Y HOC VI&T NAM THANG 1 - SO 2/2014

TAI UEU THAM KHAO 1. Bao cao ket qua hoat dgng cua tram y te xa

Dan Tien, huyen Vo Nhai, Thai Nguyen 2. Bao cao cua Bao hiem xa hoi Viet Nam ve

thu'c hien chinh sach, phap luat BHYT giai doan 2009-2012

J. Oao Van Dung (2013), Y hoc xa hoi va xa hpi hoc sffc khoe, NXB Chfnh tn quoc gia

4. Nong Van Kiem (2012), Th/ctrang congtacDan so - Ke hoach hoa gia dinh tinh Bac Kan giai doan 2005- 2010 va de xuat glai phap can thiep, Luan vSn tot nghiep ehuyen khoa II Y te cong cpng.

Ly Tri Phu'dng (2012), Th/c trang tdchdc, hoat dong Truyen thong Dan sd - Ke hoach hoa gia dinh tai tinh Ha Giang, khd khan va giai phap, Chuyen de tot nghiep chuyen khoa I Y te cong cong. Uy ban nhan dan tinh Thai Nguyen (2012), Ke hoach hanh dgng tht/c hien Chien l/dc Dan so va S&c khoe smh san Viet Nam tinh Thai Nguyen giai doan 2011 - 2-15. Guttmacher Institute va UNFPA (2010), Adding it up: The costs and benefits of investing in family plannning and maternal and newborrn health.

CAT LACH NQI SOI: KY THUAT vA KET QUA

Tran Huu Vinh* va CS

T6M TAT Muc tieu: Nghien eiTu nhm du^ a ra mot vai nhan xet

ve d3c diem benh ly, ky thuat va ket qua dieu tri trong phau thuat npi soi d t lach benh ly lanh tinh ve mau, Ddi tu'dng va phu'dng phap nghien cu'u: Gom 40 benh nhan benh ly lach lanh tinh duoc phau thuat cat lach npi soi d khoa Ngoai benh vien Bach Mai tff 2010 -2013. Phan tich cac dac diem ve benh ly, ky thuat va danh gia ket qua. Ket qua: phau thuat eat lach noi soi chi dmh chu yeu ddi vc(i cac benh ly lanh tinh ciia lach, Tuoi nho nhat 16, Idn nhat 67, trung binh 36 9,2, ty \% nam/nff = 1/3. Sd lu'png tieu cau dem duoc trUdc phau thuat trung binh 17,700 (0 - 76.000), Phan dp lach Idn tren lam sang tff I - I I I , Phau thuat thanh cong (93,10%), hai tru'dng hpp ehuyen mo md (6,90%), Ty \% bien chffng (0%). Thdi gian nam vien 5 - 7 ngay, Ket lu^n: Phau thuat eat laeh noi soi an toan va hieu qua, Tiy kboa: Q^t lach npi soi.

SUMMARY LAPAROSCOPIC SPLENECTOMY:

TECHNIQUES AND RESULTS Purpose; This study was evaluated report

pathology and results of laparoscopic splenectomy of the benign spleen disease. Methods: All 40 pateints of laparoscopic splenectomy in Bach Mai hospital (2010 - 2013) are assembled, analyse the pathology, surgical techniques, complications and results. Results: Laparoscopic splenectomy was indicated of major

* Khoa Ngoai - B$nh vi?n Bach Mai * Phan bign khoa hgc: PGS.TS Nguyen Qudc Anh

benign spleen disease. Mean age 36 9,2 (range 15 -67). The spleen was classification I - III stage. Successful! laparoscopic splenectomy (93,10%), two pateints were going on laparostomy, Low rate of complication is presented. Duration of stay in hospital was 5 to 7 days. Conclusion: Laparoscopic splenectomy was safe and effective Keywords: Laparoscopic splenectomy,

I. OAT VAN OE Laeh la tang nam sau trong vdm hoanh ben

trai, ban chat nhu md laeh rat gidn, de ehay mau va moi khi da ehay mau thi rat khd cam mau, Viec phau thuat md bung de eat lach thi khdng con ban luan. Van de dat ra trong ehi dinh cat lach npi soi nhff the nao de eho hieu qua cao, an toan va riit ngan thdi gian dieu trj cho benh nhan.

Cat lach ndi soi dffdc thffc hien lan dau tien tren the gidi bdi Delaitre B vao nam 1991. Sau do la bao eao eiia Caroll BJ, Philips va Poulins nam 1992. Emmermunn A va edng sff nam 1995 thi/e hien nghien cffu 16 benh nhan cat laeh ndi soi. Oen nay phau thuat eat laeh ndi soi da dffdc thdc hien rpng rai tren the gidi cting nhu' trong nffdc eho tat ea eac benh ly ciia lach, Phan Idn cac nghien ciru deu eho ket qua tdt nhu'ng van edn dd tiem an nhieu tai bien, bien chffng co the eoi la mot thach thffc eiia nhieu phau thuat vien do ban chat ciia lach de ton thffdng, giau maeh mau va lien quan ve vi tri giai phau, mat khac tai bien xay ra cd the lien quan vdi benh ly ciia lach.

Y HOC VIET NAM THANG 1 - SO 2/2014

Nghien cffu eiia ehung tdi nham 6\Xa ra mdt vai nhan xet ve dae diem benh ly va ket qua dieu tri phau thuat npi soi cat laeh benh ly lanh tmh.

II. BOI 7U0MG VA PHU'aNG PHAP NGHIEN CLTU 2 .1 . D61 tiTdng nghien cu'u: Gdm 40 benh nhan dffde phau thuat cat lach

ndi soi tai khoa Ngoai benh vien Bach mai tff 2010 den 2013. Chiing tdi da ghi nhan, phan tich cac dac diem benh ly, ky thuat, tai bien va bien chffng.

2.2. Phu'dng phap nghien cu'u: Hdi effu md ta cat ngang.

Ky thuat: Benh nhan difdc gay me ndi khi quan, nam

ngffa dang hai chan, nghieng ben phai khoang 60 dp, dau cao va ehan thap tdi da. Phau thuat vien dffng ben phai. Phu mo dffng ben trai va dung cu vien dffng ben phai phau thuat vien. Trocart dau tien (diing cho camera) dat dffdi rdn tren dffdng trang giffa, trocart thff hai tai diem giffa dffdng thang ndi miii ffc va rdn, trocat thff 3 tren dffdng giffa ddn trai each bd sffdn khoang 3 - 5em, trocart cudi ciing tren dffdng nach sau ben trai each mao chau tff 3 - 5em tuy vao ki'ch thffdc ciia lach. Sau khi bdm hdi C02 vdi ap Iffc o bung tff 10 - 12 mmhg, quan sat, danh gia td'ng quat mat dp di'nh, tang sinh mach. Tien hanh gd

dinh de tiep can cffc dffdi cua lach, giai phdng day Chang dai trang - lach, day chang than lach tff phfa sau. Cat day chang vj - lach cimg cac dpng maeh vi ngan tff cffc dffdi len cffc tren ciia lach d phia tru'dc. Phau tfch bde Id rd dudi tuy va cudng laeh, phau tich dudi tuy ra khdi cuong laeh. Cat cudng lach bang dung cu dinh ghlm (endo GIA) hoac bupc chi hoae kep clip, hemo-lok, Benh pham cho vao tui nilon va la^ ra ngoai qua lo trocart 10 mm dffdi rdn. Oat dan Iffu ho laeh eho tat ca cac trffdng hdp,

Hinh 1: kep cuong lach bang endo GIA

"-%.-

, KET QUA 3 , 1 . Oac diem chung Tuoi: nho nhat 16 tuoi, idn nhat 67 tuoi, trung binh 36 9,2. Gidi: nam / nff = 1/3

Bang 1: Pac diem benh iy trong chi djnh cat iach noi soi Benh ly lach

Xuat huyet giam TC Cu'dng iach p thaiassemia 0 thaiassemia

So benh nhan 19 11 9 1

Ty le Vo 47,5 27,5 22,5 2,5

Nhan xet: Jy le cat lach ddi vdi BN xuat huyet giam tieu cau la eao nhat chiem 47,5%.

Bang 2: Ki'ch thffdc lach tren lam sang Phan do lach

D6I 06I I 05 III

So benh nhan 16 17 7

Ty le % 40.0 42.5 17.5

Nhan xet: Kich thffdc ciia Iach tren lam sang cung nhff tren ehan doan hinh anh thffdng la dp I va II 33/40 (82,5%),

Y HOC VIET NAM THANG 1 - SO 2/2014

Bang 3: Cac chi so Cac thonq so

Tieu cau Honq cau Bach cau Ty prothrombin (%)

huyet hoc tru'dc phau thuat Toi da f l O ' / m l )

76 5,6

22,3 100

Toi th ieu (10 11,7

V m i ) i T m n g b inh ( lO^ /ml ) t 17,7

3,2 8,1 56

3,9 1,7 73

Niian xet: Hau het benh nhan ed tinh trang thieu nang ve sd lu'png tieu eau tru'dc phau thuat, do dae diem benh ly eiia lach. 19/40 benh nhan xuat huyet giam tieu eau phai du'dc truyen tieu cau 1 gid trffdc mo hoac trong md, 2/40 BN cd so lu'dng tieu cau dem du'dc tru'dc md diTdi 15,000, nhu'ng ty prothrombin tren 70%, dp tap trung tieu cau binh thu'dng, co cue mau hoan toan, chiing toi van chi dinh phau thuat cat lach ndi soi thanh cdng.

3.2. Cac ta i b ien t r o n g mo Bang 4: Ja\ bien trong mo

Tai bien t r ong m o Chay mau chuyen mo md Chay mau cam dUdc trong md' noi soi Truyen mau sau md'

So benh nhan 2 1 3

Ty ie Vo 5 2,5 7,5

Nhan xet: C\\mq tdi cd 2 benh nhan (BN) phai ehuyen doi ky thuat do chay mau khong kiem soat dffdc bang ndi soi. 2 BN nay cd lach Idn dp I I I , viem dfnh nhieu va ed tang sinh maeh mau vimg rdn lach. Trong qua trinh phau tfch da lam rach tinh maeh laeh.

Bang 5: Cac ch Cac thong so

Tieu cau Hong cau Bach cau

so huyet hoc sau PT 12 qid Toi da ( l O ' / m l ) 632 4.7 15.7

Tdi th ieu ( l O V m l ) 16C) 3.9 5.2

Trung btnh { 1 0 3 / m l ) 279 4.4 7.1

C") Mot BN sau cat lach 6 gid sd Iddng tieu cau dim ddg'c 16.000, khong thay ddi so vdi trddc va sau phau thuat, mac du BN nay dddc truyen 250 ml tieu cau.

3.3 Ket qua sau mo' Bang 6: ket qua phau thuat _^_ ^_^___ ,

Thdi g ian phau t h u a t (phu t ) 105,8 17.5 (75 - 190) Lffdng mau mat (ml) Thdi gian trung tien (gid) 22.3 8,8 J3^ Thdi gian nam vien (ngay) 5,7 0,6 ( 5 - 7 ) Djch dan Iffu (ml) 38,9 11.2 (10- 100)

Nh$n xet: Thdi gian phau thuat ngan nhat 75 phiit, dai nhat 190 phut, trung binh 105,8 17,5 phiit (P < 0,05). Lffdng mau mat trong mo trung binh khoang 50,2 8,9 ml (P > 0,05). Cd 3 trffdng hdp phai truyen mau sau md tff 250 -SOOml. Trong dd ed 2 BN phai md hd do ehay mau khdng cam dffdc. Tat ca benh nhan deu phai dSt dan Iffu d bung sau phau thuat va rut

dan Iffu sau 24 gid, Tdng so Iffdng dich qua dan Idu la 38,9 11,2 ( 10ml - 100ml), Thdi gian phue hdi nhu dong rudt trung binh 22,3 8,9 gid (24 - 48 gid) sau phau thuat. Thdi gian nam vien tff 5 - 7 ngay. Khong co bien chffng va tat ca benh nhan deu cd huyet dong dn djnh sau mo.

Y HOC VIET NAM THANG 1 - SO 2/2014

!V. BAN LUAN 4 . 1 . Chi dmh: Cat lach ndi soi cho den nay

da 6\idc cdng nhan la phffdng phap dieu tri an toan va hieu qua ciia cac tae gia trong nffde eung nhff nffde ngoai. Phau thuat ndi soi difdc ehi dmh eho lach benh ly nhiT: xuat huyet giam tieu eau (Immune Thrombocytopenic Purpura ITP), benh nay thffdng gap d ngffdi tre, da dffdc dieu trj npi khoa, phu thudc vao corticoid, thu'dng cd bieu hien rdi loan chuyen hda hay gia Curshing la chi dmh tdt eho eat lach ndi soi vi ki'ch thffdc laeh thffdng nhd khoang 90-100 gm. Theo ghi nhan eiia eac tac gia Chau Au thi cat lach npi soi con ehi djnh rrdng rai ddi vdi cac trffdng hdp lach co kich thffdc to tren cae benh nhan cd cac u lanh ti'nh va ac tfnh nhff Thiasemia, thieu mau tff mien, lymphoma, hpi chffng, phlnh dong mach laeh Evans, suy tiiy va ea trong chan thffdng lach [1]. Tuy nhien do nhu md lach gidn, de chay mau va nam sau d gdc phan tff tren ben trai eiia 6 bung CO lien quan vdi thiiy gan trai, da day, dudi tuy, than trai. Phau thuat vien ddi mat vdi nhieu khd khan trong phau thuat eat lach npi soi. Vi vay chi djnh ehii yeu van la cac benh ly thong thffdng eiia lach, Nhieu nhat la benh ly xuat huyet giam tieu eau (47,5%), tiep theo la benh ly cffdng laeh (27,5%), thieu mau huyet tan (22,5%). Chimg tdi thdng nhat quan diem vdi mdt sd tae gia chi dinh cat laeh npi soi eho eac benh ly ae tinh eiia laeh la khong nen do; ed nhieu hach, dffdng rach hd de lay laeh ra kha Idn.

4.2. Oieu trj tru'dc phau thuat: Trong ehi dinh phau thuat eat lach ndi soi eiia benh ly xuat huyet giam tieu cau chiem ty le nhieu nhat (47.5%). Theo mpt so tac gia can 6Mc dieu tri trffdc phau thuat de dat sd Iffdng tieu cau tren 30.000, Theo Delaitre sd Iffdng tieu eau dem dffde trffdc phau thuat trong khoang 3000 -444.000, Tuy nhien van cd nhieu y kien eho rang ehi can so Iffdng tieu eau dat tren 10,000. Nghien effu eua chiing tdi, so Iffdng tieu cau dem dffdc tff 11,700 - 75,000, trung binh 17,700. Tat ca 19/40 benh nhan benh ly xuat huyet giam tieu cau deu dffdc dimg lieu phap corticoid trffdc phau thuat vdi lieu Img/kg tren 10 ngay va dffdc truyen tieu eau tff 125ml - 250ml trffdc hoae trong phau thuat.

4.3. Ky thuat: Tff the benh nhan trong phau thuat ndi soi eat lach eho den nay van cdn nhieu ban cai. Delaitre va Malgneant da thffe hien cat lach noi soi dau tien tren the gidi vdi tff

the nam ngffa, nhu'ng nhieu tac g iacho rang vdi t d the nay ciia benh nhan thi phau thuat vien gap nhieu bat ldi do lach la tang nam sau dffdi cd hoanh trai, bi che lap da day va thuy gan trai, de phau tfch cac day chang va cuong laeh phai keo da day ra trddc va sang ben phai, ddng tac nay rat de gay chay mau, ngoai ra d tff the nay viec tiep can mat sau ciia laeh cung rat khd khan.

Theo ehung tdi tu" the BN ti iy thudc vao thoi quen ciia phau thuat vien chfnh. Benh nhan dffdc gay me ndi khi quan, nam ngffa dang hai chan, nghieng ben phai khoang 60 dp, dau eao va chan thap tdi da. Phlu thuat vien dffng ben phai. Phu mo dffng ben trai va dung cy vien dffng ben phai phau thuat vien hoae tff the benh nhan nam ngffa, dang hai ehan, ban phau thuat nghieng phai 45, dau eao chan thap 45 - 60, Phau thuat vien dffng giffa hai chan, ngffdi phu dffng ben phai benh nhan cam camera va ven thuy trai cua gan. Khdng phai hoan toan nhff Gossot sff dung "dffdng vao tff phia sau" de giai phdnq day chang laeh dat trang, day chang lach than. O mot trong hai tff the BN nhff the nay cung rat thuan ldi cho viee giai phdng day chang lach - dai trang, day chang laeh - than va day chang hoanh - lach tff phia sau. Tiep theo se giai phdng ci/c tren laeh, cat day chang vj - laeh tff phia trffdc bang dot dien hay clip, hoac dao Ligasure thi tot hdn, Oen day viee bpc Id eudng lach rat de dang va cd nhieu each de kiem soat bd maeh lach nhiT budt bang ehi, kep bang hemo-lock hoac clip doi vdi tffng ddn vi mach mot, va tot nhat la sff dung endo GIA stapler. Chiing tdi sff dung endo GIA de kep eudng lach ddi vdi nhffng BN cd dieu kien kmh te.

Thdi gian phau thuat; Thdi gian tff 75 - 190 phiit, trong dd ed 5 BN dau tien va 5 SN cd lach idn dd I I I thdi gian phau thuat keo dai nhat do thao tac va thdi gian dffa laeh ra ngoai 6 bung kha dai, phai mat tff 30 - 45 phiit. Theo Min Tan, Zhen-Xian Zhao thdi gian md 50 - 270 phiit. Co le eo sff khae nhau ve chi djnh, phffdng phap lay lach ra khdi 6 bung giffa chimg tdi va tac gia. Chung tdi khdng ed may nghien lach nen cho lach vao tui nilon. Lam giam khoi Iffdng lach bang each cat Iach thanh nhieu mieng nhd, hut mau ngay trong tiii vi Iffdng mau kha Idn. Sau do lay tui nilon qua mdt trong cac lo trocar md rong. Lay lach qua tiii nilon cdn cd y nghia trong cac trffdng hdp cat lach ITP vi khdng de sdt cac manh laeh nhd trong 6 bung lam mat tac dung cua viee cat lach gay tai phat benh sau md. Theo

Y HOC VIET NAM THANG 1 - SO 2/2014

ghi nhan cua Sotomayor trong nhffng tru'dng hdp khd tac gia ap dung mo cd "ban tay" ho trd va lay lach qua dd ludn, thdi gian mo cung nhanh hdn va viec dffa lach ra khdi o bung cijng thuan tien hdn.

Trong mo can phai tim de phat hien va cat bd lach phu tranh tai phat do sdt lach phu. Chung tdi gap mdt benh nhan ed lach phu. Theo cac nghien cffu thi ty le lach phu cd vao khoang 12-18%. Neu trong trffdng hdp bd sdt thi phau thuat cat laeh khdng cdn ed y nghTa dieu tri trong cac benh ly ve mau. Cac phffdng phap nhd sieu am hay CT trffdc mo cung khdng chan doan ed lach phu hay khdng trffdc md' mdt each chac chan, bdi vay phai chii y van de nay trong mo, Laeh phu thffdng nam d mac ndl Idn, rdn laeh, dudi tuy hoac gdc re mac treo rudt, Theo tac gia Barbaros va cdng sff da ap dyng sieu am dau dd Gamma trong mo va phat hien 2/17 trffdng hdp cd lach phu trong khi do trffdc phau thuat khdng nghi nhan dffdc [5].

4.4. Tai bien va bien chu'ng sau phau thuat: Tai bien trong phau thuat eung dffde cae tae gia nhac tdi nhff nhffng tai bien ehung eiia phau thuat ndi soi khac trong 6 bung. Odi vdi eat lach thi cd the gap nhffng thffdng ton dai trang, tuy, chay mau. Trong nhdm nghien effu ed 3 BN phai truyen mau sau mo tff 250ml ~ 500ml, trong do cd 1 BN sd Iffdng hong eau dem dffde dffdi 3 tri^u va 2 BN chay mau trong md khong cam dffdc phal chuyen ddi ky thuat md md de cam mau. Theo ghi nhan cua Makrin V ty le chuyen mo md la 7 ,1%. Bien chffng hay gap nhat la abscess dffdi cd hoanh trai, chay mau, viem phoi, Theo Delaitre ti le bien chffng chung la 12 -14%, Eduardo M. targarona la 18% [51 Eduardo M. Targarona (2000), "Complications of Laparoscopic Splenectomy", Arch Surg (135), page 1137 - 1110.], [5], trong nghien cffu nay khdng gap nhffng bien chffng abscess dffdi cd hoanh, chay mau, viem phdl, nhiem trung chan trocart.. Nhieu tac gia bao cao ngoai nhffng bien chffng tren cdn ed bien chffng khac rat ft gap nhffng vd cimg nghiem trpng cd the anh hffdng den tfnh mang cua b?nh nhan, neu khdng dffde tien Iffdng va Chan doan sdm, dd la huyet khoi tinh maeh cffa ho3c huyet khdi tinh maeh mac treo rudt, Tran Binh Giang (5%) [2] , chung tdi chffa gap trffdng hdp nao huyet khoi tinh mach sau cat lach ndi soi

trong thdi gian 3 nam nay. Huyet khoi tinh mach sau md lien quan den nhieu nguyen nhan. Hector Rodriguez-Luna and Hugo E. Vargas eho rang huyet khoi thu'dng gap tren nhffng benh nhan cffdng lach va ed xd gan, cd roi loan ve chffe nang ddng mau (25%). Mdt ly do khae gay nen huyet khdi sau md eat lach ndi soi la ap li/c du'dng tinh trong o bung sau bdm hdi phue mac gay giam Idu lu'dng ddng ehay eua he cffa, Mdt khi da ed ehan doan huyet khdi he cffa sau mo, viee dieu tri chdng ddng he thdng phai dddc tien hanh ngay lap tffc, vi 90% tru'dng hdp he cffa ed tac cap do huyet khdi ed the iffu thdng trd lai.

Chuyen ddi ky thuat theo Tarik Zafer Nursal 3/25 (3%), A.N Dalvi 3/26 [4] (11,5%), ehung tdi 2/40 (5%).

V. KET LUAN Cat laeh ndi soi chi djnh cho tat ca cac benh ly

ve mau iien quan den lach. Trong dd kfch thffdc eiia laeh tff dp I - I I I . Ky thuat an toan va hieu qua, Tuy nhien de thffc hien thanh edng phau thuat cat lach ndi soi, ngffdi phau thuat vien phai cd nhieu kinh nghiem trong finh vffc noi soi.

TAI LIEU THAM KHAO 1. Nguyen Ngoc Bich, Tran Thanh Tung (2010);

"Ket qua phau thuat noi soi cat lach co cai hen trong cac benh mau thudng gap tai benh vien Bach Mai", Y hoc lam sang; So 56 (09/2010); Tr:33-38,

2. Tran Binh Giang, Nguyen Nggc Himg (2008), " Cat lach noi soi; mot so nhan xet ve chi dinh, ky thuat va bien chu'ng ", Y Hoc TP. Ho Chi Mmh (12) 4, trg 136 - 142.

3. Carroll B3, Phillips EH, Semel O (1992), Laparoscopic splenectomy ", Surg Endos, (6), page 183-185.

q. Dalvi A.N (2005), " Laparoscopic splenectomy using conventional instruments ", Journal of Minimal Access Surgery (2)1, page 63 - 69,

5. Delaitre B, Maignien B (1991)," Splenectomie par voie laparoscopique, 1 observation (letter) ", Presse Med (20), page 2263.

6. Eduard M. Targarona (2008), " Portal Vein Thrombosis After LaparoscopicSpleneetomy; The Size of the Risk ", Surgical Innovation (15)4, page 266 - 270

7. Eduardo M. Targarona (2000), "Complications of Laparoscopic Splenectomy", Arch Surg (135), page 1137-1140.