Y HOC VIET NAM THANG 9 - SO OAC BI^T / 2011
PHI/ONG PHAP CO 0!NH TLT CUNG Mdl L/NG DUNG TRONG PHAU THUAT NOI SOI BOC NHAN XO, CAT TLT CUNG BAN PHAN
TAI BENH VIEN HQU NGHj VIET NAM - CUBA DONG HOI
Phan Xuan Khoi"
TOM TAT
U'ng dung sang kien, phu'dng phap cd dinh tli cung mdi trong phau thuat ngi soi boc nhan xd va cat t i i cung ban phan tai khoa phu san benh vien hu'u nghj Viet Nam - Cuba Oong Hdi Quang Binh t i i thang 10-2006. Sang kien nay la sir dung pozzi udn cong gap trddc mpt goc 120 do du'dc dya vao 6 bung qua tui ciing sau va cap vao mat sau-day t i i cung, tiep theo khau kinh tui cung sau, cd djnh tir cung vao pozzi bang niit chi khau qua co t i i cung. Nhd vay t i i cung da dddc CO dinh hoan toan vao pozzi, tif day pozzi co the dieu chinh tif cung, cung nhd lay benh pham qua tui Cling sau thuan ldi.
Ket qua chung toi da ap dung cho 12 tru'dng hPp phau thuat ngi soi, trong do co 6 trudng hdp bdc nhan xd va 6 trddng hdp cat t i i cung ban phan: 100% trddng hdp phau thuat dien ra thuan ldi, thdi gian phau thuat trung binh 120 -150 phiit, thdi gian dat pozzi cd dinh t i i cung 3-5 phiit, thdi gian lay benh pham 5-6 phut, khong co tru'dng hdp nao xay ra bien chiing.
Ket luan: Phddng phap cd dinh tir cung mdi trong phau thuat ngi soi dddc ap dung dau tien tai benh vien Hii'u nghi Viet Nam - Cuba Oong hdl. tuy sd Iddng phau thuat con it, nhdng da thanh cong bddc dau ap dung sang kien mdi trong ITnh viTc phau thuat ngi soi boc nhan xd va cat tir cung ban phan. Phu'dng phap mdi nay co the ap dung, khac phuc tinh trang thieu dung cu cao cap chuyen dung trong PTNS d rat nhieu benh vien tren toan qudc.
SUMMARY
With our initiative, new method of uterofixation in endoscopic surgery of fibrouterotomy and subtotal hysterectomy at the obstetric and gynecology department of Viet Nam Cuba friendship hospital in Dong Hoi, Quang Binh from October, 2006 to January, 2007. This initiative has been done with the flexible pozzi which was bended 120 degrees. We put it into the abdominal cavity through the posterior cul- de-sac and join it with the uterinejundus. Then we suture the posterior cul-de-sac and fix the uterus into the pozzi. So the uterus will be fixed in to the pozzi and we can control the uterus as well as take the tissue easily.
As the reslult, we apply the new method for 12 cases. Including 6 cases of subtotal hysterectomy, 6 cases of fibrouterotomy with 100% of these cases were operated successfully.
The average operation time for each case is 120 - 150 minutes, among them, the time to put pozzi and fix uterus is about 3 -5 minutes and the time to take tissue out is 5-6 minutes. There is no cases have complications.
In conclusion, although the number of surgeries is still small, but we were very successful when we applied the new initiative In fibrouterotomy and subtotal hysterectomy surgeries.This new method can be applied to overcome the shortage of high techniques and specialized in endoscopic surgery in many hospitals over our nations.
HOl NGHI KHOA HOC KY T H U A T M d R O N G L A N T H O X I I • B E N H V I E N H O U NGH! V I E T NAM - CU B A D 6 N G H C ? I
I.
OAT VAN OENgiiy na> phiiu Ihual ngi soi (P TNS) da dugc nhicu hi-iili \ icn iip dung Irong dieu tri
\ii md rgng ciic chi dinh phiiu lliuiil phirc lap.
Tinh hieu qua. uu (.licm ciia P INS clii tlugc gidi phim ihual \icn khiing dinh, chiip nhim Nil Ihay Ihc dim phiiu thuiit ihuimg quy (nio mo), luy nhien dc tii-p can vii irng dung ci) hieu qua PTNS viio cong liic dieu tri, bcMi canh CO dgi ngu phiiu Ihual \ ii'ii gioi con ciin CO trang thicl hi dong bg, niing ciip hicn dai
\a tinh cluncn mon boa cao, nhu Irong md cat lir cung, ngoai hg P INS chung cim dugc trang bj them cim niing lir cung (ulrine manipulator) \a miiy nghien bciili phiim (elctomecanic morcclalor) nhirng gia Ihimh rat cao (khoang 400 trieu DVN), nen chi co mgt so it Benh vien luyen Trung uang trang bi. Hau het cac benh \icn tuyen linh chua trang bj them thiet bi cao cap chuyen dung nay. tuy nhien nhu cau kham chira benh ky thuat cao ciia ngudi dan doi hoi can phai dap ung. Xuat phat tir benh vien luyen linh ngheo xa trung tam PTNS Idn trong nude (Ha Ndi, TP HCM...) do do chung tdi da tien hanh nghien curu sir dyng Pozzi (dung cy kep CTC th6ng thudng) de co djnh tir cung. nham dieu chinh tir cung trong phau thual ngi soi vii lin benh pham nhu trong ciil lir cung ban phhn va bdc nhan xa tir cung \di de tai: Phuang phap c6 djnh tir cung mdi, irng dyng trong phau thuat ndi soi boc nhan xa \ ii ciil tir cung ban phan, tai benh vien Huu nghi Viet Nam Cuba Dong Hdi.
Muc tieu
Danh gia budc d4u hieu qua phuang phiip iing dung mdi, sir dyng trang thiet bi y lc Ihimg thuirng (Pozzi cai tiln) dk hd trg mot so lang, thi trong phau thuat ngi soi
Khac phuc linh trang thieu dung cu phau thuat ngi soi cao cap, chuyen dung trong PTNS.
II. D6\ TUpNG VA WUONG PHAP NGHIEN COU
2.1. Doi tugng nghien cihi
Bao gom 12 Irucmg hgp boc nhan xa va cat tir cung biin phan bang PTNS co ap dung
"phuang phiip cd dinh lir cung mdi" thay cho phuang phtip cd dinh tir cung bang can nang va lay benh pham bang dyng cu chuyen dung. Phuang phap nay da thong qua hoi ddng khoa hgc ky Ihuat benh vien Hiiu nghi Vict Nam Cuba Dong Hdi du\et thyc hien tirthang 10-2006.
2.2. Tieu chuan loai trir
Benh nhan khdng ddng y vdi phuang phap mdi nay.
Cd cac benh u xa Idn >70mm, tang sinh ndi mac tir cung, tdn thuong cd tir cung, K tir cung
Cac benh ly khac dang dien bien nang khdng cd chi dinh phiiu thuat ndi soi.
2.3. Phu-OTig phiip nghien cihi Loai hinh nghien cim:
Phirong pliap ngliien cim tien cim can thiep Phucmg lien nghien cim:
Sir dyng dan may ndi soi Karl Storz. i, Su dyng puzzi cai tien (dugc udn cong g$p trudc 120 do cd ham cd dinh).
Y HOC VIET NAM THANG 9 - SO OAC BIET / 2011
2.4. Ky thuat PTNS co ap dung phu-ong phap co djnh tii' cung mdi
PHJONG PHAP CO OINH TU CUNG THl/ONG QUY PHUONG PHAP CO OINH TU CUNG MOl
Ngudi benh nam tu the phy khoa
Dimg 3 trocars: 1 trocai" lOnim d \\ tri rdn dua kinh soi vao, bom hoi C02 \ ao 6 byng , sau do dat 2 trocars 5 mm d hai ben ho chau tren duong Pfannenstiel de mang dyng cy phau thuat.
Trudc bet kiem tra toan bd d byng, gan, lach, mot, mac ndi Idn, u xo tir cung, phan phu, tlii cimg Douglas.
Mgt ngudi phy ngdi giu:a 2 chan cua benh nhan bgc 16 CTC de md tui ciing sau theo phuang phap cd dien co sy giam sat cua kinh noi soi.
Thi md tiii cimg sau: Dat van am dao tien hanh md tui ciing sau khi thay hoi thoat ra la dau hieu tiii cimg sau da dugc md. Qua camera th^y dugc lo md tui cimg douglar.
Thi Pozzi CO dinh tir cung: Pozzi dugc dua vao 6 bung qua tui ciing sau dudi sy kiem soat cua dng kinh. Khi quan sat ro Pozzi va CO quan d tilu khung, md dau pozzi rong va kep vao day- mat sau tir cung dudi sir chi dao, trg giiip cua phau thuat vien qua kinh soi Nhu vay pozzi da co dinh tu cung
¥ dilm B(H2). Sau dd khau kinh lo md d tui
miii vdng quanh Pozzi ngay vi tri 16 md tui ciing sau xuyen kim vao sau mat sau c6 tir cung, bugc lai chat diem A(H2). Bay gid Pozzi da c6 dinh tir cung tai hai diem A va B.
Sy c6 dinh chac chan nay tao nen mgt khoi th6ng nhat gitra pozzi va tir cung Nhu vay dieu chinh tir cung se dugc lam chu hoan toan nhd pozzi c6 dinh nay, tir cung dugc dilu chinh sang trai de bgc 16 phau trudng ben phai rgng va ngugc lai hoac tii cung dugc day len tren , ra trudc ,ve sau de co phau trudng thich hgp cho phau thuat vien tien hanh thuan lgi.
Dot va cat mach mau, phan phu
Tir cung dugc dilu khien bang pozzi day vl phia dii dien (tir cung dugc dhy qua trai dk phau thuat ben phai va ngugc lai). Dimg dao dien dit va cdt voi tu cung, day chang tron, day chang tir cung buing trimg, boc tach day chang rgng. NIU cat ca phhn phu thi dot va cat day chang that lung buong trung trudc va tilp theo cat day chang Iron.
- Dot va cat ddng mach tir cung
Ngudi phy cSm pozzi day tir cung sang phia dii dien hoan loan. Dung kep co mhu keo dhu cua day chang tron vl phia dii dien.
HOl NGHI KHOA HOC KY THUAT Md RONG LAN THOXII • BENH VlfN HOU NGHj VI£T NAM - C U B A 0 6 N G H 6 | _
ro rang dgng mach tii' cung. I)6l dgng mach lir cung bimg dao ludng circ, roi c;ll bang dao don ciic hoac bang keo.
Boc tach pbiic nine doan co ciii tir cung
DiiN po/,/i la sail sang bi'ii doi dicn db hoc liich phiic mac co tir cung diiy bang quang xuong. Dimg dan cue ciil tir cung ngang doan co lu cung, kicni tra neu chay mau dimg ludng circ ciiiii miiu lot.
Thi Po//i lay hcnh pliiuii: 1 icp theo liiN benh pham ra bang each ciit niit chi co djnh a cb tir cung (DicMii A), ciit mil cbi tui ciing sau vii ciini po//i keo benh phiim ra dudi sy h6 trg ciia phau Ihuiil \ icn. Khi dau po/./i \i tri kt?p lu cung (diem B) thiip thd 16 md tui cimg sau, tiiy theo kich thudc tir cung, b^nh pham, de md rgng them 16 tiii ciing va
dua b?nh phhm ra khdi d bung mdt each de diing htrn.
Khau lai tui ciing sau bang miii chi khau vat.
Bom hai 6 bung tot. de kiem tra toan hi) mdm cat, rira sach 6 bung va rut trocars ,kct thiic phau thuiit.
• Bdc nhan xo tOr cung Ky thuat va cac thi hoan loan gidng vdi cat tir cung chi khac biet la bdc nhan xa khau phyc hdi bao toan tir cung.
III. KET QUA
12 truirng hcrp phau thuat ndi soi co ap dung phuang phap cd dinh lu cung mdi bao g6ni 6 trucrng hcrp cat tir cung ban phan va 6 Irudng hgp bdc nhan xo tir cung.
Bang 3.1; Vc do tudi Tuo'i
<39
>40 Tong
Clttu'cung ban ph'an(n=6) 02
Bdc nhan xd tu* cung(n=6) 06
04 00
06 06
Trong 6 cases cat tir cung ban phan chu yeu tren 40 luoi 4 cases (66.6° o) Boc nhan xo tir cung 6 cases (100%) d tudi dudi 39tu6i
PTNS Bdc u xd Cat tii cung
Bang 3.2: Kich thudc u xo KT<6cm
04 05
KT>6cm 02 01
Tdng s6(n) 06 06 Bdc nhan xo tir cung kich thudc u xo •-6cm 4 cases(66,6%).
cat tir cung chii > cu kich thudc u xa<6cm, 5 cases(83,3%).
Bang 3.3: Vi tri u xo tir cung
PTNS MSt tru'dc Mat sau Tong so(n)
Boc u xd 06 00 06
Cat tir cung 04 02 06
Bdc nhan xo mat trudc tir cung 06 cases (100%) cat tir cung co u xo mat trudc 04 cases (66,6%)
Y HOC VIET NAM T H A N G 9 - SO OAC BI^T / 2011
3.4. Thdi gian phau thuat
Boc nhan xo thdi gian phau thuat trung binhl20 phut
cat tir cung thdi gian phau thuat trung binh 150 phut
3.5. Thdi gian dat pozzi co dinh
Qua trinh md tiii ciing sau \ ii c6 dinh pozzi trung binh 3-5 phiit
3.6. Thdi gian lay benh pham
Tat ca 12 trucrng hgp iii6 thdi gian la>
benh pham trung binh 5-6 phut
3.7. Thoi gian truyen dich sau mo 100% chi truyen dich 1 nga> dau 3.8. Bien chirng qua trinh dieu trj Qua 12 trucrng hgp trong phau thuat \ii hau phau kh6ng xay ra bien chimg nao.
3.9. Thdi gian nam vien
Thdi gian nam vien trung binh 6-7 ngay IV. BAN LUAN
Phuang phap cat tir cung qua ngi soi thuc hien dau tien bdi Reich bao cao nam 1989. Nam 1992 Dubuisson thyc hien boc nhan xa tir cung. Tai Viet Nam PTNS phy khoa sdm ap dyng tai benh vien Tir Dii nam
1993, tuy nhien phau thuat cat tir cung va bdc nhan xa cham ban. Benh Vien phy san Trung uong PT boc nhan xo tir cung nam 1999, cat tir cung thang 10-2004. Tai Benh vien Viet Nam Cuba Ddng Hdi Quang Binh PTNS boc nhan xa tii cung tir thang 4-2005 , cat tir cung banphSn tir thang 6-2005, din thang 10-2006 ky thuat PTNS sir dyng 4 trocars va sir dyng dieu chinh tu cung theo phuong phap c6 dien nhung vdi sl lugng cdn han chi va lung tiing do thilu dung cu PTNS chuyen dyng. Nen tir thang 10-2006 chung tdi ap dyng sang kiln phuong phap cd dinh tu cung mdi trong PTNS boc nhan xo va cat tir cung ban phhn da dua lai hieu qua hon do la:
Rill ngan thai gian phau thual trudc day keo dai ban 120-150p din nay thdi gian rill ngan ban.
Thao tac thuan lgi hon khi dieu chinh til' cung trong phau thuat nhd tii' cung dugc cl dinh lai hai diem cr day va c6 tii' cung (H2).
Lay benh pham thuan lgi hon do kh6ng ciin cat nho benb pham vii lay qua lui ciing sau thuan lgi (con dudng c6 dien) tryc tiep qua pozzi (H2)
- Trong phau thuat bdc nhan xo tir cung phuong phap cd djnh tir cung mdi kh6ng lam thuong l6n den niem mac tir cung.
- Tinh tham my cao ban vi trudc day chiing t6i sir dyng 4 trocars co 1 trocar 10 de lay benb pham hoac cd cas hgp phai xe rgng 16 trocar 4-5cm. Vdi phuang phap mdi nay chiing t6i chi sir dyng 3trocars 5mm va lay benh pham qua tiii ciing sau nen kh6ng xe rgng thanh byng, do vay khong de lai seo Idn tren thanh byng va tdn trgng sinh ly vi day la con dudng ty nhien.
Chung tdi chua cd tai lieu t6ng ket PTNS cat tir cung ban phan trong nude de ban luan them va kh6ng the so sanh vdi trung tam Idn nhu benh vien phy san Trung uong, benh vien Tir Dii hg co ddi ngu PTV dau nganh va trang thiit bi hien dai dong bg. Tuy nhien la mgt benh vien tuyin tinh trang thiit bi cdn ngheo nen chiing t6i da cd sang kien mdt phuang phap mdi ap dyng de ddng nghiep tham khao. S6 lugng phau thuat con it nhung budc dhu da co ket qua t6t chua co biln chung nao xay ra, phuang phap nay da khac phyc tinh trang thilu dyng cu ngi soi va dyng cy chuyen dyng trong PTNS qua dat phai nhap ngoai.
V. KET LUijiN
Qua 12 trudng hgp phau thuat ngi soi co
HOl NGHI KHOA HOC KY THUAT Md RQNG LAN THOXII • BENH VIEN HOU NGHj VI$T NAM - CU B A D 6 N G H 6 |
bao gdm 6 Iruimg hcrp ciit lir cung ban phiin 3.
\a 6 truirng hc^p hoc nliiiii \a lir cung cluing loi ban dim co niol so kii luiin s;m:
l)ii\ hi mot phmrng phiip mdi dugc nghii-n ciru tai Benh \ icn hiru nghi Viii Nam 4.
Cuba Dong lliri co hieu qua biroc dim.
Sir dung ihicl hi \ tc thong ihuirng tli;i\ 5.
the ihict bi CIUINCMI dung nhap ngoai
Rill ngan thdi gian phiui ihiuil, ilric biet
trong hi\ benh phiim nhanh \ ii ci) hieu qua. 6.
Ciiam bin sy dau ddn cho ngiriri benb.
dam bao tinh thiim my, tdn trgng sinh ly va
giam kinh phi cho ngiriri benh. 7 TAI UEU THAM K H A O
1. Bach Cam An (2006). Diinh giii kcl qua 8.
PTNS ciil lir cung loim phim trong benh ly u xo tir cung, Mgi nghj san phu khoa mien trung, NXB y hgc tr 333
2. Vu Hong Cu'OTig (2006), May nghiln biit benh pham. Can nang lir cung. Karl Slorz - Endoscope
B^nh vien phu san Tii' Du (2005) Phau thuat ndi soi, qiia khir vii tuong lai. Hgi nghi siin phu khoa Viet- Phap Chau A- Thai Binh Duong TP .HCM
Tran Binh (iiang (2003). Phau thuat noi .soi b bung, NXB y hcic Tr 104,217,218 Nguyen Diix Hinh (1999). Ky thuat ca ban Irong niii .soi 6 bung, Ndi soi trong phukhoa. NXByhgc.'lr43
Nguyen Ba My Nhi (2005), Danh gia budc dau Irong dieu tri bdc nhan xo. Noi san san phy khoa, NXH y hgc, Tri 15-121 Vu Ba Quyet (1999) Cat tu cung qua ngi soi, ndi soi trong phu khoa, NXB y hgc Ir 90
Carter J.E., Ryoo .1., Katz A. (1994),
"Laparoscopic - assisted vaginal hysterectomy: a case control comparative sliid\ with total abdominal hysterectomy" J .4m Assoc Gynecol Laparosc Feb, 1(2): 116.