Y Hpc TP. Hd Chi Minh * Tap 18 * So 1 * 2014 Nghien cmi Y hpc
PHAU THUAT CAT GIAM TUYEN GIAP QUA NOI SOI DIEU TRI CU^NG GIAP ON
Trdn Cong Quyen', Nguyen Vdn Vift Thanh' TOM TAT
Md (feu; Phau thudt noi soi cat tuyai gidp dieu tri benh adnig gidp dii hien chira duac dp dung rong rdi.
Day Id mot phucnig phdp mang tiidi tham my cao, giup benh nhdn nhanh chdng trd lai vdi cong viec vd tu tin tiong giao tiep. Ph&u thuat noi soi cat tuyen gidp Id an todn vd thdnh cong dio cdc tnrdng hap phinh ^dp da ididn 2 thiiy gidp chimg toi manh dqn dp dung phuang phdp ndy dedieu tri cdc tnrdng liap cuong gidp on.
Muc tieu: Xdc dinh ti li thdnh cong, tai bieh, bieh chirng, sir hdi long ciia benh nhdn dedanh gid tinh an todn vd hieu qud dmi tri ciia phircnig phdp ndy.
Phuang phdp nghien ciiu: Mo td tdt cd cdc tnrdng hap cudng gidp dirge phdu thudt cat gan trpn tuyai gidp qua ngi soi tqi benh vien Binh Ddn tie 5/2009 - 7/2013.
Kei qud: Co long cSng 32 benh nhdn: 3 nam - 29 nir. Tuoi trung binh Id 31,8 (21- 49 tuoi). Thdi gian phdu thudt tning binh 90 phiit. Khong co tnebng hop ndo phdi chuyen momd. Thai gian nam znen tmng binh Id 4 ngdy. Hai tnrdng hgp bj khan tieng nhe vd hoi phuc sdm sau nw. Hai trudng ligp te tay tam thcri sau mo. Tdi phdt cudng gidp 2 ti-ucmg hop (6,25%) sau 6 tiidng. Sau mo'tdl cd baih nhdn hdi long lie tinh tham my.
Kei ludn: Phdu thuat cat gan iron tuyai gidp qua ngi soi Id mot phumig phdp dieu tri an todn, hieu qud, thd'm my cao dw benh aediig gidp. Ddy Id mat lua chm cho cdc trudng hgp cudng gidp co chi diidi phau thuat.
Tit khoa: Cudng gidp, ngi soi ABSTRACT
ENDOSCOPIC SUBTOTAL THYROIDECTOMY FOR THE TREATMENT OF HYPERTHYROIDISM Tran Cong Quyen, Nguyen Van Viet Thanh
*Y Hoc TP.Ho Chi Minh* Vol. 18- No 1 - 2014:283 - 287 Introducticm; Endoscopic surgery is not loidely employed yet for die treatment of hyperthyroidism. The greatest baieftt is cosmetic, making patiait back to work early, confident in communication. By tlie sc^etij and success of tlie endoscopic surgery for the tieatmait of multinodular goiter, zve intend use this ftr treatmait of hyperthyroidism.
Objectives: To have tlie rate of successfid, accidences, complications and tlie satisfied of patient to evaluate the safety and efficacy of this procedure.
Materials and Methods: Descriptive study, all patiaits have hyperthyroidism treated by endoscopic subtotal thyroidectomy ftom 5/2009 to 7/2013 in Binh Dan hospitai
Results: There xoere 32 cases: 3 males - 29 females. Mean age zoas 31.8 (range 21 to 49). The mean operating time was 90 minutes. Tliere was no case needed open operating. Tlie mean post operating time zoas 4 days. Tha-e are 2 cases tanporaiy recurrait laryngeal nerve palsy and 2 cases temporary postoperative tetany. There was two case lua>e rcatrraice hyperthyroidism after 6 months. All patiaits were satisfied zoith the cosmetic results.
Conclusions: Endoscopic subtotal thyroidectomy is a safe and effective technique. Tlw patients get a cosmetic
*Khoa Long nguc - Mach mau - Budu co benh vien Binh Dan
Tdcgidlien lac. BS.CKIL Iran Cong Quyen DT,-0913 169047 Fwaifr quyentrancongig'hotmail.com
Hpi Nghi Khoa Hpc Ky Thu^l BV. Binh Dan 2014 283
Nghien a r u Y hoc
baufil. It could be tlie choice operating fijr fhe tieatmait of hyperthyroidism.
Keywords: Endoscopic, hyperthyroidism.
M O D A U
Buou tuyen giap la mot benh ly pho bien tren the gioi noi ehung va is Viet Nam noi rieng.
Hlng nam, b^nh vien Binh Dan co khoang 1000 truong hpp phau Ihuat dieu tri benh ly buou hiy&i giap. Tir nam 19%, tren the gioi, phau thuat tuyen giap khong con gioi han 6 ky fhuat mo mo tmyen thong ma dupe phat trien boi ky ihuat npi soi vdi nhieu uu diem nhu it xam lah, khong de Isu seo xau gay mat ttiam my, anh huong den sinh hoat, giao tiep cua nguoi benh.
Tai benh vien Binh Dan, phau thuat noi soi trong dieu tri benh ly buou tuyen giap da dupe trien khai tir nam 2004. Trong thoi gian dau, phlu thuat npi soi tuyen giap chi dimg lai 6 viec cat thiiy gjap trong cac truang hpp u giap don nhan 00 kich Ihuoc nho. Cho den nay, chi dinh dieu tri duoc md rpng ap dung khong nhimg cho buou gjap da nhan 2 tiiiiy ma cho ca cac truong hpp cuong giap, basedow on va ung thu giap. Ben canh viec hoan thien ve ky thuat mo, su ho trp cua cac dyng cu phSu thuat npi soi hien dai nhu dao cat sieu am da gop phan lam cho phau thuat npi soi tuyen giap phat trieh va ^ n nhu tro thanh thuong qui. Chiing toi da thuc hien 32 truong hpp cat gjam tuyen giap qua npi soi hx>ng khoang thai gian tix 5/2009 - 7/2013. Dua tren co so nay, ehung toi tien hanh nghien cuu danh gia hieu qua ciia phau thuat cat giam tuyen giap qua npi soi trong dieu tri benh ly basedow va cuong giap tai benh vien Binh Dan.
P H l / O N G PHAP NGHIEN CUtJ Thiet ke nghien curu
Mo ta hang hoat truong hpp lam sang Doi tirpng nghien curu
Cac truong hpp basedow on va cuong gjap on dupe phau thuat npi soi Kr 5/2009 - 7/2013 tai benh vien Binh Dan.
Tieu chumt chQti benh
Cac truong hop basedow va cuong giap
dupe dieu tri npi khoa on dinh:
- The tich moi thiiy do qua sieu am < 25 arf.
- Binh giap tren lam sang va can lam sang.
Tiiu ckuan loai trie
- B^nh nhan khong dbng y phau thuat npi soi.
Phuong phap phau thuat npi soi buou giap Oman bi truac mo
Ket nghiem tien phau, ehiic nang tuyen giap (TSH, T3, T4), sieu am tuyen giap, {co hay khong dimg iugol 1% 7 ngay truoc mo).
Ky thudt ino
Benh nhan nam ngua, me noi khi quan, duoc ke goi duoi vai de ngira co. Man hinh npi soi dat ve phia trai ciia benh nhan. Bac si phau thu^t diing ben phai benh nhan, nguoi phu diing doi ben. Dat 2 trocar dai duong kinh Smm tai 2 quang vu huong ve hom lie. Dat trocar 10mm a duong nach truoc ben phai ciia benh nhan huong ve hom lie va bom C02. Ong kinh Smm dat qua trocar Smm ben vu trai. Hai trocar con lai la kenh thao fac. Khoang co dupe boc tach boi dot dien don cue va duy tri bang bom khi C02 voi ap luc tir 8-lOmmHg. Sau khi tao khoang co, mo duong can co giiia co, bpc 16 tuyen giap.
Thiiy trai tuyen giap dupe bpc 16 va phau tich ra khoi lop CO CO. Sau do, dimg dao cat sieu am de cat gan trpn thiiy trai tuyen gjap. Khi cat niat sau tuyen giap va tu)'en can gjap duge chira lai de tranh cac bien chiing: suy gjap, te tay va ton thuong than kinh thanh quan quat ngupc. Thiiy phai tuyen gjap dupe thuc hien tuong tu. Buou dupe cho vao bao nylon va lay qua nga dat trocar lOmm 6 hom nach phai. E)at dan luu redon qua trocar 10mm. Bang ep viing c6.
Cham soc vd theo doi sau mo
Din luu se dupe nit vao ngay thii 2 Benh nhan xuat vien vao ngay thii 2, cat chi sau 1 tuan, tai kham sau 1 thang va 3 thang.
Hpi Nghi Khoa Hpc Ky Thuat BV. Binh Dan 2014
Y Hpc TP. Ho Chi Minh * Tap 18 * So 1 * 2014 Nghien cmi Y hpc KETQUA
Til 5/2009 - 7/2013, ehung toi da thuc hien 32 trudng hpp phau thuat npi soi cat giam tuyen giap cho cac truong hpp Basedow va cuong giap dupe dieu tri noi khoa on va theo doi sau mo 1 - 3 thang.
Gioi tinh
Nii: 29 (90,6%), nam: 3 (9,4%).
Tuoi trung binh 31,8 hioi (21-49).
Chsui doan
Cuong giap on: 12 truong hpp (37,5%).
Basedow on: 20 truong hop (62,5%).
Phuong phap mo
Cat gan trpn tuyen giap qua npi soi: 100%.
Dat din luu: 100%.
Giai phau benh
100% mo phinh gjap lan toa tang sinh mach mau.
Ket qua phau thuat
- Mau mat trong luc mo: 20ml (10-50ml).
- Thoi gian mo trung binh: 90 phut (60-180 phut),
- Bieh ehung:
+ Khan tieng t^mi then: 2 (6,25%).
+ T# tay tam thoi sau mo: 2 (6,25%).
+ Bam mau nhe 6 co va thanh nguc: 5 (15,63%).
+ Khong truong hop nao bi tran khi duoi da nang.
- Benh nhan dupe xuat vien vao ngay hau phau thii 2.
- Tai kham sau 1 thang, 3 fhang:
+ Tat ca cac benh nhan mo npi soi hoan toan deu hai long vi kh6ng co s?o 6 co, khong cam giac nuot vuong. Cac vet s?o a thanh ngue lanh tot, kh6ng truong hpp nao bi nhiem trimg vet mo.
+ 2 truong hpp (6,25%) cuong giap tai phat sau mo.
BAN LUAN
Phau thuat buou co kinh dieh (mo' mo) da co tir nam 952 sau Cong nguyen do bac si Moolish ngudi Ba Tu thuc hien. Sau do, Theodor Kocher, phlu thuat vien ngudi Thuy S dupe xem nhu nguoi dat hen tang cho phlu thuat budu giap.
Co nhieu ky thuat va trudng phai trong vi^c cat budu gjap nhung nhin ehung cac ky thuat deu CO diem ehung la "dudng mo kinh dien" rach da dudng ngang e6', chieu dai dudng mo tiiy thupc vao dp Idn cua budu. Sau mo, benh nlian co vet seo dai d co, anh hudng den tinh tham my, nhS't la ddi vdi cac benh nhan nil. Ngoai ra, sau mo, benh nhan con gap cae van de khac nhu nuot vuong di ling chi,... Phau thuat npi soi tuyen giap bat dau dupe mo la trong y van vao khoang nam 1996 - 1997. Gagner la ngudi dau tien thuc hien phau thuat cat tuyen can giap qua npi soiP>.
Mot nam sau, Huscher bao cao c^t thiiy phai tuyen giap hoan toan qua npi soi'-"'. Ngay nay, phau thuat npi soi dieu trj b?nh ly tuyen giap da trd nen pho' bien vdi muc dich tham my. Nhieu phuong phap mo da dupe bao cao eiia eae tac gia trong va ngoai nude vdi nhieu uu va khuyet diem khac nhau'^'^'^.
Ve chi dmh mo, chiing tdi nhan ttiay phau thuat npi soi eat giam tuyen giap ehi nen ap dung doi vdi nhiing trudng hpp budu gjap dp n CO the tich moi thiiy khdng qua 25 crrf. Vdi kieh thudc nay, bae si phau thuat co th^' cat tuy^n giap mpt each de dang ciing nhu tim cac caii tnic quan trpng lan can nhu khi quan, than kinh quat ngupc thanh quan, tuyen can giap, bo mach canh. Phau trudng ciia phau thuat noi soi cat tuyen giap kha gidi han. Khoang co dupe tgo ra CO the tich khoang 300 - 400 ml. Do vSy, ddi vdi cac budu giap co kich thudc qua to, bac si phau thuat se gap nhieu khd khan trong thao tac, tham chi khdng the thuc hien dupe. Day la nhupc diem Idn nhat eua phau thuat npi soi cat tuyen giap va cung la diem ma chiing toi cho r4ng
Nghien cuu Y hoc
phau thuat npi soi khdng the thay the hoan toan phau thuat mo mo truyen thong.
Ve dudng vao ciia cac trocar, nhieu each vao trocar trong phau thuat npi soi tuy&i giap dupe mo ta. Hien tai, van chua cd loai trocar noi soi nao danh rieng cho phlu thuat tuySi giap. Da so tac gia deu sir dung trocar mo npi soi d bung de thuc hien. Nhupc diem cua cac trocar nay la qua ngan gay khd khan trong qua trinh phau thuat va hon het la tat ca cac seo 16 trocar deu nam truoc nguc, lam gjam tinh tham my, vdn la uu diem Idn nhat ciia phau thuat npi soi tuyen giap, dac biet doi vdi ca dia s^o loi. Trong ky thugt mo Clia chiing toi, vdi dudng vao ciia cac trocar tir nach va quang vii, cac seo 16 trocar dupe giau Idn, dam bao tinh tham my cao giup benh nhan tu tin trong giao Hep<". De dupe dieu do, chiing toi nghien cuu va thiet ke 2 loai trocar Smm dai di tCr quang vii den hom lie. Mat khac, vdi dudng vao d giiia nay, chiing t6i cd the cat budu d ca hai thiiy khdng ma khong phu thudc vao vi tri Clia budu nhu mpt so tac gia: 3 trocar d vi tri ddi ben vdi budu, vay de cat dupe 2 thiiy phai 1 can 616 trocar.
Htnh Fvftri Trocar Dung cu tie che ^ ^ Ve khoang co, chiing tdi chpn each h>om khi C02 vdi ap luc khoang 8 - lOmmHg dam bao mpt khoang trdng tdt de thao tac va tranh dupe bien chiing tang COi mau gay toan hda mau va
tran khi dudi da<*'.
Ve ky thuat c^t budu, chiing toi diing dao c^t sieu am de cat budu. Dung cu nay co uu diem cat dupe cac mach mau cd dudng kinh dudi Smm va khdng sinh nhiet eao nhu dot dien. Vi the, chiing toi han che duoc toi da bien ehiing chay mau trong va sau mo, cung nhu khan tieng tam thdi sau mo do siic nong lan ra khi su dpng dot dienP*. Dieu nay dae biet y nghia khi md cac trudng hop basedow. Ngoai ra, vdi uu diem vira cat vua cam mau, dao eat sieu am da giiip chiing tdi nit ngan tfidi gian phau thuat so vdi dimg dot dien ludng cud^'. Sau mo, chiing tdi deu dan luu khoang co' 100% qua mpt vi tri dat trocar 10mm.
Chiing tdi cho rang dieu nay rat can ihiet vi ben canh y nghia dieu tri, dan luu cdn cd vai trd theo doi va du phong quan trpng. Khac vdi mo md, trong md npi soi tuyen giap, khoang cd la khoang kin. Khi ed bien chiing chay mau xay ra, benh nhan de bi suy h6 hap do chen ep dudng thd vi lupng mau chay ra khong the thoat ra ngoai bang each banh vet mo nhu trong mo md.
Dan luu duoc dat qua trocar d nach va dupe nit vao ngay thii 2 trude xuat vien. Dieu nay vira dam bao tinh an toan va tharn my trong ky thuat md Clia chiing tdi. Thdi gjan mo co keo dai hon so vdi md md kinh dien. Trung binh mpt ca mo npi soi keo dai khoang 90 phiit so vdi mo hd khoang 60 phiit. Lupng mau mat trung binh khoang 20ml la chap nhan duoc.
Benh nhan thudng xuat vien vao ngay thii 2 sau mo, eSt chi sau 7 ngay. Chiing toi theo doi tai kham sau 1 va 3 thang. Khong cd trudng hpp nao bi nhiem trimg vet mo va hai long vi khdng cd seo d ed. Vai benh nhan co than phien ve di cam d CO, cam giae nuot vuong, nhirng khd chiu hay gap d cac benh nhan mo md kinh dien, nhung nhanh chong mat di sau mo 1 thang. Hai benh nhan bi khan tieng va te tay sau mo da hoi phuc hoan toan sau 3 thang. Doi vdi 2 trudng hop tai phat, chiing toi cho rang phan tuyen giap chira lai qua nhieu vi kinh nghiem nhan dinh kich thudc qua md noi soi chua tot. Chiing t6i dang tiep tuc theo doi nhimg b^nh nhan nay
Hpi Nghi Khoa Hpc Ky Thuat BV. Binh Dan 2014
Y Hpc TP. Ho Chi Minh * Tap 18 * So 1 * 2014 Nghien cmi Y hpc trong mpt cdng trinh nghien ciiu khae.
Tom lai, doi vdi phau thugt npi soi tuyen giap, chiing t6i da thuc hien, theo doi, nghien cuu trong mpt thdi gjan dai. Thdi gian dau, chiing toi chpn budu don nhan, kich thudc nho.
Khi ky thuat da thuan thuc, chiing tdi md rpng chi dinh ddi vdi cac trudng hpp budu giap da nhan mpt thiiy, hai fhiiy va bay gid la cudng giap va basedow on. Nhin ehung day la mpt lua chpn mdi, phii hpp vdi xu hudng phat trien ciia the gjdi cho cac phau thuat vien tuyen giap.
KETLUAN
Phau thuat ndi soi cat giam tuyen gjap qua nga nach - quang vii bang dao cat sieu am ed nhieu uu diem nhu tham my, an toan va hieu qua. Cac phau thuat vien tuyen giap co kinh nghiem ve mo md va ky nang tot ve md npi soi deu cd th§' thuc hien. Benh nhan hoi phuc nhanh, sdm trd lai vdi cdng viec, tu tin trong giao hep.
Ti le tai bien, bien chiing tuong duong md md.
Ky thuat da cd the ap dung an toan eho cac trudng hpp cudng giap va basedow duoc dieu
tri npi khoa dn dinh.
TAI UtXJ THAM KHAO
1 Benhidjeb T, Sink MW (2006) Total \ideo- endoscopcthyrradectomyvia AxiUo-BUateral-Breast- Approach (ABBA). NakiralOnSceSurgen', 1st Meebn^eriin, June23.
2 G a g n ^ M (1996) Endoscopic subtotal paialhyroidectomy in patients with pnman'hj-poparathyroidism Br]Suig;83 875 3 Ho Nam, Nguyen Ba ^^inh Nhat, Ho Khanh E)iic, Nguyen
Van Viet Thanh (200S) Kei qua diieu ti\ tnrau ^pap don nhan bing phau ftult nra soi tai b ^ \ien Binh Dan Y Hgc TP. Ho Chi NSnh T?p 12 Phu ban cua So 4 .
4 Huscher CS, Chiodmi S, -Napolitano C, Redier A (1997) Endoscopic right thynad lobectomy Surg Endosc; 11 S77.
5 Palazzo FF, S * a g F, Henry JF (2006) Endocrine suigjcal technique EndoscopicthyTOidedomyviathelateralapiproadT.
Surg Endosc.20-339-342
6 Puntambekar SP (2007). Endoscopic IhyrcMdectomy: Our technique, Joumal of minimal access surgery; volume 3,91-97 7 Trinh Minh Tranh, Tran Thanh Vy (2006). Sir dvng khung
nang da trong phau thuat npi soi t u y m giap tai Bv Nhan Dan Gia Djnh ' H ^ n ^ phau thuat noi soi toan quoc Ian J Ha N91
Ngdy nhqn bdi bdo: 27/10/2013 Ngdy phdn bien nhdn xet bdi hao: 27/11/2013 Ngdy bdi bdo dirge dang: 20/02/2014
