sach phau thuat thuc hanh_quan y 2004

7/16/2019 Sach Phau Thuat Thuc Hanh_Quan Y 2004

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B QUC PHNG

Hc vin qun y

BI GING L THUYT- S 1

I CNG MN HC

B mn: Phu thut thc hnhTn gio vin: BSCKI Bi S Bi

Nm hc: 2004


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BI M U

ICNG MN HC PHUTHUT THC HNH

MC TIU, NHIM V, V TR CA MN HC+Mc tiu:

Gp phno to kin thcngoikhoa cho itngo to Bc sa khoa.+Nhim v:

- V l thuyt: Trang b nhng kin thccbn v chnh phu thut, nguyntc phu thut v nht l v k thut phu thut.

- V thc hnh: Rn luyn cho ngi hc c c thao tc, tc phong thchnh cbn ca mt thy thuc ngoi khoa (ng, chu o, cn thn ,chnh xc -pht trin ln kho lo, p, k xo )

+Vtr mn hc: L mt mn y hc cs, c lin quan nhiun mn gii phuhc- nht l nhng kin thc v gii phunh khu v gii phui chiu, ng thil cu ni quan trng vi ngoi khoa lm sng - Ty ngi hc c kin thcnhtnh v ngoi khoa tip cn vi cc loi hnh phu thut trn ngi.

GIO TRNH V TI LIU THAM KHO:- Phu thut tc hnh - Nxb QND - H ni 1996- Gio trnh Phu thut thc hnh T2 - Nxb QND H ni 2001

II. KHI NIM V PHU THUT

1. Lch sphu thut+ Tthngcn htthi k ci (476) :- nhiu ti liu ghi chp li cho bit t2250 nm trc Cng nguyn Ai cp ci c m cc ung nht, u bu, b gyxng. Pru c m ct cc u, ca chn tay, khoan xng s. n ct cckhi u , mc thu tinh th.- Hy lp thi k ny cn quan nim : bnh tt ca con ngi l mt s huyn b, cnguyn nhn siu nhin. Do vy m vic cha tr bnh tt cho con ngi l do cclinh mc nh thm nhim. Hypocrate- Ngi m sau ny c suy tn l thu tca ngnh y- ngay t khi c quan nim duy vt, ng cho rng: nguyn nhn gybnh c ngun gc thin nhin ch khng phi do siu nhn, thn thnh.- Galen - mt thy thuc trong qun i La m btu nghin cu v gii phuhcng vt nhm mcch cha bnh.+ Thi k trungi (476 - 1492) : Sau khi quc La m suy tn- nhiu nc c cc trng y o to cc y s cha bnh. Song v m x hu ht cn quan nim


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l cng vic th cng, chn tay do vy m thng do cc th co ( ct tc ) mnhim.+ Thi k phc hngca nn vn ho (1493 - 1870): C 2 pht minh ln lm cho yhc thi k ny pht trin, l:

- Pht minh ra thuc sng: lm cho s lng ngi b thng v tnh cht vt thngphc tp hn, do vy s thy thuc trthnh phu thut gia tng ln.- Pht minh ra ngh in : Lm cho con ngi dng hn trong vic hc hi, nghincu v c th con ngi. Trong thi k ny y hc c nhiu thnh tu ln nh :Servetus (1509-1553) tm v m tc vng tun hon phi ( tiu tun hon).Tip theo l William Harvey (1587- 1657) khm ph ra vng i tun hon. Sau Par Ambroise - mtt thy thuppc trong qun i Php btu nghin cubuc mch mu cam mu cc vt thng. Nm 1672 Dzenh - mt thy thucngi cng b nhng cng trnh nghin cu v gii phunh khu. Tip theo lcc nghin cu ca nh gii phu hc Velpeau, Mangaine m chng ta cn gp tn

tui cc ng trong cc y vn v gii phu cho n tn ngy nay.- John Hunter (1728- 1793) th nghim rt nhiu ca phu thut chuyn ghp trnng vt. Nhiu mu vt cn c lu gin tn ngy nay ti bo tng Hunterti London.+ Thi k cni (1871 - 1913): H.U Pirogov (1810 - 1881) t nn mng chomn khoa hc gii phunh khu v phu thut thc hnh ca nn y hc X vit.

Louis Pasteur TK XIX vi khun l nguyn nhn gy ra nhiu bnh tt.Lord Lister - PTV ngi Anh xut vic m v khun.Alexis Carrel ( 1902) xut phng php, k thut v loi ch dng trong

khu ni mch mu - y c coi l mt bc ngt trong lch s ngoi khoa

- Thi k hini (1914 n nay) : L thi k chng ta ang sng vi rt nhiu thnhtu to ln ca y hc. Vit nam chng ta ghp tng thnh cng, phu thut nisoi ang pht trin, Vi phu thut cngang pht trin mnh .

2 -nh ngha phu thutL hng lot nhng thao tc chc do

Thy thuc tc ng

Bnh nhn Nhm

Chnon , iu tr( 2 mcch ny thng l kt hp vi nhau nhng cng c khi bit lp nhau)

3. Tnh chtca phu thut+ Tt c cc phu thutu gy ra nhng chn thngchc (au n, mt mu,bini v cu trc gii phu)

Chnthngchc


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TKTW

Cquan png

Ri lon sinh l (cc chcnng sng) ton thn

t Nhiu+ Mc ri lon sinh l ph thuc cc yu t: khch quan v ch quanCh quan ( ngi bnh)

- Trng thi thn kinh ca mi ngi.- Th trng (sc kho, tui tc...)- Chcnng sinh l tng phu thut

Khch quan (thy thuc).

- Khilng v tnh cht mt mu.- Mc gy chnthngchc (cng, thilng)- 2 Yu t ny la phthuc vo trnh PTV.

4.Nguyn tc ca phu thut:- An ton tuyti- Hipng tp th- Chp hnh tt cc ch phu thut

5. Phn loiphu thutv ngha

A- Phn loitheo kinh ina. Phn loi theo mc quan trng

- M nh (tiu phu thut)- M va (trung phu thut)- M ln (i phu thut)

ngha:- Nhn thcng v s nguy him, mc phc tp- Chun b tt nht v mi mt- m bo kt qu tt nht cho cuc m

b. Phn loi theo tnh chtthi gian- Phu thut ti khn cp- Phu thut khn cp- Phu thut khn cp c tr hon- Phu thut theo k hoch- Phu thut mt th- Phu thut nhiu th


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ngha:- Phu thut kp thi, hoc trong iu kin tiu- Cu sng c nhiu ngi nht

c. Phn loi theo tnh chtchuyn khoa: bng, ngc, tit niu, rng, hm mt, mt ngha- Bnh nhn cnc phu thut theo ng chuyn khoa- Phu thut vin phi chuyn khoa-Nng cao cht lng phu thut.

d. Phn loi theophngtin phu thut: Ni soi, Vi phu thut,laser ngha

- Phiut trang thit b chuyn dng- Phi c kp m chuyn su.- Nng cao cht lng phu thut, gim thiu nhcim

B- Phn loiphu thuttheo danh mc BYT 1998Mcch:

- Thng k- Nghin cu khoa hc- Phn tuyniu tr- Xc nh mc bi dng phu thut

Cch phn loi:

stt Tn phu thutLoi phu thut

BI II III

A B C A B C

6. Cc th mcbnThng chia ra 4 th:- Th 1: Tong vo cquan b tnthng- Th 2: Bc l v khm xt cquan b tnthng- Th 3: X tr tnthng (c th chia ra cc th nh).- Th 4: Kt thc cuc mCc th lun lin quan cht ch vi nhau. Quan trng nht l th 3.

III. IU KIN PHU THUT V CC BC TIN HNH


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1/-iu kin phu thut: Phi c 3 yu t

Trang b k thut

Kp m Bnh nhn

+ Bnh nhn: Phi c ch nh m ( tc l bnh nhn cn phi m v iu kin

m ).

+ Kp m: c phu thut vin kh nng m v l ngi chu trch nhim chnh

trong cuc m.

C cc ph m, a dng c, gy m hi sc... phi c trnh tt p ng

c yu cu k thut nhng ton kp m phi hip ng n .

+ Trang b k thut : m bo v an ton cho cuc m.

2- Cc bc tin hnh mt cuc m :

+ Bc1: lp k hoch:

- Khm xt v chn on chnh xc, a ra ch nh phu thut ng.

- Ln k hoch m, thng qua k hoch m, phi c phn cng v cc d kin:

. Thi im m, thi gian m.

. Phng php v k thut m.

. Phng php v cm.

. Thun li, kh khn.

. Tai bin c th xy ra, cch khc phc.

. Nhn s kp m

. Dng c, phng tin, thuc men cn phi c.

- Vi bnh nhn: gii thch, ng vin, vit cam oan m...

+ Bc 2: chun b cho cuc m

- Chun b bnh nhn:

- Kp m: chun b mi mt...

- Phng tin thuc men: mu, my mc... cn thit.+ Bc 3: Tin hnh phu thut

+ Bc 4:Chm sc sau m: Phu thut vin phi:

. Ghi chp bin bn m trung thc

. Theo di BN trong sut qu trnh iu tr hu phu.


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IV. TIU CHUN PHU THUT VIN TT1. Trnh chuyn mn tt (l thuyt, thc hnh)2. oc tt (khim tn, trung thc ...) trch nhim cao

3. Bn lnh chuyn mn vng vng4. Tc phong nhanh nhn, tho vt.5. C i bn tay kho lo.

* Kt lun: Thay li kt lun, xin trnh dn li ni ca cc nh ngoi khoa niting:

1. Pi-r-gp - Nh ngoi khoa X vit ni ting ni:" Trn a chin u ca ngi thy thuc tuy khng lng ly bng trn tuyn ca

cc tng lnh binh on, nhng ngi thy thuc bnh thng rt c th nhnc mt nim vui v cng phn khi khng khc no ni vui mng thng trn trong

chin u. l tnh cm vui mng cu sng mt mng ngi thot khi nanhvut ca thn cht nh s hiu bit ca h, tht l mt chin thng khng bao giqun c".

2. Nh ngoi khoa X vit ni ting Yudin c cn dn:" C th l mt nhc s, ha s, hay mt nh vn ti nhng hc y khoa th

khng c quyn tr thnh mt thy thuc ti"!B mn P.T.T.H - Hc vin qun y mong cc /c tr thnh nhng phu thut vin

gii!

B QUC PHNGHc vin qun y



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K THUT PHU THUT PHN MM.CC NG M CHNH TRN THNH BNG

TRC BN

B mn: Phu thut thc hnh

Tn gio vin: BSCKI Bi S Bi

Nm hc: 2004

K THUT PHU THUT PHN MM.CC NG M CHNH TRN THNH BNG TRC BN.

I/-K THUT PHU THUT PHN MM.A)- K THUT RCH ,CT,CM MU1- RCH DA:


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+Chn hng ng rch: i theo cc np gp t nhin ca da,hoc song song vihng ca c chnh hay mch mu thn kinh chnh .Trnh cc ng ct ngang ccthnh phn ni trn v trnh cc ng rch gy gc, to ra gc nhn nu c.+Sau khi st trng nn v ng rch ( bng xanh Methylen) nn da ri mi tri khn

gii hn trng m.+Khi rach da nn phi hp c 2 tay: tay tri cng u da 2 bn ng rch, tay phicm dao rch da theo chiu t trn xung di hoc t tri sang phi tu theo v tr. u v cui ng rch nn dng dao hi ng ln cn khong gia ng rch dao nm, li dao vung gc vi mt da. (Tranh minh ho). Nh vy s to ra mtng rch su u nhau t u n cui, khng b lm sang bn.+ Rch dt ht t chc di da, thm mu nhn r cc ch chy mu t chc dida, dng km cm mu kp cm mu.

2-RCH CN:

+ Tu theo v tr, cn c th mng hoc dy , di cn c th l c, c th l mchmu thn kinh. Do vy k thut rch cn c s thay i m bo s an ton.+ Nu bit di cn khng phi l cc mch mu thn kinh ln th c th rch cnthng mt l, dng 2 km kp 2 bn mp l thng nng cn ln ri dng ko mrng cn v 2 u t c kch thc cn thit.( K thut 1)+ Nu di cn l cc mch mu thn kinh ln,hoc cc thnh phn quan trng mcn nh trn l d phm vo chng do vy ta nn dng 2 km c mng kp cn koln, to ra mt np ngang, (tranh minh ho) dng dao ct t np ngang to ra mt lthng, lun mt thng nng mng qua l thng xung di cn, dng ko hoc dao

ct cn trn nng ca thng m rng cn v 2 u cho n ch cn m. (K thut 2)+ Chiu di ca ng rch cn khng nn di hn ng rach da.

3-RCH CT C :

+ Tt nht l tch c theo chiu dc : Tch theo khe gia cc c, khe gia cc b choc tch gia cc th trong 1 b c tu theo v tr m.+ Khi buc phi ct ngang c phi ch cm mu cho tt theo mt trong cc k thutsau :

- Ct dn tng phn c, ct n u kp buc cm mu n y ri mi ct tipvo lp su.

- Khu bng ch ct gt 2 hng mi khu cm mu song song nhau ri ct c gia 2 hng ch buc, sau cm mu b sung nu cn chy mu.

- Nu thn c mng, dt c th kp 2 Clamps ct c gia 2 Clamps, sau kpbuc hoc khu cm mu u mch b t.

4- M PHC MC:


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+ Phc mc bao st mt trong thnh bng. v rt d dnh vo cc tng trong bngnu mp ct ca n qut vo trong. Nu n dnh vo tiu trng s gy ra tc rut chc sau m. Do vy ngay t khi bt u m phc mc cn phi tun th k thut sau:- K thut m phc mc: ging nh k thut 2 m cn. Khi m phc mc xong phi

kp t nht l 4 km vo mp phc mc 4 gc vt m. Vt m ln c th ti 6 kmhoc hn, mp phc mc khng b tt vo trong bng n khi ng vt m d bst.- Khu vin mp phc mc vo khn m borde trnh nhim vi khun t da vovt m .

5- CM MU:

+Cm mu l gim mt mu cho bnh nhn v trng m lun r rng trnh ccc tai bin do thao tc khng chun gy ra.+ Cm mu xong trong tng lp, xong lp ny ri mi rch ct ti lp khc.

+ Khi nhn r mch mu: nu c th trnh c th trnh rch ct qua n l ttnht.Khi buc phi rch ct qua th nn kp 2 km ri rch ct gia 2 km chng cm mu.+ Khi rch ct ri mi thy chy mu th dng 2 km kp 2 u mch b t cmmu. Kp vung gc vi trc ca mch mu nu nhn thy u mch mu. Kpvung gc vi mp vt m nu khng nhn r u mch mu. Lu : chiu cong cakm phi lun nga ln khi buc ch thay km khng buc vo u km.+ Cc nhnh mch nh t chc di da b ct t c th ch cn kp km lukm ti ch cho n lc kt thc cuc m tho km, khu da m khng cn buc cm

mu tng km mt nh cc nhnh mch ln.

B)- K THUT KHU PHC HI

1)- KHU PHC MC:

+ C th khu ring phc mc mt lp : bng mi ri hoc mi ti+ C th khu phc mc cng vi c thnh bng thnh mt lp , khi dng mikhu ri. C 2 trng hp trn dng ch Catgut.+ C th khu phc mc cng vi cn hoc c c thnh 1 lp : Lc ny dng chPerlon, khu mi ri.

+ Trong mi trng hp mp phc mc u phi qut ra ngoi v ch kh khutrc, ch d khu sau.2)- KHU C:

+ Khi tch dc vo khe gia cc c : khng cn phi khu g. Khi tch vo khe giacc b ca 1 c hoc gia cc th ca 1 b c : Phi khu li bao cbng ch Linkhng tiu, khu n tn u mt ca ng rch m bao c.


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+ Khi ct ngang c : Phi ni li ng cc u c vi nhau. Ni bao c l quantrng nht, dng ch lin ,khu mi ri quanh chu vi ca thn c. Nu c khu tngcng mt vi b cth dng ch ctgut t tiu trnh so c sau ny dy cm nhhng n s co c.3- KHU CN:

+ D l khu ring cn 1 lp hoc khu kt hp vi cc thnh phn khc th bao gicng phi dng ch Perlon khng tiu m bo cho lp cn vng chc. Khu bngmi ri, c ly 1-1,5 cm, khu n tn u mt ca ng rch. Buc ch Perlon gingnh buc ch catgut : buc 3 n.4)-KHU DA:

+ st trng mp da bng cn it trc khi khu da.+ Khu thng thng : bng ch lin, khu mi ri , c ly 1 -1,5 cm ,cch mp ct0,5cm. Buc ch lch v mt bn , p cho t chc di da p st vo nhau, khng ln

mp vo trong.+ Khu thm m : vng da h nh mt c Dng mi khu thm m BlairDonati hoc ch Nylon khu vt ngm di da, khi ct ch ct 1 u v rt ton b sich ra so nh p.+ Nu lp m di da dy c th khu ring m mt lp bng ch catgut ri mikhu da.+ Khi vt m c nhiu dch tit ( M bu c ) c th dt Lame cao su pha thp v khu da tha.+ Khi nghi ng vt m nhim khun : Khu da t ch ch, buc ch khi vt m kh.+ Khi vt m nhim khun : h da hon ton (bng kn vt m) n khi iu tr

ht nhim khun s khu kn da sau.

II/-CC G M CHNH TRN THNH BNG TRC BN.A)- CC TIU CHUN CA MT NG M TT

1- Phi trc tip vo c cc tng cn phu thut.2- kch thc rng khng hn ch thao tc phu thut3- C th m rng dng khi cn.4 - t lm thng tn mch mu thn kinh5 - Khu phc hi d dng.

chn v lm c 1 ng m tt ngi phu thut vin nht thit phi ckin thc v gii phu, nht l gii phu nh khu.B)- C IM GII PHU NH KHU THNH BNG TRC BN.

1- da v t chcdi da.2- c: gm 2 khi c rng 2 bn v khi c thng bng gia . Khi c rng

t nng vo su gm: c cho to pha trn l c xung thp chuyn thnh cn. C


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cho b pha di l c chy ln trn chuyn dn thnh cn. C ngang bng sauc cho b, b di c ngang cng b di co cho b to thnh gn kt hp. Hai cthng bng bm t mi c chy xung tn g mu c mt khong gia 2 c m cccn an quyn vo nhau, khng c mch mu v thn kinh l ng trng gia.

ng trng gia rng nht on gia, trn rn, hp 2 u . b ngoi 2 cthng bng l cc ng trngbn trn rn v di rn.

3- Mc ngang ; bao ph mt trong cc c rng v c thng.4- Phc mc : Bao ph lp trong cng ca thnh bng.5- Mch mu : Do cc ng mch lin sn 7 -12, /m v trong t trn i

xung, cc mch di da bng, m chu nng ( ngnh bn ca /m i ), /m mchu su ( ngnh bn ca /m chu ngoi) t di i ln .Chng xp thnh 3 lpnui dng cc c thnh bng.

6- Thn kinh : do 6 dy lin sn (7 -12) dy bng sinh dc to v nh chi phi.C)- MT S NG M CH YU.

1- Cc ng rch dc:c dng trong 70-80% cc PT bng ( V hnhtrn bng)

a)-ng trng gia trn rn : rch t cch mi c 1cm ti cch rn 1 cm , vo cc tng tng trn mc treo i trng ngang.

b)-ng trng gia di rn : rch t cch rn 1cm ti cch g mu 1 cm, vo cc tng tng di mc treo i trng ngang.

c)-ng trng gia trn v di rn : rch t im thng v ti im h v-m thm d vo cc tng c tng trn v di mc treo i trng ngang. khi cn

c th m rng v 2 pha.d)- ng cnh ng trng gia : Cch ng trng gia trn rn 2 cm ,c th

i xuyn qua c thng hoc ko c thng vo trong m bao c sau cng mc ngangphc mc vo bng

e )- ng trng bn : Bn phi hoc tri, trn rn hoc di rn tu theo yucu c th.


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2)- Cc ng rch xin :a)- ng Mac Burney : ct b rut thavim cp.Rch qua v vung gc vi chni 1/3 ngoi vi 2/3 trong ca ng nigai chu trc trn bn phi vi rn.

Phn b :1/2 trn, 1/2 di(2/3 trn v 1/3 di khi manh trng v ruttha cao)b)- ng m thot v bn : Rch t cch trngai chu 1 cm i theo ng phn gic ca gcto bi b ngoi c thng v dy cung i

cng bn , di khong 8-10 cm.c)- ng Roux: dn lu p xe RT hchu phi.Rch t trc trong gai chu trc

trn phi 1cm, song song vi cung i, di2-3 cm - t mt ng dn ludn m ra.d)- ng Schwart - Qunu : C tht dng trong ct lch. Rch t trn rn vpha khe lin sn 8-9 bn tri.

3)- Cc ng rch ngang:a)- ng Bazy :Rch t pha sau ngang mtsn 11 v pha trc ngang rn. Dng vothn.

b)-ng Pfannenstiel:Rch t b ngoi c thngbn ny ti b ngoi c thng bn kia. nh lica ng rch cch g mu khong 3-4cm.Da rch ngang, m c theo ngtrng gia di rn. Dng m ly thai.


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4)- Cc ng rch gy gc ln sng:a- Cc ng Kehr (1,2,3) vo gan mt.b-ng Riobranco :Vo gan mtc- ng Turbull vo i trng ngang: nt dc

rch theo ng trng gia, nt ngang rch t bngoi c thng bn ny ti b ngoic thng bn kiad- ng vo i trng phi / tri : Rch theo ngtrng gia di rn t di len vng sang phi hoctri.

III-K THUT M, NG THNH BNG NG TRNG GIA TRN RN.

A/- M:-Rch da t di mi c 1cm ti cch rn 1cm.

-Rch cn trng: theo k thut m cn 1- M phc mc : nh k thut m cn 2, saukhi to c 1 l thng PTV v ph m lunngn tr tay tri vo ly mp phuc mcv m rng PM ln pha trn trc. Dng 2km kp ly mp PM gc vt m ri mi rt ngn tay ra.PTV dng ngn 1 v 2 tay tri lun vo lymp PM pha di, dng dao rch m PM

khe gia 2 ngn tay. Kp 2 km vo mp PM gc di ca vt m ri rt tay ra.-c th kp thm 2 km vo mp PM qunggia ca 2 mp vt m.-Tin hnh khu che ph vt m.

B/-NG:Thng thng ng 2 lp : Lp trong gmphc mc v cn trng, lp ngoi l lp da

-ng lp trong : khu mi ri, ch Perlon,ng t pha rn ln mi c, c ly 1-1,5cm.Khi cn 1-2 mi khu cui cng th khu xongcha buc ch ngay i khu xong ton b angn tay vo kim tra li xem c mi khu nokhu hoc buc mc vo cc tng pha di


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khng. Sau mi buc nt cc mi cui cng.- ng lp ngoi : khu da nh bnh thng.

Sau khong 7-10 ngy ct b ht lp ch khu da.

B QUC PHNG

Hc vin qun y


I CNG PHU THUT MCH MU

B mn: Phu thut thc hnh

Tn gio vin: BSCKI Bi S Bi


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Nm hc: 2004

I CNG PHU THUT MCH MU

-Tn thng mch mu, nht l cc mch mu ln l loi chn thng nng vnguy him do chy mu v mt mu ,do n d gy t vong nu khng c cu chakp thi.

-T l: 0,2-0,3% chn thng thi bnh v 2,5% vt thng chin tranh.-Do v kh st thng pht trin c v chng loi v mc nguy him nn VT

mch mu cng c xu hngtng ln c v t l v mc .

I/SLC V LCH S PHU THUT MCH MU-TK XVI Par Ambroise th nghim tht mch cm mu vt thng.-1759, Hallowel khu th 2 mi trn 1 l thng /m cnh tay.-1837 Pirogov NC gii phu nh khu tm c quy lut phn b ca mch mu t chi.-1889, Ianopxki khu ni m/m trn thc nghim.-1904, Carrel ara c PP khu ni m/m v dng ch la trong khu ni m/m.yl mt thnh cng ln trong lnh vc pT mch mu.-1916, Mc Lean xut s dng heparin.-Thi i chng ta : vic tht mch mu ch l bin php btc d, cn ch yu lkhu, ni, ghp mch mu. Vi phu thut ni ghp chi th, ni ngn tay, ngn chnni ln kh nng to ln trong lnh vc ni cch mch mu nhng knh


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- Vt thng c mu t trn ngi ca /m ln, chn p lm mt mchngoi vi.

b. Phu thut mun:Di chng VT mch mu c:- Phng /m tin trin t t khng e do v (i 1,5- 2 thng cho tun hon

bn pht trin)- Thng ng- tnh mch (i 4-5 thng to thnh ng thng mi m thtng thng)

2- khai thng cc mch mu b tc, nghn do nhiu nguyn nhn khc nhau.3- khu ni cc mch mu : ghp tng, Lm cc cu ni iu tr tng p t/mgnh.4- Cc ch nh khc : pht trin theo s tin b chung ca y hc.

Cc chnh ring c trnh by trong tng mc c th trong phn di y.

III/K THUT PHU THUT MCH MU

A. K thut bc l mch mu;Bc l mch mu l cng on cn lm u tin trong bt k phu thut mch muno. lm tt cn phi:1.Chn ng m thch hp: trc tip v rng ri. t chi l cc ng chun ch.2.Tm mch mu: Phi bit da vo c im gii phu nh khu, cc mc xng ,mc GP lin quan ca vng phu thut.3.K thut tch trn ng mch: L KT bc tch /m ra khi b mch- thn kinh. Cth nh sau:

Kp 2 km to np ngang trn baomch.

M bao mch theo chiu dc ( trnthng nng mng)

Tch dc 2 bn sn /m.Tch mtsau, lun ch nng /m ln.

B - Tht mch mu: Bao gm thtng mch v tht tnh mch ty hnh /m.

1)- Tht ng mch:c tc dng cm mu ti vt thng nhng hu qu li gy rathiu mu v hoi t vng sau ch tht m n nui dng. Do vy chnh tht /mcn ht sc thn trng. Ngy nay phm vi ca chnh ny cng c thu hp.

a-Chnh:+ VT mch mu nh, tht khng gy nguy him ( khng cn phi khu ni)+ VT mch mu ln,e do tnh mng nn nhn nhng:


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- tuyn cu cha khng th lm c Pt khu ni mch mu ( do nhiu l dokhc nhau)- Tnh trng ton thn qu nng khng sc chung mt cuc m kodi.

- C gy xng chnh hoc tn thng thn kinh chnh ca chi th.- VT c tnthng phn mm ln, hoc nhim khun nng.b-V tr tht:

- Tht ngay ti vt thng : trong phn ln cc trng hp c chnh.- Tht cao, trn vt thng: khi VT c nhim khun, hoc khng tm thy

u m/m t. Bc l/m ph trn Vt v thtch thp nht c thc.Nu /m b thng cha b t hn,cn- phi ct t ng mch pha

ngoi vi khng b co tht.c- Cch tht:

- ng mch nh: tht mi u mch t =1 mi, cch mt ct 3-5 mm.- /m ln : tht mi u 2 mi ch. Mi ngoi cng phi khu buc theo kius 8.

d- Loi ch :Dng ch lin hoc ch la, khng dng loi ch trn (perlon) hoc ch t tiunh catgut hoc vycril.

2)- Tht tnh mch ty hnh:- Khi t/m b tn thng: x tr nh tn thng /m trnh by trn y.- Khi t/m khng tn thng c tht khng ? nu tht s gy tr tun hon, c tcdng lm gin n cc ngnh bn song li gy ph n d nhim khun vt m. V vy

Oppel ngh: khi tn thng cc /m nguy him nn tht t/m tu hnh.Khng nntht khi VT c du hiu nhim khun.

C Khu ni mch mu: Va x l c vt thng vam boc lu thngmu. Phm vi chnh ngy mt tng.

1- iu kin:- C phu thut vin mch mu.- C iu kin bt ng bnh nhn sau m 15-20 ngy.- C cc trang b dng c phu thut mch mu. (Nu khng iu kin nn u

tin vn chuyn ln tuyn trn)

2. Chng ch nh :khi vt m/m c chnh tht mch nh ni ti phn trn.3-Nguyn tc c bn trong khu ni mch mu- V khun tuyt i- Mch mu khu xong phi thng trc, khng xon vn, khng cng ko mingni.


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- Khng lm bm dp thnh mch, t mu di bao mch ti ming ni.- ng khu kn, mi khu cch u nhau.- Mi khu p lp ni mc vo nhau, mp ln ra, khng gy hp ng knh mch

mu.

4. Cc mi khuc bna)- Mi khu ri:

- Mi khu ri n gin

- Mi khu kiu ch U

b). Mi khu vt


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- khu vt n gin

- khu vt kiu ch Uc). Khu kt hp: Trong thc t khu ni c th kt hp trn mt ming ni c mi

khu ri v mi khu vt, mi khu n gin vi mi ch U khc phc nhcim ca mi loi mi khu.

d). Khu ni bng my

5. Cc kiu khu, ni chnha. Khu l thng rch thnh bn : p dng cho cc vt rch nh. Khu theo chiu

ngang mch mu, bng cc mi ri.

b. V thnh mch : p dng cho cc vt rch # 1/2 ng knh mch mu. nu khutheo chiu ngang s b hp. Ming v thng dng l mnh t/m t thn, kch thcthng ct ln hn ll thng. Khiung khu 1cnh khng nn nh elip,va khu va dn ming v cho va kht l thng.

c. Ni tn - bn (cu ni mch mu):Thng p dng trong cc trng hp lmcuni ( by pass) iu tr hp tc /m mtondi. mu lu thng tt th trc ca mch tnphi to vi trc ca mch bn mt gc 450 vpha ngoi vi ca dng chy.

Thng dng mi khu vt n gin, khu 1/2chu vi pha sau trc theo kiu Blalock ( khuxong mi tht ch p ming ni li gn nhau) v1/2 pha trc sau.


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d. Ni tn - tn (ni vng ngang) : p dng khi mch bti hay mton 3cm-Ngun mch ghp : T/m t thn, /m ng loi c ly v bo qun trongngn hng m, mch mu nhn to.

IV/SN SC SAU M-Bt ng chi th t th chng mch mu-Phong b Novocain gc chi-Chng chong, truyn mu b sung nu cn-Khng sinh liu cao.-Theo di chy mu th pht.


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-nh gi s hiphc tun hon tin lng kt qu+Tun hon hi phc:

. Chi th mu hng ho, m nng.

. C ng chi th pha ngoi vi bnh thng

. Bnh nhn khng au nhc chi.+Tun hon khng hi phc

. Chi th mu thm tm, lnh, ph n

. Co cng hoc hoi t c cc b do thiu mu.

. Bnh nhn au nhc chi th.Ton trng km dn i.

Ti liu tham kho

1. Cc qun y- iu l x tr vt thung chin tranh -NXBQND - 1984.2. B mn P.T.T.H - Bi ging P.T.T.H -NXBQ - H ni - 1996.3. Littman Imre, Sebeszeti Mtttan, medicina Knyv Kiad, Budapest - 1968 v

1977.

4. Hong nh Cu - P.T.T.H - NXBYH v TDTT - H ni 19655. Stfanics Janos, Sebszet 2 - Medicina Knyv Kiad - Budapest 1977.

B QUC PHNG

Hc vin qun y



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BC L NG MCH CNH ,

NG MCH NCH V NG MCH I


Nm hc: 2004

BC L NG MCH CNH

A-cim gii phu- /m cnh gc phi tch t thn /m cnh tay u phi- nn c.- /m cnh gc tri tch t quai /m ch-trong lng ngc.Nn bn tri c mt

oni trong lng ngc.- vng c bn /m cnh gci trong tam gic cnh, c gii hn bi:

.Cnh ngoi l c C


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.Cnh trn l c nh thn

.Cnh di l cb mng .- ng mch cnh gc cng vi t/m cnh trong,dy TK X to thnh b mch

TK.Cng nm trong mt bao v lin h mt thit vi cn c gia. Lin quan trongb mch: t/m ngoi, /m trong, thn kinh X sau. Khi i n trn sn gip trng1cm, /m phnh ra to thnh hnh cnh ri sau chia thnh 2 ngnh tn l /m cnhtrong vg /m cnh ngoi.

- ng mch cnh trong lc mi phn chia nmpha sau ngoi cn ng mchcnh ngoi nmpha trc trong v nm trong tam gic Farabeuf.

-Tam gic Farabeuf : Cnh ngoi l t/m cnh trong, cnh trn l quai dy h thit(XII) , cnh di l thn t/m gip li mt.

- Ngnh bn:

+ /m cnh gc khng cho ngnh bnno

+ /m cnh ngoi c 6 ngnh bn ( gip,li, mt, hu ln, chm, tai sau) v 2nhnh tn (thi dng nng, hm trong)

+ /m cnh trong c 1 ngnh bn ( mt)v 4 ngnh tn ( mch mc, no trc, nogia, thng sau)

- vng ni:+ Cnh ngoi ni vi: cnh ngoi i din v di n (qua cc ngnh tuyn

gip, hu ln v /m chm) v cnh trong cng bn ( qua mt).+ Cnh trong ni vi: cnh trong i din (qua a gic Willis) v cnh ngoi

cng bn ( mt).- Phm vi cp mu :

+ Cnh ngoi : vng mt ,c,tuyn gip.+ Cnh trong : bn cui no, mt t chc bit ho cao kh nng chu ng

thiu oxy km (khng qu 5 pht) .- Vng ni ca/m cnh trong ngho nn do vy thtng mch cnh trong l

rt nguy him, 50-80% l t vong hoc lit 1/2 ngi.- gim bt tai bin khi tht /m cnh trong hoc/m cnh gc ngi ta hay

dng th thut Maltas: p ln /m nhiu ln, tng dn thi gian, trc khi tht


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tp cho no quen dn vi tnh trng thiu mu, thiu oxy . Khi tht, thao tc tht cngt t ch khng tht nhanh nh cc /m khc.B - Ch nh

- Ch nh bc l chung:nh bi i cng- Ch nh ring :

+ /m cnh ngoi: khng ch chy mu do PT vng hm hu,li,tuyn mangtai, amydal.

+ /m cnh gc, cnh trong: x tr di chng VT mch mu (phng, thng ...).C - K thut- T th bnh nhn : Nm nga, u quay sang pha bn i din. K 1 gi vng vaigy , cn.- V tr phu thut vin : ngbn cn bc l. Ph mng bn i din.

- V cm : tu theo mcch phu thut.- ng m: bm stng chun ch ( t b trc xng chm ti khp c n

cng bn)1-Bc l v tht ng mch cnh gc

-Th1: rch da 10 cmtrn ng chun ch,cch trn sn gip 1cmv trn khp c n1cm. Gp t/m cnh nngngay di da, banh rangoi.-Th 2: rch bao c

C( l trc) banh riengthcra ngoi, rch tip lsau bao c cng cn c

gia. Banh rng vt m sthy b mch thn kinh. C th gp cb mng (Vai mng) banh c xung di,nu n qu cng c th kp km cti sau ni li sau.-Th 3: Mbao mch, tch trn ng mch. tin hnh phu thut chnh. Khi phitht: Tht xa di hnh cnh 1,5 2 cm

-Th 4: khu phc hi vt m t su ra nng tng lp mt


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2-Bc l v tht ng mch cnh ngoi, cnh trong

- Th 1: rch da 6-8 cmtrn ng chunch btu t sau gc xng hmdi 1cm ti trn sn giptrng 1 cm. im giang rch ngang sng toxng mng ko sang.Gp tm cnh ngoi, banh

ra sau.

- Th 2: rch bao c c n chm, cn c gia ( nh trn).Banh rng vt m.Tm bmch-Th 3: tch trn ng mch , lm phu thut chnh thc.

+ Phn bit ng mch cnh ngoi v trong+ V tr tht ng mch cnh ngoi: gia ng mch gip trng trn vng mch li.+ Nu c ch nh tht ng mch cnh trong: tht cao trn hnh cnh1-2 cm v dng th thut Maltas

- Th 4: Khu phc hi vt m.+ng rch Fiolle-Dellmas x tr vt thng chin tranh.( T c)

II-BC L NG MCH NCHA -c im gii phu-Gii hn : l on tip theo ca/m din, tim gia xng n ti bdi

cngc to.-ngi: Chy chch xung di, ra ngoi, nn khi tay bung thng /m rt sunhng khi dang tay xa thn ngi th /m nm rt gn vi nn hm nch v cqucnh tay.-Cty hnh : cqu cnh tay, TK tu hnh l dy gia l nhng mc tm /m.-Ngnh bn : 5 (Ngc trn,cng vai ngc,v ngoi,vai di, m)


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-Vng ni: 3 vng (quanh vai, quanh ngc,cnh tay).+ Vi/m din : to thnh vng quanh vai (vai di vai trn v vai sau) v vng quanhngc ( ngc trn, cng vai ngc, ngc ngoi V trong).

+ Vi /m cnh tay to thnh vng cnh tay (Mch m mch cnh tay su)

-on nguy him: Gia 2 vng trn v vng di khng c s tip ni no do vy

khong gia ng mch vai div ng mch m l on nguy him.Thty skhng cn c mu xung cnh tay.B - Ch nh

-Nh bi i cngC - K thut-T th BN : nm nga, tay dang ngang 900, bn tay nga.-V tr PTV: ngpha trong cnh tay, ph m dng bn i din.-V cm : Tu theo trng hp.

- ng m: ty theo ni dung v mcch phu thut c th dng :+ ng song song di xng n.+ ng Fiolle Delmas.+ ng hm nch.

K thut m hm nch:+ Xc nh ng chun ch: t nh hm nch ti im gia np gp khuu, tay

dang ngang 900.+Th 1:rch da 8-10 cm, nh hm nch lm im giang rch, 1/2 phacnh tay nm trn ng chun ch, 1/2 hm nch i song song vi b di

c ngc to.


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+Th 2: rch cn n-qu-nch, tm c qu -cnh tay, tm TK tyhnh (dy gia) banhdy ny ra phangoi,vo b mch.

+Th3: tch trn /m ln cao.Mun d tch cn gp cng tayBN lia c cnh tay ln phau lm chng c ngcto.Tin hnh th thut chnh

-Khi tht phi xc nh c /m vai di,tht pha trn n.+Th 4: hi phc vt m.

III-BC L NG MCH IA -c im gii phu:-Gii hn: L on tip theo ca /m chu ngoi, t im giacung i ti vng ckhp ln.-ngi: chy trong ng i. Khong 4-6 cm di cung i th tch ra /m i suchy ra khu sau, cn /m i nng tip tc chy theo hng c vo ng Hunter.-Cty hnh l cmay,TK ty hnh l dy TK i.Dy hin trong l mt nhnh caTKi chy cng /m vo ng Hunter ri phn nhnh vo mt trong khp gi, cngchn v c chn.


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-Ngnh bn: c 6 ngnh bn (di da bng, m chunng, thn ngoi T- D, i su,ni ln). /m i su chiacc nhnh: nui ctu, m trcv sau, cc /m xin.- C cc vng ni vi cc ng mch:

+ Chu ngoi : Thng v di, m chu su di da bng, m chu nng.

+ Chu trong : /m mng, /m ngi ngmch m v cc ng mch xin

+ /m khoeo : khp trn trong /m ni ln(gi xung).

B - Ch nhC- K thut bc l ng mch i+ T th BN: nm nga, chn hi dui v xoay ngoi+ V tr PTV : ng pha ngoi chn bn bc l, ph mng bn i din+V cm : tu theo ni dung phu thut.+ ng chunch: Tim gia cung i ti bsau trn li cu trong xng i.

-C th bc l 3 on:+ 1/3 trn ( trong tam gic Scarpa)

+ 1/3 gia (nh tam gic Scarpa)+ 1/3 di ( trong ng Hunter)

1.Bc l ng mch i 1/3 trn


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-Th 1: rch da 6 cm theo ng chunch t trn cungi 1cm, di 6 cm. Ch t/m hin trong vo tm i.- Th 2: rch cn.Pha trn cung i rch cn ccho to thy r cung i.Pha di cung i rch cn sng trnthm c rnh.-Th 3: Banh vt m, tm b mch, mbao mch trn thmc rnh, tch trn/m. Lun ch t pha trong ra ngoi nng /m ln. Tin hnh PT chnh. Khi phi tht /m ichung tht st di cung i.-Th 4: hi phc vt m.

2. Bc l ng mch i 1/3 giaTh 1: rch da 6-8 cm btu t di cung i 10-12 cm

Th 2: rch cni nng thy cmay rchbao c may, banh ring thcvotrong xung di.Th 3: tm bao mch, mbao mch tch trn /m. Ch ch tch ra ng

mchi su - thng thngngay b trn ckhp nh. Khi phi thtngmch i nng tht di ch chia ra /m i su.Th 4: hi phc vt m.

3. Bc l ng mch i 1/3 di-Th 1: rch da 10 cm theo ng chunch. u ding rch cch btrn licu trong xng i chng 4 khot ngn tay.

-Th 2: rch cn di nng thy c may rchbao cmay banh ring thcvo trong xungdi. Gp gi BN li, xoay cho i dng ngoi lm cng thng ckhp ln. Xc nhccn Hunter dn sch thnh trc ng ri rch

cch thng gn 2mm mvo ng Hunter-Th 3: Banh rng 2 mp cn tm /m lm PTchnh. Khi phi thtng mch, tht di chtch ra /m ni ln.


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Th 4: hi phc vt m.

Ch :-C i l nhngc ln nn khi tht mch nguy cthiu mu vn rt cao.-Tht /m i chung nguy him hn /m i nng, nht l khi tht thp gn ch phnchia ra /m i su d lm tc /m ny hoc vng ni chnh vi/m chu trong.Tht/m i su l nguy him nht.-T l hoi th : theo De Bakey v Simon l 81%.

Ti liu tham kho1. B mn PTTH - Hc vin qun y -NXBQDDND - 1996.

2. Cc qun y - iu l x tr vt thng chin tranh - 1984.3. Xun Hp - Thc dng ngoi khoa t chi.4. Xun Hp - Gii phu chi trn v chi di.

5. Hong nh Cu - PTTH - NXBYH v TDTT - H ni 1960.

B QUC PHNG

Hc vin qun y


I CNG CT CT V THO KHP


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Nm hc: 2004

I CNG CT CT V THO KHP

I/ NH NGHAL phu thut ct b mt phn pha ngoi vi hoc ton b mt chi th.

-Khi ng cti ngang qua xngc gi l ct ct thc th. Khi ng ctingang qua khe khpc gi l tho khp-Phn bit vi cton ( c ni lin 2 u): Cton xng,ct on khp, khng cthut ng cton chi.-

II/ NHNG BIN I SINH L - BNH L SAU CT CTA - BinitichPhn cn li ca chi th sau ct ct gi l mm ct.Bini ti mm ctc gi lbini ti ch. Bini mang tnh quy lut chung c gi l bini sinh l. Bini khc thng- l bini bnh l.


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1. Da: - Sau ct co li, nhiu t ty tng ni, ch da dy co t, ch mng co nhiu.Mt trong chi th co nhiu hn mt ngoi. Da mt cgp co nhiu hn pha cdui.2. C: - Ngay sau ct: co li (co nguyn pht), nhiu t khc nhau. Co nhiu khi:c

di, nng, chotng chnh, co t khi: cngn, bm st xng.- Sau mt thi gian: vn tip tc co (co th pht) ng thi teo v xho dn.3. Mch mu: - Ngay sau ct: co li, nhiu t ty loi mch to hay nh

- Sau mt thi gian: teo nh li ( 2 thng sau ct ct/m i teo nhcn bng/m quay, /m cnh tay - cn bng/m ngn tay)4. Thn kinh:

- Trong lc ct: gy au, d b chong.Do phi phong b trc khi ct.- Ngay sau ct: co rt ln cao, tt vo trong phn mm.- Sau mt thi gian cc si trc li mc di ra, khi gpu mm ct n cun li

to thnh u thn kinh.(nevrome). Dy thn kinh ngoi vi l dy hn hp ( gm

cc si vnng, cm gic v thc vt) do cc dn truyn thn kinh theocung phn x vn tn ti trong mt thi gian gy ra hintng chi ma. Nuto thnh u c th gy hi chng bng but.(causalgie)

5. Xng- Ngay sau ct: khng binic bit, nhng lun c chy mu t tuxng.Do vy phi cm mu ng tu cho tt.- Sau mt thi gian:

+ Tha xng : xut hin qung ngy th 10 sau m v lan ta lntrn,c khi vt qua c khp, u xng teo nh li,

+ tr nh, ngc lixng li mc di ra,cng tr mc cng nhanh, c

khi chc qua da mm ctB Bini ton thn- Gim st sc khe v sc lao ng- Ct ct chi trn: gim khnng lao ng- Ct ct chi di: nu t vnng c th gy bo ph, cao huyt p, song mm ctli teo nh.-Mt sngi xut hinau tht ngc, kh thkiu hen.

III/ CH NH CT CT TRONG CHN THNG - VT THNG- y l mt phu thut gy tn ph cho nn nhn do gy chn thng tm l rt

mnh. V vy ngi thy thuc cn ht sc thn trng trc khi ra quytnh.- Xu hng pht trin ca y hc gip cho phm vi chnh ct ct chi ngy cng thuhp.A - Chnh ctctku sm :

1. Vtthngn sm- Ct ct t nhin do vt thng, hoc chi dp nt ch cn mt cu da.- Vtthng dp nt ln ( c phn mm v mch mu thn kinh chnh) khng cn


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khnngiu tr bo tn2. Vtthngn mun

- Hoi th sinh hi hoc nhim khun nng m xt thyiu tr bo tn hociu tr bo tn m khng kt qu

- Khi vtthng c ga r mun, t chc pha di gar b hoi tB- Chnh ctctk u mun:L nhngtrng hp khm k u thy c hy vng bo tn chi th cho nn nhn nn liiu tr bo tn tch cc. Song din bin trong qu trnh iu tr ngy mtxui, e do ti tnh mng BN buc phi ct ctC- Chnh ctctk 2

- do di chng ca tnthng, hoc qua phu thut to hnh m kt qu xu.- Mm ct khng tt do:

+Ct tu vim xng mm ct hocxng chc ra ngoi da+Lch, vo, au khng lpc chi gi

D - Ch nh ct ct trong chin tranh- Da theo ch nh thi bnh, nhng lu ti:+ Trang thit b ca tng tuyn+ Trnh k thut ca phu thut vin+ Kh nng phc v ca c s iu tr + Th trng thng binh.

- c im trong chin tranh l s lng thng binh ng, tp trung t vo nhngthi im nht nh, vt thng ,nhim,tnh trng ton thn nng .Do vy Ch nhct ct c rng ri hn, song cn lu cn nhc k gia 2 yu cu:

. Trc ht phi cu sng thng binh

. C gng gi chi th v tit kim chi th ti a nu c th cIV/ K THUT CT CTA- Cc phngphp ct ct

1. Cc phng php ct trn

a) Ct trn phng

-Li dao vung gc vi trc chi, ct cng mt mc tda ti xng.-c im: n gin, nhanh, u mm ct c phi byt da n xng. u xng th ra ngoi mm ct- C gng trnh kiu ct ct ny . Ch ct trong trng

hp nhim khun ym kh v khi thng binh khng sc chu ng cuc m ko di.


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b) Ct trn hnh phu

+ L PP c tnh ton ti co ca da,c so vi v tr (mc) ca xng+ K thut c th:- xc nh mc ca xng- ct da di mc 1K- ct c nng, su- ca xng- X l m/m tk theo NT

nhng on chi thon dn t trn xung c thm thm 1 hoc 2 ng x bn d vn phnmm ln ca xng. PP ny c th gi l ct trnc ng x (rch) bn.

c) Ct trn b ng (kiu ca Pirogov)

-PP ny xc nh v tr ctphn mm trc: ct da stngay trn vt thng,ct cnng mc da co, ct c su mc c nng co, caxng ngang mc c su


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co . Do vy mc ca xngcao hay thp ph thuc vomc ct phn mm. sau ct,mm ct ng hon ton

trnh c nguy c nhimkhun ym kh- PP ny cng c th x thm1 hoc 2 ng x bn chng ph n chn p.

2. Ct hnh bu dc (hnh elp)

- Mt ct khng vung gc vi trc chi- Nu c x thm mt ng bn- gi lct hnh vt (hay dng cho ct ct ngntay, bn tay).

3. Ct 2 vt- 2 vt bng nhau- so mm ct gia- 2 vt khng bng nhau somm ct bn

K thut- tng chiu di 2 vt da bng 2 ln

ng knh trc sau ca chi oti mc ca xng

- Bao ct mc cng phi x dctheo cc rnh da, c

B-Yu cu chung i vi mm ct:


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- Mm ct di mang c chi gi, khp trn mm ct hot ng bnhthng.

- So mm ct mm mi, khng lot da,teo c, t nn khng au

C- Nguyn tc chung v k thut1- Chun b bnh nhn trc m tt:Chng Shock tt, chn PP v cm ph hp, cm mu tm thi trc m (qun

bng Esmark,garo pha gc chi) tt.2- Ct da: Nn v ng ct da trc ct cho chnh xc.Mc ct ph thuc vo

phng php CC.Ct in hnh: mc ct da di mc ca xng 1 K trc sau oti mc ca xng.Ct vt tng 2 vt di bng 2 ln K trc sau3- Ct c: c 2 cch ct chnh

- Ct mt mc ti xng ( ct trn phng)- Ct tng lp t nng vo su theo nguyn tc.

4- X tr mch mu thn kinh chnhVi cc mach thn kinh ln c 2 ln phi x tr:Ln 1- tm thi- trong th ct c ly ng vo ca xngLn 2- Sau khi ca xng xong - theo nguyn tc:

.Mch mu: buc ngang mc c m n nui dng.Tht ring ngmch, tnh mch.

.Thn kinh : Phong b vo bao dy trc khi ct, ct bng dao sc, ctcao trn mc ca xng.Tch buc ring mch nui dy thn kinh ikm (nu c)

5- Ca xng- Vn phn mm cao trn mc ca xng.- Ct, lc ct mc v pha ngoi vi.- Ca xng di ch ct ct mc 2-3 mm- Da nhn u xng, ra sch mn xng- Cm mu ng tu .

6- Cm mu mm ct- Tim thuc tr tim trc khi ni gar- Ni gar t t, kp buc ch cn chy mu .

7- X tr mm ct- Khi c ch nh khu kn:- t dn lu khu tha cc nhm c i lp, khu

cn, da.- Vt thng chin tranh: ng hon ton ( bng kn nhng khng khu)8- Sau m

- Dng khng sinh liu cao ton thn- Bt ng mm ct, bng p u mm ct chng ph n. Khi mm ct cn h nu s thiu phn mm c th ko lin tc .Theo di chy mu, x trnhim trng ti ch.


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-Tp vn ng li sm, khi c th.

D- Nguyn tc ct ct chi trong vt thng chin tranh1. Hi sc, chng chong tt.2. Chn PP ct nhanh, gn, hiu qu.3. Thc hin ct ct mc thp nht c th.4. Mm ct phi ng hon ton

NI DUNG T CGi tr ca cc v tr ct ct tng on chi

-------------------

Ti liu tham kho

1. B mn PTTH - Phu thut thc hnh - HVQY - 1980.2. Cc QY - iu l x tr vt thng chin tranh - H ni - 1984.3. Dng Thnh - Thi Vn Dy - Phu thut thc hnh - HQY - 1973.4. Hong nh Cu - Phu thut thc hnh - HN - 1965.

5. Ngoi khoa d chin - HQY - 1979.6. HVQY - Phu thut thc hnh - NXBQ - HN - 1996.7. Littman Imre - Szebszeti Mtttan - Medicina Knyv Kiad - Budapest1977.

8. Tng cc hu cn - Cc qun y - Th thut ngoi khoa chin tranh bng hnhv

- NXBQND - H ni 1987.

B QUC PHNG

Hc vin qun y


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CT CT CHI TH IN HNH


Nm hc: 2004


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CT CT CHI TH IN HNH

Ngy nay nhiu nc trn th gii lm chi gi theo yu cu ca tng mmct ct th. Tuy nhin nc ta vn cn phi dng chi gi sn xut hnh lot. Do vy

vic ct ct chi th vn cn i hi phi ctin hnh pngc vic lp vmang chi gi thun li cho bnh nhn.

mi mton chi c nhng v tr v phng php ct ct tt nht khc nhau.I/ CT CT CNG TAY1/3 DI1- Gi trchc nng ca mm ct:

y l v tr ct tt nht ca cng tay v:- Mm ct cn di mang chi gi.- Cc csp nga cng tay vnc bo tn - c bit l csp vung.Do lc

co ko ca cc ccn xng nhau nn vic s dng chi gikh khn.- C phn mmbc v mmm ct.

2- K thut.a)- Chun b bnh nhn

- Bnh nhn: nm nga trn bn m, tay bn m dang ngang 90o t trn trnmt gi hoc mt bn m nh.

-Phu thut vin: ngbn no tay tri ca mnh pha gc chi nh ct ct.- V cm: M (tnh mch, ni kh qun...) hoc gy t m ri cnh tay + tin m

,

ty theo trng hp c th .- V ng ct : (Ct trn hnh phu)

. nh du mc ca xng, cch trn

mm trm tr 3- 4cm

. o ng knh trc - sau ch

nh ca xng .

. V ng ct da bng xanh

methylen, hnh trn, thp di mc nh

ca xng mt ng knh trc sau.- Qun bng Esmark trong t th tay gicao, buc gar 1/3 di cnh tay ri

tho bng Esmark.

b)- Cc th m


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Th 1: Ct da, t chc di da, cn nng theo ng v tng 1/2 chu vi mt,

ct pha sau trc, pha trc sau. T th cng tay bnh nhn na sp na nga.

Th 2: Ct khi cc gn khu trc v khu sau sau cng tay:

- Ct pha trc: Dao ct ct nm, li dao quay v pha bn tay ca bnhnhn,chc mi dao t bny sang bkia, st mt trc 2 xng cng tay, ngay

mc ca xng. Lc li dao t trn xung di ct cc ch dnh ca khi gn

vo 2 xng cng tay.Gp bn tay BN vo cng tay chng cc gn gp. Quay li

dao 900 ct cc gn gp t su ra nng ngang mc da co.

-Ctpha sau : lm li nh trn 1/2 chu vi pha sau ctt cc gn dui.

- Ling dao ctt cc thcn li pha xng quay v xng tr.

Th 3: Ca xng

- Vn phn mm ln trn mc ca xng.- Ct ct mc hnh vng trn ti mc nh ca xng , lc ct mc xung pha

di (pha bn tay)

- Tin hnh ca xng ding ct ct mc 3-5mm. Ca theo nguyn tc:

khi u ca 2 xng, khi ca c 1/3 thn xng tr th nghing ca sang pha

xng quay ca t hn xng quay trc, sau ca t xng tr cui cng.

- Da schu xng, cm mu ng ty.

- Ra sch mn xng bng cch bm xt huyt thanh mn ng m.

Th 4: Hi phc mm ct.

y cc mch mu thn kinh u nh nn khi ct phn mm ta ctt chng

cng vi ct phn mm, khng ct ring r. Sau khi ca xng xong ta phi x tr

theo ng nguyn tc.Mch mu tht thp ngang mc ct cc gn, thn kinh ct cao

trn mc ca xng.

- Ni t t gar, cm mu b sung.

- t lam cao su hoc ng dn lu mm ct st u 2 xng, rt dn lu sau 24

- 48 gi.

- Nu c ch nh th khu kn mm ct, hoc ng theo nguyn tc.

II/ CT CT CNH TAY1/3 DI.1- Gi trchc nng ca mmct.

Ct ct 1/3 di cnh tay l tt nht v:- Mm ct di, bo tn c khi cdng v khp, vai khng b lch.- Chi gi s khng di v nng.


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- V tr ct tt nht l mm ct cn 22,5 - 23cmTheo Hong nh Cu: im ct tt nht trong khong t im gia xng cnh

tay n im ni 3/4 trn - 1/4 di.2- K thut.

a. Chun b+ T th bnh nhn, v tr ca phu thut vin nh trong ct ct cng tay.+ V cm: nn gy m+ Phng php ct ct:Ct hnh bu dc, mc ca xng pha trn ng

lin khp khuu 3-4cm. nh trong ng ct da thphn np gp khuu 1cm. nh ngoi cao hn np gp

khuu 1cm.- t gar gc chi sau khi cun bng Esmark.

b)- Cc th mTh 1: Ct da v t chc di da theo hnh v. Ct

tng na chu vi mt, pha sau ct trc, pha trc ctsau. Pha sau phi lc da ra khi mm khuu v dnh.

Th 2: Ct c+ Ct lp cnng:- Ct cnh u ngang mc da co hoc di mc da

co 1-2cm . Cnga di pha ngoi v cc b nng cactam upha sau ct ngang mc da co.

- Tm ng mch cnh tay, kp ng mch v ct tn gia 2 km, kp v ct t tnh mch.

- Ct t dy thn kinh tr, gia, b cng tay dich phong b Lidocain (theo nguyn tc).

+ Ct lp csu cn li:. Ct ccnh tay trc v cc b su ca ctam u

pha sau ngang mc cnng co. Tm v ct dy thn kinh quay + mch cnh tay su (mng nhu ngoi)Th 3: X tr xng, mch mu, thn kinh theo nguyn tc.Th 4: Kt thc: Khu kn hoc h mm ct theo ch nh.

III/ CT CT CNG CHN 1/3 GIA.1- Gi tr mm ct.


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Nu chc nng ca chi trn l s dng cng c lao ng th chc nng ca chidi l nng ton b trng lng cth v vnng. V vy phn mm bc mmct chi di cn phi dy hn v khng nn c sochnh gia mm ct.

1/3 di cng chn cc c chuyn ht thnh gn. Nu dng n bc mmct th chc chn s b lot im t v au dn khi mang chi gi. Nu ct ct1/3trn th mm ct cn li qu ngn, khng sc vnng mt chi gi qu di. Dovy m 1/3 gia l v tr ct ct tt nhtcng chn, v:

. di mm ct trung bnh mang chi gi thun li

. Gp dui khp gi d.

. Phn mm m mm ct.2K thuta)-Chun b

+ T th bnh nhn: nm nga, cng chn v u gi bn ct ct th ra ngoi bnv t ln chic bn nh khc. Chn kia c gp li v t ln mt gh thp hn.

Phu thut vin: ng bn no cho tay tri ca mnh pha gc chi ca BN.+ V cm: gy m+ Phng php ct:ct 2 vt khng u nhau. Vt trc hnh bn nguyt di

bng 1/2 ng knh, vt sau to hnh ch U, di 1,5 ng knhtrc sau, o ch nh ca xng. nh 2 rnh bn cao trnmc ca xng 1-1,5 cm.Rnh trong i theo b sau trong x-ng chy, rnh ngoi i theo khe gia c tam u cng chnv cc cmc.

+ t gar 1/3 dii sau khi cun bng Esmark.b)-Cc th m:Th 1: Ct vt trc.

Cng chn dui, ct da v t chc di da theo ngv. Ct cc cchy trc, dui chung, dui ring ngn ci( nm trong khe gia 2 xng chy v mc.) v mch thn

kinh chy trc nm trong . Sau ct khi cmc bn.Th 2: Ct vt sau: Ph m nng cao chn bnh nhn ln v hi xoay ngoi. Ct

da v t chc di da theo ng v.- Ct t ctam u cng chn ngang mc da co.- Vn lp cnng ln n mc ca xng. Tm /m chy sau kp v ct gia 2

km. Tm thn kinh chy sau phong b, kp km di ch phng b v ct di km


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- Ct lp csu ngang mc ca xng .

Th 3: Ct ct mc vng trn, thc mi dao chc thng mng lin ct. Lc ct

mc. Ca xng theo nguyn tc sau:

- Cn ca vt mo chy (t li ca cao trn mc ca xng 2cm, ca t trnxung di, t trc ra sau). Sau ca xng chy vung gc vi trc xng ti

mc ca xng, ca su chng 1/2 thn xng th dng li.

- Cat xng mc cao hn xng chy 1- 2cm,chch t trn xung di t

ngoi vo trong (v u xng mc c vt v cao hn u xng chy, s khng

gy au khi s dng chi gi).

- Tip tc cat nt xng chy.

- Da nhn u xng.

- Cm mu ng ty .

- Phun ra mn xng bng huyt thanh mn ng

nng.

- X tr mch mu, thn kinh theo nguyn tc.

Th 4: X tr mm ct.

-X tr mch mu thn kinh theo nguyn tc. Ring mch chy sau tht ngangmc ca xng.

- Ni ga r kim tra, cm mu b sung

- Sa li cc vt phn mm nu cn.

- Khu kn hoc h theo nguyn tc.

IV/ CT CT I 1/3 DI.

Ct cti l phu thut ln, d gy chong do cc nguyn nhn: au n, mt mu,

khi ct dy TK hng to d gy tt H.A .Do vy ct cti phic lm trong iu

kin gy m su, hi sc chng chong tht tt v phi hn ch tia mt mu trong

phu thut.

1- Gi tr mm ct

Cc ci nh ctu, cc ckhp, cc c ngi cngchn l nhng cdi, sc

co rt rt mnh. Khi ct ct 1/3 trn v 1/3 gia thng lm mt ch bm ca cc c


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khp nn cdng ko mm ct dng ra ngoi, hn na nu lp chi gi th chi gi s

qu to di v nng, s dng n rt kh khn. Do vy ct ct 1/3 di l tt hn c.

Ct ct i 1/3 di l tt nht v lc ckhp cn xng vi lc cdng, mang

c chi gi d dng, khp c ng d.2- K thut:a)-Chun b:+ T th bnh nhn : nm nga, mng st mp bn m, i nh ct th hn ra

ngoi bn v t ln mt bn nh khc.+ Phu thut vin ng bn no tay tri ca mnh pha gc chi ca BN.+ V cm : gy m

+ Phng php ct: Ct trn hnh phu. Mc ca xng trn ng khe khp gi10cm. ng ct da hnh bu dc, nh ngoi cao trn ng khe khp 2cm, nh

trong thp hn ng khe khp 1cm, ni cc nh qua pha trc v pha sau.+ t gar gc i sau khi cun bng Esmark.b)-Cc th mTh 1:

Ct da, t chc di da theo ng v, Ct tng na chu vimt, pha sau ct trc, pha trc ct sau.Vn da pha trc lnn nn xng bnh ch.

Th 2: Ct cc khi c

-Khu trc: ct ctui st nn xng bnh ch, hng lidao chch t di ln trn cc b su c ct cao hn cc bnng. Ctn tn xng.

-Khu trc trong: Dng ngn tay tr mc nng cmay ln, ct cmay,-Khu sau : ct lp cnng ngang mc da va vn ln ( cbn gn, cbn mc,

cnh u), tm /m i trong ng Hunter kp v ct gia 2 km. Tm thn kinhhng to, bc tch ring ng mch nui dy TK ra. Phong b Novocain vo bao dythn kinh, i 3 - 5 pht, kp bng 1 km pha ngoi vi phong b, ri ct bng daosc pha di km (ct thn kinh tm thi).Kp ctng mch nui thn kinh gia

2 km.-Ct t nt cc c lp su khu sau ngang mc c nng co hoc mc ca

xng.Th 3: Ca x ng-Vn phn mm ln n mc ca xng, ct, lc ct mc v ca xng.


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-Ca xng i: khiu ca mt trc vung gc vi trc xng. Khi cac 1/3 thn xng th nghing ca sang mt bn ca theo chiu trc sau ng rp c ca t trc khi t ton b xng i.

-Da schu xng cm mu ng tu, bm ra mn xng trong m.-X tr mch mu, thn kinh theo nguyn tcTh 4: Kt thc, x tr mm ct theo nguyn tc.

Ti liu tham kho

1. Dng Thnh - Thi Vn Dy - Phu thut thc hnh - i hc qun y 19732. Hong nh Cu - Phu thut thc hnh - Nh xut bn y hc v th dc th

thao - H Ni - 1965.3. Cc QunY - iu l x tr vt thng chin tranh - Nh xut bn qun i -

H Ni - 19844. Xun Hp - Thc dng ngoi khoa t chi.5. Cc qun y - Th thut ngoi khoa chin tranh - Nh xut bn Qun i - H

Ni 1987.

6. Hc vin qun y - Phu thut thc hnh - Nh xut bn qun i - H ni1996.

7. Littman Imre - Szebszeti Mtttan - Knyv Kiad - Budapest 1977.

B QUC PHNG

Hc vin qun y


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BI GING L THUYT - S 7

M KH QUN,CHC MNG PHIM DN LU KHOANG MNG PHI


Nm hc: 2004

M KH QUN (Tracheostomia)

I/- I CNG:-M kh qun l PT m mt l thnh trc ca kh qun bnh nhn th qua

vi mc ch cp cu ngt th hoc d phng ngt th.


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-Khi cp cu ngt th th y l mt phu thut cp cu ti khn cp, yu cuphi thao tc rt nhanh,trong khong < 5 pht phi tin hnh xong phu thut.

+c im gii phu:-Cu to KQ gm 16-20 na vng sn chng ln nhau, nm sau trm kh qun v trc thc qun,gia chng l mt vch lin c mng, rt d b chc thng trong khi MKQ to ra rkh-thc qun sau m.

-M kh qun sn 1- 3, trn eo tuyn gip c gi l m kh qun cao v m snh 4-6,di eo tuyn gip c gi l m KQ thp.

-Do cng xung di kh qun cng i chch vo su vo trong lng ngcnn m KQ thp kh hn m KQ cao .Tuy nhin MKQ thp c so thp nn c ththm m hn. tr em tuyn gip c thu thp gia che lp sn KQ 1,2,3 nn mcao kh khn- buc phi m thp.

II/- CH NH:1)- Trong cc vt thng:- Vt thng vng hm hu thanh qun : Do vt thng b ph n chn p vo

thanh kh qun gy ngt,ng thi mu t VT chy ra d b ht vo ng th gy bttc kh - ph qun. MKQ bnh nhn va d th hn va khng hit mu vo.

-Vt thng thu phi c trn kh trn mu ph mc c chc ht nhngvn kh th, th nng .M kh qun cho BN d th tng hiu sut h hp.

- Vt thng s no hoc sau phu thut s no m BN hn m su ko di;

Thng c tnh trng tng tit m di c th bt tc ng th. MKQ ch nght m di khai thng ng th, trnh tai bin ngng th.

2)-Trong mt s bnh ngoi khoa: Xp khi qun do: bu c th nhn chnp, bin chng sau m bu Basedow , sau gy m NKQ.

3) -Trong mt s bnh ni khoa: Bch hu, bi lit, un vn, ph phi cp.III/- K THUT:A/- CHUN B DNG C:

-Dao, ko, 4-6 km cm mu, banh farabeuf, b ng thng KQ -canulKrishaberg ( hoc Sioberg) va c, my ht, bm tim 20, ng ht kh qun.


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(c ng theo tui BN ; 1-3 tui c 1, 4-6 tui c2, > 6tui c 3, Ngi ln c 4)

B/- CHUN B BNH NHN:

- t nm nga trn bn m, n mt gi nh vo

vng gy c n ti a, kh qun ni r si da.(C th nm t th Fowler )

- PP V cm : Gy t ti ch bng Novocain0,25%. Khi cp cu khng cn v cm.

- PTV ng bn phi bnh nhn, ph m - bni din.

C/- TH THUT:

Th 1: Rch phn mm trc KQ.

-PTV dng ngn 1 v 3 tay tri gi cht 2 bn sngip khng cho KQ trt sang 2 bn. Ngn 2 ln tmsn nhn. Tay phi rch da ngay di sn nhn di 3-5cm.

-Qua da rch tip cn c nng ri ti cn c gia,rch tip vo khe trm KQ.

-t banh banh ton c di mng sang 2 bn,ko theo lun c cc nhnh ca t/m cnh trc. Nucc nhnh t/m ny cn tr qu c th kp km, ct gia

2 km. Cha vi buc cm mu m tip tc bc lKQ.Khi m c KQ mi buc cm mau sau.

Th 2: Bc l mt trc KQ, ko eo tuyn gip xung di, xc nh sn nhnv sn KQ 1,2,3 ngay di sn nhn.

Th 3:


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Rch t sn KQ 1-2 hoc c 3 tu theoc ca canul, mt trc ca KQ, rch vunggc vi sn, t gn khng nham nh. Nu BNb ho do b kch thch th ly ngn tay bt l KQ

va m khi ht mu vo trong..-t canul vo trongg nng KQ bng 3

ng tc c bn:+ chiu cong ca ng quay v pha

PTV la cho u ng vo trong l va m. Taytri c th dng km cm mu hoc km 3 chcbanh rng l d a ng vo.

+ Xoay ng 90 0 v pha ngc BN chiu cong ca ng nga ln trn,+ y nhanh ng vo trong kh qun, rut li ng ra BN bt u th qua

canul.- Kim tra xem t ng vo ng trong lng KQ cha hay trt ra ngoi, nm

di ton c.Th 4: -Cm mu vt m.

- Khu hp vt m pha trn v di canul, m gc sch xung 2 bn taicanul, buc 2 si ch t tai canul ra sau gy BN ng khi tut. a bnh nhn vbung theo di.

IV/- U NHC IM CA M KH QUN:A/- U IM:

1-Lm gim khong cht ca khng kh kh o trn.2-Lm gim sc cn ca kh o trn do ph n hay co tht chn p.3-D ht m di qua l m kh qun chng n tc. D a khng sinh vo

iu tr vim nhim ti ch.B/- NHC IM:

1-BN mt kh nng ho nn khng t khc c m di ra ngoi. Do vy sau

m cn phi c ngi theo di thng xuyn ht m di, c bit l khi cha quagiai on nguy him.

2- Khng kh vo phi trc tip khng c x l qua hc mi nn khng hpsinh l, d gy ra vim ng h hp c bit l ma hanh kh, ma ng.

3-D tut canul hoc tr em t rt canul, nn phi ch khi sn sc sau m.4- D r KQ sau khi rt canul nu thi gian canul di


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.V/- TAI BIN:- Chy mu nhiu khi rch phn mm ct phi cc nhnh t/m cnh ngoi.- t canul ri m BN vn kh th- do t canul ra ngoi KQ .

- R kh qun sau m- do khi rch m KQ rch lch, khng vung gc nn khlin.

VI/-SN SC SAU M.- Khi cha qua giai on nguy him phi c y t theo ri thng xuyn ti

ging bnh trnh tut hoc t rt canul v pht hin n tc ng h hp , htm di kp thi. Ht bng ng ht nh hn nng ca canul khng bt tc ngth. Mi ln ht khong 15- 20 giy li phi rt ng ht ra cho bnh nhn th, ht luqu BN s b ngt. Khong 6-8 gi thay ng trong ca canul mt ln chng nhim

khun.-Nn ph mt gc sch c tm tinh du thm trc canul ngn d vt ri vo

ng h hp v st trng khng kh trc khi vo phi.-Nn c h thng iu ho m trong phng bnh nhn ( my phun kh dung

hoc ni xng nc l thm).- C giy v bt u ging BN BN giao tip vi thy thuc khi cn- Rt canul sm khi BN qua c nguy him ( thng l khong 2-3 ngy ).-----------------------------------------------------------------------------------CHC MNG PHI

( Pleurocentse - Thoracocentse )L th thut chc kim vo trong khoang mng phi ht dch, kh trong ra

hoc bm kh vo chn on v iu tr bnh.I/- CH NH:- Vim mng phi xut tit ( do lao, do bnh khc)- Trn dch, trn kh khoang mng phi do bnh l, chn thng hoc vt

thng.- Bm hi khoang mng phi gy xp phi nhn to iu tr lao phi.

II/- K THUT

A/-CHUN B :

-Dng c cn : Kim chc mng phi, ng ht lp va c kim, bm tim 20-50cc ht dch, 2 km cm mu, bng cn st khun.


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-Bnh nhn cn c tim tin m, t nm t th Fowler l tt nht,i khi cth ngi trn gh ta theo kiu quay mt li pha ai gh, ta u ln .

B/- TH THUT:

-Chn vng chc, st trng tri khn m, chn ch chc ( Lin sn 1-2 ng

v n ht kh, lin sn 8-9 ng nch sau hoc ng gai b ht dch, dimc trn dch 1-2 khoang LS ht mu)

-Gy t da cam bng Novocain 0,25% ti khoang lin sn chn. Cm kimchc mng phi c np ng ht v kp mt km u ng, chc st btrn xng sn , vung gc vi thnhngc,qua da,cc lp c v qua PMthnh vo khoang PM. Khi c tin st nh tim ven, sau kim chc inh tay tc l vo khoang PM.

- Lp bm tim vo ng ht, m km,t t ht dch hoc kh ra. Khi ybm tim li kp km li ri mi thobm tim x cht ht ra m khngcho khng kh trn vo khoang PM. Lm li nhiu ln ht ht dch hoc kh mngphi nu sc kho BN cho php. Nu ang ht BN ku mt hn hoc chong vng thphi ngng ri chc tip vo hm khc.

-Khi rt kim dng ngn ci tay tri mit vo da chn kim, bt kn chn kim cm mu. St trng li chn kim bng cn it.

II/- TAI BIN:Thng ch gp tai bin nh nh:-Tc kim: do chc phi nhnh mch nh thnh ngc, mu chy vo kim ng

li gy tc. X tr: Khng rt kim ra chc li m nguyn kim chc, ht 1-2 mlHT mn ng vo bm tim, bm y cc mu vo khoang mng phi thng kim.

- Chc kim vo nhu m phi: do thao tc mnh kim vo su qu, do khi ht htdch, kh phi n ra nhanh di p lc ht nn phi v mng phi b kim chc vo.-BN s ho ra cht mu trong vng vi hm ri t khi.

- Nhim khun khoang mng phi: Do kim chc qua cc ch nhim khun trn

thnh ngc. Nn trnh cc ch khi chn v tr chc.-----------------------------------------------------------------------------


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I/- I CNG:-L phu thut nhm dn lu dch, m c trong khoang ph mc ra ngoi m

chc ht khng mang li kt qu, lm cho phi n ra phc hi li chc nng h hp.-Nguyn tc dn lu:Kn, mt chiu. c nghi l khng khng kh t ngoi

vo khoang mng phi v dch dn lu i mt chiu t khoang mng phi ra mkhng tro ngc li.

II/- CH NH:- Trn mu ph mc trong vt thng thu ngc.- M ph mc: do di chng vt thng thu phi, do cc abces ln cn v v o

khoang mng phi.

III/- K THUT:C 2 phng php, l:- Dn lu PM qua khe lin sn (tc dn lu PM ti thiu)- Dn lu PM c ct on mt xng sn ( tc m mng phi nh- Khi c ct

on t 2 xng sn tr ln gi l m mng phi rng)A/- CHUN B:

1-DNG C:

Ngoi dao, ko, km cm mu, tu theo phng php la chn m chun b

thm cc dng cu:-Kim Trocart v ng dn lu c c va vi nng ca n-Hoc km ct sn v cc dng c lc ct mc, gi xng,bm xng.2-BNH NHN:

- nm t th Fowler hi nghing sang bn lnh.- V cm : tin m + gy t ti ch.B/- TH THUT:

1/- Dn lu ph mc ti thiu .-Chn vng chc, st trng, tri khn m, chn v tr chc, gy t ti ch 1

khoang lin sn v c 2 sn trn v di n.a/- K thut c Trocart:

- Rch da v t/c di da gia khoang lin sn di khong 1-2 cm.- Dng Trocart chc vung gc vi thnh ngc vo khoang ph mc, ging chc

ht PM.


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-Khi vo khoang PM th lpng DL c kp 1 km cui ngvo nhnh T ca Trocart. Rt liTrocart ra y nhanh ng DL vo

khoang PM. T t rt v Trocart rakhi thnh ngc, ri ra khi ng DL,khu li vt rch da, khu c nh ngDL vo da khi tut.

-a BN v bung bnh th ning DL vo h thng cha dch v mkm ang kp ng h thng DLhot ng. Trong l cha dch lun c mt dung dch st trng, cao khng qu 10cm, u ngoi ca ng dn lu nn ni vi mt ng thu tinh trong sut, cm ngp trong

dung dch st trng, l thp hn ging bnh 70-80 cm nh vy dch s i theomt chiu v hon ton kn. ng thi ch cn quan st mc nc trong ng thu tinhdao ng theo chu k th l bit ng ang hot ng.

b)- K thut khng c Trocart:-Ta phi dng 1 dng c g a ng DL vo khoang PM. l mt km

cm mu c to. Song u km khng nhn nh Trocart nn khng th chc qua thnhngc nh trn c. Do vy k thut ch khc k thut c Trocart ch : rch daphi di 2-3cm. Sau khi rch da phi dng dao rch tip cc lp c thnh ngc choti khi nhn thy PM thnh th dng li. Sau mi dng km kp ng dn lu chc

qua PM thnh a ng DL vo, rt km ra .Tt c cc ni dung cn li hon tonging K thut c Trocart .

2/- Dn lu PM nh (ct on 1 xng sn)-Chun b : nh trn.-Gy t 3 xng sn lin nhau ct on sn gia.-Rch da ngay trn xng sn gia, qua cc lp bc l r xng sn.-Rach ct mc mt trc xng di chng 2 cm ( to hn ng knh ng DL).

Rch chn 2 u thnh hnh ch H- Lc ct mc on sn nh ct theo trnh t : mt trc, 2 b, ri mt sau.

B trn i theo chiu t sau- ra trc, b di i ngc li b trn. Pha sau dng lcct mc cong.

- Ct b on sn bc xong ct mc bng km Liston. S nhn thy phi ding theo nhp th pha sau n sn. Rch thng n sn v mngphi 1 l a ng DL chn vo trong dch, m trong khoang PM .


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-Khu cc lp c 2 bn chn ng DL cho kn khng khng kh ltvo.Khu da, khu c nh ng DL vo da thnh ngc.

-Phn cn li khng c g khc nhau gia cc phng php.

IV/- SN SC SAU M:- Ni di ng DL vi h thng

bnh cha dch hoc h thng 3 chai.Theo ri xem ng c hot ng thngxuyn khng , hay b tc.

- Hng ngy o lng dch,m /24 gi ghi vo biu theo ri.

- Hng dn BN tp th su, thgng sc bng c bng, vn ng c

honh, phi nhanh n ra.- Nu c my ht c th ht

khong 6-8 ln /ngy, 10-15 pht/ ln,vi p lc ht khi u thp v tngdn trong nhng ngy sau phi ntt hn.

- Khi t c mc ch DL ( trung bnh khong 2 tun) lng dch hng ngych cn vi ml th kp th DL 24 - 48 gi nu BN bnh thng th cho rt DL,

khu bt kn chn ng.( Tt nhin c chp Xquang v lm cc XN khc phi hp kmtheo).

TI LIU THAM KHO:1- Phu thut thc hnh- NXB Qun i. 1996. trang 222-229, 246-256

2. Hong nh Cu- Phu thut thc hnh- NXB y hc v TDTT.1965. trang256-269.


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B QUC PHNGHc vin qun y


M DN LU BNG QUANG


Nm hc: 2004


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M DN LU BNG QUANG(Cystostomia)

I/C IM GII PHU V SINH L.

1. V tr: Bng quang nm ngoi phc mc, trong chu hng b, trn c nnghu mn, sau xng mu, trc cc tng sinh dc (ti tinh hoc t cung) v trctrng.

2. Lin quan:Pha trc bng quang c khoang Retzius

- l mt khoang o, cao rng gia v trc,

hp 2 bn, to thnh hnh mng nga mly bng quang. Nu nc tiu chy vokhoang ny thng xy ra nhim trng

quanh bng quang. Pha sau l cc tng sinhdc, trc trng. Pha di l nn ca chuhng, pha trn l phc mc.- Phc mc thnh lt t thnh bng trc lnche ph mt trn bng quang. Khi ti mtsau, phc mc lch xung gia bng quang

v tng sinh dc. Ri li tch gia tng sinhdc vtrc trng, to nn ti cng Douglas v cn sinh dc - trc trng. Do vy khi bngquang rng phc mc xung thp, m vo bng quang d phm phi phc mc vtiu trng, cn khi bng quang y: y bng quang li ln vt # 3cm trn g mu,v vy c th vo bng quang b nc tiu ngay st g mu, s khng phm phiphc mc.

-Dung tch bng quang trung bnh 250-300ml , khi b i n dn to, c th ti 2

lt, thnh s mng v d v, khi xp li thng gy ra tnh trng vim bng quang.3. Mch mu nui dng bng quang:- ng mch chnh:

. ng mch rn - Tch t ng mch h v

. ng mch sinh dc - bng quang- ng mch ph:


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. ng mch bng quang di: tch ng mch sinh dc - bng quang

. ng mch bng quang trc: l mt nhnh ca ng mch thn trong- mt trc bng quang c 2 tnh mch 2 bn ng gia (chy vo cc tnh

mch pha trc tuyn tin lit) - d nhn bit bng quang4. Cu trc : thnh bng quang c 3 lp:- Lp trong l nim mc, rt di ng,- Lp gia: h nim, dnh vo nim mc bng t chc lng lo.- Lp ngoi l lp c. (Lp c c 3 lp: lp su: c ri, lp gia: c vng,lp

ngoi: c dc ).II/ CH NH

- B i do: t, tc niu o, tn thng ct sng, tu sng- Thng tn thng hoc v rch bng quang .

- Sau m bng quang : ly si, bc b u x tin lit tuyn bng ng bng quang(phng php Frayer),ct Polipe

- Khi PT niu o, chn thng vt thng niuo, khng mun cho nc tiui qua trnh nhim khun.III/ K THUT

1. Chun b bnh nhn- V sinh vng m- Khi khng c phn ch nh: Ra bng quang vi dung dch Rivanol 2 - 5%.

Bm 200ml nc mui sinh l m lm cng bng quang ln .( Nu khng thng c bng quang: khng nn c thng v s gy tn thng

niu o) .- Bnh nhn: nm nga u thp hn chn rut dn ln cao (t th

Trendelenburg).- Phu thut vin: ng bn tri ngi bnh- V cm: - Gy t ngoi mng cng , Gy t ti ch + tin m, Gy m

Ty theo ch nh

2. Cc th m

Th 1: M thnh bng:- M thnh bng theo ng trng gia di rn, bt u t cch b trn xng

mu 1cm, di 6 - 8cm.

- Rch cn trng gia: thng rt nh, ging nh si ch .

- Rch m mc ngang .


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- Banh c thng sang hai bn ng

thi lm rch cn rn trc bng quang

tm bng quang .

Th 2: Tm bng quang- Ngn tr tay phi ca phu thut vin

ltgc v tch lp lin kt khi mt trc

bng quang , y n ln pha trn cng vi ti cng phc mc, sau nht mt minggc lp m v phc mc khng tt xung di,bc l mt trc bng quang.

- Cc du hiu nhn bit bng quang:. Cc th c dc

. Hai tnh mch trc bng quang hai bn ng gia.

. Nu trc m c bm nc vo bng quang th tm mt trc bng quang d

. Nu bng quang trng rng th phi tm n sau khp mu.

. Tt nht l chc ht th.Th 3: M bng quang , t dn lua) M bng quang:- Khu 3 mi ch cng chnh gia mt trc

bng quang theo hnh tam gic u, mi cnh 1cm.

- Khu mi ti xung quanh cc mi ch cng bngch lin.( Nu m bng quang ly si th khng nnkhu mi ti trc).

- Che ph, bo v cn thn khoang Retzius.- Chun b my ht nc tiu- Chc thng bng quang chnh gia mi ti,

ht nc tiu.- Kp gi nim mc bng quang = 3 km- Th mt ngn tay vo bng quang tm si .Nu c si ly si ra bng km gp

si. Nu cn th m rng bng quang ln pha trn hoc xung pha di.- Ra bng quang bng dung dch Rivanol 2 - 5% v ht ht cc mnh vn nh

ca si ng thi nh gi tnh trng nim mc.b)-t dn lu bng quang- t mt thng Petzer chun b vo bng quang.


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- Khu c nh ng thng vo mp l thng thnh bng quang.-Ct ch cng, tht mi ti ( ming l thng m cht ly ng dn lu, khng cho

nc tiu chy ra ngoi)Th 4: Hi phc vt m- Kim tra k thut- Lau sch vt m- Khu c nh bng quang xung quanh ng thng ln cn trng thnh bng

cch ly khoang Retzius = 4 mi khu ( 2 mi 2 bn, 2 mi trn v di)

- Khu hp vt m pha trn v pha di ng thng bng ch lin.- Khu da v khu c nh ng thng vo da bng.

IV/ SN SC SAU M

- bung bnh: ng thng c ni di v cho vo mt l kn, sch, thp hn

mt ging, theo di s lng, cht lng nc tiu hng ngy.- Khi cn, hng ngy ra bng quang bng dung dch Rivanol 2 - 5% m, dung

dch thuc tm 1/4000.- Ty theo din bin, t ngy th 7 tr i, kp th ng dn lu . Nu bnh nhn t

i tiuc theo ng t nhin th nn rt ng dn lu , khng nn qu 2 tun vs b nhim khun, lit bng quang, si ti pht...

- Cng c th rt ng dn lu ra sau ngy th 7 v thay bng mt thng Nelatonqua niu o, vt m kh th rt Nelaton ra.

- Sau khi rt ng dn lu th bng v trngli, nc tiu s cn r ra nhng vt m st lin dn.V/ CC TAI BIN V BIN CHNG

1. Lm thng, rch ti cng mng bng: khi pht hin c th phi khu kn lingay, nu b st s b vim mng bng.

2. Vim khoang Retzius: phi dng khng sinh ton thn.

Ti liu tham kho

1. B mn PTTH - HVQY - Phu thut thc hnh -NXBQ - H ni 19962. Cc qun y - iu l x tr vt thng chin tranh 3. Xun Hp - Gii phu bng

4. Hong nh Cu - Phu thut thc hnh5. Nhiu tc gi - Tai bin phu thut - HVQY 1988


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B QUC PHNG

Hc vin qun y

BI GING L THUYT- S 9 +10

I CNG PHU THUT NG TIU HA



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Nm hc: 2004

I CNG PHU THUT NG TIU HA

I/ I CNGA- Mc ch chung

Tt c cc phu thut trn ng tiu ho u c mc ch chung l x l c tnthng, bnh l trn ng tiu ho, sau khu ni phc hi v gii phu v chc

nng sinh l- ngha l khu ni bo m cho thc n lu thng trong ng tiu hokhng b r r ra bng.B/ c im sinh l, gii phu ca ng tiu ha ng dng trong phu thut

1. c im sinh l.- D dy: l on phnh to nht ca ng tiu ho cha thc n, nghin thc n,

tit dch v nho trn vi thc n ri co bp y dn xung rut. Do vy n d b ccbnh vim, lot, ung th vi cc bin chng chy mu, thng, hp tc mn v. Ncng rt d b thng trong cc vt thng bng v chn thng bng kn. Tuy nhinc th d dng khu ni hoc ct b 2/3, 3/4 hoc ton b d dy khi cn.

-Rut non: L on tip theo sau d dy, di 6-8m, l ni tiu ho v hp thuchnh cc cht nh nc v cht dinh dng ca qu trnh tiu ho. v vy n hay bcc bnh nh lng rut, xon rut gy ra tc rut. Khi c vt thng bng gy tn

thng tiu trng thng tn thng nhiu quai rut, t khi mt quai n c. Cth ct b ti a: ti 5m rut non m ngi vn sng.

2- c im gii phu- Cu to ca thnh ng tiu ho gm 3 lp:+ Lp ngoi: thanh mc - bn cht l l phc mc tng , n bao bc gn ht

chu vi ng tiu ho ( b mc treo rut gia 2 l mc treo khng c thanh mc) vgn ton b chiu di ng tiu ho (ring thc qun on ngc, mt sau t trng vpha sau trc trng on di l khng c thanh mc).Bnh thng thanh mc trn

nhn gip cho rut nhu ng d dng. Khi b tn thng n tit ra Fibrrin v gy radnh. Nu l ch khu ni n lm cho ng khu ni lin dnh, khng phi chkhu ni s gy ra dnh rut vi cc tng ln cn gy tc rut . Ngc li ch khuni khng c thanh mc s khng c s lin dnh.

+ Lp gia: lp c, lp ny li c 2 lp: trong cvng, ngoi cdc ( d dy cthm lp ccho gia) lm cho thnh ng tiu ho dy chc chn.


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+ Lp trong: h nim v nim mc, c nhiu mch mu, t chc lng lo, lpnim mc c xu hng phi ra ngoi nu c l thng trn thnh ng.

3- ng dng trong phu thut- ng khu ming ni ng tiu ho lin dnh nht thit phi khu c lp

thanh mc p vo nhau vi mt din rng. Trn d dy ch khu khng c thanhmc che ph c th chm thm mc ni vo ng khu. Trn rut non nhng chrut b tn thng cht, xc thanh mc nht thit phi khu vi li, v khc vi trnd dy, khng c chm thm mc ni bt k ng khu no trn rut trnh

gy dnh, tc rut.- Lp c dy, nu mi khu ng tiu ho ly c lp c th buc ch mi chc

chn v ng khu mi vng.- Mch mu phn b lp h nim mc, mun cm mu c ng khu, ming

ni nht thit phi khu c lp h nim.- Nim mc l ni tit dch tiu ho v cht nhy, khi khu ni nu lp ny

phi ra ngoi s gy ra vim nhim bng. Mi khu xuyn ton b cc lp thnhng tiu ho s c hin tng mao dn dch tiu ho theo ch khu ra ngoi. Do vycn phi c mt lp khu khc chng li tnh trng mao dn ny ngoi mi khngbvim nhim bng.

C.c im ca qu trnh lin dnh ng khu ng tiu ho.Ngay t nm 1825 Lembert, v sau ny 1926- l Pirogov chng minh c l:

T lc phu thut n khi khi, qu trnh lin dnh ng khu ng tiu ho tintrin qua 3 giai on:

+ Giai on 1: G g dnh: 2 mp ng khu dnh vi nhau cha chc chn nhvai tr ca cc mi khu v ca fibrrin do thanh mc tit ra. Ko di trong 1 - 2 ngyu sau phu thut .

+ Giai on 2: G vim pht trin: Ko di cho n 7 - 10 ngy sau m, Vim chc do cc thao tc phu thut gy ra + vim do nhim khun. Nu khng c khngsinh ng khu ming ni thng b bc trong giai on ny. Do vy phi dngkhng sinh 7-10 ngy, bt u ngay t hm m .

+ Giai on 3: G vim gim dn v lin so : T 15 - 30 ngy sau phu thut tri . So ng khu lin vng chc nh s pht trin ca cc si collagen v t chcx.

II/ CC MI KHU CBN TRN NG TIU HAV bn cht, ch c hai loi mi khu trn ng tiu ha: mi khu ton th v mi

khu thanh mc c. Mi loi mi khu ny c hai cch khu l khu mi ri v khu


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mi vt, trong c cc kiu khu c th khc nhau. d dng trn thc hnhchng ti xp xp li nh sau :

A- Cc mi khu ri :Khu ri l mi mi khu dng mt si ch, khu c mi no buc ngay mi ,xong mi khu mi khc, gia cc mi khu khng dng chung ch vi nhau.

1. Mi khu ri ton th:( mi khu Jorbert)- Mi kim xuyn qua tt c cc lp ca thnh ng tiu ha. C th buc pha

ngoi hoc trong lng ng tiu ho tu theo cch khu. (hnh v)- Tc dng (u im): cm mu v lm kn vt thng, tng s bn chc ca

ng khu ming ni.-Nhc im: y l mi khu hu trng v c s mao dn ca dch rut theo ch

ra ngoi. Do bao gi cng phi c lp khu thanh mc - cche ph bn ngoichng li tnh trng mao dn th ng khu mi lin c.

- Cc cch khu buc:

+ Nu khu bt u t trong ra th mi bucs pha trong lng rut, mp khu ln votrong v thanh mc s p vo nhau (H1).

Hnh 1

+ Nu khu bt u t ngoi vo th mibuc s ngoi pha thanh mc .Nim mcs p vo nhau v mp ct ln ra ngoi.(H2)

Hnh 2- Cc kiu khu:

+ Khu thng thng.

+ Khu ch X : cm mu mp ct, bt kn mt l thng nh.+ Khu kiu Toupet : mi buc lun lun trong lng ng tiu ha.

2- Mi khu ri thanh mc c(mi Lembert)


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- Mi kim ch xuyn qua thanh mc ti lp choc chm ti lp h nim khng

xuyn qua nim mc.

- u im: y l mi khu v trng v si ch khng chui vo lng rut, khng

tip xc vi dch rut. Lm cho thanh mc p st vo nhau to nn s lin dnh nny l mi khu bt buc phi c trong khu ni ng tiu ha.

-Nhc im : Khng c tc dng cm mu nh mikhu ton th.

- Cc mi khu :

+ Mi Lembert thng:c s dng rng ri.(H3)

Hnh 3

+ Lembert ch X (Z)

Hnh 4

- Lembert ch U. Kiu n gin . Kiu Gould . KiuHalsted

Hnh 5

Cc mi Lembert ch X, U dng khu treo, tng cng, cc im yu...

B- Cc mi khu vt:Khu vt l dng mt si ch di khu lin tc nhiu mi ton b ng khu,

buc ch mi u tin v mi cui cng ca ng khu. Gia cc mi trn mt

ng khu c chung mt si ch lin kt chng vi nhau.


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1. Mi khu vt ton th: l mi khu vt m kim khu qua ton th thnh ngtiu ho. N c y tnh cht ca mi khu ton th nhng v tnh cht ca mikhu vt.

- Vt thng (vt bao ti ) (H6)

Hnh 6

- Vt kiu Connel - Mayo (H7a): mikim i t thanh mc vo nim mc ri li

t nim mc ra thanh mc cng bn. Sau sang mp bn i din cng lm nhvy.

- Vt kiu Schmieden (H7b): mikim lun i t trong lng ng tiu ha raqua cc lp ca thnh TH, t mp bnny sang mp bn kia.

- Vt kiu kt hp Schmieden vConnel- Mayo kt hp (H7c) : khi haimp ca ng khu khng u nhau,mp di s khu theo kiu Connel -Mayo, mp ngn s khu theo kiu

Schmieden. n khi hai mp khu diu nhau th khu theo mt kiu mt

kiu nht nh.

Hnh 7

Ch - Khi u v kt thc, si ch khu vt bao gi cng phi c c nh trnh

tut.


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- Trong qu trnh khu, c mi no th phi rt ngay ch mi hai mpng khu p st vo nhau. Ngi ph lun gi c nh phn ch rt, khng chong khu lng ra.

- Nu si ch b t th c ng khu s b bung ra.- ng khu vt lin tc bng mt si ch nn s lm cho khu knh ming ni b

co hp li v sau ny ming ni cng khng dn n ra c.

2- Mi khu vt thanh mc -cKhu vt thanh mc - cch c mt kiu

l khu vt thng (H8). N c cc tnhcht ca mi khu thanh mc c v mi

khu vtHnh 8

III/ NGUYN TC KHU NI TRN NG TIU HA1. T chc ni khu ni phi c ct lc gn, sch, trnh rch nt, bm dp,

nham nh...Cm mu tt ming ni nhng khng c gy thiu mu (sau khi khuni xong, ming ni vn hng ho...)

2. Mi khu phi chc chn, buc ch cht (khng lng, tut, t ch, khngqu cht gy ri lon tun hon ti ch).

3. ng khu phi kn, c ly gia cc mi khu phi ng v u:- Khu ni mt lp: mi khu cch nhau 2 - 3 mm, cch mp ct 1 - 3mm ty

theo dy ca thnh ng tiu ha.- Khu ni hai lp: Mi khu cch nhau 3 - 5mm, 2lp khu so le nhau v khng

c khong trng gia .4. ng khu phi ln mp vo trong, thanh mc p st vo nhau trn mt din

rng.

5. Khu theo chiu ngang ca ng tiu ha. Ming ni khng b cng ko, xonvn.

6. V trng tt ( th hu trng v v trng r rng , che ph bo v trng m th hu trng tt, rt ngn th hu trng)


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IV/ CC PHNG PHP NG BT U NG TIU HA+ Sau khi ct b on b tn thng, bnh l ca ng tiu ho,cn phi lp li s

lu thng ca thc n. C 3 phng php lp li s lu thng:- Ni tn - tn- Ni tn - bn- Ni bn - bn

Trong 3 phng php ny ch c ni tn- tn l khng phi ng bt cn 2 phngphp sau u phi ng bt 1 hoc c 2 u rut li.

C 2 phng php ng bt:1.ng bt theo phng php knNgha l trong qu trnh ng bt u TH c cp kn, khng m thng ra

ngoi. C cc kiu ng bt nh sau:

+ Kiu kinh in ca Moynihan (H9)- Khu vt ton th quanh km

- Tho b km, ng thI tht hai

u ch v buc li vi nhau

- Khu mi ti thanh mc c vi

Hnh 9

+ Kiu buc tm ca Suligu (Souligoux)- H10

- Buc thay km cng u rut bng mi

ch sao cho ri ng vo ngn km (m km t t

ng thi tht ch t t)- Khu mi ti thanh mc c vi.

+ Kiu suligu ci tin :- Lp trong thay mi buc thng bng mi

khu buc s 8.-Lp ngoi : nh trn

Hnh 10


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+ Kiu Mayo (H11)

- Khu vt thanh mc cdc theo

hai bn km

- Tho km v tht hai u ch chothanh mc cgc vo trong.

- Dn rut vo gia, buc hai u

ch vi nhau.Hnh 11

- Khu mi ti thanh mc - c vi. (Hoc buc c nh hai u ch ring

bit, ri khu thm mt lp thanh mc cmi ri na vi - dng trong vi mm

t trng).

(Ngoi ra cn cc kiu khc - t c ti liu)

2.ng bt theo phng php h

-Trong qu trnh ng bt, u TH m thng vi bn ngoi ( do khng iu

kin kp kn ch khng phi l u vit hn kiu kn)

- K thut: * Dng cc mi khu Tp -p (Toupet) khu lp trong ,ng kn

v cm mu u TH (H12). ( K thut khu buc xem trn thc hnh).

+ khu mi ton th b t do hoc b mc

treo ( mi 1), buc

+ Khu mi ton th th hai, mi kim i t

nim mc ra thanh mc mp bn ny v t

thanh mc vo nim mc mp bn kia.

+ Ko mi 1 vo trong mp rut gc vo

v buc mi th 2.

Hnh 12

+C nh vy khu tip, buc xong mi sau th ct ch mi trc, tin hnh choht u rut (hoc l thng).

+ Nn khu tin t hai pha (b t do v b mc treo) vo gia. Khi l hng cui

cng cn li rt nh, khng khu Toupet c na th ct ngn ht ch v khu ng

kn l thng (l hng) bng mi ch X ton th hoc thanh mc c.


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+ Khu lp thanh mc cmi ri vi lp khu toupet bn trong.

- Thng sdng trong ng bt mm t trng kh.

V/ CC PHU THUT CHNH TRN D DY IU TR LOT

D DY - T TRNGA- Cc phu thut tm thi

Ch c tc dng iu tr triu chng, khng iu tr c cn nguyn.

1. Khu l thng d dy

a) Ch nh: Thng d dy do vt thng hoc thng lot d dy m:

- Bnh nhn gi yu, 45 - 50 tui tr ln, sc kho yu km c km theo cc bnhmn tnh v tim, gan, thn...

- Phc mc vim do thng sau 12 - 24 gi

- Bnh nhn tr, vt lot non.- iu kin trang b cs vt cht, phu thut vin... yu km, khng iu

kin lm PT ct d dy cp cu

b) K thut:- L thng nh: ng knh 1cm, b mm mi: khu 2 lp theo chiu ngang,

lp trong l mt mi ch X ton th bng ch Catgut bt kn l thng v cm mu,lp ngoi ngoi bng cc mi ri thanh mc c, ch lin.

- L thng to, ng knh 2 - 3cm, b tng i mm mi: khu theo chiu

ngang d dy 2 lp, lp trong khu mi ri ton th bng ch catgut, lp ngoi bngmi thanh mc c,ch lin. C th chmthm mc ni khi cn. (H13)

Hnh 13

- L thng qu to: ng knh 3 - 4cm, b chai cng, mn nt, khng c khnng khu bt kn c th dng mc ni ln nht vo l thng. K thut c th nhsau:


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. Buc tm mt bi mc ni ln (to, b ty theo l thng) nht vo l thng ridng mi ch buc tm khu c nh bi mc ni ln vo mp l thng.

. Tip tc khu nh thm thanh mc d dy xung quanh l thng vo xungquanh bi mc ni , bng ch lin.

-Trng hp ung th d dy, l thng qu to,mn nt khng th khu kn c. ko di isng bnh nhn, ngi ta lm theo phng phpNiu - Man (Newmann)(H14) nh sau:

. t ng cao su c to vo d dy qua l thng.

. C nh ng cao su vi mp l thng.

Hnh 14. Cun mc ni ln quanh ng cao su. Khu c nh mc ni ln vo nhau v vo

thanh mc cd dy xung quanh l thng, to thnh ng hm mc ni quanhng cao su.

. C nh mt trc d dy hoc xung quanh chn ng hm mc ni lnthnh bng nu c.

- L thng gn mn v - t trng, sau khi khu, nu c kh nng hp tc th philm b sung mt phu thut ni v - trng.

2. M thng d dy (Gastrostomia)+ L phu thut to mt l thng t trong lng d dy ra ngoi cth v duy trn vi mc ch a thc n vo d dy trong trng hp ngn b cn trhoc trng hp bt buc phi dn lu dch d dy ra ngoi.

+ K thut: c hai k thut in hnh:a) K thut m thng d dy theo kiu Witzel

( nui dng)(H15)- Khu (hai) ba mi ch cng thanh mc c

chnh gia mt trc d dy, to thnh tam gicu, cch nhau 1,5 - 2cm.

- Khu mi ti thanh mc c st xung quanh

cc mi ch cng.

Hnh 15

- Che ph, bo v vt m- Chc thng d dy gia cc mi ch cng bng dao m, ht dch.- a ng Sonde chun b vo trong lng d dy, u trong Sonde quay v

pha tm v.Khu c nh ng Sonde vo mp l thng d dy- Buc mi ti vi ng thng.


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- Vt ng Sonde dc theo trc d dy, khu cc mi thanh mc cm kht ly ngSonde to thnh ng hm thanh mc c, di 6 - 8cm.

- Lm l i chiu trn thnh bng cho ui ng Sonde chui qua ra ngoi.C nhmt trc d dy cui ng hm ln phc mc thnh bng .

- ng vt m, c nh ng Sonde vo da.Ghi ch:

- Sau 2 tun, ng hm kn bao quanh ng Sonde c hnh thnh. C th rt bSonde, bm thc n trc tip vo qua ng hm.

- Khi khng cn duy tr ng thng na th bng p, l r s t lin sau 2-3 tun.- Nu l r khng t lin th phi phu thut ng kn l r.b) K thut Kader ( dn lu d d )(H16)- Lm nh k thut Witzel cho n khi tht

c mi ti u tin.- Khu v tht tip mi ti thanh mc cth 2,

th 3...to thnh mt ng hm thng ng.- Cc bc tip theo nh phu thut Witzel.

Hnh 16

3. Ni v- trng(Gastroenterostomia)

Ni v - trng l phu thut to mt ming ni thng t d dy vi quai hngtrng u tin. Phu thut ny do Wolfler (c) lm ln u nm 1881.Mc ch: dch v tiu thot nhanh chng khng b ng d dy. Dch t

trng qua ming ni s trung ha toan dch v. Thc n khng i qua lot ttrng s to iu kin lin khi lot nhanh

+ u im: n gin, nhanh chng

+ Nhc im: phn d dy tit a xt vn cn dn n c th lot ming ni.

+ Ch nh:

- Hp mn v m khng c ch nh ct d dy (K d dy, sc kho yu ...)

- Phi hp trong PT ct hai dy X , trnh ng d dy.

- lot qu su, kh m.

+ Cc phng php:


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-73-

- Ni v trng sau - sau (Gastroenterostomia Retrocolica Posteria) (ni mt sau

d dy vi quai rut qua pha sau i trng ngang) (H17)

* Rch mc treo T ngang, ko mt sau

d dy qua l thng, khu c nh vo mpmc treo quanh l thng, ri ni thng vi

quai rut u, kiu bn - bn.

* Ming ni di mc treo i trng

ngang, quai rut n v pha b cong ln,

quai rut i v pha b cong b d dy,

to thnh hnh ch fi ( ) Hnh 17

Phu thut ny do Hacker Petersen lm nm 1885. Kiu ny hp sinh l nht.

- Ni v trng trc - trc : (Gastroenterostomia Antecolica anterior) (mt trcd dy ni vi quai rut qua pha trc i trng ngang).(H18)

Kiu ny khng hp sinh l

lm v ming ni lm cch gc

Treitz 30 - 50cm, b i trng

ngang chn p, d tc. Cn lm

thm phu thut Braun, tc l

ni bn - bn chn quai i vichn quai n. Hnh 18

- Ni v trng sau - trc (Gatro - enterostomia Antecolica Posterior)

(ni mt sau d dy vi quai rut qua pha trc i trng ngang).

- Ni v trng trc - sau ( Gastroenterostomia Retrocolica Anterior) .

(Ni mt trc d dy vi quai rut qua pha sau i trng ngang)

Hai cch sau ny t lm, k thut c th: Xem sch.

- Ngoi ra cn c ni v trng kiu ch Y : Ct i hng trng, a u di ln

ni tn - bn vi d dy, u trn ni tn- bn vi hng trng u di.B- Cc phu thut trit d dy iu tr lot d dy - hnh t trng.

1. Mc ch ca phu thutTr b nguyn nhn gy lot, ch yu l lm gim toan dch v

Tm v: Tit nhy mucin.


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-74-

Thn v: Tit nhy + Pepsin + HCL.Hang v: Tit cht nhy + Gastrin.

S: Hang v Gastrin mu Thn v HCL

Dy X

Lot d dy - t trng lin quan ti s cn bng ca 2 h thng :

+ Cc yu t gy lot (HCL, Pepsin)

+ Hng ro bo v (cht nhy)Bi vy c hai phng php ngoi khoa chnh iu tr lot d dy - t trng l:

- Ct on d dy: Ct hang v (ni tit gastrin) v mt phn thn d dy (ni titHCl).

- Ct dy X: B nguyn nhn ch huy tit HCl

2. Ct on d dya) Nguyn tc ct: ct b rng ri

- Bnh thng: ct b 2/3 d dy . - Dn to: ct b 3/4 d dy

(Bnh thng: B cong nh di 13 - 15cm, b cong ln di 40 - 45cm

Theo Leriche, ct 2/3: B cong nh ly i 10cm, b cong ln ly i 20cm

Thc t: B cong nh: ct gn tm v, ch ng mch vnh v st vo d dy

B cong ln: ct ln trn ch ng mch v - mc ni tri tip cn vi d

dy. Mn v: ct qu xung t trng 1 - 2cm)

b) Phc hi lu thng sau ct: ni d dy - rut

+ Kiu Bilroth I (1881): (H19)

khu hp bt mm d dy ri ni tn -

tn mm vi mm t trng

Hnh 19

+ Kiu Bilroth II (1885)- ng bt c mm d dy v mm t trng. a quai hng trng qua trc

(hoc sau) i trng ngang ni thng vo d dy kiu bn- bn nh ni v trng(phng php ny ngy nay t c s dng).


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-75-

+Cc kiu ci tin Bilroth II :* Kiu Hacker: Khu c nh d dy quanh ming ni vi hng trng vo mp l

mc treo TN ming ni lun tng di mc treo TN trnh tc rut.

* Kiu Polya (1911)(H20): Mm ddy nguyn, mm t trng cngkn li. Ni d dy - hng trng theo kiutn - bn.

Hnh 20

* Kiu Hofmeister- finsterer(H21) : Mmt trng ng bt li. Mm d dy ckhu hp li mt phn pha b cong bri ni vi hng trng theo kiu tn -bn.

Hnh 21

3. Ct dy thn kinh X - (H22)+ Lch s- Nm 1914 Kuttner ct dy thn kinh X di chonh iu tr vim d dy.- Latarje lm nm 1922 v nm 1943 Dragstedt nghin cu v nu ln thnh l

lun. T phu thut ny mang tn Dragstedt.

+ Cc k thuta) Ct dy X ton b(ct thn dy X- Vagotomia tronculaire) (1)- Ct thn l ct ngay ch n va chui qua l chonh xung bng(1). Khi

ct: u phi ct b mt on di 5 - 6cm ( trnh hi phc).- on ny dy X tri v phi u c th c 1 - 3 thn (v n c th phn nhnh

sm ngay t trn lng ngc). Nh vy tt c cc nhnh dy thn kinh X chi phi cc


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-76-

tng trong bng u b mt tc dng, sau ct : d dy, rut... b dn,gy tr luthng...BN b chng bng thng xuyn, a chy. Do vy thng phi lm thmphu thut ni v - trng hoc m rng mn v .

b. Ct thn kinh X chn lc (Vagotomia slective)(2)+ Gii phu:- Dy X tri ( pha trc thc

qun) c mt nhnh i cng vi mtnhnh ng mch ca ng mch vnh vvo gan (gi l nhnh gan)

. Cc nhnh khc to lan vo mttrc d dy

Hnh 22- Dy X phi ( sau thc qun)

. Chia thnh nhnh thn tng cho m ri dng .

. Cc nhnh khc n mt sau d dy .+ K thut:

. Ch ct cc nhnh thn kinh X tri n d dy nhng gi li nhnh gan

. Ct cc nhnh thn kinh X phi n d dy, li nhnh tng.Nh vy s trnh c nhc im ca ct thn dy X nhng k thut kh khn

hn.c) Ct thn kinh X siu chn lc ( Vagotomia supraselective)(3)Ct ht cc si thn kinh i ti t bo thnh vng thn v ch huy tit a xt (cn

gi ct thn kinh tit a xt d dy) cn cc nhnh vo cc vng khc c bo tn.

d) Ct thn dy X v ct b hang v- Ct thn dy X- Ct on hang v ging ct 2/3 d dy kinh in (Theo nh gi bc u: tt

hn ct 2/3 d dy kinh in).

VI/ CC PHU THUT CBN RUT NON1. Phu thut m thng tiu trng (Enteostomia)L phu thut to s thng thng t trong lng rut non vi bn ngoi trong mt

thi gian nht nh vi mc ch nui dng hoc dn lu.


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- Nui dng: Thng lm quai u hng trng, u trong ng Sonde quayxung di.(H23)

- Dn lu: Thng lm hi trng on cui, u trong ng sonde quay ln trn.+ K thut: Dng k thut Witzel cho c 2 mc ch. L dn lu m b t do

ca quai rut.+ Nhc im: Quai ti b tr lu thng, dch rut b tro ngc . Theo Mayo-

Robson gii quyt tr cn lm thm phu thut Braun. Song tnh trng bnhnhn thng yu, PT mt nhiu thi gian nn khng phi khi no cng lm c.

Hnh 23 Hnh 24

2. Khu l thng rut (H24)-Thng do bnh l ; Do thng hn, thng hi trng v thng c 1 l.Thng

do vt thng, xy ra v tr bt k, thng c nhiu l v s l thng thng l schn.

-Khu hai lp theo chiu ngang ca rut.Khng c chm mc ni. Nu nhiu l thng gn nhau, khu c th gy hp tcrut th khng c khu m phi ct on,ni rut.

3. Ct b on rut v ni rut-Ch nh: khi rut b hoi t do lng, xon hoc do vt thng t mc treo,dp

nt rut hoc c nhiu l thng gn nhau.-K thut ct on rut: hc trong thc hnh.-Cc phng php phc hi lu thng:

+ Tn - tn+ Bn - bn Mt lp hoc hai lp


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-78-

+ Tn - bn(K thut c th xem phn thc hnh)

VII/- NHNG NGUYN NHN GY X R NG KHU NI NGTIU HO

Do lm khng ng cc nguyn tc v yu cu k thut ni trn.C th nhsau:

1-Thiu mu nui dng: do x l mch mu sai, khu qu mau, buc ch qu

cht2-Ch khu khng c thanh mc c, hoc khu ln mp ra ngoi lm cho nim

mc chn vo ng khu v thanh mc khng p c vo nhau.3- Ming ni b cng ko qu mc,gy dn cch khng lin dnh c.

4- tr lu thng do :hp tc ng knh ming ni, xon vn ming ni5-Nhim khun : Cc b hoc ton thn. (Khu li khong trng gia 2 lp, th

hu khun, v khun khng r rng khc bit- thc v trng km. Do vim phcmc..)

Ti liu tham kho

1. Dng Thnh - Thi Vn Dy - Phu thut thc hnh.2. Cc qun y - Th thut ngoi khoa - Nh xut bn qun i 1983.3. Hc vin qun y - Phu thut thc hnh - Nh xut bn qun i - H ni 1996.4. Hong nh Cu - Phu thut thc hnh - NXB y hc v th dc th thao - H

ni 1965.5. i hc y khoa H ni - Bnh hc ngoi khoa.6. Trn c Qu - Lun n tin s y dc - H ni 1997.7. Nguyn c Ninh - Phu thut ng tiu ha - NXB y hc - H Ni 1995.

B QUC PHNG

Hc vin qun y

sach phau thuat thuc hanh_quan y 2004

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