Quy trnh k thut ct thc qun qua ni soi bng ngc Trong iu tr ung th- thc qun

(Khoa phu thut tiu ha) Phu thut ung th- thc qun (UTTQ) l mt trong cc phu thut kh v nng n nht trong phu thut tiu ha v t vong v bin chng sau m cn cao v th-ng ch -c phu thut ti cc trung tm phu thut chuyn khoa ln trn Th gii. Ti BV Vit c trin khai phu thut UTTQ thnh cc phu thut th-ng quy t 1994 vi tt c cc ph-ng php p dng trn th gii nh- phu thut Akiyama, phu thut Lewis Santy, Phu thut Orringer . S l-ng phu thut trn 700 tr-ng vi t l t vong v bin chng thp ngang bng vi cc trung tm m thc qun ln trn th gii. T nm 2003, Bnh vin trin khai thnh cng phu thut ct thc qun qua ni si bng ngc, mt phu thut ni soi -c xp vo loi phu thut ni soi kh nht trong phu thut ni soi bng. Ti nay c 145 tr-ng hp -c phu thut thnh cng. Mt s liu ln so vi cc nghin cu v vn ny cng b trn th gii v cho thy kt qu sm l tt v c nhiu -u im so vi m m.
Chun b bnh nhn tr-c m : - Thm khm lm sng v cn lm sng la chon bnh nhn cho phu thut theo tiu chun trn. - Bt buc bnh nhn ngng ht thuc l t nht 10 ngy tr-c m. - H-ng dn bnh nhn tp th. - V sinh rng ming. - Tng c-ng nui d-ng tnh mch m bo > 2000 calo/ ngy cho nhng bnh nhn c suy dinh d-ng. K thut m : Th ni soi ngc : Gii phng thc qun v vt hch trung tht - Gy m : M ni kh qun, ng Carlen 2 nng, xp hon ton phi phi khi m. - T- th bnh nhn : nm sp, nghing khong 30o. - Cc b-c k thut : B-c 1 : tTrocarts : 3 trocarts, loi 10 mm

+ 1 t lin s-n 6 -ng nch gia t knh (camera).

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+ 1 t lin s-n 4 -ng nch gia cho dng c m : mc in, kp phu thut, ng ht. + 1 t lin s-n 8 hoc 9 -ng nch sau : kp phu thut, kp clip.. B-c 2 : t ng soi quan st v nh gi mc xm ln ca khi u, hch v cc tng trongngc. B-c 3 : Phu tch buc v ct quai tnh mch n, ng mch ph qun phi. + M ph mc thnh trn v d-i quai tnh mch n bng mc in. + Phu tch quai tnh mch n v buc bng ch vicryl 2/0, t clip tng c-ng v ct i quai tnh mch n. + qun phi. Phu tch , t clip v ct i ng mch ph

B-c 4 : Bc tch thc qun + M ph mc b tr-c v sau thc qun t c honh ln nh ngc. + Bc tc v to ca s vng quanh thc qun ti v tr thc qun lnh nng, y thc qun to tr-ng m. + Bc thc qun v t chc lin kt, hch quanh thc qun t c honh ln nh ngc bng mc in. Phu tch v clips cc mch mu thc qun. B-c 5 : Vt hch ng 3 kh ph qun. + Dng kp khng chn th-ng -a qua trocart lin s-n 10 kp v nng hach ln v dng mc in bc tch khi hch ny. B-c 6 : Ht ra ngc, t dn l-u v n phi v khu li cc l trocarts.

Ni soi th bng : gii phng d dy T- th bnh nhn : bnh nhn nm nga, c nghing tri, chn dng, tay phi dang ngang, tay tri t dc theo thn. Cc b-c k thut : B-c 1 : t Trocarts : 5 trocarts + Trocart rn : 10 mm, t theo k thut m, cho ng soi. + Bm hi bng p lc 12 mm Hg. + Trocart 2 : 5 mm, -ng gia x-ng n, ngang rn, t cc dng c cm nm. + Trocart 3 : 5 mm, -ng nch tr-c, d-i s-n tri, t dng kp h tr phu thut. + Trocart 4 : 10 mm, t gia trocart 2 v 3 : knh t cc dngj c thao tc chnh. + Trocart 5 : 10 mm, d-i mi c nng gn . B-c 2 : Gii phng b cong ln + Dng dao siu m hoc mc in gii phng b cong ln ngoi cung mch i t gia b cong ln xung mn v v phnh v d dy. Cn thn trng trnh tn th-ng b mch nui chnh ng d dy l ng mch v tnh mch v mc ni phi khi bnh bo, nhiu m. B-c 3 : Gii phng b cong nh. + Dng mc in hoc dao siu m ct mc ni nh ln ti tm v. B-c 4 : Ct cung mch v tri v vt hch 7,8,9. + Bc tch khi hch 7,8,9 bng dao siu m v mc in. + Phu tch ng , tnh mch v tri v t clips, sau ct st gc. B-c 5 : Bc tch thc qun bng v m rng l honh. + Bc tch thc qun bng khi 2 ct tr bng dao siu m. + Ct ct tr phi m rng l honh. B-c 6: To ng d dy

Th c v m bng nh: Ct thc qun c v to hnh thc qun. + M c tri dc b tr-c c c n chm tri. + Ct c vai mng, ng mch v tnh mch gip gia. + Bc tch thc qun c : l-u trnh tn th-ng thn knh qut ng-c. + Bc tch thc qun c xung ngc v ct i thc qun c trn khp c n khong 1 cm. + M bng 5 cm -ng gia d-i mi c. + Ko d dy v thc qun ran ngoi bng. + To ng d dy bng dng c ct thng nh- m m. + To hnh mn v ngoi nim mc, khu ngang bng ch tiu chm. + Ko ng d dy ln c qua -ng trung tht sau. + lm ming ni thc qun - d dy tn bn, khu vt , 1 lp ton th. + t dn l-u cnh ming ni v khu vt m c. + M thng hng trng kiu Witzel, khu nh thnh bng. + t dn l-u h lch. + ng bng v cc l trocart.

Chm sc sau m : - H hp h tr cho ti khi bnh nhn t th tt. - Ht lin tc dn l-u ngc. p lc 20 cm n-c. Rt dn l-u khi ht dch v phi n tt. - Nui d-ng tnh mch, nui d-ng qua m thng d dy sau 24 gi, m bo > 2000 calo/ ngy. - Chp kim tra ming ni ngy th 6 - 7, v cho n qua ming nu khng c r ming ni. - Cho bnh nhn ra vin ngy 7 - 8 nu khng c bin chng sau m. Quy trnh k thut m c im mi so vi cc tc gi khc nh- sau : T- th nm sp nghing 30o c li im l to -c tr-ng m rng hn t- th sp hoc nghing. T- th m ca phu thut vin thun li hn v th-ng ch dng 3 l trocarts so vi 4 - 5 trocarts trong cc t- th m khc.

Tr-ng m thun li nn ch cn cc dng c m ni soi thng th-ng, khng cn n cc dng c ni soi chuyn dng t tin. -ng m bng nh c 2 li im : + Bnh th-ng chn on mun, u ln ko qua vt m bng trnh ti pht u nu ko qua vt m c nh- cc tc gi khc. + S dng cc dng c to ng d dy nh- m m, khng phi s dng dng c ni soi to ng d dy nh- cc tc gi khc rt t tin v vn t -c cc -u im ca phu thut ni soi.