Y H p c T F . H b C h i M i n h * T a p 1 8 * F h u b a n c u a S o l * 2 0 1 4 N g h i e n c u u Y h p c
PHAU THUAT NOI SOI LONG NGL/C TAI BV BINH DAN
Nguyen Ngoc Binh*, Ho Klidnh E>dc*, Vdn Tdn*
T O M T A T
Dqt van de: Phdu thudt ngi soi (PTNS) dieu tri cdc binh ly tiong Idng nguc dugc dp dung ddu tien tqi BV biiih Ddn ndm 1996 diiu tri binh tang tiei nw hoi tay. Ngdy nay, PTNS duac dp dung nliieu trong cdc benli ly cua phoi, trung thai. Lgi dian. du&ng mo'nhb, kh6ng banh su&n nen hdu phdu nhe nhang, it dau, kiwng han die ho hap. Co tlie sie dung dung cu mo'thong thu&ng dej^idu tich qua du&ng monho (4-6cm), nhin qua mdn Kirii.
Co the phdu tich hodn todn qua noi soi vdi dung cu ngi soi long nguc. Muc tieu: ddnh gid kei qud dieu tri benh ly long nguc bang PTNS.
Phucmg phdp nghien cdu: Hoi ciru mo tdcdc tru&ng hap diiu tri bdng PTNS Img nguc tqi BV Binh Ddn.
Kei qud: Khoa ngoqi Wng nguc BV Binh Ddn tie 1996 deh nay dd phdu thudt hem 3000 tru&ng hgp do mo hoi tay. Chung toi cdi tieh tie 3 16 trocar con 116 trocar, bdo ddm dugc tinh hieu qud, an todn vd tham my. Tie ndm 2000, da co 112 tru&ng hgp NSLN de chan dodn vd dieu tii cdc benh ly phoi vd trung thai.
Trong do co 41 TH cat thiiy phoi bdng du&ng md'nho co su ho trg ciia ngi soi, 2 TH cat thiiy ph6i hodn todn qua noi soi. Sinh thiei qua ngi soi 52 TH. Cat phoi hinh chem dieu tri u phoi ngoqi bien 1 truong hgp. Doi v&i u trung that, diung toi da cat u hodn todn qua ngi soi cho 9 TH, sinh thiet 10 TH, 2 TH u tuyen uc Ngodi ra ehung toi con dieu tri cdc benh ly khde nhu cat ken khi, ma cira so'mdng ngodi tim.. Qua ddnhgid kii qud, cho thay ti li thdnh cong cao, an todn, thifi gian Koi phuc nhanh, it dau, it biih ehung... Ti le tie vong sau mo'thdp (3 tru&ng hop u phoi).
Ket ludn: PTNS Idng ngiec diiu tri benh ly phoi vd trung thai dw thay nhirng ira diem lian so vdi md'ma kinh dim. Kii qud dieu tri tqi BV Binh Ddn dw th^ tinh hiiu qud, an todn vd tham my cao ciia phucmg phdp.
Tie khoa: Plidu thudt ngi soi long nguc - BV Binh Ddn, tdng tiei nio hoi tay, u phot, u trung thdi.
A B S T R A C T
THORACOSCOPIC SURGERY AT BINH DAN HOSPITAL
N g u y e n N g o c Binh, H o K h a n h Ouc, Van Tan
* Y H o c TP. H o Chi M i n h * Vol. 18 - N o 1 - 2014:267 - 270
Introduction: Thoracoscopic surgenj (TS) wasftrst applied in 19% at Binh Dan hospital for treatmait of hyperhydrosis. Today, we perform TS to treat many diseases of the lungs and ihe mediastinum. The great advantage of TS ova- sternotomy or thoracotomy is aooidance of muscle diznsion and hone spread that allows for diminished duration and intaisity of pain and a slwi-ter time to return to full activity. It is possible to use the convaitional instrumaits for dissection through a small incision (4 - 6cm) loith video-assisted (VATS) or complete dissection with aidoscopic instruments
Objective: To evaluate the tieatment outcomes of the thoradc diseases zoith TS surgery at Binh Dan
Methods: In tlie reti-ospective sti.idy, the treatmait outcomes of patients who received the TS at Binh Dan hospital betioeai 2000-2012 zoere deaibed.
Results: From 1996, lue operated more than 3000 cases of hyperhydrosis. We improved from 3 to 1 ti-ocar and ensured the effidaicy, safety and aesthetics. Since 2000, there have been 112 cases of tlwradc endoscopy for
* Truong phong Chi dao tuyen va Nghien cuu khoa hpc, benh vien Binh Dan Tdc gid lien he: ThS.BS K g u y i n Ngoc Binh BT: 0903837670 Email: [email protected]
Nghien cihi Y hpc Y Hpc TP. Hb Chi Minh * Tap 18 * Fhu ban cua S o l * 2014
diagnosis and treatment of diseases of tlie lungs and the mediastinum. 41 cases of pulmonary lobectomy zoith VATS and 2 cases lobectomy zvith complete TS dissection. Endoscopic biopsy of 51 cases. Wedge resection fbr peripheral lung tumor (1 case). For the mediastinal tumor, complete ablation of the tumor by TS in Ucnses (itududiiigl cases of thymoma) and biopsy of 10 cases. In addition, zoe also perfermed the bleb abhitioii to treat the spontaneous pneumothorax or pericardial fenestiation to treat the pericardial effusion by TS. There zoas few postoperatives complications, less pain and fast recovery time. The postoperative moriality rale is low (3 cases of lung cancer).
Conclusicm: Thoracoscopic surgery far treatinent of lung and mediastinal diseases show more advantages compared to dassic open surgery. The treatment outcomes in the Binh Dan hospital showed that this meOiod is
^frctive, safe and aesthetic.
bywords: Thoracoscopic surgery - Binh Dan hospital, hyperhydrosis disease ofthe lung mediastinum K E T Q U A
Trong khoang thoi gian 12 nam, chiing toi da D A T V A N D E
Phau tiiuat mo dieu tri cac benh ly ciia phbi, tnmg that, mang phoi can phai mo nguc Ion, banh rong khe lien suon. Day la phau thuaf nang ne, thoi gian hoi phuc sau mo cham do duong mb dai, dau nhieu va co nhieu bien chiing xay ra nhu nhiem trung vet mo, tran khi dubi da.. .^\
Ngay nay, cac phuong phap dieu tri xam laim tbi thieu, thoi gian hoi phuc nhanh, mang tmh thain my cao da phat trien. Khoang hon 30 nam, ke tu khi Fhihppe Mouret cat hii mat noi soi dau tien nam 1987, phau thuat noi soi (PTNS) da khong ngimg phat trien trong nhieu chuyen khoa khac nhau, da dem deh cho ngucri benh nhieu loi ich.
Ciing trong xu huong phat trien ehung ciia cac chuyen nganh khac, phau thuat noi soi long nguc (FTNSLM) tai BV Binh Dan da timg buoc phat trien \'a da buoc dau dieu fri dupe nhieu benh ly trong long nguc
Muc tieu ciJa de tai la danh gia ket qua dieu tri cac benh ly long nguc qua PTNS tai BV Binh Dan.
DOITU'ONG-PHU'ONGPHAFNGHIENCUtJ Nghien cuu hoi ctiu mo ta.
E>bi tuong la cac benh nhan dupe PTNSLN dieu tri cac benh ly phbi va trung that tii 1/2000 - 12/1012.
phau thuat 112 benh nhan bi cac benh ly phoi va trung that qua npi soi.
Dac diem dich te mau nghien cuu Giai titih
NO N a m
S 6 T H 45 67
T T I e % 40 60
Tudi
Lon nhat 84 tubi Nho nhat: 22 tubi Trung binh: 54,12 Phdn loai benh phdu thudt
B ^ n h Uphor U trung ftat
U t u y ^ u c U mang phoi I r a n d.ch mang ngoai tim
Tran khi mang phoi T6ng
S a T H 72 30 2 4 2 2 112
Fhuomg phap phau thuat
P h u o n g phap NS smh thiet c i t ItiLiy phdi qua hd tro NS
(VATS) Cat thiiy phSi hoan loan qua NS
C i t u mang phoi CM u injng flilt C a t u tuyen u c Mcr d j a sd mang ngoai tim
Khau ken khi
s6"m
52 41
2 2 9 2 2 2
T 7 I ? % 64,28 25 1,7 3,57 1.7 1.7 100%
• n i e % 46,4 36.6
1,7 1.7 8.1 1,7 1,7 1,7
Hpi Nghi Khoa Hoc Ky Thuat BV. Binh Dan 2014
Y Hpc TF. Hb Chi Minh * Tap 18 * Phu ban ciia Sb 1 * 2014 Nghien cmi Y hpc
Ket qua dieu tri
NSLN hoan toan NS vo-i dirong m6 nho Bi^n chi>ng trong luc mo
Ti> vong sau mo
S o T H 71 41 1 {chay mau) 1 (Tran khi du'6'i da)
3
T i l e % 63,4 36,6 1,7
2,67
BAN LUAN
PTLN da duoc biet tir lau tren the gioi, nhung chi duoc phat trien manh me tir thap men 60 voi su phat trien cua gay me va hoi siic. PT de dieu tri cac b?nh ly trong long nguc la phau thuat Ion, doi hoi phai mo nguc rong, banh suon de CO diJ khoang khong thao tac. Do do, benh nhan dau nhieu sau mo, han che ho hap, khong van dbng som... tir do gay ra nhieu bien chiing hau phau*^'.
Xu huong phau thuat hien dai la xam lan toi thieu, thoi gian hoi phuc nhanh, giup benh nhan fro ve voi cube song lao dong thuong ngay nhanh chong tir do lam giam chi phi dieu tri. Tii su phat trien manh me aia PTNS trong dieu tn cac b^nh ly trong 6 bung da thiic day su phat trieh ciia PTNSLNP'^'.
Tai Vi^t Nam, PTNS Ian dau tien duoc ap dung tai BV Cho Ray voi truong hop cat tiii mat npi soi nam 1992. Nam 1996, tai BV Binh Dan, GS Van 1 ^ voi su ho tro cua cac bac si Hongkong da tien hanh ca PTNSLN dau tien ck than kinh giao cam nguc de dieu tri chirng tang tiet mo hoi tay. Sau do, cac b#nh ly cua phbi, trung that cung bat dau duoc nghien ciiu ap dung dieu tri bing PTNS tai BV Binh Dan<^'.
LTU diem ciia PTNSLN la duong mb nho
< 1cm, khong banh suon nen hau phau rat nhe nhang it dau, khong han che ho hap, van dong som. Tir do giiip giam di bien chiing xep phbi, nhiem triing phbi, nhiem trimg vet mb, giam ngan duoc thoi gian nlim vien^-^'. Ngoai ra, NS ciing giiip chan doan chinh xac tinh trang benh ly, tinh trang di can hach, hi do co the sinh thiet de chain doan xac dinh, tranh cac trudng hop phai mo nguc vo ich'-".
Chi dinh cCia PTNSLN la chan doan va dieu
tn cac benh Iy<^i:
-B?nh ly mang phoi: U, tran dich, tran mau, tran khi, mau dong, day dinh.
-Benh ly nhu mo phoi: Ung thu, not don dpc, u lao, u nam, ken khi.
-U trung that: cac loai u o trung that truoc va sau, berth nhupc co do u ton t ^ tuyen tic, b^nh ly thuc quan.
-Mang ngoai tim: tran dich, tran mau mang ngoai tim.
-Cat hach than kinh giao cam nguc dieu tri chiing tang tiet mo hoi tay
Ke tir nam 1996, sau TH cat than kinh giao cam nguc qua NS dau tien, chiing toi da co nhiing buoc phat trien manh me trong PTNSLN.
Tir tu' the nam nghieng hole sap gay nhieu tro ngai cho gay me, voi 2 16 trocar moi ben nguc, chting toi da cai tien sang nam ngira, rat thuan lpi cho gay me va chi voi 1 trocar. Den nay, chiing toi da phau thuat tren 3000 truong hop.
Tix nam 2000, chiing toi da bubc dau thuc hi?n NSLN de chan doan trong liic mb, danh gia khbi u phbi, u trung that, tinh trgng di can hach trung that. Sau do chiing toi chuyen mo ho de xir ly ton thuong. Cac truong hop danh gia khong the cat dupe, chiing toi sinh thiet qua NS, tranh cho b?nh nhan khoi duong mo nguc vo ich.
Trong 112 TH, chiing toi NS va sinh thiet 52 TH, ti 1# la 46,4%.
Sau khi tich liiy kinh nghiem, chpn benh phii hpp, diing chi dinh, tu the benh nhan, vi tri va so luong cac trocar, ky nang ph3u tich... chiing toi bat dau ben hanh xii tri cac tbn thuemg qua NS.
Lgi the ciia NSLN la khong can bom hoi, chi can xep phbi la co khoang thao tac. Tuy nhien, do khe suon hep, do do bien dp hogt dpng aia trocar hgn che hon so voi o bung. Vi vay, chon vi tri trocar cho timg ton thuong ia rat quan trpng.
Dac bi^t, cac mach mau trong LN co kich thuoc Ion, luu lupng manh, khi chay mau rat kho <am mau qua NS, phai mo nguc ngay, rat nguy hiem CO the gay tu vong
Hpi Nghi Khoa Hpc Ky Thuat BV. Binh Dan 2014 269
Nghien ctru Y hpc Y Hpc TP. Hb Chi Minh * Tap 18 * Fhu b a n cua Sb 1 * 2014
Trong cac truong hop cSt thiiy phbi, khi phau tich cac mach mau rat can than, ran co cac dung cu chuyen dung de kep dt nhu stapler mach mau. Tuy nhien, cac dung cu nay dat tien va tai nuoc ta ciing chua co, nen gjai doan dau, chiing toi phai mo duong mb nho 4-5 cm, de phau tich, kep clip hoac hemodock doi vcd timg mach mau va may phe quan gbc vdi prolene.
Trcmg 72 ca ung thu phoi, chiing toi da cat thiiy phbi voi XS ho trp la 41 TH. Ket qua phSu thuat rat tot; sau mo voi duong mo nho 5cm, khong banh suon, hau phau benh nhan rat nhe nhang va bao dam dupe ket qua dieu tri ung thu.
Chiing toi CO 3 TH tir vong sau mb, trong do co 1 TH chay mau trong liic mb do tuot mpt tinh mach phbi. 2 TH tir \''ong do bien chiing ho hap sau mb. Gan day, sau khi co nhieu kinh nghiem trong phau tich, chiing toi da tien hanh 2 TH cat thiiy phbi hoan toan qua NS, benh pham dupe lay ra tir dirong mo nguc nho 3 cm.
Dbi voi cac u trung that; chting toi chi chpn nhiing khbi u co kich thuoc nho < 5cm, kha nang lanh tinh de PTNS. Cac TH nay, kha nang c3t u dupe hoan toan qua NS la rat cao"'-^-'*. Chiing toi khong ran duong mo nguc nho de ho trp. Co the sii dung dao cat sieu am de giiip kha nang ram mau nhanh hon, nit ngan thoi gian phau thuat.
Chiing toi da thiJc hien c3t hoan toan qua noi soi 9 TH u Irung that voi kich thuoc u trung binh
< 5cm. Dac biet co TH u dinh vao mang ngoai tim, chiing toi da ck bo luon mang ngoai tim de lay trpn khbi u. Hau phlu cae t>enh nhan rat tot Benh nhan eo the ngoi day va van dpng vao ngay hau phau thii 2.
PTNSLN rat CO gia tri trong dieu tri benh nhupc CO do u hoac ton tai tuyen lic. Truoc day, de ck bo hiyen uc, chiing ta phai che xuong iic
mod CO the lay dupe toan bp mo tuyen iic. Sau do phai may bang chi thep. Sau mo, benh nhan dau rat nhieu, eo nguy co nhiem trimg xuong iic Ngay nay, voi nhiing vet mb nho 6 ngut; co the ben phai hoac trai, chiing ta co the thay the cho phau thuat che xuong ucP-^K Chiing toi ding da tien hanh eat 2 TH u tuyen uc thanh cong hoan toan qua NSLN. Ket qua phau thuat rat tuyet voi, bao dam dupe nguyen tac dieu tri la lay sach mo tuyen iic, nhung hau phau rat nhe nhang va mang tinh tham my rao.
KETLUAN
PTNSLN da timg buoc phat trieh viing chae tai BV Binh Dan Tir thoi gian dau chi cat than kinh giao cam nguc, den nay chiing toi da xir ly
^ n nhu hau het cac benh ly trong long nguc Ket qua dieu tri rat tot Ti le fhanh cong qua dieu tri XS cao, co the thuc hi^n qua duong mb nho voi ho trp ciia NS hoac xir tri ton thuong hoan toan qua NS. Ti \% bien chting va tii vong do PTXS rat thap. Chiing toi co the ket luan PTNSLN an toan, hieu qua nhung can co kinh nghiem trong mo mo va mo NS.
TAI LIEU THAM KHAO
1 Dawsor CT "Anterior Mediastmal Mass". R e s d o i t Research 200S
2. Nguyen Cong N&ih. " dan doan va d i ^ tn u tiung iat b ^ i ^ i:4iau t h u | t nga soi", E)?! hgc Y khoa Ph?in NgpcThadi, 200S
3 Shnga- P, Kislib C "Managanent of Ihe patient with a large ntenof mediatinal m a s s recurring myths", Cunr Opin Anaestheaol 20:1-3,2007.
i Stitdls D C Rasado-de-Chnstmstm ML, Jett JR" Pnmaiy mediastinal tumcas. Part L Tumors of the antenor mediasenum". Chest 1997; 112511.
Ngdy nJidn bdi bdo:
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N g a y bai bdo duac dang:
05/11/2013 01/12/2013 20/02/2014
Hpi Nghi Khoa Hoc Ky Thuat BV. Binh Dan 2014
