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PHU THUT TUYN GIP BNG K THUT NI SOI MT S NHN XT V K THUT V CH NH M

Trn Ngc Lng,Trn on Kt T Vn Bnh v Cs Bnh vin Ni tit Trung ng Tm tt Phu thut tuyn gip bng phng php m m truyn thng i hi phi rch 1 ng ngang qua c trc v phi ct c bm da c i vo tuyn gip. ng m ny li mt vt so khng mong mun c bit i vi ngi tr. Phu thut tuyn gip bng k thut ni soi t tn thng cho php ct tuyn gip khng li so nh phng php m m. Mc tiu: Nhm nh gi k thut m v kt qu bc u ca phng php. i tng: Nhng bnh nhn c bnh tuyn gip c ch nh m loi tr nhng trng hp bu qu ln, ung th, cng gip ang iu tr, bnh Basedow cha c chun b ni khoa tt v bu 2 thu nhng khng khu tr 1 cc ca thu, m trc vng c. Phng php: Nghin cu tin cu. + Nghin cu lm sng, cn lm sng nhm la chn bnh nhn, nh hng cch phu thut trc m. + K thut m: theo 2 ng - ng thnh ngc trc: t 4 trocarts, to nht cho ng knh soi l 10 mm gia 2 v. - ng nch: t 4 trocart, to nht cho ng knh soi hm nch. + nh gi trong v sau khi m bng cc thao tc m, thi gian m, lng mu mt, tnh trng suy th, chy mu, ni khn, h canxi mu v chuyn m m. Kt qu v bn lun: T 30 thng 4 nm 2003 n 30 thng 6 nm 2004 phu thut 173 bnh nhn vi kch thc ca u trn siu m ln nht l 5,6 cm, trung bnh 2,67cm. Th tch tuyn gip trong bnh Basedow trung bnh l 26,3cm3. Ch nh m ch yu l bu n nhn 1 thu 150 bnh nhn, a nhn 2 thu 2 bnh nhn, bu c n thun 1 bnh nhn v Basedow l 20 bnh nhn. Chng ti cha m c nhng bu c ng knh v th tch

Summary Title: Endoscopic thyroidectomy: some discussions of the technique and operation results. Endoscopic thyroidectomy is a new minimally invasive technique that permits thyroid excision without a left unfavorable scar that is caused by traditional thyroidectomy. Objective: to evaluate the operation,s technique and the primary results of the method. Materials: The goiter patients have been indicated for surgery excluding too big nodule, bilateral nodules but not located at the same pole of lobe, hyperthyroidisme, the carcinoma, and previous surgery in the neck. Method: prospective study. - The technique: 2 approaches performed: + The anterior chest approach: the bigest incision is 1cm made between two nipples for the scope. + The axillary approach: the incision of 1cm for the scope made in the armpit. -Assesstment: operation time, lost blood volume, breathing failure hypocalcemea and conversion to open surgery . Results and discussion - From 30 Avril 2003 to 30 June 2004, there were 173 patients operated with the average nodule diameter 2,67cm(1 - 5,6cm), the average thyroid volume in Graves deseases was 26,3cm3. Indication for surgery included the single nodule (n=150), multinodule

(n=2), single diffuse goiter(n=1), Graves desease (n=20). Because of the small operative space, we can not performed surgery for larger nodules. - The tranxillary approach had some advantages compared with the anterior chest one expecially the postoperative unvisible bigest incision is made in the armpit. - The operative space was made by the dissection according to anatomy structure with co2 pressure of 12mmHg. - To avoid injury to the parathyroid and the recurrent nerve, the dissection of the vessels have to be performed seriously and to be close to the thyroid tissue if possible. - There are 90 cases of lobectomy (52%), 60 of subtotal lobectomy (34,7%), 2 of subtotal bilateral lobectomy (1,7%) and 20 of near total thyroidectomy (11,6%) - The average operation time was 124 minutes (45-360), the average lost blood loss was 16ml. There were 2 patients (Graves desease group) converted to open surgery due to hemorrage. - There was no mortality, the lifethreaten complication and the recurrent nerve palsy. There was only one patient with trasient hyporcalcemia. Conclusion: Endoscopic thyroidectomy is a safety and efficiency method procedure with the comestic benefits. The patients have to be chosen and prepared carefully in the pre-operation time.

ln hn do phm vi phu trng cn nh cha th thc hin c hon ho cc thao tc m. - ng vo tuyn gip thc hin ch yu l ng thnh ngc trc. ng nch mi thc hin v sau 40 bnh nhn nhng t ra c u im hn ng trn v vt rch da ln nht 10mm nm nch kh nhn thy sau m. - To phu trng m bng vic tch lp cn ngc v cn c nng, tch cc lp c theo gii phu v bm kh co2 vi p lc 12mmHg, lu lng 5- 6 l/pht. - Vic bc tch, t ct cc mch mu phi theo nguyn tc i st tuyn gip trnh lm tn thng tuyn cn gip v dy thn kinh qut ngc. - Thi gian m t nht 45 pht, nhiu nht 360 pht trung bnh l 124 pht. Lng mu mt trong khi m t nht l 0ml, trung bnh 16ml, ch c 1 bnh nhn mt 500ml mu do chy t mt mch mu thnh ngc nhng cm c, khng phi chuyn sang m m v bnh nhn c xut vin sau 04 ngy. - Chim a s l ct 1 thu 90 bnh nhn(52%), ct bn phn thu 60 bnh nhn (34,7), ct gn ton b 20 bnh nhn (11,6%). C 2 bnh nhn (1,2%) thuc nhm Basedow phi chuyn sang m m v chy mu nhiu trong khi bc tch tuyn; iu ny t ra vn phi chun b tht tt trc m cho nhng ca Basedow. - Khng c bnh nhn no b suy th, ni khn, ch c 1 bnh nhn b h canxi mu tm thi sau m, khng c t vong. Kt lun: K thut ni soi m tuyn gip c th thc hin c an ton, hiu qu vi 2 ng vo khc nhau, v nhng bnh l khc nhau nhng phi c chn la v chun b trc m tht k.

1. t vn Phu thut tuyn gip bng phng php m m hin ti Vit Nam c thc hin rng ri ti cc bnh vin vi rt t nhng bin chng trong v sau m, c bit nhng tai bin i vi tuyn cn gip v dy thn kinh qut ngc. N tuy cha c bnh nhng sau m li vt so i khi qu di vng c trc gy tm l khng thoi mi cho ngi bnh c bit nhng ngi tr, nhng ngi c quan h x hi rng ri.

Vi s pht trin mnh m v kinh t ko theo nhu cu ngy cng cao v thm m. Phu thut ni soi ra i gii quyt c nhc im ca phu thut m m. c rt nhiu cc phu thut bng bng phng php ni soi c tin hnh mt cch thng quy nhiu bnh vin nh phu thut ct ti mt, ct u nang bung trng, nang thn, ly si mt, ct t cung mang li li ch ln cho ngi bnh v mt thm m cng nh vic tr li cc hot ng sm sau m. Phu thut ni soi ct thu tuyn gip c Hucher thng bo t nm 1997(4). Ti Bnh vin Ni tit Trung ng, t thng 5 nm 2003 s dng k thut ni soi cho phu thut tuyn gip. ti ny nhm xem xt li ch nh, k thut v kt qu ban u ca phng php phu thut ny i vi tuyn gip. 2. i tng v phng php nghin cu. 2.1. i tng. Nhng bnh nhn c bnh tuyn gip c chn on v c ch nh m ti Bnh vin Ni tit Trung ng trung ng. Loi tr cc trng hp: - Cng gip ang c iu tr cha n nh - Ung th hay nghi ng ung th. - b chiu x trc vng c. - m bu gip c hay m bnh khc vng c trc. - Bu a nhn > 2cm hai bn thu v khng khu tr mt cc. - Bu Basedow: Siu m doppler im mch m c >3 m/cm2 2.2. Phng php nghin cu. 2.2.1. Lm sng Khm xt trn lm sng nhm xc nh gii tnh, ngh nghip, ln, mt ca bu. 2.2.2. Cn lm sng * Siu m: - Siu m thng: nhm xc nh v tr, kch thc, th tch, mt ECHO ca bu. - Siu m doppler: nhm xc nh vn tc dng chy ca mch, m s mch/ cm2. * Xt nghim mu - Xt nghim T3, FT4, TSH nh gi chc nng ca tuyn gip. - Cc xt nghim mu phc v cho phu thut v gy m nh cc loi phu thut khc. 2.3. K thut m. 2.3.1. Gy m: Gy m ton thn c t ni kh qun, bnh nhn nm nga,hai tay dng, c n, mt quay v pha i din vi u. Nu m 2 bn th khi xong mt bn li quay v pha i din. Theo di cc ch s mch, huyt p, PO2 bng monitor. 2.3.2. My m ni soi: My KANT-STORT vi cc dng c ca m ni soi thng thng. 2.3.3. V tr ca phu thut vin v ph: Tu theo ng vo m cc v tr khc nhau: - ng thnh ngc trc: + Phu thut vin lc u ng i din vi bn c u, sau khi tch xong c c n chm th chuyn sang ng bn i din.

+ Ph 1: ng i din vi phu thut vin. + Ph 2: ng pha trn u bnh nhn. + Dng c vin: ng pha di - ng nch: + Phu thut vin: ng cng bn vi u + Ph 1: ng cng bn vi phu thut vin. + Ph 2: ng i din vi phu thut vin + Dng c vin: ng pha di 2.3.4. V tr t trocat - ng ngc + 01 trocat 10mm cho ng knh soi gia 2 nm v, gia ngc. + 02 trocat 5mm di xng n, b trn ca 2 v thng ng t 2 nm v ln. + 01 trocat 5 mm di u ngoi xng n (bn phi nu u bn phi, bn tri nu u bn tri) - ng nch + 01 trocat 10mm hm nch (bn c u) cho ng knh soi. + 02 trocat 5mm b trn ca 2 v,di xng n + 01 trocat 5mm b vai (bn c u). 2.3.5. Bm CO2: Vi p lc 12mmHg, lu lng t 5,5 lt/pht n 6 lt/pht. C 1 hay nhiu van cc trocat lun m dng kh lun thay i v y khi ra ngoi. Dao in s dng ch t, ct nng. 2.3.6. Cc bc m - ng ngc + Rch da di 10mm ngc gia 2 nm v + Lun trocat 10mm nng t vo to ng hm + Bm kh CO2 + t tip 2 trocat 5mm b trn ca 2 v di s kim sot ca ng knh soi. + Dng hook tch ln trn theo cn ngc nng v pha c. + Tip tc tch ln theo cn c nng bc l c c n chm v ng gia cho n ngang mc sn gip hay cao hn. + t tip 1 trocat 5mm t u di ngoi di xng n cng bn u i ln. + S dng 2 kp phu tch v 1 hook tch c c n chm ra pha ngoi. Tch tip c vai mng, sau tch dc theo c c gip v c mng bc l thu tuyn gip. Xc nh v tr ca u v tu theo kch thc v v tr ca u m c thi s l tip ct bn phn thu hay ct c thu. + t hoc kp mch mu cc trn. Ct mch mu cc trn, gii phng cc trn. + t ct mch mu cc di. + Tch,t mch mu tch dn thu tuyn vo pha trong kh qun, tch tuyn cn gip v dy thn kinh qut ngc ra khi tuyn gip nu gp. + Tch eo tuyn ra khi kh qun mt trc. + Ct eo tuyn,dy chng Berry. + Ly bnh phm ra ngoi qua l trocat 10mm bng ti nylon.

+ t dn lu ti ch. - ng nch + Rch da di 10mm ch np da hm nch. Dng trocat 10mm nng t nong v pha gia c hng v gia c. + Bm CO2 + t tip 01 trocat 5mm t b vai v 01 trocat 5mm di xng n b trn ca v vo di s kim sot ca ng knh soi. + Dng hook tch dn vo trong theo lp cn ngc v cn c nng hng ti ng gia bt u t hm c.Trong qu trnh ny c th i qua gia 2 b ca c c n chm hay i qua mt trn ca c ny. + Tch dc theo ng gia t hm c ln ti tn hay qu trn sn gip. + t tip 01 trocat 5mm b trn v,di xng n bn i din. + Tch tip c vai mng + Tch dc theo cc th c c gip v c mng + Bc l thu, xc nh v tr ca bu. + Tu tng ch nh m ct bn phn hay ton b thu + Ring i vi bnh Basedow th sau khi gii phng cc trn v di ca thu th ct gn ton b thu li thnh sau. + t hay khng t dn lu ti ch. Nu lm tip bn i din th t li trocat 10mm bn v cc bc tip theo cng nh trn. 2.3.7. nh gi trong khi m. - Tnh lng mu mt trong qu trnh m: tnh bng ml - Thi gian m: tnh bng pht t lc t trocat cho n khi khu da - Nhn nh cc kh khn, thun li ca tng thao tc trong qu trnh m 2.3.8. nh gi ngy u v nhng ngy sau m. - Suy th, chy mu, ni khn - Tnh trng dn lu - S ngy nm vin. 2.3.9. Theo di 03 thng sau: nh gi bng cc thng s v: - Phi m li v cc nguyn nhn khc nhau. - Tnh trng ni khn, kh ni, h canxi huyt. - Tnh trng vt m: kh p, chy nc nhim trng, hay so xu. 2.3.10. nh gi kt qu: Da vo cc kt qu thu c trong v sau m phn chia thnh cc loi: rt tt, tt, trung bnh, xu. - Rt tt: Qu trnh m tin hnh thun li, khng c bin chng trong v sau m, so p, bnh nhn rt hi lng v cuc m. - Tt: Qu trnh m tin hnh thun li, khng c bin chng trong v sau m, phi chc ht do dch ng ch t trocat 10mm sau mt vi ln s ht, so p, bnh nhn hi lng v cuc m. - Trung bnh: Phi chuyn m m ngay trong khi m hay qu trnh m tin hnh thun li, khng c bin chng ngay sau m, nhng bnh nhn phi chc ht no li ng m hay phi m li bng m m trong 3 thng u theo di, sau khi m m din bin tt.

- Xu: Bnh nhn sau m c ni khn v c cn h canxi vnh vin. 2.3.11. X l s liu: S liu dc thu thp v c x l bng phn mm EPI INFO 6.0 3. Kt qu. T 2 thng 5 nm 2003 n30 thng 6 nm 2004 chng ti tin hnh p dng k thut ni soi m cho 173 bnh nhn vi s phn b v gii nh sau: Bng 1. Phn b v gii Gii Nam N Cng Bng 2. ln ca bu S bnh nhn Bu Ia Bu Ib Bu II Cng Bng 3. Kt qu siu m Nhn bn thu (n= 152) Mt ECHO (n= 152) V tr thu (n= 152) Phi Tri C hai bn Tng Gim Hn hp Cc trn Cc di Gia thu S bnh nhn 85 65 2 51 35 66 5 51 96 T l % 55,9 42,8 1,3 33,6 23,0 43,4 3,3 33,6 63,2 25 134 14 173 T l % 14,5 77,5 8,1 100 S bnh nhn 10 163 173 T l % 5,8 94,2 100

Bng 4. Kch thc bu (cm) Ln nht Kch thc bu (n= 152) 5,6 Nh nht 1,0 Trung bnh 2,67

Bng 5. Th tch tuyn gip (cm3) Ln nht Th tch (n=20) Nng hocmn 46,7 Ln nht Bng 6. Nng hormon Nh nht Trung bnh Nh nht 16,1 Trung bnh 26,3

FT4(pmol/l) TSH(mU/l)

21,3 0,03

7,9 8,2 S bnh nhn(n=40) 40 0 0 S bnh nhn(n=173) 150 2 20 1 S bnh nhn(n=173) 133 40 S bnh nhn 61 2 90 20 173

16,0 1,3 T l % 100 0 0 T l % 86,7 1,2 11,6 0,6 T l % 76,9 23,1 T l % 35,2 1,2 52,0 11,6 100

Bng 7. X hnh (n = 40) Nhn lnh Nhn m Nhn nng

Bng 8. Chn on trc m Bu n nhn 1 thu Bu a nhn 2 thu Basedow Bu c n thun Bng 9. ng vo ng vo ng thnh ngc trc ng nch Loi Phu thut Ct bn phn 1 thu Ct bn phn 2 thu Ct 1 thu Ct gn ton b Cng

Bng 10. Cc loi phu thut

Bng11. Thi gian m (pht) Ngn nht Thi gian m 45 Nhiu nht Lng mu mt 500 Bng 13. Bin chng
Chy mu sau m Suy th Ni khn H canxi huyt tm thi Nhim trng thnh vim ni m S bnh nhn (n=173) 0 0 0 1 1 T l % 0 0 0 0,57 0,57

Lu nht 360 t nht 0

Trung bnh 124 Trung bnh 16

Bng 12. Lng mu mt(ml)

Bng 14. Chuyn m m Chuyn m m Bu nhn S bnh (n=173) 0 nhn T l% 0 L do

Trong m

khi Basedow Bu nhn Basedow

3 2 0

1,7 1,15 0 Ngn nht 2 T l% 68,2 14,5 5,8 11,6 bnh T l % 95,4 1,7 2,9 0

Sau 3 thng

Chy mu vim

Bng 15. Thi gian nm vin (ngy) Lu nht Thi gian nm vin 11 Bng 16. M bnh hc (n= 173) S bnh nhn Bu nhn 118 U tuyn 25 Carcinome 10 Basedow 20 Bng 17. Kt qu m S nhn(n=173) 165 3 5 0 Trung bnh 4,3

Rt tt Tt Trung bnh Xu 4. Bn lun

4.1. Phu thut tuyn gip Phu thut tuyn gip l mt phu thut vng c trc. Do tuyn nm su vng c trc m n c bao quanh bi rt nhiu cc lp c. Cng v khng nm cc khoang c sn nh khoang ngc, bng nn mun vo c tuyn thc hin cc thao tc phu thut phi da vo cc cu trc gii phu tch cc b c cng vi bm kh to ra khoang. Tuyn gip c lin quan rt mt thit vi cc c quan quan trng nh b cnh, kh thc qun, tuyn cn gip, v dy thanh qun qut ngc v vy cc tng ny rt d b tn thng trong qu trnh m c bit l tuyn cn gip, dy thn kinh qut ngc. Bnh l v tuyn gip gp ch yu ph n, nghin cu ny chng ti gp 163 bnh nhn vi t l 94,2%. Nu m m bnh nhn sau m thng khng thoi mi vi vt so c nht l nhng ngi lm cng tc x hi phi giao tip rng, hay nhng ph n tr. V vy sau m bnh nhn thng tm cc cch che vt so bng dy chuyn, mc o cao c.Vic ng dng k thut ni soi trong phu thut tuyn gip mang li u im rt ln v mt thm m nh Gagner, Miccoli, Bellantone R,Yamamoto thng bo(2,6,9).Ngoi ra cc tc gi cn cho thy m bng phng php ni soi t au sau m hn, trong qu trnh m c khng b ct, t b chn thng cho nn tr li vi cc hot ng bnh thng nhanh hn (6). 4.2. Ch nh m - Theo Miccoli P, ng thu thp c tt c 336 bnh nhn m bng phng php ni soi ca 3 trung tm Italie cho thy tiu chun chn bnh nhn m ni soi l th tch bu <15ml,nhn <= 3,5cm, khng c vim gip, khng c so vng c, khng b chiu tia x trc vng c(7).

- Cn vi William B Inabner th loi tr nhng nhn c ng knh > 3cm, bu a nhn ln,m trc vng c,ngi bo c rng ngn v phu trng nh. ng cng loi tr bnh Basedow v bu thng to v c rt nhiu mch mu(14). - Ngc li, Yamamoto phu thut ct gn ton b tuyn gip cho 12 bnh nhn b Basedow v cho thy rng m ni soi l mt ch nh c hiu qu i vi loi bnh l ny(11). - Gagner M m 18 bnh nhn bu gip n nhn c ng knh ln hn ti 7cm (2). V Ohgamim cng khng phi chuyn m ca no vi 5 bnh nhn c bu t 5-7cm(10). - Miccoli P tin thm 1 bc na vi vic ch nh m ni soi ct gn ton b tuyn gip cho 33 bnh nhn c ung th biu m th nh(9). Chng ti m 159 bnh nhn(92%) c bu I v II ch c 14 bnh nhn (8,1%).o ng knh trn siu m th bu nh nht l 1cm, ln nht l 5,6cm trung bnh l 2,67cm.Cho n nay cha dm m nhng bu c ln v kch thc ln hn, v phu trng khng gian c to ra bng vic tch cc c, bng bm hi cn hn ch. Nu bu to qu th ng knh soi s b chn khng th nhn thy cc phn cn phu tch thc hin cc thao tc c. i vi nhng bnh nhn Basedow chng ti m bu c th tch ln nht l 46,7cm3, trung bnh l 26,3cm3. Tt c u c chun b k trc m bng ung dung dch Lugol 1% bu sn li, cc mch mu nh i v khi siu m bng doppler mu th s mch m c phi < 3 m/cm2. Nhng bnh nhn chc t bo trc m chn on l ung th hay c nghi ngh ung th th cng cha c thc hin bng phng php ny bi l vic no vt hch cha th lm c.Tt c cc bnh nhn chc t bo trc m u chn on l bu nhn. 4.3. K thut m - Yamashita H s dng ng rch da 25 30 mm di hm c bn ct thu tuyn gip vi s tr gip ca ni soi khng cn kh v khng cn nng t bn ngoi, tt c u thnh cng khng phi chuyn sang m m(12). -Vi tng kt ca Miccolic P th vi 336 bnh nhn ng rch ln nht l 15mm trn hm c, phu thut c thc hin bng c dng c ni soi ln dng c thng(7). - Yu.T.Tsukanov s dng ng rch ln nht l 2cm m 15 ca ct thu,18 ca ct bn phn hai thu v 6 trng hp ct 2 thu (13). - Ohgami M li dng ng thnh ngc trc vi ng rch da di nht l 15mm gia 2 nm v m cho 5 bnh nhn (9). - Ikeda Y s dng thm ng nch v so snh vi nhm ng thnh ngc trc, vi m m truyn thng, s bnh nhn mi nhm l 15 bnh nhn th thy rng sau 3 thng tt c s bnh nhn m ng nch u hi lng vi vt m, cn 20% ng thnh ngc v 73% m m truyn thng khng hi lng vi vt m (5). - Chng ti s dng ng thnh ngc trc 133 bnh nhn vi ng rch da di nht l 10mm gia ngc. ng rch ny trnh c vt so c k c vt so nh 15mm trn hm c nh Miccolic thng bo. i ln ti c vng tuyn gip phi tch t di ln trn theo cn ngc nng v cn c nng. Qu trnh bc tch phi tht cn thn trnh lm tn thng cc mch mu nht l nhng mch mu c nng vng c. Trong khi bc tch th khng nn cp vo cc c vng c rt d lm rch, t c gy chy mu kh thao tc v sau m c s b cng ni m. Sau khi bc l thu tuyn gip th xc nh v tr ca bu nh vo kt qu ca siu m, x hnh, v quan st trc tip trong khi m, t nh ra c loi phu thut ct bn phn hay ct c thu.

Trong qu trnh phu thut khng nn cp vo tuyn nhiu, khng nn co ko mnh s lm rch tuyn, v nhn, v nang gy chy mu. t ct mch mu s dng dao in ch t, ct nng. Vic bc tch theo nguyn tc cng i st tuyn gip bao nhiu cng tt by nhiu trnh lm t thng tuyn cn gip v dy thn kinh qut ngc.Trong khi m nu thy tuyn cn gip th phi tch ra tht cn thn. Trong qu trnh phu thut v s dng dao in cho nn c nhiu khi, v vy chng ti s dng p lc ca kh bm l 12mmHg vi lu lng kh l 5-6lt/pht ng thi cc van trocats lun m khi thot ra ngoi nhanh lm r phu trng.Vi p lc 4mmHg hay 6mmHg nh Ohgami M hay Ikeda Y(5,9) dng th khng th lm rng phu trng c. Chng ti cha gp trng hp no tng CO2 mu do s dng kh CO2 gy ra nh Gagner M thng bo gp 3 trng hp(2). Khi bc tch bng dao in sinh ra nhit trnh lm bng da chng ti thng xuyn phi p gc huyt thanh bn ngoi. S dng 4 trocats thc hin cc thao tc m, vi v tr t trocats nh trn chng ti thy v hp l Vi 40 bnh nhn v sau s dng ng nch vi vt rch da di nht l 10mm nm hm nch cho ng knh soi. ng ny s i n tuyn gip t pha bn. Vic bc tch cng theo cn ngc nng v cn c nng, n vng trn n phi ch i theo lp xp pha di c bm da c nu khng rt d i ra nng lm tn thngda. Khi n c c n chm cng c th theo 2 ng gia 2 b ca c hoc i hn ln b trn ca c. i qua gia 2 b c th i ti tuyn gip d hn nhng phu trng li b hp hn. ng ny chng ti thng s dng trong ct bn phn cc di. ng i t nch ngoi vic trnh c vt so ln ngc n cn c u im l nhn thy r cc trn v vy vic s l mch mu v bc tch cc trn cng d hn. Nhc im chnh ca n l nu mun m tip bn i din th li phi i li thm ng hm nch bn i din. 4.4. Kt qu ca phu thut - Loi phu thut m chng ti thc hin nhiu nht l ct bn phn 1 thu, ct 1 thu. Ct 1 thu thng c ng dng cho nhng nhn gia thu, hay nhng nhn to m chim ht hoc gn ht thu. Chng ti mi m ct bn phn 2 thu cho 2 bnh nhn trong 1 trng hp c nhn 2 bn nhng nhn tp trung cc di. Vi nhng nhn khp 2 thu, tn thng ri rc m cn phi ct ton b th cha c thc hin. V 1 bnh nhn b bu c n thun ct 2 cc di lm nh th tch ca tuyn theo yu cu ca bnh nhn. - Thi gian m theo cc tc gi nh Miccoli i vi ct thu t 20 n 150 pht, ct ton b l t 30 -220 pht (7),vi Gagner trung bnh l 220 pht (120-330) (2), Yamamoto trung bnh l 259 pht (11). Thi gian m ca chng ti lu nht l 360 pht. Trong nhng bnh nhn u do cha c kinh nghim thao tc, m bo an ton cho bnh nhn nn thi gian m cn ko di. ng thi nhng bnh nhn Basedow, ct gn ton b li thnh sau c 2 bn l mt phu thut kh, yu cu phi lm t m cho nn thi gian m cng lu. Trung bnh thi gian m cho tt c cc loi l 124 pht. - Lng mu mt ca Yamamoto i vi m Basedow l 90,2ml (11), vi m ct thu l 32ml (10), Hiroshi Takami l 25ml(3). Trong s bnh nhn ca chng ti c 1 bnh nhn mt nhiu nht l 500ml, do chy mu t 1 mch mu thnh ngc nhng sau khi cm mu li tip tc phu thut bnh thng khng phi chuyn sang m m v bnh nhn xut vin sau 4 ngy iu tr. Nu trong qu trnh bc tch khng lm tn thng mch mu, cp t ct cn thn th hu nh khng chy mu. iu ny cho thy trong m ni soi tuyn gip khng nhng cn pHi Thnh tho trong m m v cng pHi Thnh tho cc k thut ca m ni soi.

- Khng c bnh nhn no b suy h hp cp, chy mu sau m, ni khn, ch c 1 bnh nhn (0,5%) b h canxi mu tm thi qua 173 bnh nhn m. Trong 336 bnh nhn ca Miccoli c 7 lit dy qut ngc tm thi, 1 trng hp lit vnh vin, 9 ca h canxi mu tm thi, 2 trng hp suy cn gip vnh vin. T l phi chuyn sang m m l 4,5% (7). Chng ti c 3 bnh nhn (1,7%) Basedow phi chuyn sang m m ngay khi vo ti tuyn thy chy mu nhiu. V vy i vi bnh nhn Basedow vic chun b trc m cn thn, ng nguyn tc ht sc quan trng mang li s thnh cng ca phu thut. C 3 bnh nhn phi chc ht v no vim theo ng t trocats sau 01 thng th ht. C 1 bnh nhn sau 3 thng phi m li do c nhng khi nh nm trn ng t trocats v vng m. Khi m ra th thy l ng t chc vim, sau khi no lm sch th khi hn. Tt c s bnh nhn ny u nm trong s 10 bnh nhn u. Khi xem xt li nguyn nhn thy do dng c ng nc ct sau khi chng ct khng m bo tiu chun, chng ti ngh dng cc bin php tit khun li; sau khng cn bnh nhn no b nh th. - Kt qu m bnh hc sau m c 10 bnh nhn b ung th nhng u l ung th biu m th nh. y l th lnh tnh nht ca ung th gip.Chng ti khng t vn m li ngay m hn bnh nhn ti khm li nh k sau 3 thng/ln x tr kp thi. i vi ung th th nh, u cn nh nm trong t chc tuyn th ct 1 thu theo nh Proye l (16), cn ct ton b tuyn gip mt cch h thng tt c bnh nhn ung th tuyn gip theoAshok.R.Shaha th nn trnh (1). - Thi gian nm vin trung bnh l 4,3 ngy, trng hp lu nht l 11 ngy do bnh nhn vo chun b trc m Basedow. - Kt qu rt tt t 165 bnh nhn vi t l 95,4% cho thy s thnh cng ca phu thut.5. Kt lun - Phu thut ni soi tuyn gip c th thc hin c an ton, hiu qu.Phu thut vin khng nhng phi c kinh nghim v m m tuyn gip m cn phi c kin thc v m ni soi. - Ch nh ca phng php mi ch p dng thng qui cho bu nhn 1 thu. Bu a nhn 2 thu v Basedow cn hn ch c bit Basedow phi chun b tht k trc khi m. - K thut c th i vo t ng thnh ngc trc hoc ng nch nhng ng nch mang li tnh thm m cao hn. Ti liu tham kho. 1. Ashok.R.Shaha: Thyroid cancer: Extent of Thyroidectomy.Cancer control 2000 ;7 ; 3:240-245 2. Gagner m,Inabnet WB:Endoscopic thyroidectomy for solitary thyroid nodules.Thyroid 2001 Feb ;11(2):161-3 (Abstract) 3. Hiroshi Takami,Masanori Niimi,Shigenao Kan,Susumu Kodaira: Comparative study of thyroidectomy: endoscopic surgery versus coventional open surgery. http://www.8thworldcongress.org. (Abstract). 4. Huscher CSG,Chiodini S,Recher,Napolitano C:Endoscopic right thyroid lobectomy. Surg Endosc 11:877,1997 5. Ikeda Y,Takami H,Sasaki y,Takayama J,Niimi M,Kan S:Clinical benefits in endoscopic thyroidectomy by the axillary approach. J Am Coll Surg 2003 Feb ;196 (2):189-195 (Abstract) 6. Miccoli P,Berti P,Raffaeli M,Materazzi G,Baldacci S,Rossi G:Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: a prospective randomized study.Surgery 2001 De ;131(2):148(Abstract)

7.

Miccoli P,Bellantone R,Mourad M,Walz M,Raffaelli M,Berti P: Minimally invasive video-assisted thyroidectomy: multiinstitutional experience. World J Surg 2002 Aug ; 26(8):972-5 (Abstract). 8. Miccoli P,Berti P,Raffaelli M,Cont M,Materazzi G,Galleri D.Minimally invasive video-assisted thyroidectomy. Am J Surg 2001 Jun ;181(6)(Abstract) 9. Miccoli P,Elisei R et All: Minimally invasive video-assisted thyroidectomy for papillary carcinoma: a prospective study of its completeness.Surgery 2002 Dec ; 132(6):1070-3(Abstract) 10. Ohgami M,Ishii S: Scarless endoscopic thyroidectomy: breast approach for better cosmesis.Surg Laparosc Endosc Percutan Tech 2000 Feb ;10(1):1-4 (Abstract)