Nội soi trong phụ khoa

Trang thiet bi, dung cu noi soi Nguyen Dinh Tdi 5.. Chi dinh trong phau thuat noi soi phu khoa Le A nh Tuan 8.. Ky thuat co ban trong noi soi 6 bung Nguyen Dice H inh 10.. Cac phuong pha

VIEN BAO VE BA ME VA TRE SO SINH

NOI SOI

TRONG

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VIEN B A O VE BA M E VA T R E SO SINH ✓

N0I SOI TRONG PHU KHOA

N H A X U A T B A N Y H O C

HA N O l - 2 000

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C h u b ien : T h a c sT Bac sT c h u y e n k h o a II N g u y e n Dire H i n h

T h a c sy- Bac sT c h u y e n k h o a I

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T h a c sy- Bac sT c h u y e n k h o a I Bac sT c h u y e n k h o a I

MUC LUC

1 Lai giai thieu

2 Lich sir phat trien noi soi va trien vong D ang Thi Minli N guyet

3 To chtic phong mo noi soi Do Kim Hang

4 Trang thiet bi, dung cu noi soi Nguyen Dinh Tdi

5 Kh u khudn va bao quail dung cu noi soi Nguyen Thi Phtfcmg A nh

6 Giai phau P ham Thi Thanh Hien

7 Chi dinh trong phau thuat

noi soi phu khoa Le A nh Tuan

8 Gay me cho mo noi soi phu khoa Tran Dinh Tu

9 Ky thuat co ban trong noi soi 6 bung Nguyen Dice H inh

10 Cac phuong phap cam mau dp dung

trong phau thuat noi soi Nguyen D ue Hinh

11 Tai bien, bien chung cua noi soi trong

phdu thuat phu khoa Do Thi N goc Lan

12 Phau thuat noi soi u nang buong trung Vu Bci Q uyet

13 Dieu tri chira ngoai tircung bang

phau thuat noi soi D6 Thi N goc Lan

14 Noi soi dieu tri vo sinh tdc voi trung Nguyen T hanh Ky

15 Lac noi mac tircung:

chan doan dieu tri qua noi soi ThiPhtiffngLan - LeThiThanli Van

16 Noi soi va triet sail Thi T hanh Van

17 Cat tir cung qua noi soi Vil Da Q uyet

18 Laser va dao mo sieu am trong

phdu thuat noi soi Nguyen D u e Hinh

19 Lich sir soi buong tUcung Thi T hanh Van

20 Cac tham do can lam sang buong tu cung Do Thi N goc Lan

21 Ky thuat soi buong tircung Nguyen D ue Hinh

22 Tai bien, bien chung cua soi buong tircung Thi P h u a n g Lan

23 Chi dinh, chong chi dinh cua soi

T r a n g

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LOTI Glffl THIEU

Li ch sir c u a p h u o n g p h a p noi soi da co tu n h u n g n a m ( 4 6 0 - 3 7 5 ) truoc

C on g n g u y e n do H y p o c r a t e s a T r u o n g dai hoc K o s m o ta voi viec soi

k h o a n g mui, o n g tai voi a nh s a ng ma t troi va d u n g g u o n g p h an c h i e u de

q ua n sat d u o c ro hon c h o thay thuoc N g a n h noi soi c h a n d o a n c a n g p ha t trien m a n h hon khi da c o anh s ang dien ra doi

Ky thuat noi soi d a pha t trien t rong mot llnh vuc c a o hon o n h u n g n a m dau the ky XX V6i soi o b u n g de c ha n d o a n vao 1910 c u a Z a b a e w s , roi na m

1944 D e c k e r d a tien ha nh soi o long n guc va n a m 1980 K S e m m (Dure) phau thuat cat q u a noi soi den 1987 Phillip M o u r e t ( P h ap ) da t h a n h c o n g trong viec cat bo tui mat lan dau tien 6 nguoi Va tu do mdi gan hai t ha p ky tiep theo n g a n h ph au thuat noi soi da d uo c phat trien n h a n h o n hi eu n u o c tren the giai n h u A nh , Phap, My, D u e va cac c h a u luc k h a c deu d u o c n h i l u thay t h uo c c h a p n h an vi n h u n g Uu di e m d a n g ke c u a p h u o n g p h a p do'i voi nguoi b e nh c u n g n h u thay t huoc

C h i nh vi vay phau thuat noi soi da d u o c phat trien m o r ong, c h o n h i e u llnh vuc k h a c nha u n h u tai, mui, ho ng , san- phu k h o a va c a n g phat tri6n m a n h 6

c ac n uo c c h a u A, Thai Binh Duon g

0 Viet N a m , nhieu c o s o phdu t huat ngoai, p h u - s a n va c a c phdu t huat noi soi dat nhieu t ha nh tuu d a n g ke D a c biet tu cu oi t ha p ky 9 0 c h o toi nay, nhieu b e nh vien t rong ca n u de d a sir d un g va p ha t trien ky t huat m 6 noi soi,

d a p ung nhu c au n g a y c a n g c a o c u a nguoi benh

Tai Vi en Bao ve Ba me Tre s o sinh, noi soi c h a n d o a n t r ong san- phu k h o a

va ph;iu t huat noi soi t rong di6u tri benh phu k hoa , vo sinh da d u o c da y

m a n h va p h a t trien C ho toi nay da co ha ng n gh in ca mc> c h u a n goa i da c o n

c h u a vo, boc bo n h u n g u n a ng b u o n g t rung va cat bo u n a n g neu c an , boc bo

n h an x o tu c u n g , phSu thuat m o th on g voi trung, tao h inh loa voi t ru n g va vi

ph au noi o n g dan trting da d e m lai n h u n g ket q u a d a n g khi'ch le, s o ng

s o ng voi viec d ao tao d u o c h a n g tram phau t huat vien m o noi soi c h o c a c dia

p h u o n g va Vie n Vi en da c o trang bi va dieu kien lam phSu t hua t noi soi de dao tao ve ky thuat noi soi c hdn d o a n va m o noi soi t rong lTnh vuc san phu

k h o a - vo sinh

D u o c sir q u a n tarn c u a Bo y te va c a c n g a n h c h u c n a n g co lien q u a n , V i e n

B V B M T S S d a n g d a y m a n h viec phat trien ky t huat noi soi va m 6 noi soi,

d o n g thoi c o gdng n g a y c a n g h o an thien llnh vuc ky t hua t mu i n h o n na y

n h a m k h o n g ngirng n a n g c a o c h at l u g n g k h a m c h u a b e nh c h o n h a n d a n d ac biet la sue k h o e Ba m e va Tre so sinh

C h u n g toi xin gioi thieu voi c a c doc gia c u o n s ac h phau t hu at noi soi n a y

voi hy v o n g p h a n n a o g o p t h e m sir hieu biet ve noi soi c h a n d o a n va p h a u

t huat noi soi t r o n g d i e u tri s an p h u k h o a va vo sinh D o n g thoi q u a do

UCH SUT PHAT TRIEN NOI SOI VA TRIEN VONG

- Ara nzi da m o ta viec d u n g c a m e r a t rong y hoc c o s u d o n g g o p c u a

L e o n a r d o d a Vinci 1519 O n g d a d u n g n h u n g tia s a n g ma t troi soi q u a m ot

16 vao m ot c u a so k h e p toi mo t g u o n g hinh c au t rong c o chufa d a y n u o c tao

t h an h mot tieu d i e m ch ieu vao hoc mui

- D e n the ky 17 P e te r Borell gioi thieu mo t g u o n g l om roi A r n a u d d u n g mot

de n long n h o de c h ie u t rong noi soi

- 1806 Bozzini d u a ra m ot d u n g cu x u n g d o n g dau tien t r on g noi soi h i e n dai

va da d u o c c h a p n hdn m o t c a c h ro ng rai O n g da p ha t trien m o t he t h o n g

p h u c h o p no truy6n a n h s a ng tCr de n q u a m o t o n g va o t ro n g am d a o c h o

p h e p c o the q u a n sat d u o c co tur cuiig

N u a the ky sau n a m 1865 D e s o r m e a u x da gio'i thieu tai V i en ha n lam Y h oc Pari ky t huat soi b a ng q u a n g O n g sur d u n g den do't c o n va n h u a t h o n g c h i e u

s a ng de k i e m tra b a ng q u a n g va nieu q ua n

1 869 P a n t e l a o n i d a dieu c h i nh g u o n g p h o n g dai c h o soi tu c u n g , c o the q u a n sat p o l y p b u o n g tu c u n g a m o t phu nur 6 0 tuoi sau m a n k i n h ra m a u va dot

no bdng nitrat bac

Su ph at trien c u a k m h v i l n v on g voi he tho'ng thau kinh b i t dau c u o i the ky

19 E d i s o n 1879 da pha t sinh ra den dien d u o c h o p nha t t r o n g k i n h vien

v o n g tao tien d6 c h o noi soi hien dai va noi soi phdu thuat

N a m 1907 D avi d da d u n g o n g soi b a ng q u a n g voi a nh s a n g b e n t r o n g o n g

va he t h o n g thau kinh de soi b u o n g tu c u n g O n g d u n g c h a t di ch l am c a n g

p h o n g t u c u n g va r ua s ach m a u n g a y de q u a n sat ro, c o the sinh t hi e t cdt

p o lyp Soi b u o n g tu c u n g p h a t trien nhcr he t h o n g n h ie u o n g k h a c n h a u c h o

p h e p hut, b o m hoi, o n g h u o n g dSn d u n g cu m6

NOI SOI CHAN DOAN (1 9 0 0 - 1 9 4 0 )

N a m 1901 D r G e o r g K e l l i n g G i a o sir a D r e s de n m o ta v ie c t h a m k h a m da

d a y va b a n g q u a n g q u a soi C u n g n a m ay V o n Ott d P e t e r b u r g m o ta viec kie’m tra k h o a n g a b u n g c u a m o t phu n u co thai q u a soi tui c u n g b a n g v iec sir d u n g g u o n g tren d a u de p h a n xa a nh sang

N a m 1910 J a c o b a c u s n g u o i da u tien d u n g tu " L a p a r o s c o p y " khi o n g c h o xuat ban tai lieu m o ta c a c q u a n sat k h o a n g p h u c m a c va k h o a n g m a n g tim Chi mo t t h a n g sau do K e l l i n g d a t h o n g b a o 45 c a noi soi va m o ta ro r a n g ve

n h u n g khoi u a gan

Ng uo i M y da u tien m o ta noi soi la B e r n k e i m ( 1 9 1 1 ) o n g sir d u n g o n g soi 10cm va a n h s a n g x u n g q u a n h de k i e m tra k h o a n g b u ng

T r o n g n h u n g n a m d a u c u a the ky, noi soi p h a t triSn t h e m n h o s u c h a p n h a n

tu the T r e n d e l e n b u r g ( dau t h a p) boi N o r d e n t o f t o C o p e n h a g e n ( 1 9 1 2 ) n h o sir d u n g C 0 2 de b o m hoi c u a Z o l l i k o f f e r o T h u y ST n a m 1 924 va n h o viec

d u n g mot k i m V e r e s s b o m khi v a o m a n g phoi de di<§u tri lao ph6i 6

B ud ape st ( 1 93 8)

NOI SOI PHAU THUAT (1 9 3 0 - 1 9 6 0 )

N a m 1933 F e r v e r s sir d u n g o x y la p h u o n g tien lam p h o n g c a n g t u c u n g va ket h o p g i ua o x y va di en t r u o n g l am loe s a n g t ro n g k h o a n g o b u ng

J o h n R u d d o c k ( 1 9 3 4 ) da m o ta m o t he t h o n g thau k inh voi c a p sinh thiet va

c a m ma u

H o p e ( 1 9 3 4 ) d a t h o n g b a o d3u tien ve viec sir d u n g noi soi c h o c h a n d o a n

c h u a n goa i tu c u n g m a c du c a c n h a ph u k h o a da sir d u n g noi soi t r u o c thoi gian do

Bosch ( 1 9 3 6 ) a T h u y ST va A n d e s s o n ( 1 9 3 7 ) 6 M y goi y viec triet s an voi

t r un g q u a noi soi

P o w e r va B ar n es ( 1 9 4 1 ) d au tien d a thirc sir thuc hi en triet san

O M y noi soi d a duo'c a p d u n g tu t h a p ky 4 0, c h o toi tan c u o i t h a p ky 6 0 thi soi tui c u n g d u o c th uc hi en t r o n g hau het c a c t r u n g tarn

O C h a u A u, n a m 1948 R a o u l P a l m e r da t h uc hi en noi soi a Pari va m u o n

P a l m e r q u e n sir d u n g d a o d i e n m o t circ d e tien h a n h triet san m a h i e u q u a

c ao K y t hu at d u o c m o ta lan da u tien boi St ep toe ( 1 9 6 7 ) o n g n hd c d e n ky

t hu at lam tdc va c at o n g ddn trufng

F r a n g e n h e i m ( 1 9 7 2 ) d u n g d a o d i e n hai c u c de trier s an va c a m m a u C u n g

thcri gian nay Jurt S e mm cf Kiel ( 1 9 7 2 ) giai thieu c a c h lam tac o n g da n trurng

b i n g nhiet tha y the, sir d u n g kep ( H u l k a 1975) ha y nhirng v o n g that ( Y o o n

va K ing 1975)

Na m 1974 o n g M A Bruhat a Ph a p thuc hien ph5u t huat noi soi t r ong chira ngoai tir c u n g va den n a m 1977 o n g da c o n g bo 26 trirong h a p pha u thuat noi soi cat bo khoi chira ngoai tir c u ng

Su phat trien d u n g cu n h u dot dien hai c uc va c a m m a u ben t ro n g b a ng lazer lazer C 0 2 d u o c t ruye n doc the o he t h o n g tha'u kinh da d u o c gioi thieu

ro ng rai a c h a u A u boi Bruhat M a u r i c e a C l e r mo n t F e r r a n d n a m 1979 va a

My boi H a m e Daniel a Na sh a vi ll e n a m 1982 N h u n g no d u o c cha'p n ha n mot c a c h n h a n h c h o n g , den dau n a m 1992 da co hon 8 0 % c a c pha u thuat vien a H o a K y cha'p n ha n p h u o n g p h a p nay C u n g thoi gi an n a y Phil lipe

M a u r e s t ( P ha p) d a c o n g bo t hanh c o n g cdt tui mat q u a noi soi m a ra mo t ky

n g u y e n m a i c h o p h au thuat noi soi

N a m 1994, dieu tra tren 103 852 t r u o ng h a p phau thuat noi soi 6 17 k h o a tai

Vi en dai hoc Ph a p ( 19 88 - 1994) g o m 15 loai pha u thuat noi soi k h a c nhau: cat tui mat, cat ruot thira, c h u a ngoai tu c u n g , u b u o n g trurng, cat tu c u n g ,

t hoat vi, cat dai t rang, cat da y than kinh X, th un g da day, d u a n g mat, c h a n

t h u a n g b u n g , cat lach va c a c pha u t huat kh ac

0 Viet N a m tai b e nh vien C h o RSy, t h a n g 9 / 1 9 9 2 ca cat tui ma t q u a noi soi dau tien d u o c tien h a nh voi p h u o n g p ha p n a n g t hanh bu ng

Tai b e nh vien Viet D u e H a Noi c u n g bat dau trien khai tir t h a n g 1 1/93 chii yeu la phau thuat noi soi cat tui mat Sau do trien khai s an g mo t so phau thuat k h a c n h u vie m ruot thua, u n a n g b u o n g trurng cat d ay than k inh X,

t ro ng loet h a n h ta trang, tac ruot do dinh, u t uye n t h u o n g than, cat p h an thuy phoi

Benh vien Phu san Tir Du t ha nh pho Ho Chi M i n h bat dau irng d u n g ' p h a u thuat noi soi tir nam 1993 voi c h u a ngoai tir cung, u na ng buo ng trung, lac noi mac tir cung vo sinh, u x a tir cung Hien nay da cat tir cung hoan toan

T h a n g 4 / 1 9 9 6 Benh vien 103 da ap d u n g phau thuat noi soi voi c a c phau thuat n go ai k h o a bung , nguc , san phu k h o a va than kinh

Tai b e nh vien Bao ve Ba me va Tre so sinh Ha Noi, noi soi c h a n d o a n b a ng nhin true tiep q u a den soi t rong dieu tri vo sinh d u o c thuc hi en n a m 19 80 va

t ro ng 5 n a m dau 1980 - 1984 da thuc hien d u o c 175 ca va n g a v c a n g d u o c

ph at trien h a n t r ong nhurng nam sau Pha u thuat noi soi bat dau d u o c thuc hien tir n a m 1996 voi dieu tri vo sinh, u n a n g b u o n g trurng, chira n g o a i tir

c u n g , d inh san, lay v o n g t r ong 6 b un g T u y moi ap d u n g b u a c da u n h u n g

c u n g da c o d u o c n h u n g t h a n h c o n g va tien bo d a n g ke

TRIEN VONG CUA NOI SOI

Ph a u t huat noi soi c h a c c h a n la pha u thuat ciia t u o n g lai Sir t h u a n loi c h o

b en h n h a n va p h u c vu sure k h oe la rat lan N o rut ngd n thoi gi an n a m vien

n h a nh c h o n g hoi p h y c sau m o , s o m tro lai lam viec, t ra n h d u o c c a c bi en

c h u n g n h i e m t ru n g d a m b a o t hd m m y

K y thuat n ay t uy b a n d au c o le c o n k h a kho khan doi voi n h u n g n g u o i m o i hoc, n h u n g voi sir t r o g i u p c u a v i de o c a m e r a da g iup c h o c o n g tac d a o tao

de d a n g h on va t a n g sir an t o a n c h o pha u thuat

Pha u t huat noi soi se d u o c a p d u n g r o ng rai a c ac n u o c tren the gioi d a c biet

la Ch au A T h ai Binh D u o n g O Vi et N a m dan dan no se d u o c tri en kh ai rong rai 6 c a c b e n h vien tren toa n q u o c va n g ay c a n g d u o c n h i e u b a c s! c h a p

n h an va nguoi b e nh doi hoi

Doi voi phu k ho a , phdu t hu at noi soi se dan dan th ay t he c h o m o d u o n g

b u n g t rong c h u a n g o a i tu" c u n g , u b u o n g trting, g o dinh, m o t h o n g voi t r u n g

t r on g vo sinh cdt tu c u n g t ro n g n h u n g b en h lanh tfnh

TAI LIEU THAM KHAO

1 N g u y l n Thi Hoa i D u e , Le T h a n h K y - Soi o b u n g c h a n d o a n n g u y e n n h a n

Ilin h 1: T h uc tap p h a u th u at noi soi tren Ion

TO CHlfc PHONG MO NOI SOI

D d Kim H a n g

I- PHAU THUAT NOI SOI:

Hi en nay dirge x e m la phSu t hu at c u a t u a n g lai No c h i e m p h a n Ion ( 2 /3 ) c a c

t r u o n g h g p chi d in h t r o ng p h a u t hu at phu k h o a a c a c n u o c pha t tri en Vi e c

to clitic p h o n g m o noi soi c a n d a y du c a c yeu to va c a c yeu c au r i e n g c u a

1 P h o n g m 6 phai r o n g va du a n h s ang M ot c u o c p h au t hu at noi soi vi nhieu ly do c o th6 phai c h u y e n sang phdu thuat m o b u n g Vi vay, p h o n g

m 6 noi soi c u n g phai da p urng d u o c ca anh s a ng c h ie u d a y du c h o c u o c

p h a u t hu at phdu thuat m o b un g ( hinh 2)

Dien tich ma t b a n g p h o n g m 6 noi soi nen tu 2 8 m 2 - 32 m" K h o n g gian

p h o n g m 6 c an d a m ba o sao c h o c a c thiet bi m a y soi, m a y tho, m o n i t o r

va c a c thiet bi k h a c k h o n g bi anh h u o n g lan n h a u (boi he t h o n g dien,

k h i )

2 P h o n g m 6 noi soi (hinh 2) can co c ac k h o a n g vi tri d a n h cho:

- Bac sy g a y m e 6 phi a dau nguoi benh

- K h o a n g d a n h c h o de’ dat da n m a y , vi tri phu t h uo c vao c a c ye u c au c u a phdu t huat vien

- K h o a n g d a n h de phau thuat vien va tro thu Vi tri na y c o th6 t h a y doi phu t h u oc v ao thoi q u e n c u a ph au thuat vien c h i n h va chi d i n h ph au thuat

- Vi tri d a n h de c h o ban d u n g d u n g cu phau thuat noi soi

5 N g u o n d i e n c u n g cap: doi voi c ac m a y m o c tinh vi hien dai t ro n g p h o n g

m 6, mo t n g u o n dien 6n d inh t r ong k h o a n g 2 0 0 - 2 2 0 V / A C la m o t ye u

c au b i t b uo c P h o n g m o c an phai d u o c tra ng bi on ap loai tren 5 K V A

du c h o c o n g suat h o a t d o n g c u a ca da n m a y N eu c o dieu kien thi tra ng

bi t h e m bo luu dien (UPS) de’ d a m b ao an toan c h o c a p h au thuat, vi da c thu c u a phdu t huat noi soi la phu t h u o c vao m a y m o c , ne u d a n g phdu

t hu at m a ma t di en thi se rat n g u y h i e m c h o n gu oi b enh

N en c o 6 c dm lay tir mo t n g u o n dien ri eng c h o d a o di en vi h o a t d o n g

c u a d a o d ie n d l g ay n h i l u c h o tin hieu c a m e r a

Ill- VE MOT SO TRANG THIET BI, VI TRI DAT MAY, VI TRI NGITOI BENH VA PHAU THUAT VIEN

1 B a n m o

Su d u n g loai ban m o phu k h o a sao c h o n gu oi b e n h co the dat c a c t u the sau:

- T u the phu k h o a (soi b u o n g tu c u n g )

- T u the d au c a o h o a c thap, n g h i e n g phai va n g h i e n g trai

Thuong ban mo noi soi phai ha thap hon ban mo thong thuong tir 15 - 3 0 cm.

2 He t h o n g C 0 2

Do i voi loai b i n h n h o di kern m a y la an toan va t huan tien, n h u n g gia t h a n h cao , k h o n g phu h o p vdi c o s o p h a u t huat noi soi nh ie u VI v ay t h u o n g d u n g loai bi nh to c u a V i e t N a m san xuat Binh C 0 2 to nen dat be n n g o a i p h o n g

mo va co he t h o n g d a y d a n toi m a y s ao c ho an toan va c hd c c h d n V e ma t

kinh te thi loai b in h to k h o n g ton kern v a de s u d u ng So s a n h g i u a b i n h to

va binh n h o (di kern t h e o m a y ) c h o thay:

Binh C 0 2 loai to do Vi et N a m s an x u a t d u n g c h o ga n 4 0 - 55 b e n h n h a n ,

s ong loai binh n h o di kern t h e o m a y chi d u n g c h o k h o a n g tir 8 - 10 b e n h

n ha n, t r on g khi gia t h a n h loai b in h n h o c a o ga p nhi6u lan so voi loai bi nh to

c u a Viet N a m san xuat

3 X e d e d a n m a y

D u n g loai xe c h u y e n d u n g , c o b a n h xe de c o the di c h u y e n bat cur liic na o

mo t c a c h de d a n g va t h u a n tien X e d u o c c h i a l am nhi6u ta n g, t h o a n g , rong

C ac thiet bi va m a y m o c phai sdp x e p sao c h o k h o n g a n h h u a n g Idn n ha u

N ha t la doi voi n g u o n s a n g c a n phai de a vi tri t h o n g t h o a n g M a y b a m hut

ne n de ta ng d u a i c u n g c u a xe D a n m a y ne n de c o d i n h tren g ia d a h o a c xe ddy

5 Vi tri p h a u t h u a t vien

Vi tri pha u t hua t vien tuy t h u o c vao phdu t hu a t vien c h i n h t h u a n t a y ph ai

ha y tay trai T h o n g t h u d n g phdu t h u a t vi en d u n g p h i a be n trai n g u o i b e n h

nguoi phu 1 d u n g ben phai ng uo i b e nh va ngucri phu hai durng a g i ua hai

c h a n nguoi b e nh (co gh e ngoi de k h o n g c h e k hua t m a n hinh)

K h o a n g c a c h tir m a y den vung m 6 k h o n g q u a 3/4 chiSu dai d a y ddn anh

s ang va d ay ddn C 0 2

6 Tir the n g u o i b e n h

- Ngu oi b e nh n a m ngura t h i n g tren ban mo, c h a n d a n g 45° so voi true than nguoi

- Hai tay n g uo i b e nh nen dat doc theo than hinh la tot n ha t, de t ra n h gay

c a n g da n q u a mure d a m roi c a n h tay

- M o n g n g u o i b e n h phai n ho ra ngoai m e p ban, tao t h u a n loi khi c a n thay d6i tu the tu c u n g

- Hai vai ngUcri b e nh d u oc gi u k h o n g c h o tut khi o tu the dau thap

7 Y ta d u n g cu vien

Y ta v o n g t rong sau khi rua tay, ma c ao m6 n h u p hu c vu c a p ha u t huat

th o n g t h u o n g : s ap xe p ban d u n g cu theo t hu tu t ung loai d u n g cu de san sang cho c uo c phdu thuat Sau do c h u y e n ra vong ngoai de tien hanh sir

d u n g m a y va c a c thiet bi vun g ngoai

Doi voi c ac phdu t huat phurc tap n h u cdt tu c u n g , boc ta ch n h a n x o q u a noi soi thi nen c o mo t y ta v on g t rong c ho de n khi c u o c pha u t huat ket thuc

8 N g u y e n tac doi voi n gu o i s u d u n g m a y

P h d u t h u a t vien: s u d u n g m a y va thiet bi noi soi t ha nh thao t ra n h ma t thoi gian c h o c u o c pha u thuat va d a m ba o do bSn, tudi tho c u a m a y

Y ta d u n g cu vien: nen da o tao m o t n h o m c h u y e n sau v6 d u n g cu noi soi de

d a m b ao c h o c u o c pha u thuat lien tuc va thay p hi en n ha u khi c a n thiet M a c

TRANG THIET Bj DUNG CU NOI SOI

I- HE THONG OITA KHI VAO

1 Ki m c h o c dira khi v a o k h o a n g b u n g (kim V e r e s s , P a l m e r , M i n t z ) la loai

kim c o hai n o ng :

N o n g t rong tu di c h u y e n dirge do c o lo xo

N o n g n go ai n h o n de khi c h o c k h o n g g a y ton thirong c h o c a c t a n g , ru ot a

- Khi b a m khi v a o t r ong 6 b u n g du ap lire m a y se tu ngirng N g o a i ra, m a y

c on tu d o n g d o a p lire thuc t rong o bu ng , vi du n h u khi b e n h n h a n tinh ap lire ta ng len tren 15 m m H g m a y se b ao do ng

- D e d a m bao lu g ng khi t rong 6 b u n g luon on dinh, t r on g c u o c m o m a y co

he t h o n g dieu c h i n h tu dong Bo p h an dieu c h i nh giai han a p lire nay se thay d6i dira vao a p lire t rong 6 b u n g Bai vi t r on g q u a tri nh p h au t huat

l ug ng C 0 2 c o the bi ma t di do trocart bi ro, d u a n g rach q u a rong h oa c khi hut, rira mo t lu g ng C 0 2 se bi rut ra, ap lire 6 b u n g g i a m x u o n g , 1 lie

na y m a y se tu d o n g d u a lu g ng C 0 2 bu va o lugng da mat

M a y b a m C 0 2 c o n c o n hi eu chtic n a n g n h u do d u gc khi tieu thu t r o ng suot

c u o c mc> h o a c dira vao c ac th o ng so hien tren m a y co the k hd n g d in h d u g c kim b a m C 0 2 c o d u g c dat d u n g vao k h o a n g 6 b u n g k h o n g Binh t h u o n g ap lire t r ong 6 b u n g l uon am Vi vay, khi bat m a y len ap luc t h u o n g la: -3, -5 hoac 0 Sau do a p lire o b un g se tang tu tu de n khi dat 15 m m H g thi d u n g lai T o e do khi b o m vao t h u o n g d u g c dat la 3 lit/ phut

M a y b o m ap luc vao 6 b u n g la dieu kien c an de tien h a n h noi soi, d o n g thai

c h o p h e p t hu c h ie n c a c ky t huat noi soi vai do an to an toi da

HE THONG DEN SOI GOM

s r - s r

N g u o n a n h s ang

Hinh 4: Kinh soi voi cac dtfdng kinh khac nhan

H e t h o n g k i n h d a m b a o c h o vi trucrng Ion nhdt, m a u sac ro net n h a t c h o

n e n phai h i e n dai nh in d u o c toan c a n h va theo true H i en c h u n g toi sir

d u n g k inh soi S T O R Z O voi hai chiSu anh s a ng vao K i n h c o d u o n g

k in h 1 0 m m , c hi du dai 3 1 0 m m

- D a y d a n a n h s an g: c au tao b a n g soi t huy tinh d a c biet, c o k h a n a n g

t r u y e n ddn a n h s a n g tot, t uy n hi en lai de durt g a y ne u bi g a p goc D o va y khi sir d u n g c u n g n h u khi b ao q u a n phai gon nhe Chidu dai c u a d a y ddn

a n h s a n g toi t hieu phai tren 2 3 d c m de de th ao tac, d u o n g k i n h c u a d a y phai tren 4, 5 m m de b a o d a m do ddn sang Khi noi n g u o n s a n g voi d a y ddn a n h s a n g phai de d a y v u o n g goc voi c u a so a n h s an g K h o a n g c a c h tir n g u 6 n s a n g d e n v u n g l am viec k h o n g q u a 3/4 c h i e u dai c u a d a y s a n g

de t r an h l a m c a n g day

- N g u o n s a n g lanh: de c u n g c a p a n h s a ng t ro n g suot c u o c m 6 H i e n na y

c h u n g toi d a n g d u n g n g u o n s a n g lanh H A L O G E N 2 5 0 W T w i n c u a h a n g

S T O R Z M a y c o hai b o n g d e n 2 4 V / 2 5 0 W khi b o n g c h i n h c h a y m a y se

tu d o n g c h u y e n s a n g b o n g phu v a d e n do hien len o p h i a trai t r u o c mat

Khi sii dung nguon sang pha i tang tic lit khong dUffc tang qua mtic.

Ill- CAC DUNG CU TRONG NOI SOI VA TROCART

2 C a c d u n g cu p h £ u t h u a t (hinh 6)

Q u e gdy de gat t6 churc

Kinh soi va c a p q u a n g de da n c a m e r a

Kim phau ti'ch d o n cuc

D ao dot mot c u c - c a p c a o tan d on cuc

lli nh 6: Cac dung cu phdu thuat noi soi co ban

III- BO XUT LY HINH ANH

Co c h u c n a n g t r u y e n da n hinh anh, d a y la c h u c n a n g q u a n t ro n g n h a t t r ong noi soi ( hi nh 7)

La m ot he t h o n g rat p h uc tap va n h av c a m Vi vay, khi sir d u n g phai tu an thu n g h i e m ng at c a c qui d in h c u a n h a san xuat C u n g n h u d a y d a n s a n g , d a y tin hieu noi tu dau c a m e r a de n bo xir ly h in h a nh c u n g c o c a c soi q u a n g h oc ben tr on g, n en khi sir d u n g phai t ra n h d o n g tac tho bao, k h o n g g a p g o c vi rat de g a y lam a n h h u o n g den c h at lu on g h inh anh T r u a c khi d u a o n g soi vao o b u n g phai d a m bao:

- Ch e do hi nh a nh da dirge c a n b a ng trdng (white b a l a n c e )

- D o s a n g dat y e u cau

D o net toi da

- D o p h o n g dai h in h a nh nhu- y m uo n

Ilinh 7: Bo xiC ly hinh anh va dau ca m era

IV- VO TUYEN MAU VA DAU VI DEO DITOC NOI TRU’C H E P VOfl BO XUT LY HINH ANH

Sau khi cai dat c a c t h o n g so, m a y se van h a n h m o t c a c h h o a n t o a n tu- d o n g

n h o bo vi xir If de di6u c h i n h c h i n h x a c a p lire hut va tirdfi Khi m o t a p lire

n ao do ta ng q u a gioi h a n , m a y tir d o n g ngirng de b a o d a m an t o a n c h o n g u o i

b e nh Sau khi d a cai dat, m a y c u n g c o the di6u c h i n h lai d u g c t h e o y m u o n

c u a phdu t huat vien

KHUT KHUAN VA BAO QUAN DUNG CU NOI SOI

Ng uye n Thi P h u o n g An h

D a y la c o n g viec rat q u a n trong, no g o p pha n q u y e t d inh va o sir t h a n h c o n g

c u a moi ca m o va c o n g viec nay c o n q u y e t dinh tuoi tho c u a d u n g cu va thiet bi N h u n g d u n g cu va thiet bi nay doi hoi c he do bao q u a n va c h a m soc dac biet, k h a c voi c a c loai d u n g cu va thiet bi t h o n g t h u o n g

I- KHUT KHUAN C6 hai phuo ng phap dugc ap dung:

1 Khir k h u i n b i n g khi e t h y l e n ocid: thoi gian 18h neu 6 p h o n g c o dieu

ho a nhiet do h o a c t rong 5 e i o neu dat d u n g cu t ro ng til 5 5 ° C ( 1 3 l " F ) va

k h o n g d u g c q u a 60° C ( 1 40 F)

N h u g c d i e m c u a p h u o n g p h a p na y la ma t n hi eu thoi gia n, k h o n g tien lgi

2 N g a m t ro ng d u n g dich k h u k h u i n Ste ra nios 2% h oa c 2 % N G ( c u a

A n i o s ) h o a c c i d e x 2 % (cua J o n h s o n and J o n h s o n ) Th oi gi an n g a m ft nhat la 15 p hut truoc khi sir d u n g ( t h u o n g m a t l Op hut de diet n a m va virus, 1 g i o de diet bao tur) Chi c an dat d u n g cu va o h o p c h u y e n d u n g (tot nhat la loai h op b i n g c h at deo), do 5 lit c i d e x 2 % va o h o p s ao c h o

d u n g di ch phai n ga p het moi d u n g cu D a y nap h o p t ro ng s uot thoi gian

n g a m , sau do vot toan bo d u n g cu s an g hop d u n g n u o c c a p vo k h ud n,

t ra nh rira n h ie u lan c h o sach het c an c i d e x roi moi sir d u n g ( hi nh 8)

P h u o n g p h a p n a y tien lgi, de a p d u n g lai k h o n g ga y ton k e m , k h o n g mat

n h ie u thoi gian, nhat la khi c o ft d u n g cu vdn c o the thuc hi en d u g c

n hi eu ca m o lien nha u Thf ch h g p voi c a c c h a t lieu d u n g cu do do g iu

d u g c d u n g cu lau ben hon

N h u g c d i e m c u a p h u o n g p h a p nay: n g a m di n g a m lai nhi6u lan c an

c i d e x se b a m vao c a c khe, ke, mat thau kfnh g a y c a u b i n d u n g cu

II- BAO QUAN DUNG CU Phai tien hanh theo cac buoc sau:

1 Rira d u n g cu: Phai lam n g a y sau m6i lan sir dung

a- Thao roi loan ho dung cu den mite toi da:

- Tat ca c a c oc vft, c a c kho'p noi tren d u n g cu c o khfa ra n g c ua: th a o, l i p

b a n g c a c h x oa y

- N h u n g k h o p noi k h o n g co dau hieu tren b i t b u o c k h o n g d u g c van, x o a y : phai rut t h a n g h o a c c a m t h a n g (thi du: da u d a y c a m va o d a o d i e n 1 c u c, hai c uc)

- Moi th ao tac phai n h e n h a n g , t ra nh va c h a m , nha t la doi voi o n g kfnh soi, dau c a m e r a

- D ay da n a n h s a n g la m ot d a y t huy tinh m e m , t ranh gap k h u c h o a c c u o n

t h a n h v o n g q u a h e p de p h o n g g i y ga p lam anh h u d n g de n sir t r u y e n d a n

a nh s an g

- R i e n g k e o phai m o liroi k e o rura s ach p h an ludi trudc khi t h a o roi

b- Ngam loan bo dung cu da thao roi vao dung dich lay rua:

N o n g do va thoi gi an n g a m t uy t h u o c vao tirng loai d u n g dich t i y rira De: lam tan m a u va c a c c h a t b an b a m tren d u n g cu, d o n g thoi diet vi k h u i n virus, yeu c au d u n g dich phai c o tfnh khir nhiSm c a o va rira sach rat m a n h , lai k h o n g an i non d u n g cu T h o n g t h u d n g sir d u n g d u n g dich h e x a n i o s h o a c

a m p h o l y s i n e

I lin h X: Ngam tiet triing d u n g cu vii trang rUa b a n g n u d e cat

c- Co rua dung cu sau khi ngam du thoi gian:

- D u n g c a c loai ban c h ai c h u y e n d u n g c o rira ky c a c k h e ke, n o n g o n g diroi voi c h i y n u d e c h o s ac h hdn c a c c h a t b i n

- Ph a n n h a m tren troc art va m a t t ha u k in h tren o n g soi phai c o rira b i n g

k h a n vai m e m de t r a n h an m o n va x a y xuo'c

2 L a m k h « d u n g cu s a u khi d a rura s ach :

- Mat n g oa i d u n g cu lau k h o b i n g k h a n vai m l m

- Mat t ro n g c a c o n g , day: d u n g m a y nen khf xi k h o ( h o a c d u n g m a y hut, hut het n u o c d trong)

3 B a o q u a n d u n g cu:

Sau khi rira s ach, lau kho, l i p lai va dat d u n g cu va o h o p c h u y e n d u n g condp de t ranh bui ban

- N h u n g d u n g cu sdc, n h o n n h u trocart, k eo c an co nut n h u a c h e d a y d dau d u n g cu de t ra nh h u hai

- Cac kim, ke o c an k i e m tra hoat d o n g ciia h a m va tay c a m x e m c o tron tru ha y k h o n g Neu co hien tu gn g ri, ket thi sau khi c o rira tra ft dau parafin va o c a c k h d p c h u y e n dong

- D e g i u d u g c do be n c u a dau c a m e r a tot nh at la de d a y c a m c o d i n h vao

bo xir ly h inh a nh va m a y tui vai (kich thudc: 12cm x 2 m ) h a p vo trung, khi m o luon da u c a m e r a vao tui nay d6 k h o n g phai tiet t ru n g bo p h an

Lu u y: M o t so trudng hop thuong gap

• D a o d ie n h o a t d o n g k h o n g c o hieu q u a do: d i e m noi tiep xu c c a c dau

d a y k h o n g d u g c lau k h o h oa c c a n c i d e x b a m tren d i e m tiep xuc Phai lau lai cdn than, hien t u g n g m uo i tren m a n h inh t h u d n g do n h i e u di en

ga y ra khi dot va cat

• D i e m noi vao, ra c u a d a y d a n a nh s a ng va o n g kinh soi, d i e m noi da u

c a m e r a vdi o n g soi phai l uon luon k h o va s ach t ru d c khi sir d u n g : sau khi lam k h o lau lai b a n g ga c c o c o n 70° de t ra n h su h in h t h a n h c a n tir

c h at khir t r u ng lam g i a m c h at lu gn g hinh a n h (neu de udt, hai n o n g tir

n g u o n s a ng se l a m k ho, d o n g c an d c a c d i e m do)

• D u n g d ic h rira o b u n g q u a n o n g se bi boc hai va c h a t l u g n g h i n h a nh se

bi g i a m N eu n hiet do ciia d u n g dich q u a 4 2 ° C m a y se ngirng h o a t d o n g

va ph at tin hieu b a o d o n g , d e n do se hien d bo p ha n b a m ciia m a y (tot

n h a t t° ciia d u n g di ch chi < 42°C)

GIAI PHAU

P h a m Thi Thanh Hien

Noi soi la m ot thao tac phdu thuat c an phai hieu biet ro r ang v6 giai phdu:

• Giai pha u toan bo c o q u an sinh due

• Giai phdu d in h khu c o q u a n sinh due

• Giai phdu be nh dai the

I- THANH BUNG TRtfQC

Phu tir xirong uc de n b d tren xirong c h a u do la c a c c an - c o m e m va c o rut

No ba o g om : da, t6 chirc dirdi da, co bo c an c u a co, c an n g a n g : lop c an na y

m o n g n h u n g d ay len d phfa dudi, phuc mac

1- D u o n g t r i i n g giira

D o la d u d n g d a n giira d u gc cau tao b d gi ua co' t h a n g to va sir bat c h e o ciia

bo c an c a r ong Dirdng trdng giira dirge c a n g tir m o m x u a n g ire d en xirang

mu No r o n g h a n d nira tren, nhat la n g a n g ron, d do p hu c m a c t rd ne n d i n h

2- M a c h m a u t h u o n g vi

La n g a n h ben ciia d o n g m a c h c h a u ngo ai , sinh ra tir ma t t ro n g vai m i l i m e t tren c u n g diii H u d n g di ciia no theo dirdng vach tir giira c u n g dui va ron di vao phia t r o ng 1cm, len c a o vao t rong h u d n g ve phia ron N h u vay, n o vach

ra mot d u d n g c o n g m a t rong pha n lom d a y c h a n g tron tua vao tru dc khi ch ui vao t r ong o n g ben Tdi b d n goai c a t ha ng to k h o a n g 5 c m tren x u a n g ve,

d o n g m a c h tiep tuc di len vao bao c a t ha n g, de n ron O do, no c h u i vao

t h a n g va tan c u n g d day No luon luon d ngoai d o n g m a c h ron

3 - B a n g q u a n g

0 n g u d i ldn , b a n g q u a n g la mo t c a q u a n n a m h o an to an sau k h d p mu (khi

no r 6n g) T h a t vay, phfa ma t b u n g (trudc d ud i) no irng vdi c a n ron t rudc

b a n g q u a n g , k h o a n g t rud c b a ng q u a n g ( k h o a n g R e t zi u s ) va irng vdi p h an trudc ciia c a n a n g ha u moil, 16 bit, c an c a va m a c h m a u

3- D udng giua ron- x u a n g ve: la v u n g d do phuc ma c de boc t ach D i e u do giai thich c h o mo t so t r u o ng h o p tran khi g i ua can va phuc m a c h th anh.

4- Ha sucrn trai: n a m d ba k h o a t n g o n tay b6 ngoai c u a ron va hai k h o a t

n go n tay d udi bo sud n D u o n g n a y thfch h o p voi n h u n g b e nh n h a n c o seo

t ha nh b u n g d uo i r on ( c h o n g chi dinh t rong t ru o n g hop b e nh n ha n la ch to ).5- D udng ron: h a y sir d u n g vi v un g n a y p h u c m a c d inh vao c an c u a d u o n g trdng giura, lam g i a m n g u y c o tran k h i duoi p h u c ma c

• Noi soi md

D e d u p h o n g n g u y c o (it ga p ) t hoa t vi ron sau mo , c an thiet su d u n g d u d n g rach theo kieu ludi le, lech 1-2 c m lo d a va lo can

• Nh&ng 16 c h o c O th a n h b u n g

D u o c hinh t h a nh t ro n g mo t t am g ia c gioi han bdi:

- 0 thap: gidi ha n tren c u a v o m b a n g q u a n g

- 0 c ao va ngoai: d o n g m a c h ron do la v u n g vo m a c h c h o p h e p th uc hien

an toan c a c th ao tac ph au t huat va de p h o n g tat ca c a c ton t h u o n g m a c h

ma u t h u o n g vi

Tat ca c ac gidi ha n d vun g n a y c o the k h o x a c d inh d b e n h n h a n m o n h i e u lan, dac biet gidi h a n tren b a n g q u a n g Su k ie m s oat c a c t h a o tac d u o c g iup

d d bdi noi soi la c an thiet

Vi tri n h u n g 16 phdu t huat phai tfnh de n the’ tfch tu c u n g N e u tu c u n g to,

n h u n g 16 ph au t hu at phai d c a o de q u a n sat r5 tui c u n g D o u g l a s

II- THANH BUNG SAU

Chu yeu bao g o m c a u true x u o n g cot s ong d o a n thdt l ung- c u n g , tren do co

n h u n g m a c h ma u ldn sau p h uc mac: c h 6 p h an c h i a c u a d o n g m a c h va tinh

m a c h chu G i u a n h u n g t h a n h ciia b un g , ngu di ta k h o n g the lien he giai phdu

c h i n h xa c vi c a c c o q u a n t r ong 6 b u n g di d o n g t ro n g k h o a n g b u n g ldn, m a

k h o a n g na y d tra ng thai sinh ly la k h o a n g ao Hai khai n i e m giai p h a u cdn

n h o t rong noi soi la:

- N h u n g m a c h m a u ldn gan t h a n h b u n g h on ma t b a n g phdu thuat

- Vi tri ciia ron doi vdi m o m n h o va c h o p ha n n h a n h ciia d o n g m a c h va tinh m a c h c h u tha y d6i tuy th eo k h o a n g c a c h g i ua r o n - x u o n g ve v a goc

ga p trirdc ciia x u o n g c hau

Giai thich r i n g n a n g t ha nh b un g trudc k h o n g c h o p he p d u p h o n g n h u n g t6n

t h u o n g d u o n g tieu hod Boi vi c ac c a q u a n t r on g b u n g se di the o t h a n h b u n g khi ta n a n g N g u g c lai, a n h u n g b e nh n h an gay, b e nh n h a n m a t h a n h b u n g

n h e o thi phai n a n g t ha nh b u n g g iup d ua xa dau c u a mui ki m t ra n h c h o c vao

m a c h m a u Ion sau p hu c ma c sau

Ill- THANH BUNG BEN

Pha u t hua t noi soi t h u o n g lien q u a n nhat den voi trung, b u o n g t r u n g , t h a n h

• Nieu qu a n: lien q ua n true tiep vai buo ng trurng ma mat ben thi lien quan:

- 0 ng u oi chira de: ho b u o n g trurng d u g c giai han bai m a c h c h a u t r o n g va nieu q u a n phfa sau D i e m b a m c u a day c h i n g rong a phfa trucrc, m a c h

m a u c h a u n go ai a phfa tren, di tfch d o n g m a c h ron va d o n g m a c h tu

c u n g a du a i

- (3 n g u a i c o n da: ho b u o n g t ru n g d u g c giai han bai nieu q u a n va d o n g

m a c h tu c u n g a phfa t r ua c , b a c u a x u a n g c u n g a phfa sau va b a t ren c u a

ho q u a le a phfa d ua i

• P h u c m a c h t h a n h c u a ho b u o n g trirng: h oa c n h u n g v un g lan can

t h u o n g la n g u o n goc c u a mo t so be nh ly n h u lac noi m a c tu c u n g hoa c dinh N h u n g bat t h u o n g nay lam th ay doi p h uc m a c (no tro nen m g

h a n ) , doi khi lam th ay doi giai phdu c a c c a q u a n sau p h u c ma c Nhurng

t hao tac thuc hien phai luon luon than trong, tfnh de n d u o n g di c u a nieu

q u a n va m a c h m a u c h a u h o n g (doi khi k h o d a n h gia) Kh i phdu thuat vien su d u n g d ao dien de c a m m a u , thich h g p la d a o hai c u c boi vi sir

k h u y e n tan nhiet d u g c giai han h a n Vi e c g a d inh la k h o k h a n a ma t be n

c u a b u o n g t r ung va p hu c m a c co the lam a n h huo'iig d e n vo b u o n g t r ung hoac ph uc m a c thanh Khi v u n g pha n n h a n h d o n g m a c h c h a u bi boc lo

ra thi phai d u n g n g a y tha o tac Ki nh n g h i e m c u a c a c n h a phdu t hua t g o dfnh noi soi chi ra r ang ton t h u o n g da y c h a n g that l ung b u o n g t r u n g la tai bien ft ga p n h u n g k h o n g n goai le Cac n ha phdu thuat l uon l uon phai

n h o giai phdu t r on g dau Doi khi k h o d a n h gia c hf nh x a c c a c c a q u a n lan c an t r on g suot thoi gian g o dfnh, d ac biet phfa ben trai

IV- TUI CUNG DOUGLAS

0 phfa tren hoa c p h uc ma c mat sau c u a a m da o lien q u a n true tiep vai tui

c u n g D o u g l a s No ba o phu mot d o a n a m d a o dai 1 5 mm K h o a n g c a c h g i ua

am d ao va k h o a n g p h u c m a c la rat nho, k h o a n g 4 m m

Tui c u n g sau c u a am d a o la c o n d u a n g uu viet de b a m khf p h u c m a c a b e nh

n h an beo T u y n hi e n, c o n d u a n g n ay c h o n g chi dinh khi c o s eo d fnh, dac biet ga y ra do lac noi m a c tu c u ng

V- KET LUAN

- N a m v un g giai phdu

- K h o n g b a o g i a c hi quail sat ton t h u o n g m a c h m a u c h a u n g oa i m a k h o n g

ki e m tra nieu q u a n

CHI DINH TRONG PHAU THUAT NOI SOI PHU KHOA

Le A n h Tuan

I- DAI ClflJNG

T r o n g phu k ho a , noi soi c h a n d o a n va phdu thuat noi soi d u o c a p d u n g ro ng rai tu n hieu n a m nay So voi phau thuat m o bung, noi soi co nhiSu iru d i e m nhu: thoi gian dieu tri n g a n tir 3 de n 5 n ga y, q u a trinh hoi p h u c sau m 6

n ha n h , g i a m chi phi do n a m vien va s o m tra n gu oi b e nh v6 voi c o n g viec ciia ho

T u y n hi en ph au thuat noi soi phu t huoc va o c o s o co m a y noi soi va tra ng thiet bi c h o p h o n g m6 Phdu thuat vien phai c o kinh n g h i e m va d u o c da o tao

II- CHI DjNH TRONG NOI SOI CHAN DOAN

1 C h i d in h t r o n g noi soi c h a n d o a n

- D a u v u n g tieu k h u n g

- Tharn do n g u y e n n ha n vo sinh

- Di vat t ro ng 6 b u n g ( vo ng t ra nh thai)

- D a n h gia tinh tra ng voi trirng

- C h an d o a n lac noi m a c tir c u n g

- X a c d in h k hoi u v u n g tie:u k h u n g

- X a c d in h b u o n g t rung da na ng

- D a n h gia tinh tra ng o b u n g t ru a c phdu thuat

- C h a n d o a n chira n goa i tir c u n g

- C h u a n goa i tir c u n g vo, c h o a n g k h o n g hoi p h uc

- Chira n go ai tir c u n g o d o a n ke voi t rung

TAI LIEU THAM KHAO

1 Patri cia C W i l s o n P R C O G Basic G y n a e c o l o g i c a l E n d o s c o p y

2 R i c a r d o A z zi z A n a A lv a r e z M u r p h y Pr ac tive M a n u a l o f O p e r a t i v e

L a p a r o s c o p y and H y s t e r o s c o p y 1992

GAY ME CHO MO NOI SOI PHU KHOA

Tran Dinh Tu

I- DAT VAN DE

P h u o n g p h a p m d noi soi dirge bdt da u b a ng n h u n g noi soi c h d n d o a n va

d u g c h oa n c h i n h dan do c a c tien bo k h o a hoc \ i c o n g n g h e c u n g n h u ky thuat y hoc Tir khi ra doi, phdu t huat noi soi da dat d u g c n h i l u t h a n h tuu

d a n g k hi ch le t ro n g lTnh vuc c h a n d o a n c u n g n h u dieu tri, giai q u y e t d u g c

c ac n g u y e n n h a n g a y benh

C u n g voi s u ph at trien c u a c ac ky t huat m o noi soi, c a c c h u y e n g i a g a y me hoi sure c u n g di sau n g h i e n c uu n h u n g van de c o lien q u a n va dS x ua t n h u n g

p h u o n g p h a p g ay m e c o hieu q ua , g o p p h a n xurng d a n g v ao nhurng t h a nh

c o n g c u a phdu t hua t noi soi

Vdi mot chi d inh m o g i o n g n ha u, a nh h u d n g t r ong m o ciia p h u o n g p h a p noi soi se q u a n t ro n g hon p h u o n g p h a p m d c o dien N g u g c lai, sir t h e o d5i,

c h a m soc va dieu tri sau mo lai d on gian hon

Vi vay, c h u n g ta c a n phai dat ra n h u n g tieu c h u a n moi de’ lira c h o n b e nh

n h an va sir d u n g m o n i t o r mot c a c h he t h o n g de theo doi, lira c h o n c a c ky

t huat g a y m e m o t c a c h thich hgp

N g a y n a y tren the gidi c u n g n h u 6 Vi et N a m , do di sau n g h i e n curu va d a o tao, c h u n g ta da c o n h u n g n h o m phdu t huat va ga y m e hoi sire tot, d a m d

ro ng c a c chi di nh m o noi soi va so lu g ng b e nh n h a n d u g c m o t h e o p h u o n g

p h a p n a y n g a y c a n g gia tang d a n g ke’

II- NHUNG THAY DOI SINH BENH LY CUA MO NOI SOI

l T h a y doi ve ho hap

Khi C 0 2 d u g c b o m va o k h o a n g p h uc ma c 6 b u n g la loai khi k h u y e c h tan rat

n h a n h , d u g c h a p thu lai tir p h u c m a c va co the’ g a y ra ta ng C 0 2

N h u n g n g u g c lai vdi ap luc C 0 2 born vao k h o a n g p h u c m a c o b u n g g ay c an trd p h an n a o tua n h o a n p h u c m a c se lam g i a m sir tai h a p thu C 0 2 Sir e p va

g i a m di d o n g ciia c o h o a n g se lam tha y doi chi so t h o n g khi / tudi m a u ( V A / Q ) ddn d e n hi en t u g n g s h u n t d n h u n g v u n g t h a p ciia nhu m o p ho i va hieu irng k h o a n g c h e t d p h a n t ru dc ciia phdi Hi eu irng k h o a n g c h e t se g o p

p h a n lam t a n g ap lire C 0 2 t ro ng m a u d o n g m a c h ( P a C 0 2) C o c h e t a n g na y mot p h a n c o n do tu the T r e n d e l e n b u r g Su ta ng C 0 2 n a y c o n c o the’ g i a t a n g khi b o m C 0 2 n g oa i p h u c m a c de lay h a c h k h u n g c h a u h o a c khi t h u c h i e n sai

ky t huat c h o c troc art q u a t h a n h bung

2 T h a y doi ve t u a n h o a n

Khi b a m C 0 2 vao k h o a n g p h u c m a c o b u n g , chi so tim g i a m t u a n g urng vai

dp luc C 0 2 dirge b a m Su g i a m chi so tim c o n lien q u a n de n s u g i a m k hoi

lu g ng m a u tinh m a c h trd ve tim c u a nira d u a i pha n c a the do s u c h e n e p c dc tinh m a c h Ion t r o ng o b u n g khi b a m C 0 2 Song s o ng vai cdc hien t u g n g neu tren, sire c an m a c h m a u he t h o n g ta ng se lam c h o h uye t dp k h o n g g i a m m a

c o n tang len m a c du chi so tim gi am

Su tang sue c an m a c h m a u d o s u c h e n e p c dc than d o n g m a c h t r o n g o b u n g

do tang dp luc khi b a m C 0 2 lam h u y e t dp ta ng va s u ta ng h u y e t dp c o n do

su giai p h o n g cdc c h a t c o ma c h

Tu y nh ie n, tu the T r e n d e l e n b u r g c u n g cai thien p h an n a o sir t r a v ! tim c u a

m a u tTnh m a c h va lam ta ng nhe chi so tim c u n g n h u vo'i dp luc d o n g m a c h phdi t rung binh va ap luc t r o ng long ngu c

3 C a c t h a v doi k h a c

Do ta ng dp luc t r o ng 6 b u n g c u n g vdi tu the T r e n d e l e n b u r g se tao diSu kien

t hua n lgi c h o sir trao n g u g c di ch d a d a y vao phdi N h u n g c o n g trinh n g h i e n

c uu ga n d ay d a x ac di nh dieu nay

Su kfch thich philc m a c do C 0 2 n h a t la a v o m h o a n h se lam d au vai va ba vai trai sau mo

Ill- KHAM TRIT0C MO VA Ll/A CHON BENH NHAN

Bilan t ru a c m o noi soi ft co van de d ac biet so vai m o t h o n g t h u d n g Chi c an hoi be nh n h a n ve tien sir va b e nh tat va k i e m tra lam s a n g va 1 so xet

n g h i e m c a ba n c o the c h o p h e p d a n h gia cdc n g u y co' d o g a y m e va q u y e t

d inh t he m mot so k i e m tra c an thiet

1 C hi di nh m o noi soi p hu k h o a

N g a y nay do di sau n g h i e n c uu sinh b e n h ly va ky t hu at m o n e n c hi d i n h m d noi soi d u g c m d ro ng Co rat n h ie u chi di nh m d noi soi vdi m u c dfch c h a n

d o a n va diSu tri ( c h u a ng oa i da c o n , diSu tri vo sinh, u b u o n g trurng va u

b u o n g t r un g x o a n , v ie m vdi tr un g, lac noi m a c tu c u n g , triet san, sinh san trg giup, cdt tu c u n g .) T r o n g p h a m vi bai nay, c h u n g toi k h o n g di s au vao cdc chi d in h p ha u t huat noi soi

2 C h o n g chi d i n h m o noi soi t r o n g phu k h o a

Cdc c h o n g chi di nh c o di en da neu t ron g p h au t hua t noi soi b a o g om :

- T a n g dp lire noi soi

- Sir doi d o n g m a u tarn that

- Shunt levine

IIinh 1°: Dung monitoring theo doi ngUoi benh trong noi soi

M ot so tinh t ra n g b e n h ly k h a c, co the’ c h o p h e p m d noi soi n h u n g phai t he odoi het sire th an trong

- Benh m a c h v a nh h o a c be nh tim: t rong q u a trinh m o phai th eo doi het sire

n g h i e m n g a t ve h u ye t d on g T u y n hi en m d noi soi c u n g c o lo'i vi c h at

lu g ng luc tinh va g i a m ty le tac ruot sau m d lam c h o sir d i l u h o a khoi

lu gn g tua n h o a n d<§ d a n g hon

- Suy ho h a p m a n (b e nh ly phe q u a n - phoi tac h o a c h e n phe q u a n tudi gia) c u n g c o the m o noi soi d u g c no ha n c h e a nh h u d n g c h u c n a n g ho hap sau md T u y n h ie n phai d u g c c h u d n bi ky va t h e o doi da c biet vi d ay

la n h u n g b e n h n h a n gia

T o i s i g n a n t va c o n g sir da c h u n g m i n h c o sir anh h u d n g d e n c h u c n a n g ho

ha p sau m d noi soi d n h u n g be nh n ha n tren 50 tudi

- N h u n g b e n h n h a n q u a be o ( beo b eu ) n g a y ca luc n gh i ngoi c h u c n a n g tim va t u a n h o a n c u n g da bi anh h u d n g Sir t an g ap lire d u d n g t h d c u n g

t h u d n g x u y e n co tren n h u n g b e nh n ha n nay Vi va y phai g a y m e that tot,

ba o d a m that m e m c o mdi gi up c h o pha u t hu at noi soi dat ket q u a tot

- N h u n g phu nir c o thai thi pha u thuat m d noi soi c a n phai ton t r o n g n h u n g

n g u y e n tac c o dien ciia g ay m e t rong q u a trinh thai n g h e n

V- TIT THE BENH NHAN TRONG MO

Benh n ha n n d m tren b a n m d, tay b e nh n h a n thay ddi t h e o loai p h a u t hu a t va theo thoi q u e n c u a n h o m p hdu thuat T u y n h i e n phai ton t ro n g 1 so d i e m c o ban sau:

- Tat ca m oi tu the b e n h n h a n c o the c h u y e n t h a n h tu the m o t h o n g

V I- SUTDUNG MONITOR TRONG MO NOI SOI (hinh 10)

N h i m m u c di ch th eo doi c a c t h o n g so c a n thiet de p h a t hi en va xir ly kip thdi c a c bi en c o x a y ra tao dieu k i e n c h o sir t h a n h c o n g ciia phdu thuat

1 T h e o doi tim m a c h

- T h e o doi d i e n tarn d 6 de p h a t hi en m o t so bi en c h t i n g k h o n g d a c hieu nhu: n hi p tim c h a m d o p ha n x a va loan nhip Ph a n tich d o a n ST de pha t hien n h u n g thoi d i e m thieu m a u c u c bo c o tim la n h u n g tien bo ldn tir khi co m o n i t o r va c o the c h o biet n h u n g t h o n g tin b a n g c a c h t h e o doi tu

d o n g N h u n g sir t h e o doi n a y c o the bi nhidu d o d a o die n, m a y m o c va

t ha y doi true di en tim do sir ha n c h e di d o n g ciia c o h o a n h

- T h e o doi h u y e t ap: s u t h a y doi h u y e t a p c o the nhi du va m a n h , n h a t la khi b o m C 0 2 va o 6 b u n g sir d o h u y e t ap tu d o n g la m o t yeu to an t o a n va ich lgi t r ong q u a trinh phdu thuat

2 D o o x y m a c h m a u

D o do ba o h o a o x y t r o n g m a u d o n g m a c h ( S a 0 2) phai d u g c t h uc h i e n mo t

c a c h he t h on g, khi c o s oc h o a c h a than nhiet nhidu se a nh h u d n g d e n su do

n a y h o a c khi c o sir bat t h u d n g ve h u y e t sdc to

3 D o n h i e t do

D o h a y c o sir ha t h a n n hi et t r o n g m o noi soi n e n c u n g c a n phai d o n hi e t do

c h o b e n h n h a n c o the dat d a y do n hiet do d m u i h au , true t r a n g q u a he t h o n g

m on i t or

4 D o t ac d u n g c u a d a n c o

T hdi gian m d noi soi t h a y doi t h e o loai b e n h ly va c a n phai c o d a n c o tot

t r o ng q u a trinh m o de d a m b a o t h o n g khi tot, p hd u t h u a n lgi n en c a n c o

m o n i t o r th eo doi tac d u n g ciia d a n c o n o c o th6 c h o p h e p sir d u n g d a n c o an toan va biet d u g c d a n c o ton d g n g sau phdu thuat

5 C a p n o g r a p h i e

N gu d i ta sir d u n g m a y n a y de do n o n g do C 0 2 t r ong he t h o n g ga y me N o la

1 p h u o n g tien k h o n g the th ay the d u o c de diSu c h i n h c h e do t h d phu hop,

t rong khi P a C 0 2 th ay ddi do b o m C 0 2 lam ta ng a p lire t r o ng 6 b u n g A p lire

r ieng pha n c u a C 0 2 t rong khi t h o ra (P|.T C 0 2 ) c u n g c o the s u y ra P a C 0 2

T r o ng thuc te P, , C 0 2 k h o a n g 30 m m H g la mo t c o n so c o the: c h a p n h a n duoc

Su c h e n h lech gi ua P a C 0 2 va P n C 0 2 da d u o c n g h i e n curu va x ac d inh khi

m d noi soi N h u n g t ha y doi chi so V a / Q do thay ddi a p lire t r ong o b u n g va

tu the da lam tha y doi sir c h e n h lech c u a P a C 0 2 va P h;, C 0 2 , g an d a y

B r a mp to n va W a t s o n d a chuTig m i n h s u k h a c n ha u phu t h u o c v a o ky t huat g3y me ( me toa n the’ h o a c te ngoai m a n g c u n g ) Vdi n h u n g y e u to c o m a c h

t rong m d c u n g c o the t ha y ddi gia tri c u a C 0 2 t hd ra c u n g n h u ha n c h e sir tai hap thu

Tr u dc moi tha y doi vS h uy et d o ng , sir ta ng P, , C 0 2 la mo t da u hieu s d m c u a tac m a c h do khi

6 C a c trirong h o p d a c biet

Dd i vdi t r u o n g h o p d u n g m o n i t o r c o dat c a t h e t e r ( c a t h e t e r Swan G a n z ) co the ly giai tinh t r an g h uye t d o n g k h o n g dn dinh, c o the’ ma t bu t r o n g t r u o n g

ho p m d noi soi do di6u kien tran khi' m a n g b un g ( g i am t rd v i c u a m a u tTnh

ma c h , g i a m luu lu on g tim va tang sue c an m a c h m a u he t h on g )

VI- KY THUAT GAY M E, GAY TE CHO MO NOI SOI

1 l ien me

- C h o n g non', c h o t h u oc c h o n g non va b u o n n on t r o ng m o noi soi la rat la rat c o y nghTa vi ty le b e nh n h a n non va b uo n n on sau m d c a o , theo Bailey, ti le n a y c h i e m 6 2 % c o n c h u n g toi ga p 3 2 % Sir d u n g a t r op i n

s u n f a t t ro n g tiSn m e da han c h e non va b ud n non sau md N eu sau m o vdn c o n b u o n non, n on thi c h o tiep a t ropi n sulfat t iem du di d a (co the

g i a m 5 0 % ) N h u n g c o the’ lam k h o m o m , n h i n kho N eu vdn n o n k e o dai

c an n g h i e n c u u c o the thiing d u d n g tieu hod

- C h o n g to an: vdi n h u n g b e nh n ha n m d co c h u a n bi thi van dS n a y it q u a n

t r on g h o n b e nh n h a n m d c a p ciifu, c h u n g ta co the c h o natri ci tra t 0 , 3 M ket h o p vdi c i m e t i d i n h oa c r a nitidin de d u p h o n g hoi c h u n g M e n d e l s o n

M a r c h i va c o n g sir d a c h u n g m i n h sir c h o n g to an t ru d c khi k h d i m e se lam t a n g pH c u a di ch vi m o t c a c h c h a c c h a n va k eo dai

2 G a v te v u n g

Chu yeu t h uc hi en t ro n g noi soi c h a n d o a n va phdu t hu a t d u d n g tieu hod

M o t so c o n g trinh n g h i e n c uu da ggi y mc> noi soi c o thS d u g c t h u c h i e n dudi g ay te vung K y t hu at n ay lam c h o b e n h n h a n k h o c h i u do C 0 2 g a y da u

kich thfch c a h o a n h va ret run t r ong mo V a lai su p h o n g be' d o g a y te n g oa i

m a n g c u n g c a o (T2 - T4) c o the ga y urc c he tim va lam n a n g t h e m sir g i a m

m a u tinh m a c h tro v<§ do ta ng hieu lire c u a 1 so tac d u n g k h o n g tot khi b o m

C 0 2 vao k h o a n g b u n g T u y n h i e n C i o f o l o va c o n g sir k h o n g tim t h a y sir thay doi ho hap co y n ghla dudi gay te ngoai ma n g c u ng trong phau thuat phu khoa

Te vu ng co the lam c h o tinh t ra n g b en h n h a n sau m d t hu an lgi h a n , t ra n h

d ug c nhurng hau q u a v6 ho ha p m a t r ong gay m e toan the t h u o n g gap

3 (Jay me t oa n the

3.1 Mot so van de can hcu y

- Vdi gay m e m o noi soi, c h o t h u o c m e phai du de t ra n h c ac k i c h thich gay p ha n xa k h o n g c o lgi

- T r o ng ga y m e phai dat o n g noi khi q u a n va ho h a p dieu k h i e n b a n g c a c h

c ho t huoc d an c a d ay du T r o n g m o noi soi phu k h o a va tieu h o a tang

th o ng khi do t a n g the tich khi luu t h o n g de d u p h o n g t a n g C 0 2

F l et c he r va J o n s o n c h u n g m i n h r ang the tich khf luu t h o n g ldn se t h u a n lgi

c h o sir k h u y e c h tan o x y hon la the tfch nho C ac chi so k h a c n h u tan so ho

ha p va ti le hit v a o / t h d ra (I/E) phai d u g c dieu c h i n h c5n than de t r a n h t an g

q u a mure ap luc d u d n g thd, co the ga y c h a n t h u o n g do e p va k h o n g tot c h o

h u y et d o ng Vi tri o n g noi khi q u a n phai d u g c k i e m tra moi khi t h a y ddi tu the b en h n ha n va sau b a m C 0 2 d b un g

Ne n dat on g hut da d a y sau khi dat o n g noi khi q u a n va t r u d c khi c h o c trocart de d u p h o n g c h o c t h u n g da d a y c a n g d o di ch ur d o n g va khi ho h a p bdng mat na luc khdi me D e tranh ho h a p b a n g mat na c o the c h o t h d o x y 100% hit sau 5 lan t rudc khi tiem t h u o c me

- D at o n g t h o n g b a n g q u a n g c h o nhurng phdu t hua t t r o ng tieu k h u n g v a m d lau

- D a t b e nh n h a n d tu the T r e n d e l e n b u r g c h o m d v u n g tieu k h u n g

- M d noi soi " N g u y e n tac 15 - 15" d u g c ton t r on g (ap luc o b u n g

15 m m H g ; tu the dau thap 15°)

3.2 Cdc loai thuoc me, ddn co, giam dau dung cho gay me

T h u o c m e

- T h u o c d u g c Ua d u n g n h a t hien n a y la p r o p o f o l ( D i p r i v a n ) t h u o c n a y c o tac d u n g tot, tinh n h a n h va khi tinh thi h o a n t o a n thoai m a i ne n n o la

t h uo c me ly t u d n g c h o n g o ai k h o a noi c h u n g va m d noi soi noi r ie ng

- T h u o c me hoi n h o m h a l o g e n c u n g h a y d u g c s u d u n g n h u h a l o t h a n ,

is oflura n

H a l o t h a n co tac d u n g d u y tri m e t h u a n lgi, m e m c a va ha h u y e t ap N h u n g

no lam loan n h i p tim khi c o t a n g C 0 2 N g u y c a k h u y e c h t an m a n g phdi ha y

t r un g that c u a C 0 2 va tac m a c h , yeu c au t h e o ddi c a n t ha n khi d u n g vdi N 20

t r on g noi soi

N h u n g n g h i e n c uu thuc n g h i e m d sue vat da so s anh s u tac m a c h do C 0 2

t rong khi th on g khi vdi hon h op 0 2/ N 20 va 0 2/ khf da c h u n g m i n h r i n g sir

d u n g N 20 lam n a n g them n h u n g hau q u a tim m a c h ho hap Khi nghT d e n tac

T r o n g duy tri me, c an su d u n g t huoc me, g i a m dau, da n c o du lieu tra nh

be nh nh an thuc tinh t r on g q u a trinh phau thuat

4 T h o i ky sau mo

4.1 S u tinh tluidc (thodt me)

- Da t be nh n h a n trd lai tu the n i m n g u a t h a n g b a ng roi t h a o d an C 0 2

t rong o b u n g m o t c a c h tu tu

- Can me du sau c h o de n khi tha o C 0 2 o bung

- Doi khi c an d u y tri o n g noi khi q u a n va t h o n g khf t ro ng p h o n g hoi tinh de’ d§ p h o n g g i a m 0 2 va tang C 0 2

- T r uy tim m a c h va bat t h u d n g ve than kinh co the la dau hieu c u a tdc

m a c h do C 0 2 bieu hien m u o n ( m o n i t o r ) tim m a c h va ho h ap phai d u o c

d u y tri c h o de n khi b e nh nh an tinh tao hoa n toan

- Su n g u n g t h d phai nghi de n t i c m a c h khi, tran khi m a n g phdi , tran khi

t rung that bieu hi en m u o n

4.2 IIau qu a va hien chung sau mo:

Buon non, non:

N g o a i c a c ye u to n g u y c o vdi tat ca c a c phau thuat (tudi, nu, b e o be u, me t moi, lo lang, liet da day, loai ph au t huat ) ne u de o n g hut da d a y se lam tang n g u y co' n on , b u o n non, co the d u p h o n g b i n g c h o t h u o c c h o n g non

t rong tien me , c a c h g a y m e va d i l u tri sau mo

Chi'nh s u d u n g t h u o c p r o po f ol han c he d u o c non, b u o n n o n sau m 6 n g a y c a khi sir d u n g ket h o p N 20 , sir d u n g p r op of ol t r ong g a y m e ket h o p vdi t h u o c

g i a m dau phi s t er oi d ( AI NS ) sau m o da han c h e m o t c a c h d a n g ke n o n va

b uo n n o n sau m d E p h e d r i n 0,5 m c g / k g tiem tinh m a c h t r o ng m 6 da c o hieu

q u a c h o n g n o n sau m d va k h o n g co tac d u n g phu Sir k e o dai c u a n o n va

b u o n n o n sau m d c u n g c an tim ton t h u o n g da day, ruot, ne u c a n thiet phai

c an thiep n g oa i k ho a

Dau: sau mo, b e nh n h a n c o dau 6 bung, vai, ba vai do C 0 2 kfch thi'ch p h u c mac, be nh n h a n da u n hi eu hon d vai trai do C 0 2 len cao D a u sau 6 c o q u a n

md, dau it hon d d i e m c h o c

Can phai c h o b e nh n h an t h u o c g ia m dau dac biet ho m o r p h i n ( f e n t a n y l Pethidin, alfe nt ani l .) rat c o y nghTa t rong m o noi soi M ot so n g h i e n cuu thay dau co the g i a m sau m d neu c h o trudc va sau m d c a c A I N S n h u

d i c lo fe n ac , i n d o m e t h a c i n , n a p r o x e n T u y n h i e n sir d u n g c a c A I N S thi ft t ho a

m a n t rong m d phu k ho a, c h o t h uo c me tai c h o lam g i a m mo t c a c h c o y nghia nhu cau g i a m da u sau md

Haii qua ho hap:

Nhieu tac gia k h u y e n c h o g i a m dau s dm va thich h o p sau m d n h a m lam gia m n g u y c o ve ho h ap va b e nh tac m a c h , nh at la n h u n g n g u d i be o beu

5 Ich loi c ua m o noi soi

- Sau mo noi soi, benh nhan ft dau hon so vdi md thong thudng do seo be

- La p h u o n g p h a p m d m a n g tinh t h a m m y do seo be

- Ty le dfnh, tac ruot sau m o rat thap, c h o p h e p b en h n h a n an u o n g trd lai sdm

- So n ga y n a m vien g ia m so vdi p h u o n g p h a p m o cd dien

- Hoa t d o n g n g h e n g h i e p s dm trd lai

N h u n g tien loi n a y dac biet d n gu di c o thai, beo beu

V II- KET LUAN

P h u o n g p h a p m d noi soi noi c h u n g va t rong phu k h o a noi r ie n g c o n t u o n g ddi mdi so vdi c a c p h u o n g p h a p m o k h a c x o n g no da dat d u o c n h i e u t h a nh tUu d a n g ke t r ong giai d o a n vua qua T u y no c o p h u c tap h on vS t h e o d o i v a xir trf t rong m o so vdi c ac p h u o n g p h a p m o t h o n g t h u d n g x o n g ve d ie n bien sau md lai d on gian hon No c o rat nhi eu Uu d i e m d u o c c a c n h a k h o a hoc

c o n g n h an x o n g c a n phai c o trang thiet bi hien dai, c o doi n gu phdu t huat vien va ga y m e hoi sue co trinh do c a o, c h a c c h a n c h u n g ta se thu d u o c

3 E d w a r d s ND , Bar clay K, Cat ling S.l et al Da y c a se l a p a r o s c o p y : a s u r v e y

o f p os t o p er a t i v e pain a nd an a s s e s s m e n t o f d i c l o f e n a c A n a e s t h e s i a ,

1991, 46: 1077 - 1080

4 For rest IB, Beattie WS G o l d s t e i n CH Risk factors for n a u s e a a n d

v o mi tt i ng after ge ner al a n ae s t h es i a Can J A n a e s t h , 1992, 39 - S90

5 F r oe se AB Bryan A C - Ef fe ct s o f a n e s t h e s i a a nd p a r a l y s i s on

d i a p h r a g m a t i c m e c h a n i c s in ma n A n e s t h e s i o l o g y 1974 ; 41 2 4 2 - 55

6 G u n a w a r d e n e RD, W h i t e DC Pr opofol a nd e m e s i s A n a e s t h e s i a 1988, 43 ( s u p p l ): 65 - 67

1991, 72: 58 - 61

16 Sc h oe f f l e r p , H a b e r e r JP M a n h e s H, et al - R e p e r c u s s i o n s c i r c u l a t o i r e s

et v e n t i l a t o i r e s de la c o e l i o s c o p i e c h e z 1'obese A n n Fr A n e s t h R e a n i m 1984; 3: 1 0 - 5

KY THUAT CU BAN TRONG NO! SOI 0 BUNG

N g u y e n D u e Hinh

T r o n g pha n nay, c h u n g toi trinh b ay n h u n g ky t huat c o ban t h u c hi en thuc hien t rong q u a trinh noi soi vl bat ky chi dinh nao, du n h i m m u c dfch c h u i n

d o a n hay phdu thuat

I- TIT THE NGirm BENH

T u the n gu oi b e n h rat q u a n t r ong t rong q u a trinh noi soi vi c h o p h e p ph au thuat vien d i d a n g thuc hien c a c tha o tac, g o p p ha n g i u p c h o tien trinh noi soi d i l n ra t h u a n loi

C h u n g toi tha y m ot so d i e m q u a n t rong c an luu y ddi vdi tu the n g u d i b en h:

• Hai c h a n duoi t h i n g , d a n g r ong, m o n g n g u d i b e nh de’ n h o ra n g o a i m e p ban Hai c h a n duoi t h i n g se k h o n g lam c a n t r d c a c d o n g tac c u a p ha u thuat vien, k h o n g c a n trd khi c a n lay b e n h p hd m ra khoi t ro c a r t 1 1 d ron

Ch an d a n g r o n g va m o n g de n h o ra khoi m e p ban g i u p c h o t h a y t h u o c co the c hu d o n g t h a y doi tu the tu c u n g , b o m x a n h m e t h y l e n , lam thu thuat

q u a d u d n g a m da o

• Bang q u a n g l uon luon d u o c dat o n g t ho ng

• Hai tay n gu di b e n h nen dat d oc t he o than ho de tra nh c a n g g i a n q u a mure

d a m roi than k inh c a n h tay va t ra n h c a n trd ph au t hua t vien t r o n g luc

mo M u o n dat d oc c a n h tay th eo than ng ud i b e n h c a n c o he t h o n g do

h u ye t a p tu d o n g ( m o n i t o r ) va b d tri d a y t r u y e n c h o that h o p ly

• K h u n g d d vai tren dau ng u di b e nh ne n dd t h a p va lui toi d a vd phfa d i u ngudi b e n h , ne u k h o n g se c a n trd c a n h tay didu k h i e n d e n soi c u a p h au thuat vien

T r o n g tu the na y, phdu t h ua t vien c o thd th uc hi en c a c t h a o tac rat de d a n g

va t hu an l a i C h u n g ta l uon l uon ghi n h d r i n g dat n g u d i b e n h d u n g tu the la rat q u a n trong M o t khi dat ng u di b e n h k h o n g d u n g tu the, t r o ng luc p ha u

t hu at g ap k h o k h a n thi k h o n g de gi dieu c h i n h lai d u g c tu the c u a n g u d i

b e n h va se c o a n h h u d n g s uot c a c u o c p h i u thuat

II- Vj TRI CUA PHAU THUAT VIEN VA M A N HINH

T h o n g t h u d n g , p h i u t hua t vien durng phfa b en trai c u a n g u d i b e n h T r g thu thu' nhat d u n g ddi d i e n vdi p h i u t hu at vien, d phfa b en phai c u a n g u d i b e n h

T r g thu vien t hu hai durng g i ua hai c h a n c u a n g u d i b e n h , c o vai trd didu

c h i n h tu the c u a tu c u n g g i u p c h o p h au t hu at vien Vai trd n g u d i t rg thu thur hai na y d ac biet q u a n t r o n g khi tien h a n h cat tur c u n g q u a noi soi D u n g cu vien durng c u n g ben vdi p ha u t hua t vien va hoi lui ra sau