TAP CHt YHOC VlgT NAM TAP 451-THANG2-so PAC BieT-2017
NHAN XET KET QUA PHAU THUAT NOI SOI DIEU TRI VIEM R U 6 T THUA tt NGUOI CO TIEN Sfr MO CO TRONG KHOANG O BUNG TAI BENH VIEN DA KHOA NONG NGHIEP
r6M TAT
Viem ruot thiia (VRT) la mgt b^nh thircmg
^ p nhat trong cac cap ciiu ngo^i khoa vl 6 bung.
Viae tieu: mo ta d|k; dilm lam sang va kit qua phau thu|t ngi soi o bung cit mpt thua trdn ihiing bfnh nhan co tien sir md cu. S l i tuwng va pbinmg phap nghiSn cira: NghiSn ciru mo ta cat ngang, khpng doi <Mtn% tren 41 bfnh nhan duoc chan dodn viem rupt thira co tien su md cG 0 bytigi dirgfc dieu tn tai B?nh vifn Da khoa Ndng
^mtxt 01/2015 din 11/2015. Ket qua: TJ 16 nafflSu !a 1:4,13. Tuoi trung binh: 45,9 ± 14,7.
Lira tuli > 35 g§p nhilu nhit (78%). Ket qua l i t : 92,5%, tnmg binh: 7,5%, xiu: 0%; Ti le th^nh cdng 97,6%. Thdi gian ndm vien 5,2 ± 1,2 ngdy. Kit luSn: PTNS d byng dilu tri VRT d ngucri co tien sir mo cu trong khoang d byng an toan va hieu qua cao, ty If bien chiing thap, thoi gian nam vien ngan, miic dp dau it, chong hoi phuc sue khoe va mdrc dp hai Idng cua ngucri cao.
Tk khoa: Viem mpt thiia, md cu.
SUMMARY
EVALUATION T H E R E S U L T S O F LAPAROSCOPIC A P P E N D E C T O M Y IN
PATIENTS W I T H P R E V I O U S OPERATIONS O F A B D O M E N IN
G E N E R A L H O S P I T A L O F A G R I C U L T U R E
* Binh viin Ba khoa Nong nghiip Chju trach nhifm chinh: Nguyen Sinh Cimg Email: bvdknnl@gmaiIcom
Ngdy nh§n bai: 18/10/2016 Ngdy phan bifn khoa hge: 11/11/2016 Ngay duyft bai: 06/12/2016
Nguyin Sink Cung*, Nguyin Thi Thi*
Appendicitis is the most common acute disease need to be operated on.
Objectives: Describe the clinical properties and the results of laparoscopic appendectomy in patients with previous operations. Subjects and Methods: An uncontrolled descriptive cross - sectional study on 41 patients with appendicitis and previous operations of the abdomen which were treated in General Hospital of Agriculture from 01/2015 to 11/2015. Results: Men and women ratio is 1:4,13. Mean of ages: 45,9 ± 14,7. The most common of ages is > 35 yeare old with 78%. Good results: 92,5%, middle results:
7,5%, bad results: 0%. Successful operations are 97,6%. Mean of time of hospitalization is 5,2 ± 1,2 days. CoDclusions: Laparoscopic appendectomy in patients with previous operations is safe, effective, low complications, short time of hospitalization, less pain, short time of recover and high pleasure of patients.
Keywords: Appendicitis, previous operations.
I.Di((TVANDl
Vidm rugt thira (VRT) la m^t bfnh thudng gdp nhat trong cdc c i p ciiu ngoai khoa ve d byng 6 Vift Nam ty le md cdt rugt thira vidm chidm 40,5% - 49,8% tdng sd cac c i p ciiu v^ d bung.Vdi su ra ddi vd phdt trien nhanh chdng cua phau thugt nOi soi (PTNS) da mang lai nhieu Igi the cho viec chan dodn Cling nhu diiu tri va dgt dugc nhidu ket qua khd quan. Mgt trong nhihig ch6ng chi dinh tucmg d6i ciia PTNS Id benh nhdn cd tidn sii md cu d khoang 6 byng vi khi dd viec phau
HNKH CHAO MUHG 50 NAM XAY Pl/NG VA PHAT TRIEW BENH VIEN tIA n n u « n m i " " "
thuat noi soi s8 gap nhiSu kh6 khan citag nhu CO nhiSu tai biln biSn ohilng. Cilng voi sir ph4t triin cua PTNS, ngay cang tidiu benh nhSn CO vit m6 cu duoc md cit rupt thita nOi soi thanh cSng dem lai nhilti Igd ich cho ngu6i bfnh.
T?i Bfnh vien Da khoa N6ng nghifp, PTNS dfa nay da dugc 4p d\mg rpng rai v6i nhilu m|t benh khde nhau nhung chua co danh gia cy thi vl nhiing kh6 khSn ciing nhu kit qua cua PTNS cit rupt thto d BN CO tiln sil ml cii 6 khoang 6 bung. Muc tieu nghien ciiru.
i. Md ta tfc mint lim sing va nhung liho lihan Irong mo cia bfnh viem mft thita & ngirdi co tiin si' mS ctt trong Ithoang 6 bung.
2. Nhfn xet ket qud s&m sau phiu thuft
II. edi TirpNG vA PHITOTNG PHAP NGHIEN ciru
2.1. Boi tiling nghiSn clhi
Gim tit ca cac bfnh nhSn c6 tiln sil ml trong khoang 6 bung dupe chin doan la VRT va dupc dilu tri bing PTNS tai Bfnh vifn Da khoa N5ng nghifp tit th&ig 01/2015 din thang 12/2015.
* Tieu chuin lua chpn - Chan dodn sau mo la VRT.
Cae benh nhan dupc dieu tri bang PTNS cit RT hoac PTNS thit bai chuylj sang m6 mcr.
- Nhiing bfnh nhan nay co h i so diy dil cac do lifu chin doan trudc sau ml, cacli thiic phlu thuat, theo doi va dilu tri sau ml.
* Tif u chuin lo^i trir:
- Benh ipSn VRT dupc ml md ngay ti diu.
- Chin dodn sau ml khdng phdi VRT.
2.2. Fhuffng phap nghien cihi 2.2.1. Loai thilt ke nghifn cihi M6 td cit ngang, kh6ng dli chung. Thu thip s5 lifu qua h i so bfnh an lim trii tai phong luu trii h i so, ghi nh|n diy dii dc thong tin theo tieu chuin lua chpn vao bfnh dnmau.
2.2.2. CS miu : Chpn miu thudn tien theo muc dich nghifn ciiu.
2.3. Bdnh gid kit qua
- Tit: phiu thujt an todn, khong c6 tai bifn, bfnh nhdn ra vifn som khdng co bien chiing som sau mo.
- Trung bmh: c6 cdc biln chiing sitai sau ml nhung nhe, dif u trj npi khoa khoi va ra vifa
- xiu: Bfnh nhdn ndng xin ve ho^c tii vong
III. Kfr QuA
Chung toi tiln hdnh nghifn ciiu tjii Bfnh vifn Da khoa Nong nghifp tir thdng 01/2015 det 11/2015, thu thdp dupc 41 truong hop ddp ling day dii cdc tieu chuin lua chpn vd co kit qui nhu sau: ^
3.1. B$c dilm tuli, gi6d Nhdm tuli
20-34 35-50
>50 Ting
n 9 16 16 ^ 41
%
24 39 39
oao
Giod Nam Nii
Ting
S6BN 8 33
41
T i l | % ', 19,5 ' 80,5 ;
100
TAP CHl Y HOC Vier NAM TAP 451 • THANG 2 • s 6 OAC BlST - 2017
Nhanxet: ,.
- Tuli trung bmh: 45,9 ± 14,7. Liia tuli >35 gap nhifu nhit: 32TH (78%). Tuli cao nhit trong nhom nghifn ciiu Id 83 tuli
- T^ If nfl: chilm ti If da sl voi 33 BN chilm 80,5"/o, nam chi c6 8 BN chilm 19,5%.
3.2. B^c dilm lam sang Bang 3.2. Ty if tien sir ml bimg cii
Tiln sir ml Ganm|t Da day - ru6t Sdn phy khoa
Khac Ting
n 2 8 31
0 41
%
4,9 19,5 75,6 0 100
Nh^n xit: Cd 75,6% trudng hgp khdng cd tidn sii md cii Id m6 sdn phu khoa, md cu lidn quan ddn b$nh ly da day -rudt cd 8 TH chidm 19,5%.
Jpang 3.3. Sd ldn md cii I f s l lan mo cii
^ l i i n 21an Ting
n 32
9 41
Tilf % 78 22 100
Nh§n xit: Da sd BN cd tien sir rad cii 1 ldn vdi 32TH chiem 78%, Cdn Igi 9 BN da mo 2 1 chiem 22%.
Bang 3.4. Tdn thuang khi xii ly dinh Tin thu-mig
Khdng tdn thuong Chdy mau Tin thuofng rudt
Tong
n 23 16 2 41
Tilf%
56,1 39 4,9 100
Nhfn xil: Co 16 BN bi chdy mdu khi tiln hdnh gd- dhih chilm 39%. So BN bj tin thuong nidtla2chilm4,9%.
Bang 3.5. Ty If chuyen md md Phiu thu$t PTNS cat RTV thanh cong
Chuyin ml md cit RTV Ting
n 40
1 41
%
97,6 2,4 100
HHI^H UHAU MUHtJ aU HAM AAT UUHto V « f H A I I KIbH UfciHH VIEN P A RHOA HUFHj Htonigr
W/(^n jcg/; Ty 1? PTNS cat RTV thdnh cdng: 40 (97,6%) BN va chuydn mo md chi co:
BN chiem 2,4%.
Bang 3.6: Phan bd thdi gian phau thugt Thai gian (phiit)
20-30 31-40
>40 Ting Trungbinh
Ngin nhit Dai nhit
n 10 20 10 40
%
25 50 25 100 35,25 ±10,8 phiit
20philt 60 phiit
Nhfn xit: Thdi gian phiu thudt < 40 phiit la 30 (75%) BN. ThM gian phau thujt trung binh: 35,25 ± 10,8 phut. Thdi gian phiu thujit ngin nhit 20 phiit Thdi gian phiu thuat dai nhit 60 phiit
Bang 3.7. Thdi gian cd nhu d$ng rupt trd Ijii Thdi gian
Trong ngdy thii 1 Trong ngay thii 2 Trong ngdy thii 3
Ting
So bfnh nhdn 6 27 7 40
T i l e % 15 67,5 17,5 100 Nhfn xet: Trung tien trong ngdy thii 2 chilm ty If cao nhit: 27 (67,5%) BN. Co trung tifn h-ong ngdy thii 1:6 (15%) BN
Bang 3.8. Thdi gian njm vifn ThM gian (ngdy)
2 - 4 5-6 7 Ting Ngin nhit
Ddi nhit Trungbinh
s l hfnh nhan 12 21 7 57
Ti If % 30 52,5 17,5 100 3 ngdy 7 ngdy 5,2±1,2 ngay
• 1
Nhfn xit: Thdi gian nim vifn duoi 6 ngay cd t^ If cao nhit vdi 33 BN chilm 82,5%|
Thdi gian ndm vifn sau ml trung bmh Id 5,2±1,2 ngay. Thdi gian nim vifn ngdn nhit Id 3 ngdy, ddi nhit id 7 ngay.
142
TAP CHt Y HQC VlgT NAM TAP 451 • THANG 2 - Sd'SAC BIgT - 2017
3.3. Ket qua dieu tri sdm sau mo Bang 3.9. Bien chung sdm sau md
Bien chirng So benh nhan Ti Ig %
Khdng cd bien chung 37 92,5
Nhiem triing Id trocart rdn 7,5
Tons 40 100
NItdn xit: Sau md sd BN khdng cd bidn chiing c h i ^ 92,5% cdc TR Nhiem tiung Id rocart rdn 03 tnrdng hgp (7.5%).
Bang 3.10. Ket qud hdi phuc sau md sdm Kit qua
Tdt Trung binh
xiu Ting
s l fof nh nh£n 37
3 0 40
Tylf%
92,5 7,5 0,0 100 Nhan xit: Kit qud tit Id: 92,5%, kft qua trung binh: 7,5%, kit qud xiu: 0,0%
IV. BAN LU$N
D$c dilm tudi vk gioi: K^t qud nghidn sim cho thdy: lura tudi tit 35 trd len g§p nhieu nhdt vdi 78% cac trudng hgp. Cdc BN trong do ttjdi tti 20-34 chi cd 9TH chidm 19,5%.
Tudi ttiing binh: 45,9 ± 14,7 va dao ddng tii 20 - 83 tu6i. Ket qua nay cd the dugc gidi thich la do da sd nhiing BN da chiu cu^c md cQ trong khoang d bung la ngain trudng
khi khdng thuc hidn dugc PTNS va phai chuyin qua md md. Trong nghien ciiu cua chiing tdi sd BN cd tidn sir m6 b^ih l;y san phu Idioa chidm phan ldn vdi 3 ITH chiem 75.6% cdn Igi la b?nh ly dg day-rudt (19.5%) vd gan mdt (4,9%). Dilu ndy m0t ldn niia gidi thich cho sd BN nft trong nhdm nghien ciiu chidm ti Id tuydt ddi vi nhdm nay cd nguy ca can thi?p vdo khoang d byng khi thdnh. NgMen ciiu ciia chiing tdi cho thay ty sinh nd ngodi ra cdn cd thi mdc them nhihig 1? VRT d nam Id 19,5% va d nG la 80,5%.
Ket qud nay phan anh mgt s\r chenh lech rat ldn gi&a hai gidi tinh. Dilu ndy cd the do phu nU phdi trdi qua qud trinh sinh con nen nguy CO cd tien su can thidp ngoai khoa cao hon nam gidi.
Tiln str mS cu: Tien sti md bung cu, dgc bi?t la nhiing tnidng hgp md cu dudi rdn, thudng gdy dinh cdc tang trong d byng vdo thanh bung gay khd cho PTNS d bung, nhdt Id tta d|t ttx>cart va thi bgc Id RT nen nhilu
b$nh \'^ phy khoa Wide niia. Theo chiing tdi, nhiing trudng hgp co tidn su md bung tii trudc hodc m6 byng nhilu 1 ^ cdn phdi tii$n trpng khi ddt trocart ddu tidn, tdt nhat la dp dung ky thudt dat trocart md "mini open"
Ve so lan mS cQ: Trong nghidn ciiu ciia chiing tdi sd BN cd tiln sut mo cfi 1 1 ^ la 32 TH chilm 78% cdn Igi Id md cii 2 ldn chilm 22% (Bdng 3.3). S6 ldn md cu va b?nh md Cli cd dnh hudng rlt ldn tdi ti Id thdnh cdng ddi vdi PTNS trong khoang o byng vi s6 ldn
HNKH CHAO MUNG 50 NAM XAY UUHO V A K M A I I K I b N B^HH Vl^N P A i m U A WUPm w
m6 CU cang nhilu thi nguy ca dinh cdc tang trong khoang d byng cdng c ^ vi thi cang gay khd khdn trong phau thuat. Ddi vdi benh md cii thi nhung ngudi cd tiln sir md nhiing bdnh can phdi phau tich didn rdng cilng cd nguy ca dinh cac tgng cao ban nen ky thudt thuc hi?n dugc ciing khd khdn han
Xii' If t^ng dinh: Sau khi da vdo 6 bung an todn tiln hdnh quan sdt danh gid tinh trgng dinh ciia cac tang trong 6 bung, tidn lugng xem cd tidn hanh PTNS dugc hay khdng, tidn lugng nhiing tai bien cd thi xdy ra vd each xit tri. Trong nghien ciiu ciia chiing tdi cd 28 TH phdi tiln hdnh gd dinh cdc tgng dl bgc 10 RT chidm 68,3%. Cd 13 TH khdng dinh hodc cd dinh tuy nhidn khdng dnh hudng ddn trudng md nen chiing tdi khdng can thidp gi cd.
Khi tidn hdnh gd dinh cd 16 BN h\ chay mdu d dien bdc tdch chidm 39%. Nhiing TH nay chiing tdi tien hdnh ddt didn dien chay mdu, ndu c ^ thidt cd thi khau hoac kep clip tdng cudng. Cd 2 BN bi tin thuang thanh mac ruOt ciiilm 4,9%. Vdi nhung TH ndy cd the dilng chi khdu Igi nhiing viing tdn thuang md vSn ddm bdo an toan.
Ty^ le chuyin ml md: Qua nghien ciiu 41 bdnh nhdn VRT cd tiln sur n:^ cii trong khoang d byng dugc dilu tri bdng PTNS 6 byng hiing tdi nhgn thdy ty le thdnh cdng cao 97,5%, cd 1 BN khdng thuc hidn dugc PTNS phai chuyin sang md md, ly do chuyin md md Id do cac quai rugt, MNL dinh nhilu vdo viing HCP va tieu khung nen khdng gO dinh dl bgc Id vd cdt RT dugc. Theo kit qud nghien ciiu cua cdc tac gia khde nhu: Boris
JCirhtein va cdng s\r cd ty Id chuyen mo fl la 9,2%; Nguyin Van Hai vd Ld Trung'rf Id 5,4% [1]; Cueto J. 2.7% [6]. Kit qi nghidn cihi cua chiing tdi cd ty le md ir tuong tu nhu cdc tac gid khac. Vdi ty ; chuyen md cua chiing tdi va cdc tdc gia khj cho thdy vdi trang thidt bi ddy du, phau thu;
vidn mo n0i soi cd kinh nghidm thi hdu hi VRT ddu cd the thuc hidn qua ngi soi.
Thdi gian phiu thuat: Thdi gian pha thudt ndi soi dilu tri VRT trung binh ciia cs tdc gid trong vd ngodi nude cd sy chSnh Ific khde nhau: Nguyin Vdn Hai vd Ld Tnin Hdi (2009) thdi gian ttimg binh ciia PTN!
cdt rudt thiia vidm la 33,6 ± 10 phiit [1' Cueto (2006) thdi gian PTNS trung hU 67,3 ±25,1 phiit [6].
Tuy nhidn cac tdc gid deu cho rdng tho gian phdu thudt ndi soi sS dugc nit ngdn ne phau thudt vidn cd nhilu kinh nghiem v.
trang thiet bi tdt, dky dix.
Ket qua nghien ciiu cua chiing tdi chi thiy thdi gian phEu thugt trung binh li 35,25± 10,8 phut, thdi gian ngdn nhit Id 21 phiit va dai nhit la 60 phiit. Cd dugc diei nay Id do chting tdi dd cd mgt thdi giai tuong ddi ddi hge tdp vd ren luydn doi yd PTNS nen ky thugt ngay mgt hodn thi$n. i
Thdi gian cd nhu d$ng ru$t trd I^i Thdi gian phyc hdi nhu dgng ru0t Id mgt ti&
chudn quan trgng de ddnh gid miic d$ he phyc nhanh hay chgm cua bdnh nhan, qua &
gidn tilp ddnh gid uu thi cda phuang phd]
phau thudt. Trong PTNS cdc tang it bj san;
chdn hem h o ^ sang chan nh? ban so vdi ra md. Theo Nguyen Vdn Hai vd Ld Trung fi^
TAP CH( Y HOC VlgT HAW TAP 451 - THANG 2 - s 6 DAC B|£T - 2017
(2009) thdi gian cd ttnmg tidn sau PTNS dieu tri VRT ttrung binh Id 28,7 ± 12,7 gid (tti 8- 56 gid). T^ Id BN trung tidn sau md trudc 36 gid chilm da s6 70,12%. Kit qud nghien ciiu ciia chiing tdi cho thiy thdi gian cd trung tidn sau ml trong ngdy ddu la 15%, ngdy thii 2 Id 67,5%, ngdy thd 3 la 17,5%. Kit qud nghien c6u cho thdy thdi gian trung ti$n sau PTNS dihi tri VRT ciing tuang tu nhu cdc tdc gia ndu tren.
Biln chdng sdm sau phSu thugt: Cdc hiSn chiing sdm sau md VRT bdng PTNS 6 byng thudng dugc nhdc din trong cdc nghien ciiu Id nhilm triing iS ddt trocar, dp xe tdn du
^ ^ ^ d bung; cdc bien chiing dinh rugt, tdc mdt sdm sau md, dd manh trdng, chdy mdu trong d bung hay thdnh bimg trong nghien cdu ciia chiing tdi khdng g^p. Bidn chiing chung sau md cda cda Ddo Tuin Id 9,37%
[3]. Bidn chiing dp xe tdn du trong 6 byng cung hay dugc dd cdp den trong nghidn ciiu cua Cueto J. Id 2,8%. So vdi ml md dieu tri VRT, PTNS 6 byng cd ty Id biln chiing chung rat thap, chi td 2,3% den 13%, tt-ong khi dd ml md rdt cao. Theo J.F.Y. I^e vd cgng sy Id 40% [7]. Trong nghidn cdu cua chm^ tdi cd 3 BN hi nhiem trung Id trocart chiem 7,5. Vdi nhiing BN ndy sau khi 1dm sach vit ml vd thay bdng hdng ngdy diu cho ket qua tdt. Khdng gdp trudng hgp nao chay mdu sau ml, dd manh trdng sau md, hay tdc rapt sdm sau ml. Chiing tdi ciing khdng thiy tmdng hgp ndo tdng CO2 mdu dc tinh trong qud trinh mo. Khdng cd ttrudng hgp ndo tii vong. Nhu vdy PTNS dilu tti VRT cd dd an
todn cao vd hi^u qua cao, rlt it bidn chiing sau ml.
Thdi gian nim vifn sau ml: Kdt qud nghien ciiu cua chiing tdi cho thiy thdi gjan ndm vi$n trung binh sau ml la 5,2±1,2 ngdy (ngdn nhit Id 2 ngdy, Iau nhit Id 7 ngdy). Kit qud nay ciing tucmg duong vdi cdc tdc gid nhu Ddo Tuin Id 6,4 ngdy nhung kit qud ndy Igi ndm vidn Idu hem cdc tac gid khde nhu ciia Cueto J. Va Hairell Id 3,5 ngdy, ciia Bouillot J.L. Id 4,9 ngdy.
Ket qud sdm sau mo: Dua vdo tidu chuan ddnh gid kit qua sau ml da dugc dgt ra, chdng tdi nhdn thiy s6 BN dgt kit qud tdt Id 92,5%, kit qud tiimg bmh Id 7,5% tt-ong dd c ^ tnidng hgp benh nhan cd bien chiing deu dilu tri cho kit qud tdt khdng can md Igi va khdng cd trudng hgp ndo tti vong hay ndng xin vd.
Kit qud nghidn ciiu ciia chiing tdi tuong dudng vdi kit qud nghidn ciiu cua mdt sd tdc gid: Hodng Tudn Vi^t kdt qud tdt Id 88%, trung bhih Id 10%, xiu Id 2% [4]; cua Ddo Tudn kdt qud tdt la 90.63%, trung binh la 7,81%, xiu la 1,56%, khdng cd tti vong [3].
Nhu vgy PTNS dilu tri VRT d BN cd tien sir md cii trong khoang d bung Id an todn vd higu qud cao, so vdi md md thi ty Id bien chiing thap ban nliilu, thdi gian ndm vidn ngdn hem, mdc do dau it vd ngdn hon, chdng hdi phuc siic khoe va mire do ngudi b?nh hdi long cao.
V. K i t LUJB^N
Bdnh gdp nhieu hem d nii gi^ vdi ti 1§
80,5%. Tien su md cii hay gap nhdt la do
HHKH CHAO MUNG 50 NAM X A T U U N B VA PHAT TRIEN BENH VIEW B A KHOA NONG NGHIEP
bfnh ly sdn phii khoa vdd 75,6%. Ton thuang xdy ra khi xCr if dinh vdi 43,9% trong do chdy mdu 14 39% va ton thucmg raft id 4,9%.
T J If biln chiing nhilm triing vit m l t h i p (7,5%) Ngdy nSm vifn trung binh: 5,2 + 1,2 ngdy. Ti If cat RT qua ndi soi thdnh cdng 97,6%, chuyin md m d 2,4%. tfng dung PTNS dilu tri VRTC d NCT thudn Ipi, khdng cd tai biln. K i t qua sdm: 92,5% t i t 7,5% trung binh. 0,0% Xiu. Nhu vdy PTNS I bung difu tri VRT d ngudi cd tiln su m l cii trong khoang d bung rit an toan va hieu qua cao, tf If biln chiing thap, thdi gian n i m vifn ngin, miic do dau it, chdng h i i phuc siic khoe va miic dg ngudi bfnh hai Idng cao.
TAI UEU THAM KHAO
1. Nguyei) Dinh Thaich, Nguyen Vdn Thdnh (2004), "Cat RT qua nga noi soi 6 byng trong dilu trj VRTC vd bien chftng", Tgp chi Yhoc 200-/, tr. 361-365.
2. Nguyen VSn Hai, Lf Trung Hdi (2009),
"Nghien ciiu kit qua ling diing PTNS cat ruot thura d nguoi cao tuli", Yhoc thiK hanh (694), So 12, n. 45-47.
3. Dao Tuin (2007), Nghien cim mg dyng
PTNS miu tri VPM do VRT tcfi benh vii Xanh Pon Hd NQI lit 2006 - 2007, Luin v8
bac sJ CK2. Dai hge y Ha Npi.
4. Hoang T n i n Vift (2010), Danh gid luii qu, phdu thugt noi soi diiu tri viem phiic mg, ru0t thira a ngudi eao tuoi tai benh vien Hin Nghi yi?! DUc Ha Noi, Ludn vdn Tli^ sJ j hoc, D?i hoc y Hd Nf i.
5. Bouillot JL, Aouad K, Alamovicli B Thomas F, Sellam P, Fourmes traux J Bethoux J P , Alexandre JH., Hopital Hotel Dieu Paris (1998), "Laparospic appendicetomiy in the adult", chirugie. 1998, 123 (3), pp. 263-9, Discussion 269-70 OSSN: 0001-4001)
6. Cueto J, D Allemagne B, Varquer - Frias JA, Gomer S., Delgado F., Trullenque L, Fejardo R; Valencia S, Poggi L; Balli J, Diar J, Gonzalez R, Mansur JH, Franklin ME, Mexico city, Mexico (2006),
"Morbidity of laparoscopic surgery for' complicated appendicitis: an iiiter national Study". Surg., Endosc.2006; 20(5): 717- 20(1SSN: 1432-2218).
7. J. F. Y. Lee, C. K. Leow and W. Y. Im (2001), "Appendicills In The Elderly", Australian and New Zealand Joumai of Surgery, Volume 70, Issue 8. pp 593-596, Published Online: 24 Dee 2001.
