Y HOC VlgT NAM THANG 8 - SO D A C BlgT / 2013 P H A N I: TIET N I E U
PHAU THUAT NQI SOI MO RQNG BANG QUANG B A N G R U Q T KET HOP V6l CAM LAI NIEU QUAN VAO BANG QUANG
VA TAO VAN CHUY^N UUU
Nguyen Vfin An' Pham Huu Do^n', V6 Tr^ng Thanh Phong'
T O M TAT:
Oat van de: Nghien CLTU kha n3ng utig dung phau thuat noi soi trong md rang bang quang bang mot ket htfp vdi cam la[ nieu quan vao bang quang tai Benh vien Binh Dan.
061 tu'dng va phurtfng phap: 68 benh nhan bang quang than krnh hoac bang quang kern gian nd du'cJc phau thuat md rong bang quang bang ruot noi soi. Trong do c6 33 tru'dng htfp ket hdp cam lai nieu quan vao bang quang va 9 tru'cJng hdp tao van chuyen lu'u nu'dc tieu c6 kiem soat.
Ket qua: TLT thang 06/2008 den 04/ 2013, CO 68 tru'cfng hdp phau thuat md rang bang quang bang ruot du'dc thi/c hien d Benh vien Binh Dan, gom 37 nam va 31 nu". Tuoi trung binh la 35,89.Thdi gian mo trung binh la 317,78 p h u t i^ot truling hdp chuyen mo hd de kiem tra va site chu^ cuong mac treo bj xoan 180^. Thdi gian nam vien trung binh 9,96 ngay. Thdi gian theo doi tCr 3 - 36 thang. Ba tru'dng hdp tac ruot hoac ban tac ruot trong khoang thcJi gian 1 thang sau mo, trong do mot benh nhan phai mo cap ctrtj.
I^ot tru'dng hdp khac v3 bang quang sau mo 10 thang phai mo khau bang quang,
Ban luan: Chung toi cung nhu' da so cac tac gia trong y van chpn each dem ruot ra ngoai qua mot lo trocar mcf rpng khoang 3 - 4 cm de khau noi ruot, nham lam giam thdi gian mo. Djnh vi tam ruot khi khau trong noi soi 6 bung kho hc(n nhieu so vdi mo hd, can c6 each de dinh vj ' Khoa Nieu A, Benh vien Binh Dan
Phan bien khoa hoc: PGS.TS. D 5 Tru'dng Th^nh
tru'dc khi khau noi ruot vdi bang quang.Oe tranh tac ruot sau mo do thoat vj noi, can khau lai phuc mac thanh sau che iat nieu quan chau.
Ket luan: Co the thi/c hien phau thuat md rong bang quang bang ruot qua nga noi soi o bung thanh cong vdi s i / hieu qua va an toan trong dieu kien cua Viet Nam. Oa c6 nhieu tac gia bao cao ve phau thuat md rong bang quang bang ruot qua nga noi soi 6 bung, nhuTig theo hieu biet cua chung toi, day c6 the la bao cao dau tien iVng dung phau thuat noi soi trong md rong bang quang bang ruot ket hcJp dong thdi vdi cam lai nieu quan vao bang quang va tao van chuyen lu'u nu'dc tieu c6 kiem soat.
Tu" khoa: phau thuat noi soi, md rong bang quang bang ruot, bang quang than kinh.
S U M M A R Y
LAPAROSCOPIC SURGERY FOR AUGMENTATION ENTEROCYSTOPLASTY
COMBINED W I T H URETERAL REIMPLANTATION AND URINARY
CONTINENT STOMA
Introduction: We study the possibility of using iaparoscopy to perform augmentation enterocystoplasty associated with ureteral reimplantation in Binh Dan hospital, Viet Nam.
Methods and materials: 68 neurogenic bladder or low-compliance bladder patients were operated by auamentation enterocystoplasty via
HQI NGH! KHOA HOC L^N THCT VII. HQI TigT Nl£U - TH^N HOC VigT NAM (VUNA) Iaparoscopy. Among them, 33 were combined
with reimplanting ureters to augmented bladders, and 9 were associated with performing continent stomas.
Results: From July 2008 to April 2013, 68 cases of augmentation enterocystoplasty by iaparoscopy were performed at Binh Dan hospital, composed of 37 men and 31 women.
Mean ages ~ 35,89. Mean operation time was -«
371,78 minutes. One case had to convert caused by t)eing twisted of pedicle of intestinal portion used for plasty. Mean hospital stay was ~ 9,96 days. Times of following-up from 3 - 3 6 months.
Three cases was suffered from intestinal obstruction 1 month post-op and one had to reoperate. Another case was suffered from augmented bladder perforation caused having no interrupted catheterization 10 months after operation and had to reoperate.
Discussion: We have performed hand- assissted Iaparoscopy, taking small intestine out of the abdominal cavity to make intestinal plasty, to save the operative time. It is difficult to determine the position of intestinal sheet, therefore we have some tips and tricks while intestino-vesical suturing. To prevent intestinal obstruction post-op caused by internal hernia, it is necessary to cover the portion of pelvic ureters by closing parietal peritoneum.
Conclusion: Augmentation enterocystoplasty via laparoscopic surgery can
be performed successfully with efficacy and safety in the condition of Viet Nam. Many authors have reported laparoscopic augmentation cystoplasty, but to our knowledge, this may be the first report which performs laparoscopic augmentation enterocystoplasty, ureteral reimplantation and continent stoma simultaneously.
Keywords: Iaparoscopy, augmentation enterocystoplasty, neurogenic bladder.
|. 0/^T VAN OE
Phau thuat md rpng bang quang bang rupt da dugc thirc hien nhiSu nam, Mikulicz (1898) diing h6i trang, Couvelaire (1950) diing manh trang...Den nay da c6 hang tram bdo c^o vl phau thuat nay boi nhieu tac gia.
Tuy nhicn phau thuat npi soi ma rpng bang quang bSng rupt dupe bao cao bdi mot so it t^c gia trong 10 nam gan day. Docimo thirc hi?n ca dau tien (1995) bang da day'". Nam 2000, Gill va Rackley bao cao 3 trucmg hop phau thu^t npi soi ma rpng bang quang bang rupt d Cleveland (Hoa Ky)'*'. Sau do Elliott (2002) thuc hi?n a California (Hoa Ky)*^*.
Lorenzo (2007) th\rc hien a Toronto (Canada)'''', Nunez thuc hi$n 6 Madrid (Tay Ban Nha)'^', moi tac gia bao cao 1 - 2 truong hop phau thuat noi soi ma rpng bang quang bang rupt.
Bai viet nay trinh bay kinh nghi?m cua benh vien Binh Dan qua 68 truong hap phau thuat npi soi mo rpng bang quang bing rupt tu thang 06/2008 d^n thang 12/2011.
II- o 6 l l a p N G VA PHUONG PHAP NGHIEN CirU
Tieu chuan chpn benh: nhihig benh nhan dirac chan doan bang quang than kinh CO that ho$c tang truang lire {spastic or hypertonic neurogenic bladder) voi bien chung u nuoc than hoac Xhk bai diSu tn npi khoa.
Phau thuat can thi^p:
Phau thuat npi soi ma rpng bang quang bang rupt (ky thuat Goodwin).
- Cam lai nieu quan vao bang quang doi voi nhihig benh nhan u: nuoc than nang do ngupc dong bang quang nieu quan hoac hep khuc noi bang quang nieu quan.
Tao van chuyen luu nuoc tilu (ky thuat Monti) doi voi nhung benh nhan gap
Y HQC VigT NAM THANG 8 - SOPAC BIET / 2013
kh6 khan trong dat thong tieu each quang nhu liet tu chi, hep nieu dao n$ng.
Ky thuat:
Benh nhan dupe gay me, nam ngira dSu thap theo tu the Trendelenburg.
Dat 4 trocar; 1 trocar du6ng kinh 10 mm ngay ron, 1 trocar 10 mm bo ngoai ca thang bung, duoi ron 2 cm, 2 trocar 5 mm vung chau ben each gai chau truoc tren 2 cm (hinh 1).
Camera quan sat dinh bang quang, goc hoi
i;
manh trang de tim phan xa h6i trang. Ma rpng 16 trocar r6n 3cm, ISy doan xa h6i trang ra ngoai. Chpn mot doan hoi trang dai khoang 30cm tu ph4n xa h6i tr^ng d^ mo rpng bang quang. Khau ph\ic h6i luu thong hoi trang bang duang khau n6i tan - tan.
Phan rupt khau phuc hoi dupe dua vao trong 6 byng. Doan rupt dupe cat ra dupe xe dpc va khau lai t^o dang chii' U ben ngoai bung bang chi vicryl 4.0 (hinh 2).
i '^ f I ' wSF ••'
\ ir
Hinh la- Vi tri cac trocars Hinh lb- Seo mo sau 1 nam Truong hpp cam lai nieu quan vao bang quang tan tao; ma phuc mac thanh sau, giai phong nieu quan den gan bang quang, kep clip nieu quan va cat roi nieu quan dua ra ngoai qua lo trocar. Cam lai nieu quan vao tarn rupt da khau, dat thong JJ Imi.
Truong hpp tao van chuyen luu c6 kiem soat; chpn mot doan hoi trang c6 mach mau nuoi tot, xe dpc va khau ngang doan hoi trang nay tao nen mot ong nho (tuong tu ky thuat Monti), khau noi ong nay vao tam rupt. Tam hoi trang dupe dua lai vao 6 bung, khau phuc hoi thanh bung va dat lai trocar.
^ m
ytf;^ ji^'f^v--'.Hinh 2a, 2b, 2c - Cat, khau noi va tao hinh rupt ngoai 6 bung qua lo trocar r6n xe r6ng
HQI NGHj KHOA HQC LAN T H Q Vir, H Q I TIET NigU - THAN HQC VigT NAM (VUNA)
Thuc hien trong 6 bung: mo phuc mac va dinh bing quang dupe ngoai phuc mac hoa. Dinh bang quang dupe x6 ngang bang dao di?n (chieu dai cua duong xe nay tuang uTig vai chu vi cua tam hoi tr^ng). Sau do khau tam h6i trang v^o dinh bang quang vai chi vicryl 3.0. Dat thong ni?u dgo de dan luu dich trong bang quang (Foley 8F). Kiem tra si^ ro ri nu6c bang cdch bom nuofc vio bang quang, khau tSng cuong nhftng nai eon ro nuoc. Ngoai phuc mgc hoa bang each khau ria phuc mac len phia tren duong khau noi rupt - bang quang voi chi chromic 3.0.
Tren nh&ng b?nh nhan t^o van chuyen luu, dau con lai cua van s6 dupe dua qua ea thang bung, khau vao da bung va dat mpt Foley 14 Fr qua van vao bang quang.
Sau khi khau xong. riia va hut sach 6 bung, din luu tui cung Douglas qua hai lo trocar viing chau. Cuoi cung, rut trocar va khau cac 16 trocar.
Ill- KET QUA NGHIEN CCTU
Tu thang 06/2008 d^n thang 04/2013. eo 68 truong hap dupe phau thuat npi soi ma rpng bang quang bang rupt dupe thi^rc hien tai Benh vien Binh Dan.
Ty le nam/nO:: 37/31.
Tu6i trung binh: 35,89 ± 17 (tir 8 - 74 tu6i).
Co 30 truang hpp chi mo rpng bang quang, 33 truang hop ma rpng bang quang ket cam l?i ni?u quan vao bang quang, 9 truong hpp ma rpng bang quang k^t hpp cam lai nieu quan va tao van chuyen luu.
Thdi gian phau thuat trung binh: 317,78
±51,34 phut (180-390 phut).
Kh6ng CO bien chung nang trong phau thuat.
Mot truang hpp phai chuyen m6 ma yi sau khi khau n6i ruot vao bang quang thi thay rupt bi tim. Khi ma ra ki^m tra thi thay cu6ng mac treo bi xoin 180 dp do dinh vj khong dung trong luc khau n6i. Sau khi thao cac m6i chi khau. dinh vi lai cho dung va khau n6i lai rupt - bang quang thi rupt hong tro lai va dien tien hgu phau tot.
Mau mat trung binh trong mo: 1^7,02 ± 84.21 (ml) (5-400 ml)
Thoi gian nam vien trung binh: 9,96 ± 2,85 ngay ( 6 - 1 7 ngay).
Theo d6i sau mo lii 3 den 36 thang.
Co 6 truang hop bien chumg nang sau mo dupe ghi nhan:
3 trucmg hop tac ruot sau mo, hai truofng hop tu khdi va 1 truong hop phai mo lai. Khi mo lai thay nguyen nhan tac rupt la do thoat vi npi cua hoi trang chui qua khe cua nieu quan doan cuoi do khi mo khong khau phuc mac che phii ni^u quan.
Mot va bang quang tu phat sau mo 10 thang do ngii quen qua 12 gia khong d^t thong tieu (nhihig truang hpp tieu khong hieu qua se duac hucmg dan dat th6ng tieu each quang moi 6 gia). Trucmg hop nay cung dupe phau thuat cap cuu khau lai bang quang va.
Truong hpp thu 5 nhiem trung nang suot 2 thang, benh nhan dupe dieu tri khoi bang khang sinh manh (Timentin).
Truang hop thir 6 bi suy than khong hoi phuc, phai dupe dieu tri bang Ipe miu djnh ky.
Da s6 nhiJng trucmg hpp con lai theo doi sau mo CO diln tien thuan lai, nhi^u truong hpp cai thien mure dp chuang nuoe than hit sire ngoan muc (hinh 3)
Y HOC VIET NAM THANG 8 - SO DAC BIET / 2013
Hinh 3a- UIV truac mo Hinh 3b- Cystography sau mo 6 thang
H i n h 3 c - U l V s a u m F T l
Hinh 3: Benh nhan Tran Hong D., n u 2 2 tuoi.
(Chan doan: bang quang than kinh tang truong luc, gay I'r nuoc than 2 ben)
IV- BAN LUAN
4.1. Ban ve so bao cao trong y van:
Cho den nay sau 18 nam ke tir bao cao cua Docimo ' " , trong y van chi c6 khoang 15 bao cao ve de tai nay, c6 le vi theo Rackley;
phau thuat npi soi ma rpng bang quang bang rupt phuc tap va keo dai. Hau het cac bai bao trinh bay mot so it benh nhan, trong do El- Feel (2009) bao cao nhieu nhat la 23 truang hpp '^'. Cac bao cao cua chung toi c6 le la c6 so lupng benh nhan nhieu nhat trong y van;
nam 2012, chung toi da bao cao a Hoi nghi Nieu khoa The gioi o Fukuoka (Nhat) vol 48 truang hpp '''• nam nay loat benh cua chung toi la 68 benh nhan.
4.2. Ban ve ky t h u a t mo:
- Hau het cac tac gia deu dung hoi trang nhu trong mo ma. Quan diem ciia chung toi, hoi trang c6 Ipi the han so voi da day ve phuang dien vi tn' va mach mau nuoi, khau noi h6i trang dan gian va it bien chirng han dai trang.
- Nhung phau thuat vien thuc hien phau thuat trong phuc mac thuang diing nhung
dung cu ho trp nhu; Endo-GIA cho khau noi rupt. Endostitch cho khau bang quang rupt (12.:i) [^{^gpg (-5 nh&ng dung cu ho trp tren, nham rut ngan thoi gian phau thuat, chung toi mo rpng 16 trocar ron 3cm, dua rupt ra ngoai, cat va khau noi truoc khi dua vao 6 bung khau voi bang quang. Gill *''* cung thuc hien tirong tu va da dat dupe ket qua tot. Thai gian phau thuat cua Docimo rat dai (gan 11 gio)''' nhimg day la truang hpp dau tien dupe bao cao. Han nu'a, khau da day can can than va phai dua mach mau mac treo tir dong mach thupng vi den vung chau ben ro rang la can thuc hien ti mi vai phau thuat npi soi.
Thoi gian phSu thuat cua chung toi tuong duong voi ket qua cua nhiing tac gia khac, ngan han Docimo va khoang gap d6i m6 mo.
Tuy nhien thai gian mo se ngan hem khi phau thuat vien tro nen kinh nghiem va ky nang dupe cai thien.
Theo quan diem cua chiing tpi, thai gian phau thuat c6 the rut ngan va sir phuc tap cua phau thuat c6 the don gian hem neu chiing toi diing phau thuat npi soi ho trp bang tay thay
H6| NGHj KHOA HQC LAN T H J VII. HQI TI^'T NI|U - TH^N HpC VlgT NAM (VUNA) vi chi diing phau thu^t npi soi thuan tuy: mpt
doan hoi trang dupe mang ra ngoai qua vet mo 3cm, cat, noi, khau va dua vao 6 byng de mo rpng bang quang npi soi (hinh 2a va 2b), Trong trucmg hpp cam !ai nipu quan vao
bang quang. nieu quan cung dupe cam vao tam hoi trang truac khi dua vao 6 bung khau vao bang quang (hinh 2c). Seo m6 khong qua ldn(hinh lb).
Bang 1: so sanh k^t qua cua chung toi va bao cdo cua mpt so tac gia khac.
Tdc gia DOCIMO (1995)
GILL (2000) LORENZO
(2007) NIJNEZ (2007) EL-FEEL
(2009) NGUYEN VAN
AN (2013)
Soca 1 3
1
2
23
68
Doan ruQt Da day Hoi trang Dai trang sigma Dai tranq xuonq Hoi trang
Hoi trang
Hoi trang
Hoi trang
Kv thuSt Pure Iaparoscopy
5 trocars Hand-assissted
Iaparoscopy 4 trocars Hand-assissted
Iaparoscopy 3 trocars Hand-assissted
Iaparoscopy 4 trocars Hand-assissted
Iaparoscopy 4 trocars Hand-assissted
Iaparoscopy 4 - 5 trocars
Dung cu ho trtf Endo-GIA Endo-stitch
Khong
Endo GIA Endostitch
7
Khong
Khong
Thdi gian mo 10 gid 55 phut
5.3 gid 8glcf 7gld 7
4 giiS 30 phut den 6 gId 3 gId 22 phut
(165-330) 5 gId 18 phut
(180-390 phut)
- Ve so trocars: Mpt so tac gia diing 5 trocar nhu Docimo va Elliott (hinh 4a), trong khi mot s6 tac gia khac dung 3 trocar nhir Lorenzo (hinh 4b). Chung toi diing 4 trocar tuong tu nhu Gill (hinh 4c) nhimg thinh thoang chung toi diing trocar thir 5 de mo bang quang ra da. Bku nam 2009, Noguera va cong su '" bao cao mo rpng bang quang bang ruot diing 1 trocar (mpt loai moi vai 4 kenh thao tac dyng cu, hinh 4d).
y
• \ /
Hinh 4a. Eliott diing 5 trocar
Y HOC V|6T NAM THANG 8 - S6 BAC BIST / 2013
i f 0 « •
^ y
/
1
\ 1
^ - IS cm - y
4d) Noguera diing 1 trocar
4b) Lorenzo diing 3 trocars 4e) Gill dung 4 trocars
4.3. Rut kinh nghiem tu' cac tai bien - bien chii-ng trong luc mo hoac sau khi md:
Nen CO nhimg miii khau dinh vj tam mpt truoc khi dua lai vao trong bung, de khi khau noi rupt voi bang quang se de nhan dinh hem, tranh de xoan cuong mac treo rupt.
Nen khau dong phiic mac thanh sau che doan nieu quan chau (doan sap sCra cam vao phan rupt cua bang quang tan tao). nham tranh bi tac rupt do thoat vi npi.
V- KiT LUAN
Qua 68 truang hpp cho thay phau thuat npi soi ma rpng bang quang bang rupt la kha thi va hieu qua trong dieu kien Viet Nam.
Thai gian phSu thuat dai hem mo mo nhung benh nhan hoi phiic tot hem, thai gian nam vi6n ngan han va seo mo tham my ban. Ket qua theo doi 3-36 thang c6 the xem tuong tu nhu mo mo.
Tim kiem can than trong y van cho thay so luang bdo cao khong nhieu. Bao cao cua chiing toi c6 le c6 so benh nhan nhieu nhat va CO le la tac gia dau tien bao cao ve phau thuat n6i soi mo rpng bang quang bang rupt ket hpp cam lai nieu quan vao bang quang va tao van chuySn luu c6 kiem soat nuoc tieu.
TAI LIEU THAM KHAO
t. Docimo SG, Moore RG, Adams J et ill (1995).
Laparoscopic bladder augmenlalion using stomach.
Urology 46: 565-569.
- Elliott SP, Meng MV, Anwar HP, Stoller ML (2002). Complete laparoscopic ileal cysloplasly.
Urology 59(6): 939-943
3. El-Feel A, Abdel-Hakim MA, Atrauel-Fettouli H, Abdel-Hakim AM (2009). Laparoscopic Augmentalion lleocyslaplasly Results andOiilcome. Eur Urol 55:721- 728.
4. Gill IS, Rackley RR, Meraney AM, Marcello PW, Sung GT (2000). Laparoscopic enlerocysloplasty.
Urology 55(2)' 178-81.
5. Lorenzo AJ, Ccrveira J, Farhat WA (2007).
Pediatric laparoscopic ileal cysloplasly complete inlractirporeiil surgical technique. Urology 69(5):
977-81.
6. Noguera RJS, Astigueta J C , Carmona O, De Andrade RJ, Luis S, Cuomo B, Marique J, Gill IS, Desai MM (2009) Laparoscopic .\ugmenlalion Enterocy.stoplasly Through a Single Trocar. Urology 73; 1371-74.
7. Nguyen \'an-An (2012). Laparoscopic augmentalion enterocystoplasty for treatment of contracted bladder. Urology 80 (3A): S58.
8 Nunez MC, Cansino AR, Alonso GS, Martinez- Piileiro LL, De la Peiia BJ (2009). Laparoscopic augmentation enterocystoplasty initial experience.
Actas Urol Esp (2007) Jan; 31(1); 17-22. [abstract]
9. Rackley RR, Abdelmalak JB (2001). Laparoscopic augmentation cystoplasty surgical technique. Urol ClinNorlhAm28(3):663-70.
