Đánh giá kết quả ứng dụng đặt tấm lưới nhân tạo theo phương pháp Lichtenstein điều trị thoát vị bẹn ở bệnh nhân từ 40 tuổi trở lên

Header Page of 123 B GIO DC V O TO I HC HU TRNG I HC Y - DC Lấ QUC PHONG NH GI KT QU NG DNG T TM LI NHN TO THEO PHNG PHP LICHTENSTEIN IU TR THOT V BN BNH NHN T 40 TUI TR LấN LUN N TIN S Y HC Hu - 2015 Footer Page of 123 Header Page of 123 B GIO DC V O TO I HC HU TRNG I HC Y - DC Lấ QUC PHONG NH GI KT QU NG DNG T TM LI NHN TO THEO PHNG PHP LICHTENSTEIN IU TR THOT V BN BNH NHN T 40 TUI TR LấN Chuyờn ngnh : Ngoi tiờu hoỏ Mó s : 62.72.01.25 LUN N TIN S Y HC Ngi hng dn khoa hc: PGS.TS NGUYN VN LIU PGS.TS Lấ LC Hu - 2015 Footer Page of 123 Header Page of 123 LI CAM OAN Tụi xin cam oan õy l cụng trỡnh nghiờn cu ca chớnh bn thõn tụi Cỏc s liu, kt qu nờu lun ỏn l trung thc v cha tng c cụng b bt k cụng trỡnh no khỏc Tỏc gi lun ỏn Lờ Quc Phong Footer Page of 123 Header Page of 123 Li Cm n Cho phộp em c by t lũng bit n sõu sc, vụ hn n Quý thy, Quý Ban ngnh, Quý ng nghip n cỏc bnh nhõn v gia ỡnh ó ht lũng giỳp em hon thnh lun ỏn ny Em xin trõn trng gi li cm n, chõn thnh bit n n: - Ban Giỏm c v Ban o to sau i Hc - i Hc Hu - Ban Giỏm Hiu Trng i hc Y Dc Hu - Ban Giỏm c Bnh vin Trung ng Hu - PGS.TS Nguyn Vn Liu Trng khoa ngoi tiờu húa Bnh vin Trng i hc Y Dc Hu - PGS.TS Lờ Lc Phú Giỏm c Trung tõm o to, Trng khoa ngoi tiờu húa Bnh vin Trung ng Hu Nhng ngi Thy ó trc tip hng dn, tn tõm, tn tỡnh ch bo, gúp ý xõy dng, b sung, giỳp , to iu kin cho em sut quỏ trỡnh hc tp, nghiờn cu v hon thnh lun ỏn ny Xin gi li cỏm n sõu sc n: - Phũng sau i hc Trng i hc Y Dc Hu - Ban ch nhim v b mụn Ngoi Trng i hc Y Dc Hu - Th Vin Trng i hc Y Dc Hu - Ban ch nhim v khoa Ngoi tiờu húa Bnh vin Trung ng Hu - Ban ch nhim v khoa Ngoi Nhi Cp Cu bng Bnh vin Trung ng Hu - Ban ch nhim v khoa Ngoi Tng Hp Bnh vin Trung ng Hu - Khoa Chn oỏn hỡnh nh Bnh vin Trung ng Hu - Khoa Gõy mờ Bnh vin Trung ng Hu - Th Vin Bnh vin Trung ng Hu - Phũng h s Y lý Bnh vin Trung ng Hu - Ton th Gia ỡnh ni ngoi hai bờn, luụn ng viờn giỳp v to mi iu kin cho em sut thi gian hc tp, nghiờn cu Lờ Quc Phong Footer Page of 123 Header Page of 123 CC CH VIT TT ASA : American Society of Anesthesiologists (Hip hi gõy mờ Hoa K) BMI : Body Mass Index (Ch s c th) EHS : European Hernia Society (Hip hi thoỏt v Chõu u) ePTFE : Expanded PolyTetraFluoroEtylene (Mnh ghộp ePTFE) IL-6 : Interleukin-6 (Yu t 6) IL-10 : Interleukin-10 (Yu t 10) IPOM : Intra Peritoneal Only Mesh (t tm li phỳc mc) N10,11,12 : Ngc 10,11,12 NRS : Numerial Rating Scale (Thang im s) n : S trng hp thoỏt v bn PP : Phng phỏp PSH : Prolene System Hernia (Tm li PSH) PTFE : PolyTetraFluoroEtylene (Mnh ghộp PTFE) TAPP : Trans Abdominal Preperitoneal (Vo bng t tm li ngoi phỳc mc) TEP : Total Extra Peritoneal (t tm li hon ton ngoi phỳc mc) TL1,2,3 : Tht Lng1,2,3 TNF- : Tumor Necrosis Factor- (Yu t hoi t U) VAS : Visual Analog Scale (Thang nhỡn hỡnh ng dng) VRS : Visual Rating Scale (Thang im nhỡn) Footer Page of 123 Header Page of 123 MC LC Trang ph bỡa Li cam oan Mc lc Danh mc cỏc bng Danh mc cỏc s , biu Danh mc cỏc hỡnh Trang T VN Chng TNG QUAN TI LIU 1.1 Lch s iu tr thoỏt v bn 1.2 Phụi thai hc v gii phu hc 1.3 c im sinh lý hc ng bn 16 1.4 Nguyờn nhõn a n bnh lý thoỏt v bn 19 1.5 C ch bnh sinh, phõn loi thoỏt v bn 21 1.6 Lõm sng thoỏt v bn v siờu õm vựng bn - bỡu 25 1.7 Phu thut thoỏt v bn bng mụ t thõn 28 1.8 Phu thut thoỏt v bn bng tm li nhõn to 30 1.9 Tai bin v bin chng phu thut thoỏt v bn 38 Chng I TNG V PHNG PHP NGHIấN CU 41 2.1 i tng nghiờn cu 41 2.2 Phng phỏp nghiờn cu 42 Chng KT QU NGHIấN CU 61 3.1 c im chung 61 3.2 Lõm sng thoỏt v bn v siờu õm vựng bn - bỡu 66 3.3 Ch nh v c im k thut 69 3.4 Kt qu chung 72 Footer Page of 123 Header Page of 123 3.5 ỏnh giỏ kt qu gn 78 3.7 ỏnh giỏ kt qu xa 80 Chng BN LUN 85 4.1 c im chung 85 4.2 c im lõm sng 90 4.3 Phõn loi sc khe theo ASA v phng phỏp vụ cm 92 4.4 Ch nh, kớch thc, k thut Lichtenstein t tm li 96 4.5 Kt qu chung sau phu thut 102 4.6 T l nhim trựng sau phu thut v khỏng sinh 105 4.7 ỏnh giỏ au thi k hu phu v au kộo di sau phu thut 110 4.8 Bin chng sau phu thut 113 4.9 Siờu õm vựng bn - bỡu trc v sau phu thut 115 4.10 T l tỏi phỏt sau phu thut iu tr thoỏt v bn bng tm li 117 KT LUN .120 DANH MC CễNG TRèNH KHOA HC LIấN QUAN CễNG B TI LIU THAM KHO PH LC Footer Page of 123 Header Page of 123 DANH MC CC BNG Bng Tờn bng Trang Bng 2.1 ỏnh giỏ mc au 56 Bng 3.1 Phõn b bnh nhõn theo gii tớnh 62 Bng 3.2 Phõn b bnh nhõn theo ch s c th 63 Bng 3.3 Phõn b bnh nhõn theo lý vo vin 64 Bng 3.4 Phõn b thi gian mc bnh 64 Bng 3.5 Tin s bnh lý ni khoa 65 Bng 3.6 Phõn b tin s phu thut 65 Bng 3.7 Tin s m thoỏt v bn 66 Bng 3.8 Phõn loi thoỏt v bn theo Nyhus (1993) 68 Bng 3.9 Phõn b kt qu siờu õm bn - bỡu 68 Bng 3.10 Phõn b bnh nhõn theo v trớ thoỏt v bn ch nh phu thut 69 Bng 3.11 Phõn b tng thoỏt v phu thut 70 Bng 3.12 Phõn b kớch thc tm li 71 Bng 3.13 Phõn b bnh nhõn theo thi gian phu thut 71 Bng 3.14 Phõn b thi gian trung tin sau m 72 Bng 3.15 Phõn b bnh nhõn theo mc au ngy u tiờn sau m 72 Bng 3.16 Phõn b thi gian phc hi sinh hot cỏ nhõn sau m 73 Bng 3.17 Phõn b thi gian dựng gim au 73 Bng 3.18 Phõn b thi gian dựng khỏng sinh 74 Bng 3.19 Phõn b thi gian nm vin sau phu thut 75 Bng 3.20 Thi gian tr li hot ng bỡnh thng 76 Bng 3.21 Phõn b bin chng vụ cm 77 Bng 3.22 Bin chng sau m 77 Bng 3.23 ỏnh giỏ kt qu sau phu thut 78 Bng 3.24 ỏnh giỏ kt qu thỏng sau phu thut 78 Footer Page of 123 Header Page of 123 Bng 3.25 Bin chng v cm giỏc sau thỏng 79 Bng 3.26 ỏnh giỏ kt qu sau phu thut thỏng 79 Bng 3.27 Phõn b dy mụ x ca tm li di siờu õm 81 Bng 3.28 Phõn b v trớ tm li di siờu õm 81 Bng 3.29 Bin chng xa sau phu thut 12 - 24 thỏng 81 Bng 3.30 Phõn tớch trng hp tỏi phỏt 82 Bng 3.31 Kt qu theo dừi sau m 82 Bng 3.32 ỏnh giỏ kt qu sau phu thut 12 thỏng 83 Bng 3.33 ỏnh giỏ kt qu sau phu thut 24 thỏng 83 Bng 4.1 Kt qu phõn loi theo v trớ gii phu ca cỏc tỏc gi 91 Bng 4.2 T l tỏi phỏt k thut Lichtenstein ca cỏc tỏc gi 119 Footer Page of 123 Header Page 10 of 123 DANH MC CC S , BIU Biu Tờn biu Trang S 1.1 Phn ng ca c th dựng tm li nhõn to 38 Biu 3.1 Phõn b bnh nhõn theo nhúm tui 61 Biu 3.2 Phõn b bnh nhõn theo a d 62 Biu 3.3 Phõn b bnh nhõn theo ngh nghip 63 Biu 3.4 Phõn b theo v trớ thoỏt v 66 Biu 3.5 Phõn b thoỏt v bn nguyờn phỏt v tỏi phỏt 67 Biu 3.6 Phõn loi thoỏt v theo v trớ gii phu 67 Biu 3.7 Phõn b bnh nhõn theo phõn loi ASA 69 Biu 3.8 Phõn b phng phỏp vụ cm 70 Footer Page 10 of 123 Header Page 133 of 123 + Thi gian m trung bỡnh: thoỏt v bn mt bờn l 54,0 9,9 phỳt, v thoỏt v bn hai bờn l 98,8 17,8 phỳt + Tm li cú kớch thc: nh 95,9%, ln 4,1% ỏnh giỏ kt qu gn v xa sau phu thut - Kt qu sau phu thut: + Bin chng sm: t dch vt m 1,5%, t mỏu vt m 1%, t mỏu bn bỡu 2,1%, nhim trựng vt m 0,5%, sng vựng bỡu 2,1% + Bin chng mun: au mn tớnh sau m 2,6%, tờ vựng bn - bỡu 15%, thoỏt v bn tỏi phỏt 1,6% - ỏnh giỏ kt qu gn: + Sau thỏng: tt 147 trng hp 77%, khỏ 44 trng hp 23% + Sau thỏng: tt 158 trng hp 81,9%, khỏ 34 trng hp 17,6%, trung bỡnh trng hp 0,5% - ỏnh giỏ kt qu xa: + Sau 12 thỏng: tt 179 trng hp 92,7%, khỏ trng hp 2,1%, trung bỡnh trng hp 0,5%, kộm trng hp 1,0% + Sau 24 thỏng: tt 180 trng hp 93,1%, trung bỡnh trng hp 0,5%, kộm trng hp 1,6% 121 Footer Page 133 of 123 Header Page 134 of 123 DANH MC CễNG TRèNH KHOA HC LIấN QUAN CễNG B Lờ Quc Phong, Nguyn Vn Liu, Lờ Lc (2010), ỏnh giỏ kt qu ng dng tm li nhõn to theo Lichtenstein iu tr thoỏt v bn Y hc thc hnh, s 718+719, trang 197 - 206 Lờ Quc Phong, Nguyn Vn Liu, Phm Nh Hip, Lờ Lc (2011), Nghiờn cu ng dng tm li nhõn to Polypropylene iu tr thoỏt v bn bnh nhõn trung niờn v ln tui Tp Y hc lõm sng, s 9, trang 117 123 Lờ Quc Phong, Lờ Mnh H v cng s (2013), Kt qu iu tr thoỏt v bn bng k thut Lichtenstein v ni soi ngoi phỳc mc Y hc thc hnh (878), s 8, trang 55 - 58 Lờ Quc Phong, Phm Nh Hip, Nguyn Vn Liu, Lờ Lc (2014), Nghiờn cu ng dng siờu õm chn oỏn v iu tr thoỏt v bn bng k thut Lichtenstein Tp Y Dc hc, s 22+23, trang 105 110 Footer Page 134 of 123 Header Page 135 of 123 TI LIU THAM KHO TING VIT Vng Tha c (2003), Nhn xột v k thut Lichtenstein iu tr thoỏt v bn, Y hc TP H Chớ Minh, 7, ph bn s 1, tr 174 - 180 Vng Tha c (2011), au mn tớnh vựng bn ựi sau m thoỏt v bn, Y hc TP H Chớ Minh, 15, ph bn s 1, tr 115 - 123 Vng Tha c (2011), ỏnh giỏ kt qu lõu di ca k thut Lichtenstein iu tr thoỏt v bn, Y hc Y hc TP H Chớ Minh, 15, ph bn s 1, tr 108 - 114 Vng Tha c (2004), So sỏnh Lichtenstein vi Bassini iu tr thoỏt v bn, Y hc TP H Chớ Minh, 8, ph bn s 1, tr 30 - 36 Vng Tha c (2010), Thoỏt v bn tỏi phỏt: tn thng v iu tr, Y hc TP H Chớ Minh, 14, ph bn s 1, tr 127 - 133 Lu Ngc Hot, Vừ Vn Thng (2011), Phng phỏp nghiờn cu sc khe cng ng, Nh xut bn i hc Hu, tr 11 - 286 Xuõn Hp (1985), ng bn, Gii phu bng, Nh xut bn Y hc, tr 40 - 49 Ngụ Th Lõm (2009), ỏnh giỏ kt qu ca vic ng dng k thut Lichtenstein m thoỏt v bn ngi ln ti bnh vin tnh Khỏnh ho, Hi ngh ngoi khoa Khỏnh ho m rng, tr 96 - 101 Nguyn Vn Liu (2004), Nghiờn cu ng dng phu thut Shouldice iu tr thoỏt v bn, Lun ỏn tin s y hc, Hc vin quõn y 103, tr - 119 10 Nguyn Vn Liu (2006), Nghiờn cu ng dng phu thut Shouldice iu tr thoỏt v bn bnh nhõn trờn 40 tui, Tp y hc thc hnh, tr 217 - 225 11 Nguyn Vn Liu (2007), iu tr thoỏt v bn, Nh xut bn i hc Hu, tr - 105 Footer Page 135 of 123 Header Page 136 of 123 12 Lờ Quang Ngha (2006), Mnh ghộp iu tr thoỏt v, Y hc TP H Chớ Minh, tp10, ph bn s 1, tr - 14 13 Bựi c Phỳ (1998), ỏnh giỏ kt qu lõu di cỏc phng phỏp phu thut thoỏt v bn ti Hu, Tp san nghiờn cu khoa hc, tr 41 - 28 14 Nguyn Quang Quyn (1990), ng bn, Bi ging gii phu hc, Tp II, Nh xut bn Y hc, tr 41 - 46 15 T Xuõn Sn, V Huy Nựng (2003), Nghiờn cu c im lõm sng v cn lõm sng v kt qu iu tr thoỏt v bn nght, Ngoi khoa, 53, tr 12 - 15 16 Ngụ Vit Tun (2000), Phu thut Shouldice ci biờn hai lp iu tr thoỏt v bn bnh nhõn trung niờn v ln tui, Lun ỏn tin s Y hc, Trng i hc Y dc thnh ph H Chớ Minh, tr - 20 17 Trnh Vn Tho (2010), Nghiờn cu ng dng ni soi t mnh ghộp hon ton ngoi phỳc mc iu tr thoỏt v bn, Lun ỏn tin s y hc, Hc vin quõn y 103, tr - 120 18 Phm Hu Thụng (2003), Nhn xột kt qu ban u ca phu thut iu tr thoỏt v bn qua ngó ni soi bng, Y hc TP H Chớ Minh, 7, ph bn s 1, tr 192 - 202 19 Phm Minh Trớ, ỡnh Cụng (2003), t li polypropylene ngó tin phỳc mc iu tr thoỏt v bn, Y hc TP H Chớ Minh, 7, ph bn s 1, tr 187 - 191 20 Phan Minh Trớ (2013), Vai trũ ca mnh ghộp polypropylene iu tr thoỏt v vt m thnh bng, Lun ỏn tin s Y hc, Trng i hc Y dc thnh ph H Chớ Minh, tr 30 - 40 TING ANH 21 Alam A, Nice C, Uberoi R (2005), The accuracy of ultrasound in the diagnosis of clinically occult groin hernia in adults, Eur Radiol, 15, pp 2457 - 2461 22 Alfieri S et al (2011), International guidelines for prevention and management of post - operative chronic pain following inguinal hernia surgery, Hernia, 15, pp 239 - 249 Footer Page 136 of 123 Header Page 137 of 123 23 Ali N et al (2008), Recurrence after primary inguinal hernia repair: Mesh versus Darn, Pakistan Journal of Surgery, Vol 24, Issue 3, pp 153 - 155 24 Andresen K et al (2011), Lichtenstein versus onstep for inguinal hernia repair: protocol for a double - 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377 43 Chiow A K H, Chong C K, Tan S M (2010), Inguinal Hernias: A current review of an old problem, Proceeding of Singapore Healthcare, Vol 19, N0 3, pp 202 - 211 44 Chung J, Norrie J, ODwyer P J (2011), Long-term follow-up of patients with a painless inguinal hernia from a randomized clinical trial, British Journal of Surgery, 98, pp 596 - 598 Footer Page 138 of 123 Header Page 139 of 123 45 Corcione F, Pede A et al (2005), Treatment of primary inguinal hernias by held in mesh repair: ourexperience related to 3,520 cases, Hernia, 9, pp 263 - 268 46 Dalenbọck J, Andersson C et al (2009), Prolene hernia system, Lichtenstein mesh and Plug-and-patch for primary inguinal hernia repair: 3-year outcome of a prospective randomized controlled trial, Hernia, 13, pp 121 - 129 47 Dasari B, Grant L, Irwin T (2009), Immediate and long - term outcomes of Lichtenstein and Kugel path operation for inguinal hernia repair, The Ulster medical journal, 78, pp 115 - 118 48 Debord J R, Whitty L A (2007), Biomaterials in hernia repair, Mastery of surgery, Vol II, pp 1936 - 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640 Footer Page 139 of 123 Header Page 140 of 123 55 Elorza Ortie J L et al (2000), The ePTFE patch in inguinal hernia repair: one surgeons experience with 246 consecutive cases, Hernia, 4, pp 95 98 56 Elshof J W M, Keus F et al (2009), Feasibility of right-sided total extraperitoneal procedure for inguinal hernia repair after appendectomy: a prospective cohort study, Surg Endosc, 23, pp 1754 - 1758 57 Fawole A S, Chaparala R P C, Ambrose N S (2006), Fate of the inguinal hernia following removal of infected prosthetic mesh, Hernia, 10, pp 58 - 61 58 Flint L et al (2011), Hernia, Selected Readings in General Surgery, Vol 37, N0 8, pp - 47 59 Fortelny R H et al (2014), Assessment of pain and quality of life in Lichtenstein hernia repair using a new monofilament PTFE mesh: comparison of suture vs fibrin - sealant mesh fixation, Frontiers in Surgery, Vol 1, Article 45, pp - 60 Frey D M et al (2007), Randomized clinical trial of Lichtensteins operation versus mesh plug for inguinal hernia repair, British journal surgery, 94, pp 36 - 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BỘ GIÁO DỤC VÀ ĐÀO TẠO ĐẠI HỌC HUẾ TRƢỜNG ĐẠI HỌC Y - DƢỢC LÊ QUỐC PHONG ĐÁNH GIÁ KẾT QUẢ ỨNG DỤNG ĐẶT TẤM LƯỚI NHÂN TẠO THEO PHƯƠNG PHÁP LICHTENSTEIN ĐIỀU TRỊ THOÁT VỊ BẸN Ở BỆNH NHÂN TỪ 40 TUỔI... điều trị thoát vị bẹn lƣới nhân tạo 1.1.2.1 Lịch sử điều trị thoát vị bẹn lưới nhân tạo mổ hở Năm 1958, Horwich sử dụng nylon điều trị thoát vị bẹn rộng thoát vị bẹn tái phát Năm 1962, Usher sử dụng