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K NNG V KIN THC CN BN TRONG PHU 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 th c chia lm cc nhm chnh sau y: o Dng c ct o Dng c bc tch o Dng c cm mu o Dng c kp m o Dng c kp kim o Dng c thm d o Dng c nong o Dng c vn o Dng c ht Dng c ct (hnh 1) c chc nng chnh l ct m. Ko l i din chnh cho nhm dng c ct. Tu theo loi m v v tr ca m c ct m ko c cu to hnh th v chiu di khc nhau. Ko Mayo, nng v chc chn, c s dng ct ch hay ct cc m dy 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 s loi ko c bit khc c s dng ct ch thp, ct m mch mu Dng c bc tch c chc nng chnh l ct v phn tch cc m. Dng c bc tch c phn 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 v cho 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 thc hin cc vt rch di. Li s 11 cho cc vt rch nh v li s 15 cho cc vt rch rt nh. Li dao s 15, khi c dng ct trong su, s c lp vo cn dao s 7. Khi s 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 kp mch 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 cng thuc nhm ny, nhng thng c dng cm gi m rut. Dng c cm gi m c rng hay khng c rng. Trn nguyn tc, dng c c rng s gy sang chn m. Dng c c rng nh khng hay t gy sang chn. Cn nh rng dng c c rng s c tc dng cm gi m chc chn hn dng c khng rng. Cc nhp c rng ln (nhp rng chut) ch c dng cm gi da. Nhp c rng nh hay khng rng c th c 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 ct b, 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 thng trong lng mch mu. cm mu trc tip t mt u ng mch (hay tnh mch) ang chy mu, chng ta c kp ng mch. Kp ng mch c th c thit k c bit kp cc mch mu c bit (th d kp ng mch phi). Kp c th c chia lm hai loi: kp sang chn, cn gi l kp nghin hay kp cht v kp khng sang chn, cn gi l kp sng. Trong trng hp kp rut, s dng kp nghin 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 m rng phu trng, lm cho thao tc phu thut c thc hin d dng hn mt vng hay mt tng m khng lm tn thng cc tng ln cn. Dng c vn c th l dng c vn bng tay hay dng c vn t ng. Kp mang kim (hnh 5) c s dng cm gi kim khi khu. Kp gc v kp khn m dnh 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 c lm 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 c ng k thut

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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 l ch 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 t gy phn ng ca c th i vi d vt hn. So vi ch nhiu si, ch loi mt si t c nguy c gy nhim trng hn, nhng d b tn thng bi dng c phu thut. Vic ch nh 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 tr na. o Nguy c nhim 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 nhc im l gy phn ng m, lm tng nguy c nhim trng. Hin nay chromic catgut ch cn 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 tiu ho hay khu ng lp m m di 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 c honh... Nylon ch c dng khu ng da. Silk l loi ch khng tan loi nhiu si hin nay ch cn c s dng buc hay khu buc 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 c th, nguy c phn ng i vi vt l ca c th cng cao. o Khu cng nhiu lp, nguy c nhim 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 Tan Khng tan Mt si Nhiu si catgut, chromic catgut polyglactic acid (Vicryl) polyglecaprone25 (Monocryl) polyglycolic acid (Dexon) polypropylene (Prolene) silk nylon Ethybond ch thp Bng 1- Mt s loi ch khu c s dng 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) v kch thc ca kim.Hnh dng ca mi kim v thn kim quyt nh vic chn la kim cho 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 d m xuyn nh m di da, phc mc, cc tng trong xoang bng (nht l ng tiu ho). o Kim ct (cutting): kim c u hnh tam gic, thn vung, trn hay dt. nh ca tam gic u kim c th hng ra ngoi (phi b li ca thn kim, c gi l kim ct thng qui) hay vo trong (phi b lm ca thn kim, c gi l kim ct ngc). Kim ct lm t cc m trong qu trnh m xuyn qua m. Kim ct ngc 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-Kim nhn-ct, E-Kim t

o Kim nhn-ct: kim c mt on rt ngn u hnh tam gic, mc ch lm tng kh nng m xuyn nhng khng ct nhiu m (kim trocar). o Kim t: kim c u t, c s dng cho cc m b v 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 th t cm mu v ct m. Trong ch t cm mu, xung in c 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 ngang mt 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 th t cm mu. Xung in c phng ra gia hai bn in cc (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 t lng 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 laser c 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 gp nh sng c bc sng c hiu. Nng lng 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 tr ni: nng lng pht ra t chm tia hng ngoi s tp trung ch yu vo lp di nim mc, t chy cc xoang tnh mch tr m t lm tn thng lp nim mc b mt. 1.3.6-Cc phng tin s dng sng cao tn: Dao ct siu m (Harmonic scapel): nng lng c pht ra t s rung ng vi tn s rt cao (55.000 ln/giy) lm ct v cm mu m ni tip xc m khng lm tn thng cc 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 lng pht 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, ct gan, ct thn v ct cc khi u trong lnh vc ph khoa. 1.4-S ty trng v tit trng: Tit trng c nh ngha l loi tr tt c cc vi sinh vt gy bnh, bao gm c bo t ca 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, hn ch nguy c nhim 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 nng gy 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 xm nhp qua da hay nim mc. Tt c cc dng c phu thut (bao gm c kim khu) v dng c ni soi c xp vo nhm ny. Cc phng tin ny hoc l phi c tit trng 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 vi nim mc nhng khng xm nhp qua nim mc. Hu ht dng c khm bnh thuc nhm 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 nim mc nhng c th dnh mu hay cc cht tit t nim mc. Cc trang thit b y t thuc nhm 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 trng o Ty trng bng tia cc tm o 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 Phenilic o Amonium bc 4 Hin nay, trong bnh vin, dung dch ty trng c s dng ph bin nht l natri hypochlorite (cn gi l thuc ty). Ty trng l bc u tin trong quy trnh s l dng c 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 phng php tit trng chnh: tit trng bng nhit , tit trng bng ho cht v tit trng bng chiu x (bng 2).
Tit trng bng nhit Tit trng bng hi nc di p lc (autoclave) Tit trung bng nhit kh (hp kh) un si Tit trng bng ho cht Tit trng bng chiu x Tia X Ethylene oxide (EO) Tia gamma Ozone Cc ht bn nguyn t Natri hypochlorite Glutaraldehyde, formaldehyde (subatomic particles) Ortho-phthalaldehyde (APA) Hydrogen peroxide Bng 2- Cc phng php tit trng

Tit trng bng hi nc vi p lc l phng php tit trng c s dng ph bin nht trong phng m. Khi c tit trng, cc dng c s c tip xc vi hi nng nhit 121C di p lc 15 psi trong thi gian 15-20 pht (hay nhit 134C di p lc 30 psi trong thi gian 3-5 pht). Phng php ny c u im l nhanh v r tin nhng c th lm h tn cc dng c bng nha tng hp hay si quang hc. Cc dng c phu thut thng c tit trng bng phng php ny. bo m kh nng tit trng 100%, hi nc vi p lc v nhit nh trn phi tc ng u trn tt c cc dng 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 lm bng nha tng hp, dng c quang hc hay dng c in c kh nng chu ng sc nng ln ti 60C. Khi tit trng, nng kh EO c duy tr mc 200mg/L800mg/L, trong mi trng c nhit 30-60 C, m 30% v trong khong thi gian 3 gi. Cc dung dch glutaraldehyde v ortho-phthalaldehyde (OPA) cng c th c xem l dung dch tit trng, vi iu kin l cc dng c phi c ngm trong dung dch vi thi gian lu (thi gian ngm c th ln n 12 gi i vi glutaraldehyde c th dit ht cc bo t). So vi dung dch glutaraldehyde , dung dch OPA c tnh n nh cao 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 trng cc 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, ngha l nhng ngi tip xc vi vng m ca BN v cc dng c phu thut v trng, s phi ra tay, mc o v mang gant theo nguyn tc m bo v trng cho cuc m. Vic chi ra khng lm cho tay tr nn v trng, nhng n gip hn ch nguy c nhim trng ca cuc m. Trc khi chi ra tay, cn ch cc iu sau: o Tho cc trang sc tay o 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 ngoi da). 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 quy trnh chi ra tay ring ca mi bnh vin. Tt c cc quy trnh u ging nhau mt im: chi ra tay ti thiu 5 pht trc ca phu thut u tin v 3 pht cho cc ca phu thut tip theo. K thut chi ra tay (hnh 8) c mt s iu 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 khuu tay. 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 lng vng m tt hn l co lng v nn c tin hnh trong phng m. Ngay trc khi cuc m bt u, ra vng m v vng ln cn vi nc v x-phng. St trng vng m v vng 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 nhiu hn 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 tc phu thut, bn tay ca phu thut vin khng phi chm vo vng da cha c st trng.

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 khn cng 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 s gy m tin hnh cc thao tc nghip v ca mnh. o Phn khn m nm bn di bn m c xem nh khng v trng. Sau khi tri khn, khn m c c nh bng cc kp (hnh 12).

Hnh 12- Tri khn m v c nh khn m bng 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 l y 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 ln rch. 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 ch khng 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 m di da dy, c th khu ng ring m m di da. Mi khu ng m di da l mi ri, bt u t y vt thng ln ln n ch xung pha di (hnh 14). Ch dng khu m m di da phi l loi ch tan (tt nht l polyglactic hay polyglycolic acid 3-0 hay 4-0). C th dng ch khng tan khu ng m m di da, 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 s ng vt thng 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 buc cng ngn cng tt. 36

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Khi buc cm mu mt mch mu tng i ln, hay khi nghi ng nt ch buc cm mu c th b st, nn cm mu bng khu buc. Vic cm mu bng khu buc c thc hin bng cch xuyn kim qua mch mu v sau buc vng quanh mch mu. t mt 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 k u 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 n ch khng b lng. o Nt ch cng nh v hai u ch cng ngn cng tt gim thiu nguy c phn ng ca c th i vi vt l. 37

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o Khi buc ch, nn trnh gy ra s c xt gia hai nhnh ch buc khng lm tn thng si ch. o Khng dng dng c phu thut kp si ch (tr vic kp u ch khi buc ch 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 ch hay 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 n th nht, gi cho mt nhnh ch cng. ng tc ny s trnh c lng n. o N buc 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 buc chnh trong ngoi khoa: nt vung (hnh trn tri) v nt ca nh ngoi khoa

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

5
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10

11

12

13
Hnh 18- K thut buc nt vung bng hai tay

14

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10

11

12

13

14

Hnh 19- K thut buc nt vung bng mt tay

15

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

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