Ky Nang Ngoai Khoa

8/14/2019 Ky Nang Ngoai Khoa

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NGOI KHOA LM SNG-2007

K NNG V KIN THC CN BN TRONGPHU THUT

1-K nng v kin thc cn bn trong phng m:1.1-Dng c phu thut:

V tnh nng, dng c phu thut c thc chia lm cc nhm chnh sau y:

o Dng c cto Dng c bc tcho Dng c cm muo Dng c kp mo Dng c kp kimo Dng c thm do Dng c nongo Dng c vno Dng c ht

Dng c ct (hnh 1) c chc nng chnh l ct m. Ko l i din chnh cho nhm dngc ct. Tu theo loi m v v tr ca m c ct m ko c cu to hnh th v chiudi khc nhau. Ko Mayo, nng v chc chn, c s dng ct ch hay ct cc mdy chc nh cn, cKo Metzenbaum, ngc li, mnh v nh, c s dng ct

cc cu trc m mng mnh nh thanh mc (mng bng, mng phi, mng tim). Mt sloi ko c bit khc c s dng ct ch thp, ct mmch mu

Dng c bc tch c chc nng chnh l ct v phn tch cc m. Dng c bc tch cphn lm hai loi: dng c bc tch sc v dng c bc tch cn.

Dao l i din cho dng c bc tch sc. Li dao c nhiu loi khc nhau, phc vcho mc ch thc hin ng rch di hay ngn, nng hay su. Cc li dao c s 10,11, 12, 15 khp vi cn dao s 3. Li s 10, c s dng ph bin nht, dng thchin cc vt rch di. Li s 11 cho cc vt rch nh v li s 15 cho cc vt rch rtnh. Li dao s 15, khi c dng ct trong su, sc lp vo cn dao s 7. Khis dng cn dao ln hn (cn dao s 4), cc li dao s 22-25 c s dng.

bc tch cn, c th dng ko (ko Mayo hay Metzenbaum cong v u t), cc kpmch mu (cong v u t), phn nh ca cn dao, no (curett) v dng c nng(elevator).

Nhp l i din cho nhm dng c cm gi m (hnh 3). Kp allis v Babcock cngthuc nhm ny, nhng thng c dng cm gi m rut. Dng c cm gi m crng hay khng c rng. Trn nguyn tc, dng c c rng s gy sang chn m. Dng cc rng nh khng hay t gy sang chn. Cn nh rng dng c c rng s c tc dngcm gi m chc chn hn dng c khng rng. Cc nhp c rng ln (nhp rng chut)chc dng cm gi da. Nhp c rng nh hay khng rng c thc s dng cm gi m di da, cn c. Nhp khng sang chn c dng cm gia thnh rut

hay mch muKp Allis l dng c cm gi gy sang chn, cn kp Babcock l dng

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c cm gi khng gy sang chn. Khi kp rut, dng Allis kp phn rut sp c ctb, cn Bobcock kp rut bn pha c gi li.

Mt s dng c kp m c tnh nng tm thi ngn chn s lu thng trong lng rut(kp rut), kp ly si mt , kp ph qun

Kp mch mu (kp cm mu) (hnh 2) c tnh nng tm thi ngn chn s lu thngtrong lng mch mu.

cm mu trc tip t mt u ng mch (hay tnh mch) ang chy mu, chng tac kp ng mch. Kp ng mch c thc thit kc bit kp cc mch muc bit (th d kp ng mch phi).

Kp c thc chia lm hai loi: kp sang chn, cn gi l kp nghin hay kp cht vk p khng sang chn, cn gi l kp sng. Trong trng hp k p rut, s dng kpnghin cho phn rut sp c ct b, cn kp sng cho pha bn rut c gi li.

Dng c vn (hnh 4) c s dng vi mc ch mrng phu trng, lm cho thao tcphu thut c thc hin d dng hn mt vng hay mt tng m khng lm tnthng cc tng ln cn.

Dng c vn c th l dng c vn bng tay hay dng c vn tng.

Kp mang kim (hnh 5) c s dng cm gi kim khi khu. Kp gc v kp khn mdnh cho vic cm gi gc m v khn m.

Cc dng c phu thut c lm bng thp khng r. Mt s dng c phu thut clm bng titanium, chromium, vanadium, hay molybden

Cch cm cc dng c phu thut ng l tun theo nguyn tc ba im ta (hnh 6) dng c va c cm gi chc chn va to c s linh hot trong thao tc.

Hnh 6- Cch cm mt vi dng cng kthut

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Hnh 1- Dng c ct

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Hnh 2-Dng c kp cm mu

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Hnh 3- Dng c kp m

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Hnh 4- Dng c banh

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Hnh 5-Dng c khc

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1.2-Ch khu v kim khu:

1.2.1-Ch khu:

C nhiu loi ch khu, chng c phn loi da trn tnh cht tan hay khng tan, mt

si hay nhiu si (bng 1).Cc loi ch b phn hu v mt i kh nng chu lc trong vng 60 ngy c xem lch tan. Kh nng chu lc ca ch c th gim vi cc mc khc nhau trc khi ch

bt u b phn hu.

So vi ch khng tan, ch tan c thi gian duy tr kh nng chu lc ngn hn nhng tgy phn ng ca cthi vi d vt hn.

So vi ch nhiu si, ch loi mt si t c nguy cgy nhim trng hn, nhng d b tnthng bi dng c phu thut.

Vic chnh ch tan hay khng tan, mt hay nhiu si ph thuc vo cc yu cu sau

y:o Thi gian mt vt thng lnh hon ton v khng cn lc h trna.o Nguy cnhim trng ca vt thng.o Mc phn ng ca vt thng i vi d vt.

Chromic catgut l loi ch mt si c thi gian tan nhanh (7-8 ngy). Chng c nhcim l gy phn ng m, lm tng nguy cnhim trng. Hin nay chromic catgut chcn c dng trong khu ni lp nim mc rut.

Polyglactic acid (Vicryl) v polyglycolic acid (Dexon) l hai loi ch tan loi nhiu si

c x dng ph bin nht hin nay. Chng c chn la cho vic khu ni ng tiuho hay khu ng lp m mdi da.

Polypropylene, nylon v ch thp i din cho nhm ch khng tan loi mt si.Polypropylene c s dng trong khu ni mch mu, khu ng chonh... Nylon chc dng khu ng da.

Silk l loi ch khng tan loi nhiu si hin nay ch cn c s dng buc hay khubuc cc mch mu.

Mt s vn cn lu khi s dng cc loi ch trong phu thut:

o Ch cng hin din vi s lng nhiu trong cth, nguy cphn ng i vi vtl ca cth cng cao.

o Khu cng nhiu lp, nguy cnhim trng vng khu s cng tng.o Cm gi ch loi mt si bng dng c (kp) s lm gim 50% kh nng chu lc

ca chng.

o Vi cng mt loi ch, khu trong da s to ra so xu hn so vi khu di da.Loi ch Mt si Nhiu siTan catgut, chromic catgut

polyglecaprone25 (Monocryl)polyglactic acid (Vicryl)polyglycolic acid (Dexon)

Khng tan polypropylene (Prolene)nylon

chthp

silkEthybond

Bng 1- Mt s loi chkhu c sdng trong phu thut

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1.2.2-Kim khu:

Kim khu c phn loi da theo hnh dng (ca mi kim, thn kim v ui kim) vkch thc ca kim.Hnh dng ca mi kim v thn kim quyt nh vic chn la kimcho vic khu vt thng ca cc m khc nhau.

Kim c phn thnh cc loi chnh sau (hnh 7):o Kim nhn (taper): kim c mi nhn, thn vung hay trn. Lc m xuyn vo m

ch yu l lc cng. Kim nhn khng lm t m trong qu trnh m xuyn.Kim c s dng cho cc m dm xuyn nh m di da, phc mc, cctng trong xoang bng (nht l ng tiu ho).

o Kim ct (cutting): kim c u hnh tam gic, thn vung, trn hay dt. nh catam gic u kim c th hng ra ngoi (phi bli ca thn kim, c gi lkim ct thng qui) hay vo trong (phi blm ca thn kim, c gi l kim ctngc). Kim ct lm t cc m trong qu trnh m xuyn qua m. Kim ctngc c lc m xuyn mnh hn kim ct thng qui v c s dng cho cc

m kh m xuyn nh da, bao gn

Hnh 7- Cc loi kim dng trong phu thut: A-Kim nhn, B-Kim ct, C-Kim ct ngc, D-Kimnhn-ct, E-Kim t

o Kim nhn-ct: kim c mt on rt ngn u hnh tam gic, mc ch lm tngkh nng m xuyn nhng khng ct nhiu m (kim trocar).

o Kim t: kim c u t, c s dng cho cc m bv d rch nh gan v thn.Khi s dng kim khu, cn ch :

o Kp kim v tr 1/3 trong v 1/3 ngoi. Kp kim bng u ca kp mang kim.Hng ca kp mang kim vung gc vi mt phng ca kim.

o Hng m ca u kim qua lp m vung gc vi b mt ca m.o Hng di chuyn ca u kim trong lp m cng nh khi rt kim phi trng

vi chiu cong ca thn kim.

o Khng kim v kp mang kim ri nhau trong sut cuc m.1.3-Ct v t in:

1.3.1-My ct-t in (electrocautery) :

Nguyn tc: s dng nng lng in cao tn t cm mu v ct m.

My t n cc c tht cm mu v ct m. Trong cht cm mu, xung inc phng cch qung, lm cho vng m b kh v to ra huyt khi trong lng mch.Trong ch ct, xung in, c phng lin tc, lm t chy tht nhanh v ct ngangmt vng m, nhng t gy tn thng nhit vng m ln cn. My t n cc bt

buc phi c bn tip xc gia BN vi mt t (bn tip t).

My t lng cc ch c tht cm mu. Xung in c phng ra gia hai bn incc (hai u t). Khng c tn thng m no khc ngoi vng m gia hai u t.

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Phng php t lng cc c s dng rng ri trong phu thut ni soi. My tlng cc khng cn bn tip xc gia BN vi mt t.

1.3.2-My t vi tia argon:

o My pht tia argon v s dng tia argon lm ng dn cho cc electron.o C th gy cm mu m khng chm vo b mt m.o c ng dng cm mu mt ct tng c.

1.3.3-Laser tr liu:

o My s dng nng lng ca tia laser ct t v ph hu mt s loi m.o c ng dng rng ri trong ph khoa, chuyn khoa u mt v da liu.o Ba loi my laserc s dng nhiu nht l argon laser, carbon dioxide laser,

neodymium-yttrium aluminum (Nd-YAG) laser.

1.3.4-Quang ng tr liu (photodynamic therapy):

Mt s cht s pht sinh nng lng khi g p nh sng c bc sng c hiu. Nnglng sinh ra s ph hu cu trc m m cht lu tr.

Phng php tr liu ny c ng dng ph hu cc bu lnh hay c tnh.

1.3.5-Quang ng hng ngoi (infrared photocoagulation):

c ng dng trong iu tr trni: nng lng pht ra t chm tia hng ngoi s tptrung ch yu vo lp di nim mc, t chy cc xoang tnh mch trm t lm tnthng lp nim mc b mt.

1.3.6-Cc phng tin sdng sng cao tn:

Dao ct siu m (Harmonic scapel): nng lng c pht ra t s rung ng vi tn srt cao (55.000 ln/giy) lm ct v cm mu m ni tip xc m khng lm tn thngcc cu trc xung quanh. My c ng dng nhiu trong phu thut ni soi.

My ct-ht siu m (Cavitron Ultrasonic Surgical Aspirator): my s dng nng lngpht ra t s rung ng vi tn s rt cao ca mt u d, ct vn m chung quanh,sau ht chng ra ngoi. My c ng dng trong phu thut c thu tinh th, ctgan, ct thn v ct cc khi u trong lnh vc ph khoa.

1.4-Sty trng v tit trng:

Tit trng c nh ngha l loi tr tt c cc vi sinh vt gy bnh, bao gm c bo tca chng, cn ty trng l loi tr phn ln chng.

Tit v ty trng cc dng c v trang thit b trong bnh vin l iu bt buc, hnch nguy cnhim trng cho BN cng nh cho nhn vin y t.

S chn la phng php tit trng hay ty trng tu thuc vo vic nh gi kh nnggy ly nhim ca cc phng tin l nghim trng hay khng nghim trng.

Phng tin c kh nng gy ly nhim nghim trng l cc phng tin c th xmnh p qua da hay nim mc. Tt c cc dng c phu thut (bao gm c kim khu) vdng c ni soi c x p vo nhm ny. Cc phng tin ny hoc l phi c tittrng hoc l c hu b.

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Phng tin c kh nng gy ly nhim trung bnh l cc phng tin c th tip xc vinim mc nhng khng xm nh p qua nim mc. Hu ht dng c khm bnh thucnhm ny. Cc phng tin ny nn c tit trng hay c ty trng ng cch.

Phng tin c kh nng gy ly nhim thp l cc phng tin khng tip xc vi nimmc nhng c th dnh mu hay cc cht tit t nim mc. Cc trang thit b y t thucnhm ny. Cc phng tin ny phi c ty trng thch hp.

Cc phng php ty trng chnh bao gm:

o Ty trng bng dung dch ty trngo Ty trng bng tia cc tmo Ty trng bng kh ozon

Cc loi dung dch ty trng c s dng ph bin hin nay l:

o Alcohol (ethanol, isopropanol)o

Aldehyde (glutaraldehyde)o Halogen (chloramine, chlorine, hypochlorite, iodine)o Tc nhn oxy ho (oxidizing) (chlorine dioxide, hydrogen peroxide, ozone,

peracetic acid, permanganate kali)

o Phenilico Amonium bc 4

Hin nay, trong bnh vin, dung dch ty trng c s dng ph bin nht l natrihypochlorite (cn gi l thuc ty). Ty trng l bc u tin trong quy trnh s l dngc phu thut: sau khi kt thc cuc phu thut, cc dng c phu thut c ngm 30

pht trong dung dch natri hypochlorite, sau c ra sch bng dung dch x-phng(detergent) v cui cng c tit trng.

bo m tiu dit 100% vi sinh vt, cc dng c phi c tit trng. C ba phngphp tit trng chnh: tit trng bng nhit , tit trng bng ho cht v tit trng bngchiu x (bng 2).

Tit trng bng nhit Tit trng bng ho cht Tit trng bng chiu xTit trng bng hi nc dip lc (autoclave)Tit trung bng nhit kh(hp kh)

un si

Ethylene oxide (EO)Ozone

Natri hypochloriteGlutaraldehyde, formaldehyde

Ortho-phthalaldehyde (APA)Hydrogen peroxide

Tia XTia gammaCc ht bn nguyn t(subatomic particles)

Bng 2- Cc phng php tit trng

Tit trng bng hi nc vi p lc l phng php tit trng c s dng ph binnht trong phng m. Khi c tit trng, cc dng c sc tip xc vi hi nng nhit 121C di p lc 15 psi trong thi gian 15-20 pht (hay nhit 134C di plc 30 psi trong thi gian 3-5 pht). Phng php ny c u im l nhanh v r tinnhng c th lm h tn cc dng c bng nha tng hp hay si quang hc. Cc dngc phu thut thng c tit trng bng phng php ny. bo m kh nng tittrng 100%, hi nc vi p lc v nhit nh trn phi tc ng u trn tt c ccdng c.

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C mt s phng php xc nh qu trnh tit trng c c bo m hay khng.Cc phng php ny bao gm vic s dng cc cht ch th mu hay ch th sinh hc.

Tit trng bng kh EO l phng php tit trng c chn la cho cc vt dng lmbng nha tng hp, dng c quang hc hay dng cin c kh nng chu ng scnng ln ti 60C. Khi tit trng, nng kh EO c duy tr mc 200mg/L-800mg/L, trong mi trng c nhit 30-60 C, m 30% v trong khong thi gian3 gi.

Cc dung dch glutaraldehyde v ortho-phthalaldehyde (OPA) cng c thc xem ldung dch tit trng, vi iu kin l cc dng c phi c ngm trong dung dch vithi gian lu (thi gian ngm c th ln n 12 gii vi glutaraldehyde c thdit ht cc bo t). So vi dung dch glutaraldehyde , dung dch OPA c tnh n nhcao hn, t bay hi hn, t gy kch tch da v mt hn, c hot tnh khng khun, nm v

bo t mnh hn nhng c gi thnh t hn. Cc dung dch ny l chn la tit trngcc dng c khng chu c sc nng (th d nh dng c ni soi).

1.5-K nng phng m:

1.5.1-Ra tay, mc o v mang gant:

Trc bt k mt cuc phu thut no, tt c cc thnh vin trong -kp phu thut, nghal nhng ngi tip xc vi vng m ca BN v cc dng c phu thut v trng, s phira tay, mc o v mang gant theo nguyn tc m bo v trng cho cuc m.

Vic chi ra khng lm cho tay trnn v trng, nhng n gip hn ch nguy cnhimtrng ca cuc m.

Trc khi chi ra tay, cn ch cc iu sau:

o Tho cc trang sc tayo Kim tra cc mng tay. Ct mng tay nu mng di. Mng tay di l ngun ly

nhim, ng thi c th lm rch gant khi tin hnh phu thut.

o Kim tra cc tn thng da tay (cc vt xc, try xt hay nhim trng ngoida). Ngi c tn thng tay khng nn tin hnh cuc phu thut.

Chi ra tay phi ng k thut. Hin nay tt c cc bnh vin u thit lp c quytrnh chi ra tay ring ca mi bnh vin. Tt c cc quy trnh u ging nhau mtim: chi ra tay ti thiu 5 pht trc ca phu thut u tin v 3 pht cho cc ca phuthut tip theo.

K thut chi ra tay (hnh 8) c mt siu cn nh:

o Ra tay di vi nc ang chy.o Sau khi thoa x phng, chi ra tt c cc mt ca ngn tay cng nh ca bn tay,

cng tay v khuu tay, theo hng t ngn tay ln khuu tay.

o Sau khi chi ra tay, dng cnh tay ln sao cho dng nc chy xung khuutay.

o Kho vi nc bng khuu tay.Sau khi chi ra tay:

o Lau kh tay vi khn v khun.o Gia cho cnh tay v khuu tay lun cao hn khuu

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o Mc o m (hnh 9).o Mang gant m (hnh 10).

Hnh 8- Ra tay

Hnh 9- Mc o m

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Hnh 10- Mang gant m

1.5.2-Chun b vng m:

BN nn tm ra vo m trc ngy m. Lng vng m nn c ly i. Vic ct lngvng m tt hn l co lng v nn c tin hnh trong phng m. Ngay trc khi cucm bt u, ra vng m v vng ln cn vi nc v x-phng. St trng vng m vvng ln cn bng dung dch st trng, bt u t vng trung tm ra pha ngoi vi (hnh

11). Chlorhexidine v iodine l hai dung dch st trng da thng c s dng nhiuhn alcohol. Cc dung dch st trng phi c duy tr trng thi t trn da ti thiu 2

pht.

Cn nh l vng ra v st trng da phi rng hn vng m, khi tin hnh thao tcphu thut, bn tay ca phu thut vin khng phi chm vo vng da cha c sttrng.

Hnh 11- St trng vng m

1.5.3-Tri khn vng m:

Ch nn tri khn m sau khi mc o v mang gant m.

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C nhiu phng php tri khn m, tu thuc vo loi khn. Tuy nhin,vic tri khncng tun theo mt s nguyn tc nht nh. Cc nguyn tc ny l:

o Tri khn che kn ngi BN, ch cha li hai vng, vng m v vng cho bc sgy m tin hnh cc thao tc nghip v ca mnh.

o Phn khn m nm bn di bn mc xem nh khng v trng.Sau khi tri khn, khn mc cnh bng cc kp (hnh 12).

Hnh 12- Tri khn m vcnh khn mbng kp

2-K nng v kin thc cn bn trong phu thut:

2.1-Rch da v khu da:

Cc vn cn ch khi rch da (hnh 13):

o D tr sn di ca ng rch bo m bc ly phu trng.o Gi yn da vi hai ngn ca mt bn tay, tay cn li cm dao rch da vi ng

rch lin tc. Mt phng ca li dao c gi vung gc vi mt phng da.

o Mi ln rch, rch tng lp mt. Gi nguyn di ca ng rch sau mi lnrch. Nu c thi gian, cm mu sau mi ln rch.

Phng php khu ng da thng c thc hin nht l khu ng mt lp vi chkhng tan v mt si (tt nht l ch nylon 3-0 hay 4-0). Mi khu da thng l mi ri.Mi khu cn 1 cm m hai pha (hnh 13). Cc mi khu cch nhau 1 cm.

Trong trng hp lp mdi da dy, c th khu ng ring m mdi da. Mi khung m di da l mi ri, bt u ty vt thng ln ln nch xung pha di(hnh 14). Ch dng khu m mdi da phi l loi ch tan (tt nht l polyglactichay polyglycolic acid 3-0 hay 4-0). C th dng ch khng tan khu ng m mdida, vi iu kin chng phi l ch loi n si v khng phi l nylon.

Khi vt thng b dy trng ng k, tt nht l h vt thng, khu cc mi ch(hnh 15), p gc tm nc mui sinh l vo vt thng. Sau 2-5 ngy sng vtthng bng xit cc mi ch ch.

2.2-Cm mu:

Nu mu chy ri r, cm mu bng cch p ch chy bng gc.

Nu thy mt mch mu ang chy mu, cm mu bng t in, buc hay khu buc(hnh 16). V tr t in khng qu gn da. Nu buc cm mu, ct hai u ch buccng ngn cng tt.

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Khi buc cm mu mt mch mu tng i ln, hay khi nghi ngnt ch buc cm muc th b st, nn cm mu bng khu buc. Vic cm mu bng khu buc c thchin bng cch xuyn kim qua mch mu v sau buc vng quanh mch mu. tmt nt ch buc th hai bn di ca nt khu buc.

Hnh 13- Rch da v khu ng da Hnh 14- Khu ng m di da

Hnh 15- Mi khu ch(khu da ku mun)

Hnh 16- Khu buc cm mu

2.3-Buc ch:

Cc nguyn tc cn bn ca buc ch trong phu thut:

o Nt ch phi dt v chc chn, cc nch khng b lng.o Nt ch cng nh v hai u ch cng ngn cng tt gim thiu nguy cphn

ng ca cthi vi vt l.

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o Khi buc ch, nn trnh gy ra s c xt gia hai nhnh ch buc khng lmtn thng si ch.

o Khng dng dng c phu thut kp si ch (tr vic kp u ch khi bucch bng dng c). ng tc ny c th lm tn thng si ch.

o Khng lm cng si ch qu mc khi buc. ng tc ny c th lm t si chhay t m.o Khng buc ch qu cht. ng tc ny c th gy thiu mu, dn n hoi t

m.

o Sau khi buc nth nht, gi cho mt nhnh ch cng. ng tc ny s trnhc lng n.

o Nbuc cui cng nn cng nm theo chiu ngang cng tt.C hai loi nt ch: nt vung v nt ca nh ngoi khoa (surgeons knot) (hnh 17)

Hnh 17- Cc nt ch bucchnh trong ngoi khoa: ntvung (hnh trn tri) v ntca nh ngoi khoa

Cc nt ch c thc buc bng mt tay, hai tay hay bng dng c (hnh 18,19,20)

12

3 4

5 6

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7 8

9 10

11 12

13 14Hnh 18- Kthut buc nt vung bng hai tay

1 2

3 4

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5 6

7 8

9 10

11 12

13 14

15

Hnh 19- K thut buc nt vung bngmt tay

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Hnh 20- Kthut buc nt ca nh ngoi khoa bng hai tay

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