 2 - 4 con
> 5 con Tien can cat til cung
Tien can md khac:
67,03 ±11,1 2 TH (5,9%) 8 TH (23,5%) 24 TH (70,6%)
8TH(17,6%) 3 TH (8,7%)
Lam sang: 100% benh nhan vao vien khi cd trieu chiing. Thdi gian khdi benh trung binh 31,26 thang (4 - 48). 100% benh nhan cd trieu chiing lam sang dau tai chd; tieu khd
97,1%). Suy chiic nang than 14,7%), nhilm tning tilu 70,6%. Sa tu cung 28 TH (82,4%), sa vdm am dao 6 TH (17,6%), 100% cd kem sa bang quang. Sa true trang 11 TH (32,4%)).
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HQI NGH! KHOA HOC LAN THLT IV • HOl TIET NIEU - THAN HOC VIET NAM
Ket qua phdu thuat: Thdi gian md trung binh 234,2 phiit (115 - 400). Cd 8 TH (23,5%)) xu tri benh kit hgp trong qua trinh md. Lupng mau mdt trong md trung binh la 92,1 ± 35,1 ml. Tai biln chi cd I TH (2,9%) tu mau vung mdm nhd trong qua trinh bdc tach. Khdng cd TH nao phai truyen mau trong md va chuyen md md. Bien chiing sdm sau md chi cd 1 TH (2,9%)) rd nudc tieu qua dan luu Douglas vao ngay hau phau thii 4, dupc dieu tri ndi khoa dn dinh va xuat vien vao ngay thii 25. Nhiem trung vet md cd 6 TH (17,6%). Khdng cd TH nao tii vong. Thdi gian nam vien trung binh 7,76 ngay (4 - 25).
Ket qua sau khau treo: Tat ca benh nhan SSD diu cai thien ve dp 0 - 1 . Cai thien so vdi trudc md cd nghia thdng ke (phep kilm phi tham sd Cramer'V, p = 0,002).
Khdng cd TH nao tai phat trong qua trinh theo ddi. 100%) sa bang quang va true trang diu cai thien ve dp 0. 100%) bet dau tai chd sau khau treo. Dau vung chau miic dp it sau I thang cd 29 TH (85,3%). 6 thang cdn 3 TH (8,8%). 100%) benh nhan cai thien tilu khd.
100%) benh nhan deu cai thien tdn luu nudc tieu. Cai thien tdn luu nudc tieu sau khau treo so vdi trudc md cd y nghia thdng ke (phep kiem phi tham sd Cramer'V, p<0,0001). Tat ca benh nhan deu hai ldng vdi ket qua phau thuat.
Moi lien quan ciia cac yeu to lam sang len ket qua phau thuat
Tai bien va bien chung sau mo voi sa tir cung hay sa vom: Tai bien trong mo giiia nhdm sa tii cung va sa vdm am dao khac biet khdng cd y nghia thdng ke (phep kilm phi tham sd Cramer's V, p = 0,6). Bien chiing rd nudc tieu chi xay ra d nhdm sa vdm am dao, khac biet cd y nghia thdng ke (phep kilm phi tham sd Cramer's V, p.= 0,02). Biln chiing tieu khdng kiem soat xay ra d nhdm sa vdm
am dao cao hon nhdm sa tu cung cd y nghia i thdng ke (phep kilm phi tham sd Cramer's
V,p = 0,02). , . I Moi lien quan ket qua phau thuat vdi
muc do sa tu cung: Dau vung chau sau khau i cd dinh xay ra d SSD dp IV cao hon dp III co y nghia thdng ke (phep kiem phi tham s6 i Cramer's V, p = 0,01). SSD dp I cdn lai sau ; khau cd djnh deu thudc nhdm SSD dp IV I trudc md va cd thdi gian khdi benh hi 12 1 thang trd len, mdi lien quan nay cd y nghia '' thdng ke (phep kiem phi tham sd Cramer's V, p < 0,05). Thdi gian md d nhdm cd xu tri them benh ket hgp dai hon nhdm khdng xii tri berth ket hgp trong md cd y nghia thong ke (phep kiem T khdng bat cap, p = 0,001).
Thdi gian md d nhdm SSD dp IV lau hon nhdm SSD dp III cd y nghia thdng ke (phep kiem T khdng bat cap, p = 0,017).
IV. BAN LUAN
Trong nghien ciiu cua chiing tdi, tren 50 tudi chiem 94,1%. Ti le benh tang theo nhom tudi. Sd benh nhan sanh 3 den 4 lan cd 8 TH (23,5%)), sanh tir 5 lan trd len chiem den 24 TH (70,6%)). Ket qua chiing tdi tuong tu cac tac gia khac. Tran Ngpc Sinh [3], benh sa sinh due tang theo tudi, sd lan sanh.
Cd I TH (2,9%)) tu mau vung mom nho do bdc tach de cd dinb ludi. TH nay chi khau ep va berth nhan dn dinh den xuat vien.
Lugng mau mat trong md trung binh cua chiing tdi la 92,1 ml. Theo Rivoire C. [5], co 2 TH (1%) tdn thuong khi bdc tach thanh trudc am dao. CCing theo tac gia nay [5], da cd bao cao tdn thuong bang quang tu 2,59 - 4,5% va ton thuong rudt tu 1,29 - 2,27%.
Nguyin Ba My Nhi [1], cd I TH (4.7%) chay
mau trudc xuong cung. j Kit qua chi cd 1 TH (2,9%) bi rd nudc \
tilu qua ddn luu Douglas tu ngay hau phdu j
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Y HOC VIET NAM THANG 11 - SO 2/2010
thii 4 va giam ddn din hit vao ngay thii 21.
Benh nhan dugc dilu tri ndi khoa bao tdn on dinh va xuat vien vao ngay thii 25.
Sau md tdt ca SSD diu cai thien ve dp 0 -I (100%)). Ket qua cua chiing tdi khdng cd TH nao khau cd dinh thdt bai. Tdt ca cac TH sa bang quang va sa true trang diu cai thien vl dp 0. Trong thdi gian theo ddi khdng cd TH nao tai phat. Theo Trdn Ngpc Sinh [2], phdu thuat ndi soi dilu tri SSD thi nang cd ti le thanh cdng 90,9%. Theo Rivoire C. [5], cd 12 TH (11%)) md treo thdt bai. Dau vung chau miic dp nhe sau 1 thang cd 29 TH (85,3%), sau 6 thang cdn 3 TH (8,8%). Kit qua dau viing chau cua chiing tdi cao hon cac tac gia khac, cd thi do tieu chudn chpn benh ciia chiing tdi la SSD thi nang (dp III, IV).
Theo Petros Peter [4], ti le cd trieu chiing nay sau md la 20%). Nguyin Ba My Nhi [I], dau sau viing chau md cd 5 TH (23%)).
Tdt ca benh nhan cua chung tdi (100%) deu hai Idng ve kit qua phau thuat vdi cac miic dp khac nhau. Theo Rivoire C. [5], cd 80% rdt hai ldng, 18%) hai ldng va 2% khdng hai ldng.
V. KET LUAN
Phau thuat cd dinh san chau vao mdm nhd xuong cung bdng ludi dilu tri SSD thi nang la mdt phau thuat an toan va hieu qua.
Ket qua ciia phau thuat cd lien quan din mdt
sd yeu td lam sang nhu: sa tu cung hay sa vdm, miic dp sa SSD, thdi gian md. Tuy nhien, de cd ket luan chac chdn hon cdn nghien ciiai vdi sd lugng benh nhan ldn hon va cd thdi gian theo ddi dai hon.
TAI LIEU THAM KHAO
1. Nguyen Ba My Nhi (2010). Danh gia budc dau hieu qua va dp an toan cua phlu thuat treo tli cung vao mom nho qua npi soi 6 bung trong dilu tri sa tu cung tai Benh vien Tur DQ.
YHgc Tp Ho ChiMinh. 14(2): pp. 89-95.
2. Tran Ngoc Sinh (2008). "Kit qud phdu thudt ndi soi d bung cd dinh sdn chdu vdo mdm nhd xuong cimg diiu tri sa sinh due". Hpi nghi Ngoai khoa va Phau thuat Noi soi Viet Nam. Truong Dai Hoc Y Dupc TP. H6 Chi Minh.
3. Trdn Ngoc Sinh (2010). Sa co quan tilt nieu - sinh due trong benh ly sa co quan day chau.
YHgc Tp. Hd ChiMinh. 14(3): pp. 1-11.
4. Petros Peter (2007). "The Female Pelvic Floor". 2" ed. Springer.pp. 1-248.
5. Rivoire C , et al. (2007). Laparoscopic Promontofixation Results of a 138 Clermont - Ferrand Series. Journal of minimally invasive gynecology. 14(6): pp. 712-718.
6. Wattiez A., et a!. (2003). Promontofixation ' for the treatment of prolapse. Urol Clin North
^ffj. 28(l):pp. 151-157.
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