Y Hoc TP. H o Chi Minh * TSp 21 * So 6 * 2017 Nghign cuu Y hpc
P H A U THUAT ROBOT CAT BANG QUANG TAN G6C, TAO HINH BANG QUANG BANG H 6 I TRANG NOI THANG:
BAO CAO M 6 T TRU'CJNG HOfP D X U TIEN
Nguyen Phuc Cam Hodng**, Trdn Vinh Hung*, Do Vd Phuang**, Vdn Thdnh Trung**, Do Anh Toan**, Li Trong Khoi**, D8 L^h Hiing**
TOMTAT
Muc tiiw Bdo cdo kit qud quanh phdu thuqt mdt tne&ng hap ph&u thu&t robot cdt bdng quang tan gdc, tqo hinh bdng quang bdng hoi trdng ngodi ca thenoi thdng Ian d&u tiin duac thuc hiin tqi Khoa-Bd mdn Tiet niiu benh znin Binh Ddn trong th&i gian znea qua.
Tu li$u vd phuong phdp nghien dm: Binh nh&n nam hi budu bdng quang xdm lan ca dugc chdn dodn bang cdt ddi ndi soi sinh thiei bu&u va duac ph&u thu^t robot cdt bdng quang t&n gdc, tqo hinh bdng quang bang hoi trdng ndi thdng ngoai ca tiiil Hi thdng robot da Vind'^^ Si v&i bdn cdnh tay dugc diing diphdu thu&t, ket qud quanh phBu thudt duac ghi nhan va bdo cdo.
K& qua: Bmh nhdn nam, 45 turn; dii so ASA tne&c mo': 2, chdn dodn tru&c mo: ung thu bim md ti'bdo diuy^ tiip bdng quang, giai doqn cT2bMoMo. Ky thudt md: cdt bdng quang t&n gdc, tqo hinh bdng quang bang Hoi trdng ngodi ca thenoi thdng ki^ Hautmann. S^port: 6 ports; Cat bdng quang theo ky thuqt cdu triic co tM hgc ciia Guru. Thai gian md: 660 phut; Liegng mdu m&i: 500 mL. Nam viin sau mo: 15 ngdy. Md hgc bu&u: ung thu biiu md ti'bdo chuym tiep (TCC) biet hoa kem x&m ldn co sau bdng quang.
K^ lu4m Tne&ng hap ph&u thu&t robot cat bdng quang t&n gd'c, tqo hinh bdng quang bang Kdi trdng rm thdng d&u tiin cim doing tdiddcAket qud phdu thu&t dang khich li dii thdi gian mokhd ddi Cdn thuc thim nhieu tru&ng hap niea vdi th&i gian mo dugc rut ngdn hem vd phdi c6 nqo hach ch&u.
Tie khoa: Phau thudt robot, cdt hdng quang tdn goc.
ABSTRACT
ROBOT-ASSISTED RADICAL CYSTECTOMY
AND EXTRACORPOREAL ORTHOTOPIC ILEAL NEO-BLADDER: AN INITIAL CASE REPORT Nguyen Phuc Cam Hoang, Tran Vinh Hung, Do Vu Phuong,Van Thanh Tmng, Do Anh Toan, Le Trong Khoi, Do I^enh Hung * Y Hoc TP. Ho Chi Minh * Vol. 21 - No 6 - 2017:83 - 88 Objectives: Report the perioperative outcomes of the first robot-assisted radical cystectomy and extracorporeal orthotopic ileal neobladder recmtly performed at the Department of Urology of Binh Dan hospital.
Materials and Methods: A male patimt suffering from bladder transitional cell caridnoma tumor underwmt a transuretiiral resection of bladder tumor and robot-assisted radical cystedomy and extracorporeal orthotopic ileal neobladder, using the robot da Vind™ Si system with 4"= arm. The perioperative outcomes were documented and reported.
Results: A male patimt, 45 years old, preoperative ASA score: 2, preoperative diagnosis: transitional cell caranoma of bladder, clinical stage of cT2bMoMo. Operative technique: robot-assited radical cystedomy and extracorporeal orthotopic ileal neobladder, Hautmann type. Number of ports: 6 ports; Radical cystedomy
* Bp mon Ngoai, Dai hoc Y khoa Phgm Ngoc Thgch TP.HCM
** Khoa - Bp mon Tie't nieu, Bfnh vifn Binh DSn
Tac gid liSn Iqc: PGS.TS. Nguyin Phuc Cam Hoang DT. 0913719346 E-mail: [email protected]
Nghien cuu Y hoc Y Hgc TP. H o Chi Minh * Tap 21 * So 6 * 2017
performed according to the anatomic foundation technique presmted by Guru. Operative time: 660 minutes, Estimated bUwd toss; 500mL. Postoperative hospital stay: 15 days. Histololy of tumor: poorly differenciated h-ansitional cell cardnoma of bladder, invading the deeper layer of detrusor.
Conclusions: Our first case of robot-assisted radical cystectomy and extracorporeal orthotopic ileal neobladder had encouraging penoperative outcomes though the operative time was quite long. More cases mlh shorter operative time and zvitit pelvic lymphadenectomy are to be performed.
Keywords: Robot-assisted surgery, radical cystectomy, pelznc lymphadenectomy.
D A T V A N D E
Phau thuat robot la buoe tien moi nhat hien nay trong ky thuat mo it xam hai da duoc pho bi&i kha rpng rai tai cac Trung tam phlu thuat Ion 6 cac nuoc tien den P'. Tit cuoi nam 2016 vira qua, lan dau tien phlu thuat robot duoc thue hien tren benh nhan nguoi Ion tai Viet Nam. Bai viet nay nham bao eao ket qua quanh phlu thuat mpt tnjong hpp phau thuat robot cat bang quang tan goc, t^o hinh bang quang bang hoi trang ngoai co the nm (ii3ng Ian dau tien dupe thue hien tai Khoa-Bp mon Tiet nieu Benh vien Binh Dan trong thoi gian v£ra qua.
DOITUONG-PHUtlNGPHAPNGHIENaJlJ Doi hipng
Benh nhan nam, bi buou bang quang xam ]an eo dupe chan doan bang cat dot noi soi dupe phau thuat cat bang quang tan goe tao hinh bang quang bang hoi trang noi thang ngoai co the bang he thong robot da Vind Si™ tai Khoa - Bp mon Tiet nieu Benh v i ^ Binh Dan trong thai gian vira qua.
Phtnmg phap n ^ e n cmi
Hi thdng robot ph&u thudt da Vinci Sz™ ciia Inhiitive Surgical® (Hoa Ky) voi bon canh tay.
He thong nay gom hai phan ri&ig biet diroc ket noi voi nhau (he thong "Ong chu - Day to",
"Master-Slave system").
Phdn thdp (Tower) (Hinh IA): duoc dat true ti^ len benh nhan, gom co 4 canh tay robot 3 canh tay de gjij cac dimg cu phlu thuat va 1 canh tay gii> camera 3-D dp phan giai eao.
Bdn dieu khim (Console) (hinh IB): la noi phau thuat vien ngoi va tiiao tac cac can dieu
khieh robot trong khi nhin vao mot man lunh ISp the CO hinh anh truong mo 3-D dp phan giai cao va dixgc phong dgi. Phau thuat vien dieu khi&i 4 canh tay robot bang each dimg cae ngon tay lliao tac tren can dieu khioi. Phau thulit vien con dimg cae ban dap chan de ehpn cac nguon nang lupng (dien don cue hay luong cue).
Ngoai ra, man lunh video thii hai ket noi vai nguoi phu mo voi Wnh anh 2-D ma tren man hinh nay hien thj noi phlu thuat vien chinh dang nWn vao khi mo.
Hinh 1. Hi thdng robot ph&u thuqt da Vind Si'". A Thdp (Tozoer). B. Bdn diiu khiih (Console) Dung cu phdu thudt '^ 0inh 2)
Keo cong dien dan cm HotShears'"^: dung de phau tich va dot dien don arc.
Forceps dien luong citt: Maryland: dimg de nam mo, ven m6, phlu tich tu dau, va dot dien luong cue.
Forceps ProGrasp"^: dung cu khong co nang lupng CO dac diem tuong tu forceps dot dien luong cue co 16.
Kep mang kim ldn: dimg de khau noi nieu dao-eo bang quang tan tgo, khau dong phuc mac.
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Y Hpc TP. H o Chi M i n h * Tap 21 * So 6 * 2017
Hinh 2. A. Keo diin HotShears™ .B.Forceps Maryland C. Forceps ProGrasp™.D. Kep mang kim l&n.
Tu the'bpih nhdn vd phdn ho cdc port Tu the^henh nh&n '^^
Benh nhan nam ngiia tu the phlu thulit lay san vcn gac chan hai ben, ban mo ngang, hai tay benh nhan 6m sat hai ben h6ng. B&ih nhan dupe CO dinh vao ban mo nho hai day co dinh quanh hai did, cang chan va nhimg eh6 ti de dupe dem lot eh&ig ap luc. Hai gac chan sau do dugc ha thap va faenh nhan dupe dat 6' tu the Trendelenburg doc 30° (Mnh 3B).
Ph&n bd'cdc port: ky thudt 6 port
Dimg ky thuat Hassan, dat port dau tien 12mm cho camera 6 ngay tren ron (Hmh 3C), bom hoi 6 bung den 15 mmHg voi mpt ong soi 30 dp. Cac port con Igi dupfc dat duoi quan sat true tiep. Hai trocart robot Smrn dugc dat ngay bo ngoai cua co thang bung theo duong tir 2 den 4 cm duoi ron. Dat them mpt port 12mm a tren ho chau phai khoang 3cm tren mao chau tren duong nach giiia. Dat 1 port 5mm nam giua camera va port robot ben phai, dat port robot cuoi cung (cho canh tay thii tu) doi xiing voi port 12mm ben phai o phia tren ho chau trai (Hinh 4). Tien hanh docking.
Hinh 3. Cdt bdng quang tan gdc A. Cdc mdc dqt port B. Tu thi'Trendelenburg dd'c 30°. C. Vi tri cdc port. D. Docking
Hinh 4. A.B. Phdn bd'cdc port trong cdt bdng quang tan gd'd^'
Ky thuqt mo
Noi soi trong phiic mctc, hen hanh cat bang quang tan goc dimg ky thudt theo cdu true ca thi' hgc ciia Guru (Hinh 5)PJ: phau tich theo thii tir hai nieu quan sat bang quang, mat sau bang quang va hai tui tinh, hai thanh ben bang quang, mat truoc bang quang va tayen tien liet. Trong tnrong hgp nay da khong ti&i hanh nao hach chau bit vi la truong hgp dau tien, thoi gian mo' con dai.
Chuyen luu nuoc tieu bang tqo hinh bdng quang ngodi ca the bang hoi trang theo Hautmann: rach da dai khoang 5cm di tu port eho camera den ron, lay benh pham bang quang ra ngoai qua duong rach nay, lay hoi trang qua ducmg rach nay de lam bang quang tan tao va
Nghien cuu Y hpc Y Hpc TP. H b Chi M i n h * T|lp 21 * So 6 * 2017
cam 1^ nieu quan vao bang quang ngoai co the c6 dqt fhdng Jf ldm nong. Sau do, dua bang quang hoi trang vao lai eo the va ti^ tuc tien hanh khau noi co bang quang tan tgo vol mom nieu dao bang mui khau vat, diing chi V-lock® 3-0.
M& bdng quang ra da bdng thdng Pezzer sd'20 Fr.
Hinh 5. Cat bdng quang ky thu&t theo cdu true ca thi' hgc theo Guru'^'A. Phdu tich quanh niiu qudn. B, Phdu tick dianh bin di sdt vdch. chdu. CCdt cuong ben BQ, D. Chudn M hq thdnh tru&c BQ.
KETQUA
Bgnh nhan nam, SN 1971 (45 hioi). Nhap vien ngay 30/12^016 vl ly do tieu mau dai the.
Benh nhan dugc mo cat dot npi soi sinh thiet buou bang quang truoe nhap vien 2 tuan. Ket qua m6 hoc: carcinoma te bao chuyen tiep bang quang, xam lan co bang quang. Chi so ASA truoc mo cat bang quang: 2, chan doan tnroc mo:
buou TCC bang quang, giai doan eT2bMoMo.
Chan doan hinh anh truoc mo: MSCT bung-chau CO dimg hinh: buou bang quang, hach cheiu am tinh (Hinh 8.AB,), MSCT nguc: hach don dpc trung that nglu hach viem. Mo ngay: 04/01/2017.
Ky thu^t mo: cat bang quang t$n goe dimg ky thu&t iheo cau trdc ca the hgc eiia Guru, taio hinh bang quang bSng hBi trang noi thang, tao hinh bang quang ngoai eo the, kieu Hautmann, noi eo bang quang tan teio-mom nieu dao biing npi soi robot.
So port: 6 ports; Ihoi gjan mo (phiit): 660;
Lugng mau mat (mL): 500.
Hau phau: benh nhan trung tien ngay h$u phau 3, dugc nit Sng d i n luu ngay hau phlu 13, nit thong nieu dao ngay hau phlu 15, mang thong bang quang ra da ve.
Nam vien sau mo (ngay): 15.
M6 hpc buou sau mo: Ung thu bieu mo te bao chuy& tiep (TCQ, biet hoa kem, xam lam lop CO sSu bang quang, chua xam lah co bang quang, tiii tinh.
^ # ,
Hinh 6. Bu&u bdng quang. AB. MSCT tiem cdn quang co dung hinh. C. Seo tdi khdm sau md'.
BANLUAN
Nhimg loi ich cfia he ttiong robot phau tiiuatot
Ve phia phdu thudt viin
He thSng robot mang den hinh anh 3D, lam tang dp kheo leo, dp ehinh xac ciia phlu thueit, tang tam cii dpng, giiip lam giam rung tay, phan dp cii dpng va tang cong thai hpc (ergonomics) va su ihoki mai cho phau thuat vien. H& th^ng da Vind^" mang d&i hinh anh 3D, phong dai, vung chic, khong gay moi mat do ehinh phau thuat vien dieu khien tnic dep. Phlu thuat vien thao tac ca camera va tir hai den ba canh tay mang dung cu. Cong nghe Endowrist^" ciia da
Y Hoc TP. Hb Chi Minh » T$p 21 * Sb 6 * 2017 N ^ e n cuu Y hpc
Vinci^" (hinh 7) cho phep sir dung cac dimg cu voi 7 dp tir do. Cac cii dpng ciia dung eu dirge dieu khien boi ngon tay, ban tay va co tay ciia pMu thuat vi&i lam cho phdu thu&t bang robot co cam gidc gan v&i phau thu&t m& han so vdi mo ndi soi obung tiiu chudn. Voi nhung Igi ich nay, h# thong robot phau thuat cho phep cac phlu thuat vi&i diua CO kinh nghiem ve npi soi 6 bung tieu chuan co the hpc tap d^ thyc hi#n ngay cac p h l u thuat npi soi phiic tap nhu cat tuyen tien liet tan goc, tao hinh khiic noi be than-nieu quin,...
Hinh 7. A. Endowrisf^*^. B. Bdn tay ph&u thudt viin diiu khim dung cu'^'
Vephia binh nhdn
Co th^ giiip giam mSit mau, giam ti le truyen mau, thoi gian nam vien, thoi gian d|it thong va cac bien chiing p h l u thuat, chiie nang eo quan dupe bao ton t6't hon. C^c loi ich khac la duong rach da nho, it dau hon, hoi phuc nhanh hon va nhanh tro ve voi cong viec. Ri&ig cat tuyeh tien li?t t$n g6c va eat bang quang tan g&: da dugc chiing minh la lam giam lugng mau mat va ti le tmyen mau.
Cac phau tfau^t Tilt ni^u nao dupe uu tien thuc Men bing robot ?
Theo Sehachter<3), thii tir uu tien g i ^ dan nhu sau:
Cat tuyCTi tien tiet.
Tao hinh khiic noi be than-nieu quan.
Cat bang qucing.
Cat than (cit mgt phan th$n, cat thiin tan goc).
Treo CO bang quang vao mom nho xuong cung.
Noi ohg dan tinh.
Phlu thuat tiet nieu nhi (cat than, cat mgt phan than, tao hdnh be tiiaiv dicaig ngugc dong
bang quang-nieu quan).
Cat tuyCTi thugng than.
Nieu quan giai, cam nieu quan vao nieu quan.
Nhin chung, cdc phau thuqt zmng ch&u rihu cat tuySh tien Hit, c^t bdng quang, treo wbdng quang vm mom nhd xuang ciing, cho theaf uu dian dm robot mang lai so zxn md'md rd ret hem cdc ph&u thudt than nhu cdt than. Cae p h l u thuat vung chau nhu eat bang quang tan goc co ban do phan bo cac troceul: tucmg doi hang dinh hon so vol phau thuat than thuong c6 ban do phan bo trocart thay doi theo Wnh dang bung eiia benh nhan (bung be so voi bung thon). Ciing vi vay trong phSu thuat bang quang, tuySn tien H|t, viec docking tuong doi de hon so voi phau thuat than (de bi "eh6i" cae canh tay robot). Trong ca phau thuat nay, canh tay thii tu co vai tro de dimg dung cu ProGrasp'^" rat quan trpng de giii hay ven mo gan vimg thao tac, giiip n6ng hoa va phoi bay ro v ^ g nay.
Cimg trong mpt loai phlu thuSt, he thong robot giiip de thue Wen cac 1^ thuat chuyen biet 6 sau trong vimg chau va doi hoi tmh uy&i chuy&i ciia cii dong ciia dung cu phau thuat. TW du; trong truong hgp nay dimg robot phau thuat vien de khau cot tmh mach lung duong vat hon, de khau noi mom nieu dao - co bang quang tan tao hon so vol npi soi 6 bung tieu chuan. Trong khau noi, neii dimg loai eW eo gai (barbed suture) nhu V-lock® hay StratafijtfS se giiip khau nhanh va kin hon vi soi cW co co che tu giii moi eWkWkhau.
Nhan xet ve truong hpp mb dau tien nay Ca mb ti&i hanh khk thuan loi Ky thuat aia Guru ma chiing toi ap dung trong truang hpp nay co loi diem la giiip p h l u tich vimg hai ben nieu quan, vimg thanh ben bang quang hai ben va mat truoc bang qu^lng chu yeii bang ky thu&t phdu tich til (blunt dissection) nen kha nhanh chong t h u ^ Igi va eo the it mat mau hon, khong can dimg endoGIA"^" von rat dat tien de eat hai canh ben bang quang. Nhu da neu, vai tro ciia
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Nghien cuu Y hoc Y Hpc TP. Hb Chi Minh * T^p 21 * So 6 * 2017
canh tay thii tu (4*arm) dimg ProGrasp™ de ven va giii m6, dae biet la trinh bay mat sau bkig quang hai tiii tinh, rat quan hxing, giiip rat rihieu cho su thuan Igi va thanh cong ciia phau thuat.
Ky thuat teto hinh bang quang bang hoi trang theo Hautmann co han che la thai gian thvrc Wen kha dai, hoi phiic tap. Bii lai, hai "ong khoi" de cam lai nieu quan vao bang quang co tic dimg giiip ngpai phiic mac hoa cho cam lai raeu quan mpt each tu nWen theo tu the, dac biet ben trai co the kh6ng can lam thii thuat chuym nieu quan trai xuyen mac treo dai trang sigma.
TH dua bang quang tan tao vao 6 bung de khau noi trong ea nay gap kho khan eo dden la cam giac ch6 noi hoi cang. Huong khac phuc trong nhung ca sau la trong ttii n6i soi robot, sau kW eat bang quang can uom thii doan rupt eho lam CO bang quang xuong mom nieu dao de chpn doan hoi trang va vj tri cb bang quang tan tgo thich hop, tranh gay eang kW khau noi doan ru6t voi mom nieu dao.
Tong thoi gian mo la 660 phiit, trir thtri gian docking (khoang 50 phiit) va thoi gian tai tao bang quang ngoai co the (khoang 60 phiit) la khoang 110 phiit, flii thoi gjan dieu kW&i robot (console time) van eon kha dai, co nguy eo gay ra nhieu bat Ipi va thlan cW bien ehiing xay den do tu the Trendelenburg doc, bom hod 6 bung keo dai. Theo cae tae giaf^A^), gioi han thoi gian an toan la 5-6 gio. Ciing vi ngai thoi gian mo dai ma t6i da khong nao hach chau trong tnrong hgp nay, ma khuynh huong moi la nao hach chau rgng von doi hoi tay nghe ky nang ciia p h l u
thulit vien that thuan thuc.
Tao Wnh bang quang ngoai co th^' nen thiic Wen trong nhiing ea d^u nhu ca nay kW phlu thuat vien con phai lam quen voi cac tW mo cat bang quang tan goc (co neio hach chau rpng) von Cling doi hoi nWeu ky nang va su quen tay. Hon niia, tgo Wnh bang quang trong co the se Iam chi pW cupc mo tang hon niia do cW phi dimg may noi rupt npi soi rat dSt tien.
KETLUAN
Truong hgp phau thu|t robot cat bang quang tan goc, tao hinh bang quang bang hoi trang dau tien ciia chiing toi da co ket qua quanh phau thu^t dang kWch le. Can thue them nhieu ca nua vai thoi gjan mo dugc nit ngan hon va phai CO nao hach chau.
TAI l i t U THAM KHAO
1 Fumo M.J., Badani KK., Menon M. (2008). Robotic Radical Cystectomy. Rdxitics in Urologic Surgeiy. Saunders, Elsevier, CopyTig}it©by Saunders.117-123
2 Curu K A . Robot-assisted radical cystectomy / Antenor Exenteration wifli lymph node dissection. Anatomical foundation and description of surgical technique \^deo presentation. Roswell Park Cancer Institute.
3 Schachter LR., Kau&nan MJL, HerreU S.D. (2008) Estabhshment of a Robotic Prostatectomy Program, Robotics in Urologic Surgery, S a u n d « s , Elsevier, Copynght © by S a u n d e i s : ? ^ ^
4 Wang G.J. and Scherr D.S. (2001). Robot-Assisted Radical Cystoprostatectomy. Atlas of Robcrfic Urologic Siugeiy, Current Clinical Urology. Humana Press: 91-105.
Ngdy nhdn bdi bdo: 12/06/2017 Ngdy phdn bien nhan xet bdi bao. 29/06/2017 Ngdy bdi bdo duac dang: 30/10/2017
