H p l NGHI KHOA HOC BENH VIEN HLfU NGHI VIET TIEP H A I PHONG LAN THCT 37
PHAU THUAT NOI SOI SAU PHUC MAC LAY SOI NIEU QUAN
> • • •
DOAN 1/3 TREN TAI BENH VIEN VIET TIEP HAI PHONG
Bui Van Chien*, Nguyen Cong Binh*
TOM T A T
Muc tieu: Danh gia ket qua dieu trj, tai bien Vci bien chirng cue phUdng phap phau thuat noi soi sau phiic mac lay sol nieu quan doan 1/3 giii'a tai khoa ngoai tiet nieu Benh vien Viet Tiep Hai phong.
Doi tif^ng va phu'dng phap nghien cu'u: 750 benh nhan dUOc mo lay soi nieu quan IUng qua nga npi soi sau phiic mac tiT LO/2004 den 10/2011 tai Benh vien Viet Tiep- Hai Phong theo phUdng phap tien ciru.
Ket qua: Nam 370, nu' 380 tru'dng hdp. Tuoi trung binh: 41,25±11 tuoi..Thap nhat 22, cao nhat 71 tuoi.
Soi ben phai: 426 ca, ty le 56,8%
Soi ben trai: 324 ca, ty le 43,2%
Sol khic noi be than nieu quan, 147 ca, ty le 19,6%
Soi luYig thap: 603 ca, ty le 80,4%
Thdi gian nam vien trung binh 5,2±3,3 ngay (ft 2 ngay, nhieu 19 ngay)
Thdi gian mo trung binh: 59,4±22,4 phut (ft 20 phiit, lau nhat 120 phiit)
Thdi gian riit dan lUu trung binh: 4,09±2,5 ngay.
(ft2 ngay nhieu 15 ngay).
Thiing PM: 68 ca, 9 , 1 %
Soi chay len than chuyen mo md 29 ca, 3,9%
Do nUdc tieu: 72 cas, 9,6%
Ket luan: Phau thuat noi soi sau phuc mac lay soi nieu quan IUng an toan, hieu qua can dUdc phat trien rong rai d cac tuyen tinh thanh.
ABSTRACT
Retroperitoneal-laparoscopic ureterolithomy for managing ureteral stones
Obejective
Asessement of the complications intraoperatively and postoperatively of upper ureteral stones treatment by retroperitoneal-laparoscopic approach
* Benh vien Him Nghi Viet Tiep Hdi Phong
From oct 2004 to oct 2011 at Viet Tiep Hospital, 750 patiens underwent retroperitoneal ureterolithotomy
Result
370 males and 380 females were at the age of 22 to 71
Operative time :min 20. max 120 minutes, mean 59,4 ± 22,4 minutes.
Hospital stays were ranged from 2 to 19 days, mean : 5,2 ±3,3 days .
72 patiens (9,2%), who has urine leakage postoperatively.
the open operation: 29 cas (3,9%) due to migration of stone toward kidney.
Conclusion: The technique of retroperitoneal ureterolithotomy is highly effective anh safety this is a kind of operation that can be applied universally
I.
OAT VANol
Ngay nay nhir co sir phat trien manh me ciia khoa hoc ky thuat, nhieu phuong tien can thiep it .\am lan ra doi da lam thay doi nhieu phuong thirc dieu tri trong do co phau thuat noi soi sau phiic mackn soi nieu quan lung.
Phau thuat noi soi sau phuc mac lay soi nieu quiin lung la mot tien bo trong dieu tri soi nieu quan, dac biet hiru hieu trong nhihig truong hgp tan soi ngoai co the va tan soi noi soi qua chi dinh. Phucmg phap nay gop phan lam giam ty 1? benh nhan co soi nieu quan mo mo xuong thap ban, dem lai hieu qua cao, an toan va it sang chan.
Nam 1992, Gaur mo ta ky thuat t^o khoang sau phuc mac bang bong de phau thuat noi soi tren co quan tiet nieu {4}
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Y HOC VIET NAM THANG 10 - SO DAC BIET/2011
Tai Viet Nam, co thh noi tir 3/2002 Le Dinh Khanh ihn dhu tien bao cao 7 truong hgp phau thuat noi soi sau phuc mac iiiy soi nieu quan tilp theo la Doan Tri Dung \a\ 14 truong hgp cho den nay da co nhilu bao c:\o voi so lieu tang ddn nhu cua Ngu> en Quang voi 40 ca, Vo Van Quy, Vu Oanh 31 ca. TrAn Th Kha, Trhn Thugng Phong, Vu l c C lui>cn.
Dao Quang Oanh \a CS \a\ 14K ca.
Phau thuat noi soi da to ro tinh an loan.
hieu qua va thhm my cao dang ddn iha> thh mo mo von ga\ nliieu sang chdn cho nguoi benh.
II. 06l TUONG VA PHUONG PHAP NGHIEN COU 1. Doi tuoTig nghien ciiu: G5m 750 benh nhdn dugc mo lay soi nieu quan kmg qua noi soi sau phuc mac tai Benh \ ien Viet Tiep Hai Phong trong tir 10/2004 dhn
10/2011
2. PhtfOTig phap nghien cihi Nghien cuu tien cuu, mo ta
- Lura chon benh nhan
• • •
- Benh nhdn co soi nieu quan doan lung dugc xac djnh tren KUB va UIV.
-Vi tri soi nam tir bo tren xuong ciing den khuc noi be than nieu quan.
Soi gdy tac hoan toan hoac kich thuoc >
7nim
Khong CO vet mo cu viing hong lung ciing ben can phau thuat
Khong CO roi loan cam mau va nhiem triing cap do soi gdy ra
* Ky thuat
Phuong phiip \o cam: Me noi khi quan Sir lao khoang sau phiic mac dugc tien hanh dua theo kv Ihuat Gaur: Dat bao cao su
\(i khuan \ao viing sau phuc mac.
Vi tri lidcar: Su dung hai trocar 10mm
\ a niol trocar 5mm
Du> tri khoang sau phuc mac bang khi CO: \6i ap luc 12mmHg.
Tim nieu quan dira \ ao co tliat lung chdu.
- Xac dinh vi tri soi. co dinh soi, xe doc nieu quan bang dao lanh Idy soi.
K-icm tra sir thong suot ciia nieu quan bang ong thong oxy 8F xuong doan nieu quan duoi va bom nuoc muoi sinh ly.
Khdu lai nieu quan bang Vicryl 4/0 miji rod.
Dat ong ddn luu viing sau phuc mac qua 16 dat trocar.
III. KET QUA
Tir 10/2004 dhn 10/2011 co 750 benh nhdn dugc mo PTNS sau PM
Tuoi trung binh: 41,25±11 tu6i, thdp nhdt 22, cao nhdt 71 tuoi.
Nam 370, niJ 3800 truong hgp
Vj tri sol
Ben phai Ben trai Tonq conq
Soi khuc 1 n
132 15 147
Bang :
l o l BT-NQ Ty le (%)
31 4,6 19,6
: Vi tri soi
Soi doan n 294 309 603
Ung thap Ty le (%)
69 95,4 80,4
Tong cong n
426 324 750
Ty le (%) 56,8 43,2 100
Soi ben phai: 426 ca, ty le 56,9%
Soi ben trai: 324 ca, ty le 43,1%
Soi khiic n6i hh than nieu quan: 147 ca, ty le 19,6%
Soi lung thdp: 603 ca, ty le 80,4%
Thoi gian ndm vien trung binh: 5,2±3,3 ngay (it 2 ngay, nhilu 19 ngay)
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HOI NGHI KHOA HOC BENH VI^N HUfU NGHI VI^T TIER H A I PHONG LAN THLf 37
Thc7i gian mo trung binh: 59,41 22,4 phiit (Nhanh 20 phut, lau 120 phiit) Thtri gian riit dan kru trung binh: 4,091 2,5 ngay (it 2 ngay, nhieu 15 ngay)
Bang 22^rai bien va hien chirng
Tai bien va bien chu'ng Thung PM
Soi len than Thiing cd quan lan can
Do nUdc tieu sau mo
n 68 29 0 72
TyleC^/o) 9,1 3,9 0 9,6
Lugng mau mdt trong mo khong dang ke, chi tham uot 1 gac noi soi
So ca dat sonde J,l sau mo do do nuoc tieu: 30ca
Khong CO trudng hgp nao bi thiing tang, rach mach mau
Khong CO nhiem triing \ ct thuong 71,6%) benh nhdn tu ngoi day trong 12 gio ddu sau mo
80,4%) CO tai lap luu thong tieu hoa trong khoang thoi gian 12-24 gio
,.x
IV. BAN LUAN
I. Chi dinh dieu tri
Ngay nay tai cac trung tdm Ion phau thudt mo mo co dien ngay cang han che. Tan soi ngoai co the (TSNCT), tan Idy soi than qua da (TLSTQD), tan soi nieu quan ngugc dong (TSNQND), mo NQ Idy soi qua noi soi da dugc ap dung rgng rai. Tren ly thuyet nhimg vien soi < 4mm co kha nSng ti^r tilu ra ngoai (90%)), soi 6mm tu tieu ra dugc >20%), va thuong bi ket o doan NQ chau, thanh bang quang, nhung truong hgp nay co the giai quylt de dang bdng TSNQNS [1],[2]. Nhirng vien soi Ion hon thuong ket doan khiic ndi va lung thdp, ddy la nhimg vi tri ma phuong phap tan soi noi soi nieu quan bi han che, cdn phai mo mo hodc mo noi soi. Mot so tac gia chi djnh mo Idy sol ngi soi khi kich thuoc soi
>15mm.
Chung toi chi dinh mo lay nieu quan lung qua nga NSSPM voi soi co duong kinh ngang >7mm gdy be tac duong tieu bao gom vi tri doan tren khuc noi \ a doan lung thap.
2. T a i bien trong mo
2.1. Thdng ca quan lan can
- Thuong ton tang va thung phiic mac trong mo noi soi thudng gap khi dat Trocar, de han che tai bien nay nhieu tac gia chon phucmg phap ddt mo, boc tach phiic mac bdng ngon ta\. Chung toi diing pince ddu tu tach cac lop co \ a choc thiing can that limg di vao khoang sau phiic mach sau do dat bong bom hoi tach dan phuc mac.
Thiing phiic mac la mot tai bien khong ngu> hai nhimg rat kho khdn cho cuoc mo, thiing thuong gap khi boc tach tim nien quan bi lac dircmg khong di \ ao khoang sau PM nieu.
Chiing toi gdp 68cas thimg PM khi di tim NQ ca 68cas na> deu keo dai cuoc mo rat may khong phai ddt them Trocar va khong ton thuong cac tang
2.2. Soi chay len than chuyen md hd Chiing toi gap 29 cas soi chay len than, ca hai deu la soi khiic noi be than nieu quan, soi di chuyen khi boc tach to chuc mo bao quanh doan nieu quan co soi, viec co dinh soi 6 doan nay thudng gap kho khan vi to chiic mo nhieu va nhat la be than gidn to va u dich.
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Y HOC VIET NAM THANG 10 - SO DAC BIET/2011 3. Ket qua
3.1. Do nir&c tiiu
La mgt phien toan cho ngudi benh va rV, phdn Idn cdc trudng hgp diu hit do sau li dat sonde JJ hoac tvr lanh. Trong nghien m nay, tat ca benh nhdn diu dugc dat thong cy 8F xuong doan nieu quan dudi soi va Dfm nude kiem tra sir thong thucmg doan leu quan dudi soi.
Chiing toi gap 72 cas do nude tieu sau 10, 30cas lugng nude tieu nga>' dem xdp xi 00ml phdi dat JJ, 42cas con lai do it. tu bjt ao ngay thir 9. So lugng nude tieu do xap xi 00-150ml/ ngay theo chiing toi khong cci gi ang ngai.
3.2. Thdi gian mo vd th&i gian nam ien
1 Thdi gian mo trung binh cua chiing toi la 9,4±22,4 phiit, nhanh nhdt 20 phiit, cham hat 120 phiit. Trong nghien cuu nay chiing 3i khong tien hanh dat thong nieu quan trudc
10 mot each he thong nhu Diing(2003).
Thdi gian m6 trung binh ciia Gaur nam 996 la 60 phut.
Qua nghien cuu chiing toi thdy thdi gian 10 chii yeu danh cho viec tim nieu qudn va hdu nieu quan. Trong nhiing trudng hgp au, thdi gian tim nieu quan keo dai nhung mg dugc nit ngdn d nhimg trudng hgp sau.
V. KET LUAN
Phdu thuat soi nieu quan lung qua nga noi soi sau phiic mac la mot phdu thuat it sang chan, rut ngan ngay dieu tri, it dau, hieu qua \a tham my cao.
TAI UEU THAM KHAO.
1. \'u Le Chuyen, Nguyen Van Hiep, Dao Quang Oanh va cong sy; "'Phdu thudt ngi .soi nieu tren 499 henh nluin tgi b<^nh vi(m Binh Ddn sau mdt nam (4/2004-4/2005)";
Tap tri Y hoc Viet Nam, tap 313, so dac biet 8/2005; tr.5-11
2. Vu Le Chuyen: "'Soi nieu vd ngi soi nieu'' Nieu hpc lam sang; XNBYH; 2002; tr.l30-
142.
3. Nguyen Te Kha, Tran Thirffng Phong, Nguyen Van An va cong su*; "Phdu thudt ngi soi ngodi phuc mgc trong benh ly soi ni?u qudn: Kinh nghiem diiu tri 148 truang hgp tgi benh vien Binh Ddn'"''; Tap chi Y hpc Viet Nam, tap 313, s6 dac biet 8/2005; tr.128-133.
4. Gaur DD: '"Retropertionedal laparoscopic ureteral ithdtmy'" Word J, Urol 1993:
ll(3);175-7.
5. Gaur DD: '"Laparoscopic condom dissection: new technique of retroperitoneoscopy" J. Endourol
1994,8:149-151.
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