TCNCYH Phu trwong 74 (3) - 2011
NHAN XET THQI GIAN PHAU THUAT NOI SOI CAT TU' CUNG BAN PHAN CO SU' DUNG MORCELLATOR TAI BENH VIEN
• • • •
PHU SAN TRUNG U'QNG
Nguyin Duy Hu'ng\ Nguyin DCPC Hinh^, Dang Thj Minh Nguyet^
'Sen/) vien Gang thep Thai Nguyen, ^Trwang Dai hpc YHa Ndi
Nhan xet thdi gian phau thuat ndi soi phu khoa cd sw dung morcellator tai benh vien Phu san Trung Wang. Doi twang: Tit ci ngwdi benh cd u xa tir cung hoic khdng phai u xa nhung cd du aiu kien, chi anh di Iwa chpn cat tir cung bin phin vi bdc tich u xa qua ndi soi tai BVPSTW trong thdi gian tw 5/2007 din khi du cd mau. Phwang phip:
hdi cwu md ta cat ngang. Kit qua: Thdi gian phau thuit cat tir cung ban phin, nhdm < 60 phut la chu yiu, chiim 74,2%, tir 60 - 90 phut chiim 25,8%. thdi gian phau thuat trung binh ciia cat tir cung ban phin la 58,84 ± 5,12 phut Thdi gian phiu thuit vi kich thwdc ngang tren sieu am twang quan vdi nhau theo phwang trinh y = 2,239 x + 46,221.
He so twang quan r = 0,227 vdi p < 0,05. Thdi gian phiu thuit cat tir cung bin phin cd moi twang quan vdi trpng luvng cua tir cung thep phwang trinh y = 0,4 x + 51,88. he sd twang quan r= 0,4 vdi p < 0,05. Thdi gian liy benh phim ciia PT cat TCBP < 5 phut, thdi gian trung binh doi vdi phau thuat cat TCBP la: 7,05 ± 2,56 phiit. Kit luan: Thdi gian phau thuit tmng binh cua cat tir cung bin phin la 58,84 ±5,12 phut Thdi gian phau thuat vi kich thwdc ngang tren sieu am twang quan vdi nhau theo phwang trinh y = 2,239 x + 46,221. He si twang quan r = 0,227 vdi p < 0,05. Thdi gian phiu thuit cat tir cung ban phin cd mil twang quan vdi trpng Iwpng ciia tir cung theo phwong trinh y = 0,4x + 51,88, he si twang quan r= 0,4 vdi p <0,05. Thdi gian liy benh pham trung binh ddi vdi phau thuat cit TCBP la: 7,05 ± 2,56 phut
TCr khoa: c^t ttjp cung ban phin, u xo- tCr cung
I. DAT
V A N D ^Phau thuit e i t tu- cung qua ndi soi la mpt loai phiu thuit mdi d u g c H Reich nha p h i u t h u i t phy khoa ngudi Hoa Ky, thuc hien dau tien vao n i m 1989, tir dd d i n nay ky thuat n i y da v i dang dugc thye hien d nhiiu nude tren t h i gidi. P h i u thuat c i t tu- cung ban p h i n , bdc t i c h u x a tCr cung qua npi soi cung da thuc hidn, song van cdn khd khan d thi l i y benh pham. C i e p h i u t h u i t vien phai cho benh p h i m vao tCii, c i t nhd l i y qua t h i n h byng bing troeart 10 h o i c lay qua dudng am dao l i m cho thdi gian p h i u t h u i t keo d i i , g i y khd khan cho ca PTV v i ngudi benh. SLP dyng morcellator, dyng cu c i t nhd benh pham l i mdt tien bd mdi trong phiu thuit ndi soi phu khoa. ChT djnh trong eic trudng hgp c i t tLP cung b i n phan do u xa tu- cung hoac phau thuit bdc tich u xa tu- cung khi c i n phai bao ton tCp cung. Bdnh vien Phy san Trung uang b i t d i u su- dung morcellator trong phau thuit ndi soi phy khoa tir thing 5 n i m 2007. Cho d i n thdi d i i m niy, chua cd tii lidu nio trong nude dinh gia hieu qua cua phuang phip niy. De gdp p h i n nghien cCru vide Crng dyng ky thuit d i neu trdn, ehung tdi thye hien de tai vdi mye tidu: Nhin xdt thdi gian phau t h u i t ndi soi phy khoa ed su- dung morcellator tai bdnh vien Phu san Trung U'ang.
II. D 6 | TU'QNG VA PHU'QNG PHAP
1. Ddi tu'ang
1.1. Tieu chuan Iwa chon
Tat. ca ngudi benh cd u xa tu- cung hoac khdng phai u xa nhung cd du d i i u kien, chi djnh de lua chpn c i t tLP cung ban p h i n va bdc t i c h u xa qua ndi soi tai BVPSTLT trong thdi gian tir 5/2007 d i n 5/2008. Tieu c h u i n ky t h u i t e i t tCp cung b i n p h i n cung nhu bdc tach u xa qua npi soi, theo mye tieu nghien CCPU l i p h i u t h u i t phai dugc t i i n h i n h qua NS tip dau cho d i n khi l i y benh pham bing may morcellator.
1.2. Tieu chuan loai trw
Trudng hgp ngudi benh dugc chT djnh c i t tu- cung ban p h i n hoac bdc t i c h u xa qua ndi soi nhung q u i trinh p h i u t h u i t khdng thye hien dugc phai chuyin sang mo md. Nhung trudng hgp ngudi benh khi dd c i t tCr cung hoac bdc t i c h u xa xong, d i n thi l i y benh p h i m , khdng l i y dugc b i n g morcellator m i cho v i o tCii h o i c c i t nhd d u a ra ngoai thi deu loai trir ra khdi nghien eCru ngiy.
2. Phu'ang p h i p
2.1. Thiit ki nghien cuv
L i nghien CCPU: hdi eCru md ta c i t ngang.
2.2. C&mau va chon mau
* Cd miu:
- Ap dyng cdng thCre tinh ea miu:
^ ~ ^(\-all\
p(y-p)
Trong dd:
n: Sd benh nhin can nghien eCru
p: Tl le tai biin cua phuang phap l i 0,1 (10%) q = 1 - p
e: L i khoang each sai lech tuang ddi (chpn e = 0,09) Z (1 - a/2): He sd tin cay 95% (= 1,96)
Thay vao cdng thCre ta tinh dugc ed miu tii thieu n = 43
* Chpn miu:
Trong thdi gian tir thing 5/2007 din thing 5/2008, t i t ea nhu-ng ngudi benh ed du tieu chuan lya chpn c i t tii- cung ban phin va bdc tich u xa tu- cung qua ndi soi tai BVPSTLf, khdng ed tieu chuan loai trCr thi dugc dua v i o danh sich mau eua nghien cu-u niy.
III. Ktl QUA
1. Thd'i gian phlu thuat
Thd'i gian
< 60 phut 60 -90 phut
> 90 phut
Thdi gian PT trung Tdng
Bangl.
binh
Thd'i gian phau thuat(ph Cit tip cung ban phin
n 23
8 0
58,84 31
% 74.2 25.8 0,0
±5,12 100
Lit)
Bdc tich u xa
n % 10 28,5 25 71,5 0 0,0
65,17± 10,15
35 100 (Thdi gian phiu thuat dwoc tinh tir thi vao 6 bung din khi khau xong thdnh bung)
Phiu thuit eit TCBP: thdi gian phau thuit (PT) trung binh l i 58,84 ±5,12 phut cd 23 trudng hgp thdi gian PT < 60 phut, cd 8 ngudi benh thdi gian PT tir 60 - 90 phut, chiim 25,8%.
Phiu thuat BTUX: Thdi gian PT trung binh cua phiu thuit BTUX l i : 65,17 ± 10,15 phut, cd 25 trudng hgp thdi gian PT tir 60 - 90 phut, chiim 71,5%), cd 10 trudng hgp thdi gian phau thuat < 60 phut (28,5%), khdng cd trudng hgp nao > 90 phut.
70-H
6 5 -
Obs«iv«d . Linear
~SS S Jo S S "
Kich thude ngang tu- cung tren sieu i m
Biiu ddi. Mdi lien quan giira thd'i gian phlu thuat va kich thu'O'C ngang tu' cung tren sieu am Thdi gian phiu thuit v i kich thude ngang tren sidu i m tuang quan vdi nhau theo phuang trinh y = 2,239 X + 46,221. Trong dd y l i thdi gian phau thuit (phut), x l i kich thude ngang eua tCr cung tren sidu i m . He so tuang quan r = 0,227 vdi p < 0,05.
TCNCYH Phu trwong 74 (3) - 2011
3. Mdi lien quan giii'a trpng lu'p'ng tu- cung va thd-i gian phlu thuat cd dung morcellator
70-
6S-
«0-
5S-
50- o
o
o
— 1
o o o
o
o
o o o o o o
o o
0000
o o
o o
o
O ^ ^ , * . - ' ^
— Uie.v
Trpng lugng tu- cung
Biiu dd 2. Mdi lien quan giipa thd'i gian phau thuat cd dung morcellator va trpng lu'gng tu" cung
Thdi gian phiu thuit cat tu- cung ban phin cd moi tuang quan vdi trpng luang cua tu- cung theo phuang trinh y = 0,4 x + 51,88. Trong do y l i thdi gian phiu thuit, x la trpng lugng cua tu- cung, he sd tuang quan r = 0,4 vdi p < 0,05.
4. Thd'i gian liy benh phim bing morcellator
Bang 2. Thd'i gian liy benh phim Thd'i gian
< 5 phut 5 - 1 0 phut
> 10 phut
Thdi gian PT trung Tong
Cit tip cung ban phin n
5 24
2
31
7,05 ±2,56
% 16,1 77,4 6,5
100
Bdc tach u xa
n % 27 77,1
8 22,9 0 0
4,65 ± 1,25
35 100 (Tinh tir khi thin tu- cung, u xa tCr cung dugc cit hoic bdc tich xong, liy hit ra ngoai qua thinh byng bing moreerilator).
Thdi gian liy benh phim cua PT c i t TCBP < 5 phut, ed 5 trudng hgp (16,1%), > 10 phut cd 2 trudng hgp (6,5%), chu yiu l i tir 5 - 10 phut (77,4%) thdi gian trung binh doi vdi phiu thuit cit TCBP l i : 7,05 ± 2,56 phut.
Thdi gian liy bdnh pham cua PT BTUX: Chu yiu l i < 5 phut cd 27 trudng hgp, chiim 77,1%, tip 5 - 10 phut ed 8 trudng hgp, chiim 22,9%, thdi gian trung binh ddi vdi phiu thuat bdc tach u xa la: 4,65 ± 1,25 phut
IV. BAN LUAN
Thd'i gian phlu thuat
* Thdfi gian phau thuat cat tw cung ban phan, nhdm < 60 phut l i chu yiu, cd 23 trudng hgp, chiim 74,2%, tip 60 - 90 phut ed 8 tardng hgp, chiem 25,8%, thdi gian phiu thuit trung binh cua eit tu- cung bin phin l i 58,84 ± 5,12 phut. Theo nghidn CCPU eua Phan Xuin Khdi thi thdi gian trung binh eua PT eit TCBP l i 150 phut, d i i han nhiiu so vdi nghien
CCPU eua ehung tdi. El- Mowafi D, so sinh thdi gian phiu thuit ndi soi gitJ-a eit TCBP v i eit TCHT qua
ndi soi thi thdi gian trung binh cua eit TCBP l i 120 phut ± 3 v i eit TCHT l i 150 ± 5 phut vdi p = 0,07 [2].
Theo Nghien CCPU eua Wang CJ thi thdi gian trung binh cua PT eit TCBP qua ndi soi l i 87 ± 11 phut, eit TCHT qua NS l i 111:2 ± 28,8 phut [5].
Thoma L, thdi gian phiu thuit ndi soi cua eit TCBP l i 67,7 ± 14 phut, eit tu- cung hoin toin l i 74,6 ± 25,6 phut [4]. Nhu viy, so sinh vdi cie loai PT khic nhau thi kit qua nghien CCPU cua ehung tdi, thdi gian phau thuit ngin han nhiiu so vdi eic tic gia trong v i ngoii nude.
2. Mdi tu'ang quan giipa thd'i gian p h i u thuat v i kich thiPO'c ngang tip cung tren sieu i m
Theo bieu dd 1 thdi gian phiu thuat va kich thude ngang tren sieu am cd su tuang quan vdi nhau theo phuang trinh y = 2,239, x + 46,221.
Trong do y la thdi gian phau thuat (phut), x la kich thude ngang cua tCr cung tren sieu am. He so tuang quan r = 0,227 vdi p < 0,05.
Kit qua nay cho thiy thdi gian PT cd phu thupc vao kich ngang cua tCr cung tren sieu am theo tuang quan ty le thuan [1], khi kich thude ngang cang Idn thi thdi gian phiu thuat cang keo dai, khi kich thude ngang cang nhd thi thdi gian phlu thuat cung ngin han. Oiiu do cang khing djnh, kich thude ngang do tren sieu am la mpt trong nhCrng yiu td tien lugng thanh cdng cua cupc phiu thuat.
Trpng lipgng tip cung sau p h i u t h u i t va cac mdi lien quan
Chung tdi khdng tim thiy tai lieu trong nude nghien CLPU ve trpng lugng cua tCp cung sau PTNS cit TCBP Theo tie gia L.Thomas (2001) [3], qua 329 trudng hgp PT c i t TCBP khdng dung morcellator, co 54 (16,4%) co trpng lugng 300g, thdi gian PT 115 ± 10 phut, cd 31 (67%) trudng hgp cd trpng lugng > 500g, thdi gian PT 152 ± 6,2, trong so nay cd 5 bien chu-ng trong va sau PT [ 4].
Tac gia El -Mowafi D da phiu thuat cat TCBP ddi vdi tLP cung cd trpng lugng 235g thi thdi gian phiu thuat 120 ± 3, trpng lugng tu- cung 280g thdi gian phiu thuat 145 ± 5,7 [2].
Kit qua nay cho thay thdi gian phiu thuat co su phu thupc vao trpng lugng cua tCr cung dugc c i t theo tuang quan thuan [1] khi trpng lugng Idn thi thdi gian phiu thuat cang keo dai, khi trpng lugng tLP cung cang nhd thi thdi gian phiu thuat cang ngin.
Nhu vay, so sanh vdi tac gia trong va ngoai nude, ta thiy phiu thuat cit TCBP diing morcellator liy benh pham thi trpng lugng TC > trpng lugng tu- cung cua PT c i t TCHT la thuc hien dugc. Trong nghien CCPU cua chung tdi lua chpn ngudi benh PT v i n cdn khiem tdn, diiu nay dugc ly giai vi day la ky thuat mdi dugc ap dung d i u tien tai Benh vien PSTLf, cho nen chung tdi cd su than trpng.
Thd'i gian l i y benh p h i m b i n g morcellator Thdi gian lay benh pham cua phau thuat c i t
TCBP < 5 phut cd 5 trudng hgp (16,1%), cd 2 trudng hgp tu- cung xa hda to, phai liy > 10 phut (6,5%), chu y i u la tir 5 - 10 phut (77,4%). Thdi gian liy benh pham trung binh phiu thuat c i t TCBP la:
7,05 ±2,56 phut.
Thdi gian lay benh pham cua phiu thuat BTUX:
Chu y i u la < 5 phut cd 27 trudng hgp, chiem 77,1%, tir 5 - 10 phut ed 8 trudng hgp, chiim 22,9%. Thdi gian lay benh pham trung binh phiu thuat bdc tach u xa la: 4,65 ± 1,25 phut.
Chung tdi khdng tim dugc tai lieu nghien ciru v i vin d i nay, nhung tir thuc te phlu thuat cho thay, khi chua su- dung morcellator liy benh pham, cd nhung trudng hgp phai liy > 30 phut (dac biet la khi c i t TCBP, phai c i t nhd benh pham va liy qua troeart 10mm). Oiiu dd cang khang djnh, su- dung morcellator liy benh pham la yeu td quyet djnh rut ngin thdi gian phlu thuat.
V. KET LUAN
Thdi gian phlu thuat trung binh cua cit tu- cung ban phin la 58,84 ±5,12 phut.
Thdi gian phlu thuat va kich thude ngang tren sieu i m tuang quan vdi nhau theo phuang trinh y
= 2,239 X + 46,221. He so tuang quan r = 0,227 vdi p < 0,05.
Thdi gian phlu thuat c i t tCp cung ban phan co mdi tuang quan vdi trpng lugng cua tCr cung theo phuang trinh y = 0,4 x + 51,88, he so tuang quan r
= 0,4 vdi p < 0,05.
Thdi gian liy benh pham trung binh ddi vdi phlu thuit c i t TCBP la: 7,05 ± 2,56 phut.
TAI LIEU THAM KHAQ
1. Le Khanh Trai, Hoing HCPU Nhu' (1979).
U'ng dung xic xuat thing ke trong y, sinh hpc, Nha xuit ban Khoa hpc va Ky thuat, 122 - 123.
2. El-Mowafi D, Madkour W, Lall C, Wenger JM (2004). Laparoscopic supracervical hysterectomy versus laparoscopic- assisted vaginal hysterectomy, J Am Assoc Gynecol Laparose, May; 11(2): 175 -180.
3. Raju K.S., Auld B.J. (1994). A randomised prospective study of laparoscopic vaginal hysterectomy versus abdominal hysterectomy each with bilateral salpingo- oophorectomy, Br j Obst gynaecol. 101;
1068-1071.
TCNCYH Phu trwong 74 (3) -2011
4ThomasLLyonsM.D.,MS,AllysonJ.AdolphMD. 5. Wang C J , Yuen L.T, Lee C.L, Yen C F , and Wendy K. Winer R.N. (2005). Center for Soong Y . K ( 2 0 0 5 ) . Laparoscopic - assister varinal women,s care and Reproductive surgery, Atlanta, subtotal hysterectomy, J L a p a r o e n d o s e A d v Georgia, Available online 10 June. s u r g T e c h A. F e b ; 1 5 ( 1 ) : 3 3 - 7
Summary
ASSESSMENT OF TIME OF ENDOSCOPIC PARTIAL UTERECTOMY USING MORCELLATOR AT THE NHOG
Evaluate the time of gynecological endoscopy using morcellator at the NHOG. Subject: All the patients with uterine fibroids or not that had full of condition, indication to select for partial uterectomy and fibroma ablation at the NHOG from 5/2007 to specimen sufficiency. Exclusion: The patients were indicated to endoscopic partial uterectomy or fibroma endoscopy. Study methodology: interrupted, retrospective descriptive method. Results: The time of partial uterectomy: 60 minutes group is main (74.2%), 60 - 90 minutes group is 25.8%). The average time of partial uterectomy is: 58.84 ± 5 . 1 2 minutes.The operating time and transversal size on the untrasound are correlative together with the equation: y = 2.239 x + 46.221. r (coefficient of correlation) = 0.227 with p< 0.05.The time of partial uterectomy and uterine weight are correlative together with the equation: y = 0.4 x + 51.88. r = 0.4 with p < 0.05.The time to get medical waste of partial uterectomy: 5 cases < 5 minutes ( 16.1%), 2 cases > 10 minutes (6.5%) and the highest rate is 77.4% for 5-10 minutes group. The average time of partial uterectomy is: 7.05 ± 2.56 minutes.
Conclusion: The average time of partial uterectomy is: 58.84 ± 5 . 1 2 minutes. The operating time and tranversal size of uterus on the untrasound are correlative together with the equation: y = 2.239 x + 46.221.
r (coefficient of correlation) = 0.227 with p < 0.05. The time of partial uterectomy are correlative with uterine weight, with the equation: y = 0.4 x + 51.88. r= 0.4 with p < 0.05. The average time to get the medical waste of partial uterectomy is: 7.05 ± 2.56 minutes.
Keyword: partial uterectomy, uterine fibroids
001 CHIEU KET QUA SOI C6 TU' CUNG VQI PHIEN 06 AM OAO CO TIJ CUNG a CAC BENH NHAN DEN SOI CO TU' CUNG TAI
KHOA KHAM, BENH VIEN PHU SAN TRUNG L^QNG
C u n g T h j T h u Thiiy Trwang Dai Hpc Y Ha Ndi
Dii chiiu kit qua soi co tir cung va chin doin te bao hpc. Ddi twang va phwang phip: Nghien cwu dwac thwc hiin tren 280 benh nhan din spi co tir cung (CTC) tai benh vien Phu san Trung wang. Cie benh nhin a mpi Iwa tuoi, dwac soi CTC t?i khoa Kham, benh vien Phu sin Trung Wang dii tieu chuan duvc Iwa chpn. Tinh dwac 280 benh nhin.
Phuang phip nghien ciru tiin ciru md ta cat ngang. Kit qua: Khi cd sw thay doi cac TT CTC (ton thwang co tir cung) qua soi thi kit qua phiin do AD - CTC (im dao -CP tir cung) cung cd sw biin doi rd ret Kit qui TBH (ti bio hpc) bit thwdng cing ning thi ty 1$ TT (tan thwang) nghi ngd qua soi CTC cing cao. Cd 3 benh nhin (27,1%) cd kit qui soi CTC li Cdndildm nhpn nhung kit qui ti bao Koilocyte (-). Ty le TT nghi ngd CTC qua soi CTC a nhdm TBH (ti bio hpc) bit thwdng: HSIL (High grade squamous intraepithelial lesion) la 33,3%, LSIL (Low grade squamous intraepithelial lesion) li 14.9%. ASCUS (Atypical squampus cells of undetennined significance) li 25.9% va AGUS (Atipycalglandular cells cf undetennined significance) li 7,4%. Kit luin: Cie hinh anh tin thwang qua spi CTC cd lien quan chit che vdi cie tin thuxyng ti baa hpc.
Tip khoa: Soi co tCr cung (CTC), T§ bao hpc am 6PO C6 tu- cung (TB AB- CTC)