Y Hpc TP. Hb Chi Minh * T^p 21 * So 6 * 2017 Nghifin cmi Y hpc
PHAU THUAT ROBOT TRONG TIET NIEU:
BirdC D A U U N G DPVG TAI BENH VIEN BINH DAN
Nguyin Phuc Cam Hodng**, Trdn Vinh Hung*, Vu Le Chuyen*, Nguyen Vdn An**, Bo VU Phuang**, Bo Anh Toan**, Le Trgng Khoi**, Bo Lenh Hdng**, Phqm HOu Bodn**
TOMTAT
Muc tieu: Phau thuSt robot t&n 3&u tiin tan dau tiin diegc thuc hiin trong Tiii niiu tqi Viet Nam. Bdi zdii ndy nham bdo cdo 26 truang hgp (TH) dau tiin dung hi th&hg robot da Vind Si ™ thuc Men cdc tru&ng hgp ph&u thu&t Tiet niiu a ngu&i l&n dugc thuc hiin tqi Khoa-Bd mdn Tiii niiu Binh viin Binh Ddn tiong th&i gian viea qua.
Doi tmng vd phuang phdp n^ien cdu: Tie 30/11/2016 din 8/02/2017 co 26 truang hap binh ly Tiit niiu dtegc ph&u thu&t robot bao gdn cd phau thu&t tqo hbih va phau thu&t cat bo, a cd du&ng tiii niiu trin vd du&ng tiii nieu duoi. Robot da Vind Si ™ vdi boh cdnh tay dugc sie dung trang tot cd cdc truang hgp trin. Ddnh gid ket qud ngay trang th&i gian nam znin sau mo(k^ qud s&m).
Ket qua: 10 TH cat tiiyen tien Hit (TIE) tan goc do ung thu TTL: tudi trung Unh: 66,9 (49 - 75), th&i gian mo: 297 phiit (105 - 480), nqo hqdi ch&u bit: 4/10 TH, bdo tdn bo mqch than kinh cuang: 2/10 TH, mdu m&i: 355 ml (100 -1000), nam vien sau md': 6,3 ngdy (2-11); 4 TH tqo hinh khiic ndi niiu qudn - be than co mdt TH than mong ngua: tudi trung binh: 39,5 (23 - 64), th&i gian mo: 157,5 phiit (120 - 210), mdu mat: 60 mL (10 - 200) nam znin sau mo: 5,25 ngdy (3 - 7); 3 TH cddjnh am dao vdo mom nhd xucmg cimg cd mot TH cat tie cung kem theo: tudi trung binh: 60 (55 - 66), th&i gian mo: 233.3 phiit (180 - 300), mdu mat: 66,6 mL (20 -150) nam viin sau md: 4,33 ngdy (4-5); 2 TH cat budu tuym thugng th&n bin phdi (buou myelolipama vd Schwannoma): tudi trung Unh: 37,5 (26-49), thai gian mo: 97,5 phut (45 -150), mdu m&t: 75 mL (50 -100) nam viin sau md: 8 ngdy (4 -12); 2 TH cdt mgt phan th&n cho bu&u than nho (bu&u md-ca- mqch vd buou chu mo thdn): tudi trung Unh: 34 (32 - 36), th&i gian md: 210 phut (165-255), mdu mat: 50 mL, th&i gian thim mdu nong: 15 phiit (10-20), nam znin sau mo: 5,5 ngdy (5 -6);1TH cat th&n-nieu quan phdi cho buou niiu mac be th&n: tiidi: 54, th&i gian mo: 240 phut, mdu mdi: 800 mL, nam vien sau mo: 6 ngay; 1 TH cat bdng quang tan gdc + tqo hinh bdng quang bang hoi trdng ndi thang cho bu&u bdng quang xdm lan ca: turn: 45, thai gian md': 660 phut, mdu mSi: 500 mL, nam viin sau mo: 15 ngdy; 1 TH cdt than dan gian ben phdi vi than mSi chiec ndng: tiidi: 52, th&i gian mo: 120 phut, mdu mat. 150 mL, nam vien sau md: 4 ngdy; 1 TH cam Iqi nieu qudn vdo bdng quang theo Lich-Gregoir:
tiim: 42, th&i gian md': 180 phut, mau mdt: 50 mL, nam viin sau md: 7 ngdy; ITHcdt th&n tan gdc cho budu chii md than phdi chuyen md'md vi bu&u th&n cue tren x&m ldn g&y znim dinh nhiiu.
K^ luam Phdu thu&t robot co uu the han ph&u thuqt ngi soi hnh dien nhd su phdt trim cua cdng nghe (mdn hinh 3D-HD, cdnh tay robot van dgng uym chuym, bdn console giiip thao tac phdu thu&t thodi mdi, v.v.) giiip bdc SI Tiit niiu thuc hien dugc nhieng phau thuat phiec tqp vai duang cong hgc tap ngdn han. Lgat ung dung phau thu&t robot ciia chiing t&i qua 26 truang hap ddu tiin dd co kei qud bu&c dau ddng khich li. Can thuc hiin thim nhieu truang hgp han nda trong th&i gian tai day.
Td khoa: Phau thu&t robot, cat tuyih tiin liet tan gdc, cat bdng quang tan gdc, cat mdt phan than, cdt thdn t^n gob, cdt tuym thugng th$n
* B6 mon Ngogi, DH Y khoa Phgm Ngpc Thgch TP.HCM ** Khoa - Bo mon Tiet nieu, Benh vi?n B'mh Dan Tdc gid lien lac: PGs. Ts. Nguyin Phuc Cam Hoang DT. 0913719346, E-mail: Npchoang#gmail.com
Nghien cmi Y hpc Y Hpc TP. Ho Chi M i n h * Tap 21 * So 6 * 2017
ABSTRACT
ROBOT-ASSISTED SURGERY IN UROLOGY: INTUAL APPUCATION AT BINH DAN HOSPTTAL Nguyen Phuc Cam Hoang, Tran Vinh Hung, Vu Le Chuyen, Nguyen Van An, Do Vu Phuong,
Do Anh Toan, Le Trong Khoi, Do Lenh Hung, Pham Huu Doan
* Y Hoc TP. Ho Chi Minh * VoL 21 - No 6 - 2017; 65 - 76 Objectives: Just recently, the rchotic surgery has been applied in Urology fjr the first time in Viet Nam This paper reports the first 26 cases cf robotic urological procedures using the Robot da Vind Si ™ system performed at the Departmmt of Urology of Binh Dan hospital.
Materials and Methods: From November 2016 to February 2017, hventy-six rci}ot'assisted urological procedures, reconstructive arui ablative, upper trads and lower tracts, were performed using the da Vind Si™
rc^tic system. The perioperative outcomes were assessed and reported.
Results: In 10 cases of robot-assisted prostatedomy: mean age: 66.9 (range: 49-75), operative time: 297 minutues (range: 105-480), pelvic lymphadenectomy: 4/10 cases, neurcruascular bundles sparing: 2/10 cases, EBh 355 mL (range: 100 -1000), postop hospital stay: 6.3 days (2 —11); In 4 cases of robot-assisted pyeloplasty pr UPJO there was one with horseshoes kidney: mean age: 39.5 (range: 23-64), operative time: 157.5 minute (range 120-210), EBL: 60 mL (range: 10-200), postop hospital stay: 5.25 days (range: 3-7); In 3 cases of robot-assisted promontofixation for genital prolapse there zoas one hysterectomy: mean age: 60 (range: 55-66), operative time:
233.3 minutes (range: 180-300),, EBL: 66.6 mL (range: 20-150), postop hospital stay: 4.33 days (4-5); In 2 cases of right robot-assisted adrenalectomy (myelolipoma and Schwannoma): mean age: 37.5 (range: 26-49), aperatwe time: 97.5 minutes (range: 45-150),, EBL: 75 mL (range: 50-100), postop hospital stay: 8 days (range: 4-12); In 2 cases of robot-assisted partial nephredomy (AML and RCC tumors): mean age: 34 (range: 32-36), operative time:
210 minutes (range: 165-255), EBL: 50 mL, warm ischemia time: 15 minutes (range: 10-20), postop hospital stay:
5.5 days (range:5-6); In 1 case of robot-assisted nephraurderectamy pr upper tract TCC tumor: age: 54, operative time: 240 minutes, EBL: 8(X) mL, postop hospital stay: 6 days, In 1 case of robot-assisted radical cystectomy and orthotopic cystoplasty for muscle-invasive tumor: age:45, operative time: 660 liiinutes, EBL: 500 mL, postop hospital stay: 15 days; In 1 case of robotic-assisted simple nephrectomy for non-pnctioning kidney: age: 51, operatizx time: 120 minutes, EBL: 150 mL, postop hospital stay: 4 days; In 1 case of robotic-assisted ureteral rdmplantatian of Lich-Gregoir: age: 42, operative time: 180 minutes, EBL: 50 mL, postop hospital stay: 7 days;
One conzKrsion to open surgery in robotic-assisted radical nephrectomy for right kidney upper pole RCC tumor due to profuse tumoral perirenal invasion and adhesions.
Conclusicms: Robot-assisted surgery, zvith many advantages croer standard laparoscopic surgery thanks to tedmological innc^ations (3D-HD monitor and optical system, robotic arms zvith zvrists, the comprtabk console table, dc.) has helped tiie urologist to perform the sophisticated procedures zoith sfwrter learning curves. Our initial series of 26 robot-assisted urological procedures has achieved encouraging autcomes.Further cases are to be performed in future.
Keywcnds: RcAot-assisted procedures, radical prostatectomy, radical cystectomy, partial nephredomy, radical nephredomy, adrmaledomy.
DAT V A N DE 1 ^ ^ ^^ nuoc tien tisi ^. Tir cuoi nam 2016 viia qua, Un ^ u tien phau thuat robot dugc thuc Phau ihuat robot la buoc tien cao nhat hien hien tren benh nhan nguai Ion tai Viet Nam. Bai nay trong ky Ihuat mo it xam hai da duac pho ^ ^^ ^ | ^ b i „ ^^ 26 tmimg hm, (TH) dau biOT kha rong rai tai cac Trung tam phau thuat
66
Y Hpc TP. Hb Chi M i n h * T^p 21 * So 6 * 2017 Nghidn ciiu Y hpc
tien diing he thong robot da Vind Si™ thyc hien cac truang hop pMu tiiuat Tiet ni?u d nguoi Ion duoc Ihuc hien tai Khoa-Bo mon Tiet nieu benh vien Binh Dan,
D6lTlJ'gNG-PHIJtNGEEl4FNGHIENCUt^
Doi tupng
Cac b ^ i h nhan benh ly ti^t nieu nguoi Ion d o i kham va d i ^ tri phau thuat tad Khoa-Bo mon Tiet nieu benh vi|n Binh Dan dugc phiu thuat bang he Ihong robot da Vinci Si™ trong thoi gian ti:r cuoi thang 11/2016 d a i dau thang 2/2017.
Fhinmg phap nghien cuu Dung cu phdu thudt
He dicing robot phau diii$t da Vind Si™ voi bon canh tay. H§ thong nay gom hai phan rieng biet dugc k ^ noi voi nhau (he ihong "Ong chii - Day to", "Master-Slave system").
Phdn thdp (Tower) (Hinh IA): dugc dat true t i ^ len benh nhan, gom co 4 canh tay robot: 3 canh tay de giu cac dung cy phau thuat va 1 canh tay giu camera 3-D do phan giai cao.
Bdn dUu khim (Console) (Hinh IB): la noi phau thuait vien ngBi va thao tac cac can dieu khien robot trong khi nhin vao mot man hinh lap the CO hinh anh truong mo 3-D do phan giai cao va dugc phong dai. Phau thuat vien dieu khi&i 4 canh tay robot bang each dung cac ngon tay thao tac tren can dieu khi&i. Phau thuat vien con dimg cac ban dap dhan de chpn cac nguon nang lugng (dien don circ hay luong cue).
Ngoai ra, man hinh video thii hai ket noi voi nguoi phu mo voi lunh anh 2-D ma tren man hinh nay hien thi noi phau thuat vien chinh dang nhin vao khi mo.
EBrdi 1. Hi thong robot phdu thudt da Vind Si™. A. Thdp (Tower). B. Bdn dieu hhim (Console) Cdc dyng cu phdu thuqt chinh ^
Keo cong ificw dan cifc HotSfcefl«™(Hnh 2):
dimg de phau tich va dot dien don cite.
Forceps dien li^fng CM Maryland (Mnh 3):
dimg de nam mo, ven mo, phau tich tu dau, va dot dien luong cue. Dimg trong phau thuSt bang quang, tuy&i tien liet.
Forceps ProGrasp™ (Hinh 4): dung cu khong CO nang lugng co dac diem tuong ttr forceps dot dien luong cue c616.
Hinh 2. Keo diin Hot Shears'^'^ Hinh 3. Forceps dien lumig cue Maryland
Nghien ciiu Y hpc Y Hpc TF. Ho Chi Mmh * T$p 21 * So 6 * 2017
Hinh 4. Forceps ProGrasp'^'^ Hinh 5. Forceps dien luong cue co Id I^ih 6. Kep mang kim ldn Forceps diin luang cue co lo (Mnh 5): dimg Kep mang kim lan (Hinh 6): dimg de khau de nam mo, ven mo, phau tich tii dau, va dot noi nieu dao-c5 bang quang, tao hinh co bai^
dien luong cue. Dimg trong p h l u thuat than, quang, khau dong phuc mac.
duong tiet nieu tren.
Tu the henh nhan va phan bo cac port
Benh nhdn phau thuqt Thdn-DuangTiei niiu tren'^>
Hinh 7. Phong md'cho tqo hinh cdt r&i be than ben trdi qua phuc mac Hinh 8 Phan bd port trong tao hinh bet) trdi qua phuc mqd^>
Hinh 9. Tu the binh nhdn md'tgo hinh be th&n phdi
Benh rihdn phdu thudt vdng nieu qudn doq.n xa, phdu thudt bdng quang, tuyen tidn li$t <^ »
Y H p c TP. H b Chi M i n h * T^p 21 * S£i 6 * 2017 N g h i e n ciiu Y hpc
C D
Hinh 10. Cat tuyen tien Hit tan gSc. A. Cdc moc dqt port. B. Tu thi'Trendelenberg doc 30" C Vi tri cdc port. D.
Docking
^i«^' t^^Hlteteta^ ^ ^ _ l _ _ _ _ _ _ | - _ 'Y^ cat bang quang t$n g^cftao hinh bang quang bang hoi trang noi thing; 3 TH treo co bang quang vao mom nho xuong cimg dieu tri sa sinh due; 2 TH cat buou tuy&i thugng than; 1 TH eat than tgn goc (chuyen mo mo); 1 TH cat than-nieu quan cho ung thu t^bao chuyen tiep be tlmn; 1 TH cat than don giim cho thSn mat diik nang; 1 TH cam lai nieu quan vao bang quang.
Muod. b n c n g h p p cat hiyein tien liet tan goc (Hinh 12)
Tuoi TB: 66,9 (49 - 75); ASA 2:9 TH, ASA 3:
ITH.
Benh ket hgp: Tang huyet ap + Dai ihao duong: 2 TH; Tang huyet ap: 2 TH.
PSA mau TB (ng/mL): 32,15 (8,76 - 93).
Kich thuoc tuyen tien liet tren MSCT/MRl (mL): 39,46 (31-60).
Diem s6 Gleason truoe mo: 6,4 (4 - 8) ; Xa hinh xuong : 7/10 TH.
A B Hinh 11. A.B. Phdn bffcdc port trong cdt tuyih tiin liet t&n gdc ^^^
K E T Q U A
Tit 30/11/2016 d a i 08/02/2017: eo 26 truang hgp (TH) tiet nieu dugc pMu thuat bang he th&ig robot da Vind Si™ nhu sau: 10 TH cat tuy&i tim li|t tan goe cho ung thu tuyeh ti&i liet;
4 TH tao hinh khiic n6i be than-nieu quan; 2 TH eat mgt phan than dio buou chu mo than nho; 1
N g h i e n ciiu Y h<?c Y Hoc TP. Ho Chi M i n h • T | p 21 * So 6 * 2017
Staging buou trmjc mo: TlbNoMo: 1 TH ; T2aNoMo: 3 T H ; T2bNoMo: 4 T H ; T3aNoMo: 1 TH ; T3bNoMo: 1 TH. So port 5 ports; 9 TH; 6 ports: 1 TH.
Ky thuat mo: npi soi tiong phiic mac (theo Isy thuat Monisouris).
Thai gian mo TB (phut): 297 (105-480); Mau mat TB (mL): 355 (100 - IGOO).
N?o hach ch?u bit Ueu chuan: 4/10 TH; Chvra bo madi than Idnh cuong: 2/10 TH.
Cat finh mach lung duong v§t, khau sau:
3/10 TH, Khau cot firih mach lung duong vat, c5t sau: 7/10 TH; Lam miii khau Rocco (Rocco'satch):3/10TH.
Riit ong dan luu ngay h§u phau: 5,2 (1 -10);
Nam vien TB sau mo (ngay): 6,3 (2 -11).
Bi&i chiing sau mo; ty dich hoc chau: 2/ 10 TH.
Hinfc 12. BN lam Van Th., 58T, UT TTL, cTibNoMo. A MRI tru&c mS.B.Xa hinh xmmg Bon truong h ^ tao hinh khuc noi b^' Ihan-
nieu quan (Hinh 13)
Gioi: Nam: 3 ; Nil: 1; Tuoi TB: 39,5 (23 - 64);
ASA2:4TH;BenP:2TH;BenT:2TH.
Ton thuong he nieu ket hop: Than mong ngua: 1 TH; San than cung ben: 2 TH.
Phuong phap mo; Tao hinh khiic noi cat roi+lay san than: 2 TH; Tao hinh khiic noi cat roi:
2TH.
Thai gian mo TB (phiit); 157,5 (120 - 210);
Mau mat TB (mL): 60 (10 - 200).
Dimg canh tay thii 4:2 / 4 TH; Nam vien sau mo TB (ngay): 5,25 (3-7).
A B.
Hinh 13. A, B. MSCT Hem cdn quang: hep khiic twi be than-nieu qudn phdi
Hai tru6ng h o p cat mgt p h a n than cho buou than nho (Hinh 14)
Gioi: 2 benh nhan nil; Tuoi TB: 34 (32 - 36);
Y Hpc TP. Hb Chi Minh * Tap 21 * Sfif 6 * 2017 Nghien ciiru Y hpc
ASA2:ca2TH
Kich thuoc buou TB (mm): 34 (31 - 37) Buou cue tren P, cTsNoMo: 1 TH; Buou cgtc duoi T, cTiaNoMo: 1 TH
1 truong hgp khong dimg dugc canh tay thii tu (de dimg ProGrasp'^'^) do khi dat port b;
"ch6i" gjiia canh tay thii ba va thii tu Then gian mo (phut): 210 (165 - 255); Thoi gian thieii mau nong TB (phiit): 15 (10 - 20)
C^ip cuong than: Day that mach mau: 1 TH;
Bulldog ngi soi: I T H
Khau chii mo than 2 lop: lop trong dimg chi V-lock® 3-0, lop ngoai dimg chi vicryl® 1-0
Mau mat TB: 50 mL; Nam vien sau mo TB (ngay): 5,5 (5-6)
M6 hgc buou: buou mo-co-maeh (AML) va buou ung thu te bao than te bao sang (CC-RCC)
A B C Hinh 14. Bu&u than trdi CC-RCC cue du&i.
A Phim MSCT tiim cdn quang. B.C. Mau benh pham buou
Mpt tn^mg hpp c^t bang quang tan gocftao hinh bang quang bang hoi trang noi thang cho ung thu t^bao chuyen ti% b ^ g quang xam l i b co (hinh 15)
4 B C Hinh 15. Bu&u bdng quang. A.B. MSCT tiim cdn quang co dung hinh. C. Seo tdi khdm sau md'
Benh nhan nam, 45 tuoi; ASA: 2, chah doan truoe mo: buou TCC bang quang eT2bMoMo.
Ky thuSt mo: eat bang quang tan g^c, tgo hinh bang quang b5ng hoi trang noi thang, tao hinh bang quang ngoai ca the, kieu
Hautmann.
So port: 6 ports; Thai gian mo (phiit): 660;
Lugng mau mat (mL): 500.
Nam vien sau mo (ngay): 15.
Mo hoc buou; Ung thu bieu mo te bao
Nghien cmi Y hpc Y Hpc TP. Hb Chi Minh * T^p 21 * Sfi 6 * 2017
chuyai tiep (TCC) xam lan ca bang quang.
Ba truong h^p treo cb bang quang vao m6m nh6 xmmg cung (Sacrocolpopexy)
Tuoi TB: 60 (55 - 66); ASA 2 : 3 TH.
Cach mo: 1 TH treo co bang quang vao mom nho xuong cimg; 1 TH c3t tu: cung + treo co bang quang vao mom nho xuong cimg; 1 TH co djnh mom am dao vao mom nho xuong cimg.
Thcri gian mo TB (phiit): 233,3 (180 - 300) ; Mau mat (mL): 66,6 (20 -150).
Nam vien sau mo TB (ngay): 4,33 (4 - 5).
Hal truong hpp cat buou tuyen tfaupr^ than phai(Hinhl6)
Gioi: 2 benh rihsn nir; Turn TB: 37,5 (26 - - ASA2:2TH.
Kich ttiuoc buou (mm): 34,5 (30 - 39).
Thoi gian mo TB (phiit): 97,5 (45 -150); Mau mat TB (mL): 75 (50 -100).
Nam vi$n sau mo TB (ngay): 8 (4 - 12); M6 hgc buou: buou Myelolipoma va Schwannoma.
Wnh 16. Schwannoma tuyih thugng than phdi. A.B. MSCT tiem cdn quang. C. M&u binh pham bu&u Mpt truong hop cat than-nieu quan phai cho ung tiiu te bao chuyen tiep be ttian (hinh 17)
Hiidi 17. Bu&u niiu mac be th&n phdi. A MSCT tiem can Benh nhan nam, 54 tuoi; ASA: 2 , Chim doan truoc mo: buou TCC be than phai
Thoi gian mo (phiit): 240; Mau mat (mL): 800;
N5m vien sau mo (ngay): 6
Mo hgc buou: ung thu bieu mo te bao chuy&i tiep biet hoa vua, do ac cao.
Mpt trucmg hpp cat t h | n don gian ben phai vi ttian mat chuc nang
Benh nhan nu, 52 tuoi: 52; ASA: 2 Thoi gian mo (phiit): 120; Mau mat (mL): 150
; Nam vien sau m6 (ngay): 4
quang. B.C. hMu birih phdm
Mo hpc than; Viem than - be thgn man tinh xohoa
Mpt tiuong hop cam lai nieu quan phii vao bang quang (NQnh 18)
Benh nhan nii, 42 tuoi, ASA 2, Chan doan truoc mo: hep ni^u quan phai sat bang quang.
Ky thuat mb: cam lai nieu quan vao bang quang nga ngoai bang quang (Lich-Gregoir)
Thoi gian mo (phiit): 180; Mau mat (mL): 50;
Nam vien sau mo (ngay): 7
72
Y H p c T P . H b C h i M i n h * T a p 21 * So 6 * 2017 N g h i e n c u u Y hpc
•m' •
^ ft" '
m
Hinh 18. Hep niiu qudn chdu phdi. AB. MSCT tiim cdn quang
B A N L U A N
Nhihig Ipi ich cua h^ thong robot p h a u tiii4t<"
Vi phia phdu thudt vien
Mang d a i hinh anh 3D lam tang do kheo leo, do chmh xac cua phau thuat tang tam cu*
dgng, giiip lam giam rung tay, phan do cu dgng va tang c6ng thai hgc (ergonomics) va su thoai mai eho pMu thu^t vien. He thong da Vind^"^
mang den hinh anh 3D, phong dai, vimg chac, khong gay moi mat do chinh phiu thuat vien dieu khi&i true ti%i. Phlu thu^t vien thao tac ca camera va tir hai den ba canh tay mang dgng cu.
Cong nghe Endowristi^" ciia da Vind^" (hinh 19) cho phep sif dung eae dung cvi voi 7 do tu do.
Cac cii dgng ciia dimg cu duge dieu khien bcri ngOTi tay, ban tay va eo tay cua phlu ttiuat vien lam cho ph&u thu&t bdng robot co cam gidc gan zM phdu thuqt ma han so v&i md' ndi soi S bi^ng tieu chudn. Vai nhiing Igi ich nay, he thong robot phau Ihuat cho phep cae phSu thuat vien chua c6 kinh nghiem ve ngi soi o bung tieu ehuah co the hoc tap de thue hien ngay cac phlu thuat ngi soi phiic tap nhu cat tuy&i tien liet tan goc, tao hinh khiic noi be than-nieu quan, v.v..
Hinh 19. A. EndovTrist™^. B. Bdn tay ph&u thu&t znin dieu Miim dung cu Ve phia hinh nhdn
Co ttie gjiip giam mat mau, gjam ti le tmyen mau, thoi gian nam vien, thcri gian d^t ttiong va cae biai diiing phlu thuat, chiic nang co quan dugc bao ton tot hon. Cac Igi ich khac la duong rach da nho, it dau hon, hoi phuc nhanh hem va nhanh tra ve vai cdng viec. Rieng cat tuy&i tien liet tan goc da dugc chiing minh la lam giam lugng mau mat va ti le truyen mau.
Cac p h l u thuat Tiet nieu nao dime u u tien thuc hien b a n g robot ?
Theo Schachter<^, theo thii tu uu tien gjam dan nhu sau:
Cat tuyrai tien liet*^^>
Tao hinh khiic noi be than-nieu cjuan^' cat bang quang'^'
cat than (cat mgt phan thgn, e3t than tan goc)ni
Nghien cuu Y hpc Y Hpc TP. Hb Chi M m h * T^p 21 * So 6 * 2017
Treo c6 bang quang vao mom nho xuong cimg''"
Noi ong dan tinh
Phau thuat tiet nieu nhi (cat than, eat mot phan than, tao hinh be th§n, chong ngugc dong bang quang-nieu quan)
Cat tuyen thugng than'^)
Nieu quan gjai, cam nieu quan vao nieu quanP*
Noi chung, cdc ph&u thuqt vung chau nhu cat tuyih tiin Hit, cdt bdng quang, treo cd bdng quang vdo mom nhd xuang ciing, v.v. cho thay uu diim cua robot mang lai so vai md'ma ro ret han cac ph&u thuqt th&n nhu cdt than. Cae phau ttiuat vung chau nhu cat tuyen tien liet tan goc eo ban do phan bff cac trocart tuong doi hang dinh hon so voi phlu thugt th|in ttiuong co b ^ do phan bo trocart thay doi theo hinh dang bung ciia benh nhan (bung be so voi bung thon). Ciing vi vay trong phlu thuat tuyen tien ti|t, viec docking tuong doi d^ hon so voi phau thuat than (de bi "choi"
cac canh tay robot). Dang chii y la trong bon truang hgp mb tao hinh khiic noi co 2/4 truong hgp khong dimg dugc canh tay fliii tu va trong hai truang hgp cat mgt phan than co 1 truong hgp khong dimg dugc canh tay thii tu deu tir nguyen nhan dat port bi "choi" cac canh tay robot. Trong phlu thuat robot, canh tay ttiii tu co vai tro de dimg dung cu ProGrasp'^" de giit hay ven mo gan vimg thao tac, giiip nong hoa vimg thao tae hay phoi bay ro hon vimg nay.
Cimg trong mgt phlu thuait, he thcmg robot giiip de thuc hien cac ky thuat chuyen biet doi hoi tmh uyen chuyen cua cii dpng ciia dung cu phau thuat. Thi du: trong cat tuyai tien liet dimg robot se de thgc hien khau noi nieu dao-eb bang quanh hon, khi lam miii khau Rocco thay ro rang cau tnic mo hon va khau de hon, khau cot lmh mach lung duong veit de dang hon; Trong tao hinh khiic noi be ttian-nieu quan thay thi khau noi nieu quan-be than kha de dang, nhanh
chong, (am nHn ro va bao quat hon, mui khau tir tin la kin nuoc hon. Trong khau noi, neu dimg loai chi eo gai (barbed suture) nhu V-lock® hay Stratafix® giiip khSu nhanh va kin hon vi soi chi CO CO die tu giii moi chi khi khau.
He thong uy nhiem
Theo cac tac giaP), phau thuat vien robot can dugc liy nhi$m bang mgt h^ thong liy nhiem tot bao gom: (1) Lap Ban ehiing nhan phau thuat robot, (2) L/U tien nhu nhau dio ea phlu thuat mo va npi soi 6 bung tieu chuan dugc thi^w: hien bang robot, (3) Hoan thanh mgt khoa huan luyen robot die biet, (4) Thuc hien phlu thuat robot tr&i dgng v|it thgc nghiem, (5) Quan sat phau thuat robot dugc tiiuc hien mau muc, (6) Lam ngucri phu mo tai giuong trong phau thuat robot, (7) Thue hiSn cac ca phau thuat robot dau tien duoi su giam sat cua gjam thi (proctorship), va (8) tiep tuc theo doi ket quA phlu thuat.
Rieng chiing toi da duge huah luyen khoa ngan ngay t ^ Trung tam huMi luyen phau thuat robot dugc chiing nhan boi Intuitive t?i b ^ vien Severance, Dai hgc Yonsei, Seoul, Han qu6c, dugc cap Giay chiing nhan phlu thuat vien robot (Certificate of da Vind system Training as a Console Surgeon) sau khi trai qua hue&i luyen tren mo hinh va tren dgng vat thuc nghiem ^leo) va kien tap 6 ca phau thuat robot boi cac phau thuat vien robot giau kinh nghiem ciia Tnmg tam nay. Ba piilu thuat vien robot ve Tiet nieu khi ve nuoc dugc thuc hi^n 5 TH phau thuat du»5i su giam sat ciia giam thi la phau thuat vien robot ngucri nuoc ngoai gom: mgt TH tao hinh khiic noi be than-nieu quan, hai TH cat tuy&i tien liet, mgt TH cat mgt phan th§n, mgt TH treo CO bang quang vao mom nho xuong cimg. Trong eae ca mo eo gjam tt4 nay, nguoi mo va giam thi
Y Hpc TP. Hb Chi M m h * T§p 21 * So 6 * 2017 Nghien cuu Y hpc
da thay nhau giiia hai vai tro phau thuat vi&i chinh va ngucri phu mo tgi giuong.
Nhan xet ve loat phau thuat robot ddu tien ndy
Nhin chung trong loat phlu thuat dau tien nay, hai loai phau thu|t dugc ini tien dimg phSu thuat robot chiem ti le cao nhat: cat tuyen tien liet tan goc, ke deh tao hinh khiic noi be than- nieu quan dung theo khuyai cao chi dinh phau thuat robot eiia cac tac gia. Loat Ion nhat la ung thu tuyoi tien liet, mat benh ma robot the hien tinh uu viet ro rang nhat so voi mo mo va npi soi o bung tieu diuan. Trong loat nay co hai truang hgp buou an lan ra ngoai vo bgc tuyoi tien liet va hii tinh (T3aNoMo va T3bNoMo) van mo robot thanh cong. Trong mo npi soi 6 bung ti^
chuan, chiing toi rat e nggi cac trucmg hgp buou xam lah ra ngoai vo bao vi de chuyoi mo mo do mo ung thu tham nhiem ciing. Qua nhiing truong hgp dau tien dimg robot mo benh ly ung thu nay chung toi co suy nghi rSng dimg robot ngoai viec giiip nao hach vimg de dang no con giiip phlu fhuat tni can de thanh cong ma khong bi chuyoi mo mo nha nhiing tinh nang mi viet da neu tren.
Van de thu nap benh nhan, so ca mb de duy tli he thraig
De fhu nap benh nhan phlu thuat robot can giai thich ro nhiing loi dion ciia phau thuat robot so voi ngi soi 6 bung tieu chuan (kho) va so voi mb mo (de hon). Kinh ngjiiem rieng trong thoi gian vira cjua ciia chiing toi Ihay can phai ket hgp cac yeu to: (1) Hieu iing tuyen tiiong (truyen hinh, phat fhanh, hgi thao, apphich, to red,...), (2) Uy tin ciia phau thuat vien (dugc huaii luyen bai ban 6 cac Trung tam huah luyen ciia Intuitive Surgical® o nuoc ngoai, kinh nghiem va tham nien phau thuat), (3) Su tan tuy
ciia phau thuat vien khi tu van cho benh nhan giiip de thuyet phuc benh nhan chap nhan phlu ttiuat cong nghe cao von co gia thanh cao hon.
Dieu kho khan tro ngai trong thu nap benh nhan la uu tien tiiu nap benh nhan uoc muon va CO kha nang chi tra chi phi phau thuat robot hay benh nhan co phuong phap mo uu tien dimg robot? Neu thu nap benh nhan co uoc muon phau fhuat robot bat chap loai phau thuat se thuc hien fhi co nguy co day cao ti le gia thanh / hieu qua khong can thiet, neii uu tien thu nap benh nhan co b^iih ly uu tien chi dinh phau thuat robot thi trong nhom benh nhan nay se co nhieu nguoi khong chi tra noi dugc gja fhanh ciia phau fhuat trong boi canh Bao hiem y te chua chi tra, so ca mo vi vay se bi gioi han.
KETLUAN
Phau thuat robot co uu the hon phau fhuat ngi soi kinh dioi nho su phat trien ciia cong n ^ e (man hinh 3D-HD, canh tay robot van dpng uyoi chuyoi, ban dieu khien giup thao tae phau fhuat fhoai mai....) giiip bac si Tiet nieu thirc hien dugc nhiing phau fhuat phiie tap voi duang cong hoc tap ngSn hon. Lpat iing dung phlu thuat robot ciia chiing toi qua 26 truong hgp dau tien da co ket qua buoc dau dang khich le. ( 3 n thue hien them nhieu truong hgp hon niia trong thai gian toi day.
TAI LIEU THAM KHAO
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2 John H, Peter Wiklund P, Witt JH (2013). Atlas of Robotic Prostatectomy. Springer.
3 Leveillee RJ, Bracho J, Williams SK, Shields JM, and Moore CR (2011) Robot-Assisted Pyeloplasty. Atlas of Robobc Urologic Surgery, Current Clinical Un^gy Humana Press; 159-172 4 McGee SM, Shimko MS, EUiott DS, and Chow GK (2011)
Robot-Assisted Laparoscopic Sacrocolpopexy. Atlas of Robotic UrxJogic Surgery, Current Clinical Urology. Humana Press 107-
Nghien cmi Y hpc Y Hpc TP. Hb Chi Minh * Tap 21 * So 6 * 2017
Mufarrq P, Hyams E, and Stifelman M (2011). Robot-Asasted Ureteral ReconstructiML Atlas of Roiwtic Urdogic Sur^ry, Current ainical Urr^ogy. Humana Press 187-214.
Palel MN, Patil N , Bhandari M, Narra V, Menon M, and Rogers CG (2011). Robot-Assisted Total and Partial Adrenalectomy. Atlas of Robotic L/rotogic Surgery, Current ainual Urotisy. Humana Press-121-132.
Sdiaditer LR, Kaufinan MR, Henell SD (2008). Establishment of a Robotic Prostatectomy Program, Rciwlies m Urologic Suigay, Saunders, Elsevier, Copyright © b y Saunders:79-84 Stem ]M and Lee DI ^ 1 1 ) . Transperihmeal Robot-Assisted Laparoscopic Radical Prostatectomy. Anterior Approach Atlas of Robotic Urriogic Surgery, Current Qinical Urology.
Humana Press: 33-45.
Wang Gf and Sdierr DS (2011). Robot-Assisted Radical Cystoprostatectomy. Atlas of Robotic Urotogic Surgery, Current Clantai Urology. Humana Press- 91-105.
Willis D, Pugji J, Paiekatta SJ, Alalah H and Su LM (2011).
RdMl-Assisted Radical NEphroureterectomy. Atlas cfRobolic Urologu: Surgery. Currmt Clinical Urolo^. Humana Press- 143- 158.
Ngdy nhSn bdi bdo: 13/07/2017 Ngdy phdn bien nhan xet bdi bdo. 20/07/2017 Ngdy bdi bdo duac dang: 30/10/2017
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