caÉt tuÙi maÄt noÄi soi -...
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CAÉT TUÙI MAÄT NOÄI SOI
LEÂ QUAN ANH TUAÁN
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Lòch söû
1985: Muhe, Ñöùc
1987: Philippe Mouret, Phaùp
1988: Reddick, Olsen, Myõ
1992: Nguyeãn Taán Cöôøng, Vieät Nam
Caét tuùi maät noi soi nhanh choùng trôû thaønh “gold standard”
ñieàu trò soûi tuùi maät.
Phaãu thuaät noäi soi nhanh choùng ñöôïc môû roäng sang nhieàu
loaïi phaãu thuaät khaùc, nhieàu chuyeân khoa
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CHÆ ÑÒNH
Cholelithiasis and biliary colic or cholecystitis
Symptomatic gallbladder polyps
Gallstone pancreatitis
Symptomatic biliary dyskinesis
Calcified gallbladder wall
Large gallstones (> 2 cm)
Nonfunctioning gallbladder
Chronic typhoid carrier
Surgical Clinics of North America
Volume 80 „ Number 4 „ August 2000
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CHÆ ÑÒNH
Soûi TM coù trieäu chöùng
Soûi to (>10mm), nhieàu soûi
Polyp TM > 10mm, hay polyp TM coù trieäu chöùng
Voâi hoùa thaønh TM (Porcelin gallbladder)
Ung thö TM T1, T2
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Ñaùnh giaù tröôùc moå
Tieàn söû ñau
Sieâu aâm buïng: vaùch tuùi maät, soûi keït coå, tuùi maät caêng, to
Caùc yeáu toá nguy cô coù soûi OMC:
Tieàn söû vaøng da
Tieàn söû vieâm tuïy caáp
Bili TP > 1 mg/dL
Men gan > 2 laàn bình thöôøng
Sieâu aâm OMC > 10mm, oáng TM to
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Chuaån bò beänh nhaân
Nhö 1 PT tieâu hoùa
Khoâng caïo loâng mu
Khoâng ñaët thoâng tieåu
Khoâng ñaët thoâng muõi - daï daøy
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Voâ caûm
Meâ noäi khí quaûn
Meâ Mask thanh quaûn
Teâ tuûy + ngoaøi maøng cöùng: nhöõng beänh nhaân nguy cô suy
hoâ haáp cao, choáng chæ ñònh gaây meâ NKQ
Khaùng sinh döï phoøng
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Tö theá beänh nhaân
Naèm ngöûa, ñaàu cao, nghieâng traùi 300: Reverse
Trendelenburg
Myõ: PTV ñöùng beân traùi beänh nhaân
Phaùp: dang chaân, PTV ñöùng giöõa 2 chaân
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Vò trí Trocar
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Caùch ñaët Trocar
Trocar ñaàu tieân ôû roán: 10mm
Phöông phaùp kín: nhanh, khoâng xì CO2, an toaøn. Khoâng neân
duøng pp naøy khi coù moå cuõ hay khi ñaët trocar ôû vò trí khaùc
roán.
Phöông phaùp Hasson: raïch roäng, môû töøng lôùp, duøng ñaàu tuø,
khaâu bôùt caân ñeå traùnh xì CO2
vaø coá ñònh trocar
Duøng kim Veress: maát nhieàu thôøi gian, vaãn coù nguy cô toån
thöông caùc maïch maùu lôùn vaø toån thöông taïng
Caùc trocar sau: quan saùt treân maøn hình
Kyõ thuaät ñaët trocar
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Duïng cuï
Kính soi: 450, 30
0
Duïng cuï phaãu tích (dissectors): Maryland
Keïp caàm naém: graspers, coù raêng, caùn coù khoùa
(ratchet)
Keùo
Moùc ñoát, moùc ñoát + oáng huùt
OÁng huùt
Keïp clip (clip applicator): 10mm, 5mm
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TAÏO KHOAÛNG KHOÂNG THAO TAÙC
Bôm CO2
AÙp löïc 12-15mmHg
AÙp löïc thaáp: < 8mmHg
Bôm khí Helium
Naâng thaønh buïng: raát ít söû duïng hieän nay
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Kyõ thuaät
Gôõ dính
Xaùc ñònh oáng maät chuû, xaùc ñònh tam giaùc gan maät
Phaãu tích tam giaùc gan maät: boäc loä ÑM tuùi maät, oáng tuùi
maät.
Keùo coå tuùi maät xuoáng döôùi, ra ngoaøi
Duøng keàm phaãu tích
Haïn cheá ñoát ñieän
Phaãu tích maët tröôùc vaø maët sau tam giaùc gan maät
OÁng tuùi maät: noái vôùi pheãu TM, noái vôùi oáng gan
chung, khoâng coù caáu truùc gì ôû tam giaùc gan maät
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Kyõ thuaät
Clip, caét ÑM vaø oáng TM. Clip Applicator 10mm, 5mm
Chuïp X quang ñöôøng maät trong moå:
Nghi ngôø coù soûi OMC
Nghi ngôø coù toån thöông ñöôøng maät
Moác giaûi phaãu khoâng roõ raøng
Kyõ thuaät:
Chuïp qua oáng TM
Chuïp qua TM
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Caét TM khoûi gan:
Moùc ñoát, keùo
Caét vaøo gan
Thuûng TM: chaûy maät, muû, rôi soûi vaøo buïng
Laáy tuùi maät ra:
Qua roán, qua loã thöôïng vò.
Cho TM vaøo tuùi, condom
Caét môû roäng caân
Duïng cuï nong loã trocar
Kyõ thuaät
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OÁng tuùi maät ngaén
OÁng tuùi maät ngaén: 2cm
Phaãu tích ñeå clip vaø caét oáng TM: 1 cm
Soûi keït oáng tuùi maät
Hoäi chöùng Mirizzi
Coøn soûi ôû oáng TM sau khi caét TM noäi soi ?!
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Keùo OMC
Tenting
Deã laàm OMC vôùi oáng TM toån thöông ñöôøng maät
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Thuûng tuùi maät
Nguyeân nhaân: caét thuûng, caàm naém laøm raùch, tuït clip
oáng TM
Haäu quaû:
Maät chaûy ra buïng
Soûi rôi vaøo buïng
K tuùi maät: teá baøo ung thö lan traøn
Xöû trí:
Huùt saïch dòch maät
Coät laïi choã raùch
Clip hay coät laïi oáng TM
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Tai bieán
Chaûy maùu:
ÑM TM
Gan
Giöôøng TM
Toån thöông ñöôøng maät
Toån thöông taù traøng, ñaïi traøng
Toån thöông ruoät do trocar
Chaûy maät, muû vaøo oå buïng
Rôi soûi vaøo oå buïng
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Vieâm tuùi maät caáp
Moå caøng sôùm caøng toát
Khoù do moâ vieâm deã chaûy maùu, vieâm dính khoù phaãu tích,
khoù nhaän ñònh caùc moác giaûi phaãu
Neân phaãu tích vuøng coå TM tröôùc, xöû lyù ÑM TM vaø oáng TM
Chæ neân caét ngöôïc doøng khi ñaõ khoáng cheá ÑM TM
Chuïp X quang ñöôøng maät trong moå neáu nghi ngôø coù soûi
OMC hay moác giaûi phaãu khoâng roõ raøng.
Daãn löu döôùi gan
Hoài phuïc sau moå toát
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Sau moå
Ñi laïi sau 1 ngaøy
AÊn uoáng laïi ngaøy 1
Xuaát vieän sau 2-3 ngaøy
Trôû laïi laøm vieäc sau 7-10 ngaøy
Day Surgery
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Bieán chöùng
Toån thöông ñöôøng maät: VPM maät, roø maät, taéc maät
Chaûy maùu sau moå
ÑM TM
Trocar site: thöôïng vò, roán
Maïc noái: luùc laáy TM ra, buïng goàng
Nhieãm truøng veát moå
Thoaùt vò loã trocar
Heïp ñöôøng maät
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Caét tuùi maät duïng cuï nhoû
Needlescopic, Micro Lap Chole
Caùc TH ñôn giaûn
Duïng cuï 1,7-3mm
Thaåm myõ cao
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2 Trocar Lap Chole
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Robotic Lap Chole
Ñaét tieàn
Chöa coù öa ñieåm hôn moå thöôøng
TeleRobotic Surgery