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Ph?u thu?t n?i soi ?i?u tr? ch?ng ra m? hi tay

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  1. Ph??ng php xm nh?p t?i thi?u ny lm gi?m ?ng k? nh?ng tai bi?n, bi?n ch?ng h h?p sau m?, lm gi?m r r?t nh?ng trng ph?i, rt ng?n th?i gian n?m vi?n.
  2. Cho php quan st r rng nh?ng c?u trc c? th? h?c v?i di?n ti?p c?n r?t g?n. Ngoi ra, do quan st trn mn hnn nh?ng thnh vin khc trong kp m? ??u c th? th?y r, r?t t?t trong hu?n luy?n.
  3. Rt ng?n th?i gian m? v gy m do bc s? ph?u thu?t m?t r?t t th?i gian cho vi?c m? v ?ng v?t m?.
  4. L t??ng ??i v?i nh?ng b?nhn c r?i lo?n ?ng mu nh? nh? ???ng r?ch t?i thi?u.
  5. Vi?m gan v ngy nay l AIDS ?ang l v?n ?? ngy cng ???c quan tm nhi?u h?n, nh?t l cc nhn vin y t?. Ph?u thu?t l?ng ng?c qua ng? n?i soi l m?t k? thu?t khng ??ng ch?m s? gi?m nguy c? ly nhi?m.
  6. t ?au sau m?
  7. Tnh th?m m? cao.

N?u t?ng ti?t m? hi nhi?u, nh?t l ? bn tay s? ?nh h??ng nhi?u ??n lao ??ng, sinh ho?t, giao ti?p trong x h?i, tm l c?a ng??i b?nh. C?t th?n kinh giao c?m s? lm gi?m s? bi ti?t m? hi ? ph?n c? th? t??ng ?ng nh?ng c th? lm t?ng ?? m? hi ? n?i khc, g?i l t?ng ?? m? hi b tr?.

Ch?ng t?ng ti?t m? hi tay c th? ???c ?i?u tr? b?ng cc ph??ng php sau:

- ?i?u tr? n?i khoa: dng thu?c ch?n beta, dn m?ch ngo?i vi v thu?c ch?n knh calci. ?i?u tr? n?i khoa th??ng khng mang l?i hi?u qu?.

- H?y h?ch giao c?m b?ng huy?t thanh nng hay ha ch?t.

- Ph?u thu?t c?t th?n kinh giao c?m ng?c.

- Ph?u thu?t c?t th?n kinh giao c?m ng?c qua ng? n?i soi.

C nhi?u ???ng m? kinh ?i?n ? ???c s? d?ng, nh?ng nhn chung ??u c nh?ng b?t l?i. ???ng m? trn x??ng ?n kh kh?n do c nhi?u c?u trc quan tr?ng ? vng c?. ???ng m? pha sau, tr?c ti?p nh?ng ph?i c?t m?t ph?n x??ng s??n v gy ?au h?u ph?u. ???ng m? vo ng?c cho php quan st tr?c ti?p nh?ng ph?i ch?u nhi?u tai bi?n, bi?n ch?ng c?a m? ng?c.

Ph?u thu?t c?t th?n kinh giao c?m ng?c qua n?i soi

Trang thi?t b?

Trang thi?t b? l t??ng l b? d?ng c? ph?u thu?t n?ng ng?c qua ng? n?i soi. Tuy nhin c th? t?n d?ng d?ng c? s?n c c?a ph?u thu?t n?i soi ? b?ng v?i m?t s? d?ng c? thm vo: trocar ng?c, cy p ph?iCc tc gi? Israen ? s? d?ng trang thi?t b? ph?u thu?t c?t ti m?t qua ng? n?i soi km trocar ng?c ?? ti?n hnh ph?u thu?t c?t th?n kinh giao c?m ng?c qua ng? n?i soi

Ch?n l?a ph??ng php v k? thu?t ?i?u tr? ngo?i khoa

Hi?n nay ? c nhi?u bi bo, nhi?u h?i ngh? v? ph?u thu?t n?i soi l?ng ng?c s? d?ng mn hnh, trong ? c ph?u thu?t c?t th?n kinh giao c?m l?ng ng?c qua ng? n?i soi ?? di?u tr? ch?ng t?ng ti?t m? hi tay.

?i?u tr? ch?ng t?ng ti?t m? hi tay b?ng n?i khoa t? ra khng hi?u qu?. Ph?u thu?t c?t th?n kinh giao c?m ng?c kinh ?i?n mang l?i hi?u qu? t?t song qu n?ng n?, nhi?u bi?n ch?ng khng ph h?p v?i m?t ch?ng b?nh hi?n lnh. Ph?u thu?t c?t th?n kinh giao c?m qua ng? n?i soi ???c ch?n l?a v?i m?t t? cch l m?t ph?u thu?t trung gian c s? xm nh?p t?i thi?u, k? thu?t l?i ??n gi?n nh?ng hi?u qu?. Hnh ?nh chu?i h?ch giao c?m ng?c ???c nh?n ??nh d? dng nh? s? ti?p c?n r?t t?t c?a camera v hnh ?nh phng ??i ln mn hnh. V th? ph?u thu?t c?t th?n kinh giao c?m ng?c qua ng? n?i soi l ph??ng php ???c l?a ch?n ?? ?i?u tr? ch?ng t?ng ti?t m? hi.

Ph??ng php v c?m

Gy t t?i ch?, Guerin ? b?nh vi?n La Groix-Rousse, Php ? dng ph??ng php t t?i ch? ?? n?i soi l?ng ng?c v ph h?y h?ch giao c?m b?ng phenol. Theo ki?n c?a m?t s? tc gi?, t t?i ch? ch? nn s? d?ng cho nh?ng th? thu?t nhanh nh? soi l?ng ng?c ch?n ?on, m? khoang mng ph?i trong lc ti?n hnh ph?u thu?t c th? gy nn tnh tr?ng l?c l? trung nh?t ? nh?ng b?nh nhn th? t? . Tnh tr?ng ny c th? gy nn r?i lo?n trao ??i kh n?ng n?.

M ton thn v v?n ?? gy x?p ph?i

Gy m gin n?, th? my, ??t n?i kh qu?n 1 hay 2 nng l ph??ng php v c?m th??ng ???c l?a ch?n. Vi?c lm x?p hon ton m?t bn ph?i l b?t bu?c trong ph?u thu?t n?i soi l?ng ng?c nh?m quan st t?t v ti?p c?n ???c t?n th??ng. Ph?i ???c lm x?p b?ng cch dng ?ng n?i kh qu?n hai nng (carlens) ho?c b?m CO2 vo khoang mng ph?i c th? gy nn tnh tr?ng trn kh mng ph?i c p l?c v gy nn cc cc bi?n ??i nghim tr?ng c?a h? tim m?ch t??ng t? nh? s? h?p thu CO2, ton thn gy nn t?ng CO2 mu. Tai bi?n b?m CO2 vo m?ch mu c th? gy nn thuyn t?c kh nhi?u kh? n?ng d?n ??n t? vong. Cc c?u trc gi?i ph?u trong l?ng ng?c nh? m?ch mu l?n, ph?i, tim c th? b? t?n th??ng do cc thao tc trong lc m?. V th? m?t s? tc gi? ch? tr??ng khi b?m CO2 nn cho t?c ?? b?m khng qu 2,5 lt m?i pht v p su?t th?p h?n 10mm Hg. Trn kh mng ph?i c p l?c v thuyn t?c kh l tai bi?n c th? g?p khi b?m CO2 v th? c?n h?t s?c ch nh?t l khi b?nh nhn h? huy?t p ??t ng?t trong khi ?ang c ch?y my v b?m CO2.

?ng n?i kh qu?n hai vng cho php ti?n hnh thng kh ch?n l?c m?t bn ph?i trong khi ph?u thu?t, ??ng th?i gy x?p ph?i bn kia. ?ng ny cn cho php ki?m tra x kh bn kia ph?i ?ang ???c ph?u thu?t. V v?y c?n ph?i cch ly hon ton hai ph?i. V? tr ??t ?ng n?i kh qu?n ph?i th?t chnh xc. C th? s? d?ng ?ng soi ph? qu?n m?m ?? ki?m tra v? tr c?a ?ng n?i kh qu?n hai nng sau khi s?t.

? cc b?nh nhn n?u b? gi?m oxy trong mu khi ti?n hnh thng kh ch?n l?c m?t bn ph?i, c? th? t?ng oxy trong kh th? vo ??n 1,0. C?n ph?i lo?i tr? b?t th??ng c?a ph?i ???c thng kh vo cc tuy?n nguyn nhn khc c th? gy ra gi?m oxy trong mu nh? thng kh, gi?m phn p oxy trong kh th? vo, n?i n?i kh qu?n b? di l?ch hay b? t?t. T?i ?u ha cung l??ng tim b?ng cch duy tr ??y ?? th? tch trong lng m?ch.

?i khi h? oxy mu c? th? ???c c?i thi?n b?ng cch b?m oxy vo bn ph?i x?p, ?i?u ch?nh th? tch khi l?u thng v s? d?ng p l?c d??ng cu?i k? th? ra ? bn ph?i ???c thng kh. C th? dng Dobutamin li?u th?p. C th? s? d?ng p l?c d??ng trong kh ??o bn ph?i x?p v?i oxy (gip ph?i n? tr? l?i) ?? c?i thi?n ?? bo ho oxy trong mu ??ng m?ch trong khi c?n thi?t. Tuy nhin ph??ng php ny c th? lm ph?i x?p n? ra m?t ph?n lm ph?u thu?t kh th?c hi?n.

Cc thi?t b? sau ?y c?n c cho m?t cu?c gy m n?i kh qu?n: my phn tch kh CO2, my theo di p l?c kh ??o, my ?o c??ng ?? dao ??ng t? ??ng, my ?o O2 mu ??ng m?ch, my theo di l??ng CO2cu?i k? th? ra, my kch thch th?n kinh ngo?i vi.

T? th? b?nh nhn

Ph?u thu?t xm nh?p t?i thi?u th??ng ?i h?i t?n d?ng t?i ?a t? th? b?nh nhn ?? ph?i by c?u trc gi?i ph?u m?t cch r rng nh?t.

- N?m nghing: l t? th? ?p ?ng ???c cc yu c?u trn. T? th? ???c ?? ngh? nhi?u nh?t l n?m nghing v g?p gc 30 ??. ?? m? r?ng cc kho?ng lin s??n t?o ?i?u ki?n vo khoang mng ph?i d? dng nh?t. Cnh tay c?a b?nh nhn ?? t? th? g?p v ??a ln trn ?? b?c l? hm nch. Camera ???c ??t vo khoang lin s??n t?o ?i?u ki?n vo khoang mng ph?i d? dang nh?t. Cnh tay c?a b?nh nhn ?? t? th? g?p v ??a ln trn ?? b?c l? hm nch. Camera ???c ??t vo khoang kin s??n 6 trn ???ng nch sau. Bc s? ph?u thu?t ??ng ? pha b?ng b?nh nhn. Cc trocar ph? ???c ??t d?c ???ng nch t? khoang lin s??n 2 ??n 4. C th? cho nghing bn m? v ?u cao ?? ph?i d?n xu?ng th?p theo tr?ng l??ng. b?ng cch ny theo kinh nghi?m c?a tc gi? H?ng Kng c th? ti?n hnh ph?u thu?t m khng c?n ??t thm b?t c? trocar no thm ?? p ph?i

-N?m s?p: theo kinh nghi?m c?a cc tc gi? Israel b?nh nhn n?m s?p k g?i d??i ng?c, hai tay dang ngang, dng 2 l? trocar. Camera ???c ??t ? khoang lin s??n 5-6 ???ng ngch sau, m?t trocar nh? ??t d??i m?m vai ch? dng ?? ??t, ph h?y h?ch giao c?m s? 2 ho?c 3 ho?c 2 v 3. T? th? ny c th? ti?n hnh cho c? hai bn.

- T? th? n?m ng?a: theo kinh nghi?m c?a B?nh vi?n kanazawa, Nh?t B?n, b?nh nhn ???c ??t ? t? th? n?a ng?i v?i gy hn m ton thn b?ng ?ng n?i kh qu?n m?t nng ???ng r?ch ra 1cm ? khoang lin s??n 3 ???ng nch tr??c. V gy x?p ph?i b?ng b?m 1,8 lt CO2 qua 1 kim ch?c d ? vng ??nh ph?i.

-T? th? n?m ng?a: William lohn Byrne (Anh) ??t b?nh nhn n?m ng?a, m ton thn v?i ?ng n?i kh qu?n hai nng. Hai tay b?nh nhn du?i th?ng m?t gc 90 ??. V?i t? th? ny gy m d? dng ??t cc d?ng c? ?? theo di huy?t p, ?i?n timB?m kh CO2 v?i th? tch 500ml b?ng kem Veress ???c ch?n l?c vo khoang lin s??n 4 ???ng nch d??i. Sau khi gy m cho x?p bn ph?i t??ng ?ng v ch? thng kh m?t bn ph?i cn l?i, bc s? ph?u thu?t s? r?ch m?t ???ng nh? ? khoang lin s??n 4, ???ng nch tr??c ?? ??t camera. B?m thm CO2 ?? lm x?p ph?i thy trn. M?t ???ng r?ch khc ? ???ng trung ?n. Cu?c m? ???c ti?n hnh t?ng bn m?t lc v?i t? th? ny, khng c?n xoay tr? b?nh nhn.

M?t s? nguyn t?c k? thu?t

V? tr ???ng r?ch da ?? ??t ngu?n sng (camera) kh?i ??u trn khoang lin s??n h?i l?ch ra sau v xu?ng d??i gip chng ta ??nh h??ng ???c c?u trc trong khoang l?ng ng?c. ph?u tr??ng ny gi?ng v?i ph?u tr??ng m? l?ng ng?c qua ???ng m? sau bn tiu chu?n.

Ty thu?c vo lo?i ph?u thu?t, c th? ch?n thm v? tr ?? r?ch 1, 2,3, l? ?? ??a d?ng c? vo l?ng ng?c cho chnh xc. Landreneau v c?ng s? ??a ra m?t s? nguyn t?c sau:

-Nh?ng Trocar nn ?? cch t?n th??ng m?t qung ?? c kho?ng tr?ng cho cc thao tc.

- Trnh ???c cc d?ng c? qu g?n nhau do lm c?n tr? thao tc l?n nhau.

- Trnh hnh ?nh ??i x?ng g??ng do ??t cc d?ng c? v ?ng knh soi cng m?t gc 180 ??, ngh?a l ngu?n sng v d?ng c? ti?p c?n t?n th??ng cng m?t h??ng.

-Thao tc d?ng c? v my quay hnh ?nh nn theo th? t? h?n l cng m?t lc. Cc d?ng c? ch? ???c thao tc khi nhn th?y tr?c ti?p.

Cc bi?n ch?ng c th? g?p

Theo ghi nh?n c?a cc tc gi? ?i Loan cc bi?n ch?ng c?a c?t th?n kinh giao c?m ng?c qua ng? n?i soi theo th? t? th??ng g?p l:

-Hi?n t??ng ?? m? hi b tr? t? 21%-70% ty bo co. Sau khi m? hai bn tay b?nh nhn kh nh?ng nh?ng vng khc c?a c? th? nh?t l thn mnh v hai chn l?i t?ng ti?t m? hi.

-Trn kh mng ph?i: Plas v Fugger ? o ghi nh?n c 2,7% tr??ng h?p trn kh mng ph?i l??ng nhi?u c?n ph?i d?n l?u, 4,4% tr??ng h?p trn kh mng ph?i vng ??nh l??ng t, khng c tri?u ch?ng, khng c?n can thi?p.

-Trn kh d??i da chi?m kho?ng 2%.

-Trn d?ch, trn mu mng ph?i chi?m 0.1-1%.

- X?p m?t phn thy ph?i chi?m 0,4%.

-?au sau m?: hi?n t??ng ?au sau c?t th?n kinh giao c?m (Postsympatheitc neuralgia) th??ng x?y ra ? th?n kinh giao c?m l?ng h?n giao c?m ng?c. hi?n t??ng ?au ny th??ng x?y ra do s? t?ng tnh nh?y c?m c?a th?n kinh ngo?i vi vng da ln c?n (vng khng c?t) ??i v?i cathecolamy. ?i?u tr? b?o t?n t? 3-6 tu?n cc tri?u ch?ng s? h?t. Thu?c ???c dng: Phenytoin sodium (Dilatin), Carbamazepine (Tegretol), nh?ng ch?t ch?n kn calci (Litwin 1962).

-H?i ch?ng horner: cc bo co g?n ?y cho th?y h?i ch?ng horner g?n nh? khng x?y ra v?i k? thu?t c?t th?n kinh giao c?m ng?c qua ng? n?i soi. Ng??c l?i t? l? c h?i ch?ng horner r?t cao khi ph?u thu?t c?t th?n kinh giao c?m ng?c kinh ?i?n. H?i ch?ng horner l h?u qu? c?a t?n th??ng cc s?i giao c?m xu?t pht t? C7 v C8 (ph?n trn c?a h?ch sao b? c?t b?). H?i ch?ng horner bi?u hi?n b?ng cc tri?u ch?ng : ??ng t? co nh?, m?t th?t vo, s?p mi, ?? m?t cng bn, v m?t s? bi ti?t m? hi vng t??ng ?ng.

?nh gi k?t qu? ?i?u tr?

? nh?ng trung tm ph?u thu?t n?i soi l?n c ?? ph??ng ti?n, trang thi?t b?, c th? ?nh gi hi?u qu? nh? sau:

- Theo di l?u l??ng mu ??n bn tay b?ng my Doppler m?ch mu: l?u l??ng mu s? t?ng khi h?ch giao c?m ???c c?t b? hon ton.

- Theo di nhi?t ?? c?a da b?ng my: nhi?t ?? vng da t??ng ?ng s? t?ng h?ch giao c?m ???c c?t b?.

V? m?t lm sng c th? ?nh gi theo cc tiu chu?n c?a William John Byrne (ti khm m?t tu?n sau m?, r?i m?i thng m?t l?n):

-K?t qu? t?t (c?i thi?n nhi?u): tay kh, t?ng ti?t m? hi b tr? t, b?nh nhn th?a mn v?i k?t qu? ?i?u tr?.

-K?t qu? trung bnh (c?i thi?n t): tay kh h?n so v?i tr??c m? nh?ng b?nh nhn ch?a hi lng v?i k?t qu? ?i?u tr?.

-Khng thay ??i: tnh tr?ng t?ng ti?t m? hi tay khng thay ??i so v?i tr??c m?.

-K?t qu? x?u: khi c m?t trong nh?ng bi?n ch?ng sau:

1.t?ng ti?t m? hi b tr? qu nhi?u l b?nh nhn than phi?n hay ng??c l?i tay qu kh.

Cc v?n ?? ?ang nghin c?u

M?t trong nh?ng bi?n ch?ng th??ng g?p nh?t c?a ph?u thu?t c?t th?n kinh giao c?m ng?c ?? ?i?u tr? ch?ng t?ng ti?t m? hi tay l tnh tr?ng t?ng ti?t m? hi b tr?. Tr??c dy c?t th?n kinh giao c?m ng?c chu?n m?c ?? ?i?u tr? ch?ng t?ng ti?t m? hi tay l c?t b? chu?i th?n kinh giao c?m v cc h?ch giao c?m ng?c 1,2,3 (c?t b? 1/3 d??i h?ch sao) (Urchel v Rajjuk, 1986) v?i cch ny t? l? t?ng ti?t m? hi b tr? kh cao. V th? m?t s? tc gi? ch? tr??ng nn c?t cc nhnh thng n?i ch?n l?c. Kinh nghi?m c?a cc tc gi? ?i Loan, ch? k?p ( Clip) ?? ch?n chu?i giao c?m ? T2. Kinh nghi?m ? b?nh vi?n Bnh Dn ch? c?n h?y thn giao c?m ?o?n T1-T2 v T2-T3 l ??. Nhn chung c nhi?u bi bo v? k?t qu? ?i?u tr? v?i bi?n ch?ng t?ng ti?t m? hi b tr? c lin quan t?i v? tr v s? l??ng c?a th?n kinh giao c?m ???c l?y ?i nh?ng v?n ch?a th?ng nh?t. Vi?c h?y, ch?n th?n kinh giao c?m c?ng c nhi?u cch: ??t ?i?n, laser, my ??t nhi?t pht ra t?n s? sng radio, dng ha ch?t (phenol) hay k?p b?ng clip.

Nn ?i?u tr? s?m ch?ng t?ng ti?t m? hi tay n?ng ? tr? em b?ng cch ph?u thu?t c?t th?n kinh giao c?m ng?c qua ng? n?i soi nh?m trnh ???c nh?ng b?t l?i v? m?t th? ch?t, quan h? x h?i v tm l trong su?t qu trnh tr??ng thnh v pht tri?n.

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