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Y HOC VIET NAM THANG 2 - SO 2/2014
DANH
GIA KET QUA PHAU THUAT CAT TUI MAT NOI SOI
DO
BENH
LY
VIEM
TUI MAT
TOM TAT
Muc
tieu:
Danh gia ket qua phau thuat noi soi
dieu
tri viem
tiii
mat cap va man tinh tai benh vien
hffu
nghj
da khoa Nghe An.
Doi tu'dng va phu'dng phap nghien
cffu:
Nghien cffu mo ta hoi cffu ket hpp tien cffu 44 benh
nhan viem tui mat cap va man tfnh
dUdc
PTNS cat
tiii
mat
tai
Benh
vien
hffu nghi da khoa Nghe An tff

01/2009
d^n
12/2013.
Ket
qua: Tff thang
1/2009
den 12/2013, 44 benh
nhan du'dc phau thuat npi soi cat tui mat vdi 23 Nam,
21
na
theo ty le 1,09; tuoi trung binh 52,0 ± 14,2(25-
86)
tuoi;
Viem
tiii
mat man tinh 78,24
%,
viem
tiii
m|t
cap 21,76%. Khong co trUdng hop nao phai chuyen
mo md; Co 1 benh nhan (2,3%) ap xe ton dU sau mo.
Th6i gian phau thuat 50,22 ± 16,3 (30-120) phiit; Thdi
gian hau phau 4,88 ± 1,7 (3-11) ngay.
Ket luan; Phau thuat cat tui mat noi
soi
di'eu tr;
viem tui mat cho ket qua tdt va trd thanh thu'dng qui,
it bien chffng va khong co
ty

vong trong va sau mo,
TO'khoa:
Phau thuat npi soi,
Viem
tui
mat.
Cat
till mat,
SUMMARY
ASSESSMENT OF RESULTS OF
TREATMENT FOR CHOLECYSTITIS
LAPAROSCOPIC CHOLECYSTECTOMY
Objective: Asessment of results of laparoscopic
surgery for treatment cholecystitis in Nghe an general
friendship Hospital.
Matrials
and Methods: Retrospective
descriptive study combined a prospective of 44
patients with acute cholecystitis and chronic
endoscopic surgery cholecystectomy from January
2011 to December 2012 in Nghe an general friendship
Hospital
Results: from January 2011 to December 2012,
fourty- four patents were laparoscopic surgery for
treatment cholecystitis . Male/Female ratio was 1.09,
average age was binh 52,0 ± 14,2(25-85), Acutes
cholecystitis was 21.76 percent and Acutes
cholecystibs
was 78.24 percent. No conversion to
tradihonal

laparoscopic or open
surgery.
There was
one patient (2.3%) Posoperation abscess; mean
operative time was 50,22 ± 16,3 (30-120) minutes;
Hospital stay was 4,88 ± 1,7 (3-11) days.
*
Benh
vien HuU
nghi
Da khoa Nghe An
Phan bien khoa hoc: GS.TS Le Gia Vinh
Nguyin Van Hircmg*
Conclusion: Laparoscopic cholecystectomy
cholecystitis treatment gives better results and become
routine, fewer complications and no deaths during and
after surgery.
keywords: Laparoscopic surgery, cholecystitis,
cholecystectomy.
I. DAT VAN OE
Benh ly viem tui mat la benh mpt benh kha
pho bien tai Viet Nam. Mo cat tui mat bang
dffdng md bung kinh dien lan dau
tien
dffdc thyc
hien bdi Carl Joham Langenbueh (Berlin,
Offc)
thang 7 nam 1882. Hdn 100 nam sau, ca cat till
mat qua npi soi 6
byng

dau tien dffdc Phillip
Mouret (Lyon, Phap) thffc hien thanh eong vao
thang 3 nam 1987 [1], [2]. Tff do tdi nay phau
thuat cat
tiii
mat npi soi da trd thanh phffdng
phap dieu trj ngoai khoa chuan cho nhffng benh
nhan viem tui mat cd trieu chffng nhd nhffng
IAJ
viet cua no so vdi cat
tiii
mat md nhff hau phau
nhie
nhang, dffdng rach nho, thdi gian nam vien
ngan va ngffdi benh nhanh ehdng trd lai lam viec
binh thffdng [3].
Tai Benh Vien Hffu Nghi Da khoa Nghe An,
ehiing tdi da thffc hien phau thuat cat tui mat npi
soi ap
dyng
dieu tri benh nhan tij cac benh ly
tOi
mat. Chung tdi thyc hien de tai nay vdi mue tieu
danh gia tinh an toan va ket qua cua PTNS cat
till mat trong benh ly viem till mat tai Benh vien
hffu nghi da khoa Nghe An.
II.
DOI
TLTONG
VA PHU'aNG PHAP NGHIEN CLTU

2.1.
Doi
tu'dng nghien cufu
44 benh nhan (BN) viem till mat dffdc chi
djnh mo' cat
tiii
mat noi soi tai khoa Ngoai Benh
vien Hffu Nghj da khoa Nghe An tff thang
1/2009
den thang 12/20113
_
2.1.1. Tieu chuan chpn benh
Benh nhan dffde chan doan viem
tiii
mat dffa
tren trieu chffng lam sang gdi y va ket qua sieu
am ft nhat 2 lan vdi bac sT sieu am Cd kinh
nghiem ket hdp vdi chup CT scanner dffdng mat
(neu cd).
2.1.2.
Tieu chuan ioai
triy
Benh nhan cd vet mo cu tren ron va co
chdng chi dmh phau thuat npi soi
Y HOC VIET NAM THANG 2 - SO 2/2014
2.2.
Phu'dng phap nghien cu'u:
Nghien cffu mo ta hoi ciTu ket hdp tien
cffu.
2.3.

Cac bffdc
tien
hanh nghien cu'u:
Ghi nhan cac trieu chffng lam sang nhff dau
ha
sffdn
phai,
cd phan ffng viing ha sddn
phai.
Cac xet nghiem can lam sang nhd sieu am , chyp
CLVT, sinh hda, huyet hoc. Ket qua dieu tri phau
thuat
npi
soi.
Phu'dng tien, dung
CIJ
phau thuat va cac
bu'dc thu'c hien. Dan phau thuat ndi soi
ciia
hang Karl - Storz
- Ky thuat mo;
+ Gay me
npi
khf quan
+ Benh nhan nam
ngii^,
dau cao, nghieng
trai;
Phau thuat vien ddng d ben trai benh nhan,
ngffdi phu mo dffng canh ben trai phau thuat viem

+ Oat cac trocar: chung tdi sff dyng 3 lo
trocar theo kinh
dien
d tren ron, thffdng vj va d
mang sffdn
phai.
+ Oanh gia tinh trang
tiii
mat va cae tang
xung quanh: tien hanh tham sat tham dd
6'
byng,
till mat,
giai
phong viem dfnh quanh tui mat, bdc
tach
bpc^
Id viing tam giac gan mat ( tam giac
Calot)
de bdc 16 ro
tiii
mat, ong co till mat, ong
mat
ehii.
+ Tien hanh cat tui mat theo ky thuat ngddc
dong hoac cat xudi ddng.
Tru'dng hdp
tiii
mat cang to, khd kep tien
hanh chpe

hiit
dieh mat lam xep tui mat,
giai
phdng
giu'dng tiii
mat bang hook.
Tiii
mat
ddpc
cat bo cho vao tui va lay ra ngoai qua lo trocar
10mm d rdn. Lau rffa va dan
Idu
o bung .
- Ghi nhan thdi gian phau thuat,
tai
bien trong
phau thuat.
- Theo doi sau mo bao gom; thdi gian trung
tien,
cac bien chffng sau mo, thdi gian nam
vien.,.
2,4.
Xff ly so
lieu:
bang phan mem SPSS 16.0
III.
KET QUA NGHilN
CU'U
3.1.
Dac diem doi tu'dng nghien cu'u

Nghien'cLTu
44 benh nhan
viem tiii
mat cap va man tfnh dffdc chi djnh phau thuat cat tui mat npi
soi tai benh vien Hffu nghj da khoa Nghe An tff
thangl/2009
den thang 12/2013 gom 21 nff va 23
nam theo ty le bang
1,09.;
95,4% benh nhan sdng d ndng thdn va mien
niii;
93,2% la ngffdi ndng
dan va c6ng nhan.
Bang 1: Phan bo benh nhan theo dp tuoi
Phan bo theo do tuoi
Di/a 31
tuoi
31-40 tuoi
41-50 tuoi
51-60 tuoi
>60 tuoi
N
4
4
14
10
12
Ty le
%
9,10

9,10
31,8
22,7
27,3
Dp tuoi th&dng gap la d trin 40
tuoi;
Tuoi
trung binh
52,00
± 14,2
(25-86)
tuoi
3.2. Dac diem iam sang, can lam sang
Bang 2:
Dac
diem lam sang
Trieu chu'ng lam sang
Sot tren 38 do
Dau Ha sffdn Phat
Da,
ket mac vang
Phan ffng vung H5P
Tien
sff phau thuat o byng
Ty le %
56,S
93,2
Nhuhg trieu
chuhg
lam

sang^
th&dng gap nhit la: dau ha s&dn phai (93,2), co phan &ng vung ha s&dn
phai 81,8%, 6,8% co tien
s&phau
thuat
dbung.
Bangs:
Nhffnq clii
so smh
tioa
mau
Thonq so sinh hoa
Bilirubin TP
SGOT
SGPT
Amylaza
X
17,7
50,2
57,4
77,3
SD(±)
14,6
62,9
90,3
105,5
Thap nhat- cao nhat
16,6-
37,8
38,5-

68,8
37,5-56,6
68,4-210,2
NhOng
chi so
men gan, bilirubin TP, Amylaza aia nhil'ng benh nhin trong nhom nghien c&u tang han
binh thudng nh ung & trong gidi han cho phep
Y HOC VIET NAM THANG 2 - SO 2/2014
Bang 4.
Hinti
anh sieu am
Dac diem hinh anh Sieu am
Thanii
day > 4mm
Dich mat khong thuan nhat
Tu
dich
quanh tui mat
Soi ket CO tui
mat
N
44
44
4
5
Ty le %
100
100
10
11,3

100%
benh nhan
co thanh tut mat
day,
va
dich mat
khong
thuan
nhit,
chi
co
10% la co
dich
d quanh
tui
mat,
CO
5
benh nhan
(11,3%) co hinh
anh
viimm tui mat
do
soi ket d co tui mat.
3.3. Ket qua dieu trj phau thuat npi soi
c^t
tui mat.
3.3.1. Vi tri dat
Trocar:
Trong nghien cffu nay chung toi thffc hien 42 ca

sy
dyng 3 trocar chiem
95,5%,
2 ca sff dung 4 trocar
v)
qua trinh phau tfch bpc Ip tam giac
Calot
khd khan va khdng co
trffdng hdp nao chuyen mo md.
3.3.2,
PhWdng
phap cit tui mat va thdi gian phau thuat: Cd 38 trffdng hdp dffdc cat till
mat ngffdc ddng chiem 86,4%, va 13,6% dffdc eat tui mat xudi ddng.Thdi gian phau thuat:
50,22
±
16,3 phiit ngan nhat la
30
phiit, dal nhat la 120 phiit.
Bang
5:
Tinh
trang tui mat trong mo
Tinh trang tui mat trong mo
Tui mat viem, mac noi dinh
Tu dich quanh tui mat
Dich mat va qia mac d tronq 6 bunq
N
37
31
2

Ty le
»/o
84,1
70,5
4,5
Tinh
trang tui mat viim, mac noi
dinh co
37
tr&dng
hdp
chiem 84,1 %, chi
co 2 tr&dng hdp
(4,5%) co
ft
dich va gia mac
d
ha s&dn
phai
Cach dat dan
Iffu:
Tat ea cac trffdng hdp mo cua chiing toi deu dffdc dan
Iffu
dffdi gan chiem
100%
trffdng hdp;
chiijeu
la
datl
dan Idu.

Theo doi hau phau; Trong thdi gian hau phau, cd 29 benh nhan dffdc sff dung phdi hdp 2 loai
khang sinh (
Metronidazol
+ Cephalosporin the he III) chiem 65,9% va
15
benh nhan sff dyng khang
sinh ddn thuan.
Bang 6. Cac thong so theo ddi trong thdi
gian
hau phau
Thong
sd
ThcJi gian trung tien
(gicJ)
Thdi qian
dunq qiam dau (nqay)
Thdi
gian
hau phau (ngay)
X±SD
32,86 ± 10,37
2,18 ± 0,62
4,88 ± 1,7
Thap nhat- cao nhat
24-72
1-4
3-11
Bien chffng sau mo: Cd 1 trffdng hdp bj abcess tdn dff sau mo, trffdng hdp nay
6\S<ic
ehung toi

dieu tri bao ton npi khoa thanh c6ng. Khdng cd trffdng hdp nao bj chay mau sau mo, dd dddng mat,
ton thffdng dffdng mat chfnh hay tff vong trong qua trinh phau thuat.
Ket qua giai phau benh ly: 100% la
viem tiii
mat.
IV. BAN LUAN
Tff nam 1882, Langebuck da tien hanh eat
till mat theo phffdng phap kinh dien dau
tien.
Qua tren 100 nam ton tai, den thang 3 nam 1987
ca cat till mat npi soi dau tien dffde Phillip Mouret
thffc hien thanh cong. Hien nay phau thuat noi
soi cat till mat dffdc coi la tieu ehuan vang trong
dieu
tri ngoai khoa benh ly viem
tiii
mat cap,
man
tfnh [1],[3],
Chan doan trffdc mo dffa vao trieu chffng
lam sang, can lam sang va chan doan hinh anh
(sieu am, CT scanner). Benh nhan
6,\S^c
chan
doan viem
tiii
mat khi cd eac yeu to: sdt, an ha
sffdn phai dau, phan ffng ha sffdn
phai,
so Iffdng

bach eau > 10.000/ mm3, cac tieu chuan chan
doan viem till mat tren sieu am ( djch quanh
tiii
mat, thanh till mat day, tfnh chat dich mat ).
Trong nghien cffu
ciia
ehiing toi, sot tren 38 do
chiem 56,8%, dau ha sffdn phai chiem 93,2%,
100%
thanh tui mat day va djch mat khong
thuan nhat.
Salam
Zakko (2008) nhan xet 2 trieu
chffng quan trpng tren sieu am chan doan Viem
tui mat cap ia thanh
tiii
mat day > 4mm va dau
Murphy, va mpt nghien cffu khac
ciia
Y HOC
VIET
NAM THANG 2 - SO 2/2014
Satambrogio cho rang sieu am khong quan sat
dffdc viing tam giac gan mat, do dd can
phai
ket
hdp vdi CY Scanner de nhan dmh va tien tffdng
tot hdn cho cupc phau thuat[2].
Theo Chris N Daniak va cpng sff (2008) va
mot so tac

gia
khac cho rang doi vdi vien
tui
mat
cap nen mo trong vong 72 gid dau se thuan ldi
hdn,
do khi viem
tiii
mat cap cdn sdm, cd dinh
quanh tui mat nhieu nen de phau tfch vi cd dich
viem quanh till mat chffa to
chffe
hda thanh dai
xdday
[4].
Qua trinh phau thuat chung toi thffc hien 42
ca sff dung 3 trocar ehiem 95,5%, 2 ca sff dyng
4 trocar vi qua trinh phau tich bpe Ip tam giac
Calot khd khan va khong cd trffdng hdp nao
chuyen mo md.
Trong phau thuat ehung toi hau nhff chi
diing 3 trocar de thao tac, trong nhffng trffdng
hdp khd nhff
tiii
mat viem dfnh qua nhieu phau
tieh kho khan, gan trai Idn che phau trffdng khi
dd ehung toi mdi dat them 1 trocar 5mm thao
tac. Diing 3troear tranh dffdc mot vet mo tren
thanh byng, lam tang tinh tham my
ciia

cupc
phau thuat.
Trong nghien cffu nay, kh6ng ed trddng hdp
nao chiing tdi phai chuyen mo md co le do so
Iffdng phau thuat edn it, chan doan trffdc mo cd
sy ket hdp giffa sieu am va CT Scanner. Chiing
toi dong y
vdi
y kien cho rang chuyen mo md
khong phai la that bai cua phau thuat npi soi. An
toan cho benh nhan dffdc dat len hang dau. Van
de la phau thuat vien phai biet
liic
nao can phai
chuyen mo md. Theo Samer KA, Murayama KM
(2002), cupc mo npi soi tien trien khong tdt sau
60 phiit nen chuyen mo md [6].
Thdi gian phau thuat trung binh
ciia
ehiing
tdi la 50,22 ± 16,3 phiit ngan nhat la 30 phiit,
dai nhat la 120 phiit, So
vdi
Nguyen Cffdng
Thinh:
41,4 phut (dao ddng tff 20 - 180 phiit);
Hoang Ngpc Ha; 75 ± 26 phut. Thffc te thdi gian
phau thuat phy thudc
chii
yeu vao tinh trang tui

mat nhff
dinh,
viem
cap
phii
ne, mun de chay
mau,
Ngoai ra cdn mpt sd khd khan do trang
thiet bj nhff Camera, khf Co2 Trong phau thuat
chung toi gap
tinh
trang tui mat viem, mac
noi
dfnh cd 37 trffdng hdp chiem
84,1%,
djch mat va
gia mac 6 bung chiem
4,5%[1],[3].
C6
1 trffdng hdp bj abcess ton dff sau mo,
trffdng hdp nay dffde chimg toi
dieu
tn bao ton
npi khoa thanh cong bang 2 loai khang smh sau
11 ngay
b?nh
nhan
6
dinh ra
vien.

Trong nghien
cffu nay khdng c6 trffdng hdp nao
bi
ehay mau
sau mo, do du'dng mat, ton thffdng dffdng mat
chfnh hay tff vong trong qua trinh phau thuat.
Theo
Shamiyeh
A va cs (2004)
ty
le to thu'dng
dffdng mat trong phau thuat eat
tiii
mat npi soi
cung rat khac nhau, phu thudc vao kinh nghiem
phau thuat
vien,
tinh trang
tiii
mat, cd sd vat
chat.
Manousos
M (2004) tong ket nhffng nguyen
nhan gay ton thffdng dddng mat bao gom: Nham
lan khi xac dinh ong mat
chii,
dng gan
phai
hoac
dinh ong gan phai giong

nhu'
ong ed
tiii
mat; keo
cang qua mffc
tiii
mat dan tdi keo theo ca ong
mat
chii;
to thddng nhiet hoac to thu'dng do thieu
mau ong mat
chii;
yeu td tai cho bao gom sff
viem
nhiem,
chay mau, cat va giai phong giu'dng
tiii
mat qua sau; tut Clip dng co till mat [5],[7].
Trong nghien cffu
ciia
ehiing toi thdi gian
trung
tien
trung binh la 30,18 ± 7,57 gid ( dao
dpng 24 den 50 gid); Thdi gian diing giam dau
sau mo 2,18 ± 0,62 ngay (dao ddng 1 den 4
ngay); Thdi gian hau phau la 4,88 ± 1,7 ngay
(dao dpng 3 den 11
n^ay).
So vdi cae tac

gia
trong ndde nhd Nguyen Cffdng Thinh, Hoang
Ngoc Ha hay cae tae gia nddc ngoai nhff
Shamiyeh A, Chris
N
Daniak,
Muhammas
SP cung
CO
ket qua tffdng tff [2], [4],[7].
TAI UEU THAM KHAO ^
1.
Do Kim Sdn, Nguyen Thanh long (2003),
"Nghien cffu nguyen nhan va
phUOng
phap xir ly
tai
bien,
bien chyng
cua phau thuat npi
soi
cat
tiii
mat
tai
Benh
vien
Viet Difc", Tap chi Ngoai khoa,
so
3,

tr
9-14
z.
Hoang Tuan Viet, Nguyen Hoang
Linh,
Biii
Quang Kinh (2008), "Danh
gia
ket qua cat tui
mat
noi soi tai
benh
vien
Da khoa
Sai
Gon" Tap
chi
rhoc
TR Ho Chi
Minh,
tap 12(1), tr. 1-7
3. Nguyen Cu'dng Thjnh, Diem Dang Binh
(2008), " Danh
gia
ket qua cat
tiii
mat
noi soi
qua
1231 trudng hop",

Tap
chi
Y
hoc
TP.
Ho
Chi
Minh,
tap 12(4), tr. 11-15
4.
Chris N Daniak et al (2008), "Factors associated
with time
to laparoscopic cholecystectomy for
acute
cholecystitis",World
J Gastroenterol, 14 (7);
1084 -
1090.
s.
Manousos M et al (2004),
Inraoperative
finding and postoperative complication
in
laparoscopic cholecystectomy: The Greek
experience
with
5539 patient
in
a single
center",

Journal of laparoscopic and advanced surgical
techniques, 14, pp 31-36
u.
Samer KA., Murayama KM., et al
(2002) "Risk
factors for conversion from laparoscopic to open
cholecystectomy", Journal of Surgery
Reserch'vol
106,
no.l:20-24
7. Shamiyeh A et al (2004),
"Laparoscopy
choiecystectomy:
Early and late complication and
their treatment ", Langenbecks Archive of Surgery,
20,
pp
1-16.