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UNG TH I TRNG V TRC TRNG

1-i cng: 1.1-i cng v polyp i trng: Polyp l mt ch nh ln trn b mt lp biu m ca i trng. Polyp i trng c th c cung hay c chn rng. V mt bn cht m hc, polyp i trng c th xut pht t lp biu m (polyp tuyn, polyp tng sn) hay lp m m (hamartoma). ngi trn 60 tui, polyp i trng chim t l khong 10%. Polyp i trng c th c chia lm ba nhm chnh: polyp tng sn (90%), polyp tuyn (10%) v cc hi chng a polyp (t l khng ng k). Cc hi chng a polyp c th c chia thnh hai nhm: cc hi chng a polyp c yu t di truyn v cc hi chng a polyp khng c yu t di truyn. Polyp tng sn: o Thng gp on cui i trng v trc trng o Kch thc thng nh hn 5 mm o Hnh dng ph bin: trn, nh, khng cung o Khng c nguy c chuyn dng sang c tnh Polyp tuyn: o c chia lm ba loi: tuyn ng (tubular), tuyn nhung mao (vilous) v tuyn ng-nhung mao (tubulovilous). Polyp tuyn c th gp bt k on no trn i trng v c cung. Polyp nhung mao tp trung ch yu trc trng v khng cung. o 90% c kch thc nh hn 1,5 cm o Nguy c c tnh ph thuc vo: kch thc (ln hn 2 cm) v thnh phn nhung mao trong polyp (polyp nhung mao c nguy c c tnh cao nht) Hi chng a polyp c yu t di truyn: o Hi chng a polyp tuyn: Hi chng FAP (Familial Adenomatous Polyposis Syndrome) Hi chng Gardner Hi chng Turcot o Hi chng a polyp m m: Hi chng Peutz-Jegher (PJ) Hi chng a polyp ngi tr (FJP-Familial Juvenile polyposis) Bnh Cowden Hi chng Ruvalcaba-Myhre-Smith Hi chng a polyp khng c yu t di truyn: hi chng Cronkhite-Canada. 1.2-Cc hi chng c yu t di truyn trong ung th i trc trng:

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1.2.1-Hi chng Lynch: Cn gi l Ung Th i Trng Do Di Truyn Khng Phi a Polyp (HNPCCHereditary Nonpolyposis Colorectal Cancer). Hi chng Lynch chim 5% cc trng hp ung th trc trng. Nguyn nhn ca hi chng ny c xc nh: c s t bin ca mt trong nm gene Sa Li Bt Cp Nhim Sc Th (Mismatch Repair Genes: MLH1, MSH2, MSH6, PMS1, PMS2). Ngi c HNPCC c nguy c mc cc bnh l c tnh ca i trc trng (70-80% trong sut cuc i), ni mc t cung (30-60%), bung trng, d dy, rut non, niu qun, tuyn b da. chn on hi chng Lynch, trc tin cn ngh n kh nng c th c hi chng ny. Tiu chun chn on cht ch nht hin nay l tiu chun Amsterdam: o C ti thiu ba ngi trong ph h mc ung th i trng, v o Mt ngi l trc h ca mt trong hai ngi cn li, v o t nht c mt ngi b ung th i trng tui di 50. 20% ngi b HNPCC c t bin gene t pht. Chn on xc nh HNPCC da vo xt nghim mu xc nh s t bin ca cc gene ni trn 1.2.2-Hi chng a polyp tuyn c tnh cch gia nh (FAP): Ti M, hi chng FAP c tn sut 1/6000-1/30000. Nguyn nhn ca hi chng FAP l do c s t bin gene APC, mt li gene c vai tr c ch s hnh thnh ca khi u tn sinh i trng. Ngoi hi chng FAP, s t bin ca gene APC cn xy ra trong hi chng Gardner v hi chng Turcot. tui bt u xut hin triu chng ca hi chng FAP l 16. BN c chn on hi chng FAP trung bnh tui 36. Chn on hi chng FAP da vo: o U qui trong xoang bng hay vng sau trc trng o Soi y mt: ph i lp biu m sc t vng mc o Chn on da vo hnh nh trn ni soi: hng trm n hng ngn polyp i trng, nhiu polyp d dy (polyp phnh v v polyp tuyn hang v), t trng (polyp tuyn, tp trung ch yu vng quanh bng Vater). BN c hi chng FAP c nguy c b ung th i trc trng (100% khi n tui 40), ung th d dy, ung th t trng (4%), ung th tuyn gip, u h thng thn kinh trung ng v hepatoblastoma. 1.2.3-Hi chng Peutz-Jegher: Hi chng Peutz-Jegher c tn sut 1/60000-1/300000. Nguyn nhn hi chng Peutz-Jegher l do c s t bin gene STK11. tui bt u xut hin cc triu chng ca hi chng Peutz-Jegher l 25. Chn on hi chng Peutz-Jegher da vo:

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o Cc polyp (hamartoma) ri rc trong ng tiu ho, nhng tp trung ch yu rut non o Cc sang thng sc t da v nim mc khoang ming o U tinh hon (u t bo Sertoli) Ngi c hi chng Peutz-Jegher c nguy c mc cc bnh l c tnh ca: ng tiu ho (t thc qun n trc trng, cao nht l i trng), tu, phi, v, c t cung, bung trng. 1.3-i cng v ung th i trc trng: Ung th i trc trng l bnh l c tnh ph bin (ng th ba ti M). Hu ht ung th i trc trng l adenocarcinoma. Cc bnh l c tnh cn li bao gm carcinoid, lymphoma v sarcoma Mt iu quan trng cn bit l hu ht ung th i trc trng (93%) xut pht t mt polyp tuyn ca i trng. Thi gian chuyn t mt polyp lnh tnh sang c tnh trung bnh khong 3-5 nm. Khng c s khc bit v gii tnh cc BN b ung th i trng. i vi ngi b ung th trc trng, nam gii c t l mc bnh cao hn n gii. tui b ung th i trc trng ph bin nht l 70-80. Hu ht ung th i trc trng c lin quan n cc yu t ngoi cnh. Ch mt s t do di truyn. Ung th i trng xch ma v trc trng chim 50% cc trng hp ung th i trc trng. Ung th i trng xung c t l thp nht (hnh 1).

Hnh 1- Phn b ca ung th itrc trng (s liu 1996 ti M)

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3% BN b ung th hai v tr tr ln trn khung i trng v trc trng. Yu t thun li ca ung th i trc trng: ch n ung t cht b, nhiu tht, m ng vt v cholesterol. Yu t nguy c ung th i trc trng: o Ln tui o Polyp tuyn i trng o Di truyn o Bnh vim lot i trng Ung th i trc trng l mt trong s t bnh l c tnh c tin lng kh tt. Khong 50% BN b ung th i trc trng c th c phu thut trit cn. 1.4-Gii phu i trng v trc trng: i trng v trc trng c cung cp mu nui bi cc ng mch khc nhau. c th tin hnh phu thut ct mt on i trng hay trc trng, cn phi hiu r s cung cp mu cho on (hnh 2, bng 1):
M chnh M nhnh Mc treo trng Hi-manh trng-rut tha i trng phi trn i trng gia Mc treo trng i trng tri di Xch-ma Trc trng trn Trc trng gia Trc trng di on i trng Manh trng i trng ln i trng ngang i trng xung i trng xch-ma 2/3 trn trc trng 1/3 di trc trng Bng 1, hnh 2- S phn on v cung cp mu nui ca i v trc trng A-Manh trng B-i trng ln C-i trng ngang D-i trng xung E-i trng xch-ma 1-M mc treo trng trn 2-M hi-manh trng-rut tha 3-M i trng phi 4-M i trng gia 5-M mc treo trng di 5a-M i trng tri 5b-M i trng xch-ma

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Mt s c im gii phu ca trc trng c lin quan n phu thut ung th trc trng: o Trc trng di khong 12 cm, tnh t b trn ng hu mn n ni gip vi i trng xch-ma. o Mt sau trc trng c lp m kh dy, c gi l mc treo trc trng. Cc t bo ung th c th n lan trong mc treo trc trng xa hn l n lan trong thnh trc trng. o Trc trng c bao ph bi l tng ca mc ni chu (mc trc trng). Lp mc tng ny c tc dng lm cho ng khu ni trc trng c kn. o Phi trc, trc trng lin quan vi tin lit tuyn, ti tinh, bng quang (nam) hay vch sau m o (n). C mt lp mc (Denonvillier) ngn cch gia tin lit tuyn v ti tinh vi trc trng. o Phi sau, trc trng lin quan vi xng cng. Mt trc xng cng c ph bi l thnh ca mc ni chu (mc trc xng cng). Mc cng chu (mc Waldeyer) ni mc trc xng cng vi mc trc trng. Gia mc cng chu v mc trc xng cng c m ri tnh mch trc xng cng v cc nhnh thn kinh cng. o Phc mc ch ph 2/3 trc v hai bn trc trng. Ni m np phc mc t mt trc trc trng lt ln ph mt sau bng quang c gi l ngch trc trngbng quang. Ngch trc trng-bng quang cch ra hu mn khong 7,5 cm (cch b trn ng hu mn 3-4 cm), bng chiu di ca mt ngn tay. Khi thm trc trng, ngn tay chm vo khi u c ngha l khi u 1/3 di trc trng. Dn lu bch mch ca i trng v trc trng i theo cc cung mch chnh. Dn lu bch mch i trng v 2/3 trn trc trng ch i theo mt hng. Dn lu bch mch 1/3 di trc trng c th i theo nhiu hng: ln trn (vo nhm hch cnh ng mch ch), sang bn (vo nhm hch chu trong) hay xung di (vo nhm hch bn). Phu thut ung th trc trng c lin quan trc tip n hot ng chc nng ca c tht v hot ng sinh dc. 2-Chn on: 2.1-Chn on lm sng: 2.1.1-Ung th i trng: Triu chng ca ung th i trng thay i ph thuc vo v tr ca khi u. BN b ung th i trng phi c th nhp vin v: o Thiu mu thiu st (do chy mu r r t khi u) o St cn o Khi u bng Triu chng thng gp ca ung th i trng tri: o au bng, to bn o Thay i thi quen i tiu o Tiu mu 40% BN ung th i trng nhp vin vi khi u gy tc hay thng i trng. Chn on tc rut do ung th i trng hay ung th i trng thng da vo: 227

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o Tui tc ca BN o Tin cn: au bng m , thay i thi quen i tiu. o Khi u gy tc: hi chng tc rut thp (to bn, chng bng). o Khi u i trng thng biu hin di hai th lm sng: p-xe trong xoang bng v vim phc mc ton din. Nu khi u va gy tc rut va b thng, BN s nhp vin trong bnh cnh sc nhim trng nhim c rt nng. o X-quang bng khng sa son: Tc i trng (hnh 3): on trn ch tc: i trng chng hi on di ch tc: khng c hi trong i trng Nu van hi manh trng h: cc quai rut non chng hi v c mc nc hi Thng i trng: lim hi di honh

Hnh 3- Hnh nh tc i trng trn X-quang bng Hnh 4- Hnh nh tc rut do ung th i ng khng sa son. Trn X-quang, ch tc c trng trn X-quang i trng. V tr tc d on t ch ni i trng xung-i trng xch- ch ni i trng xung-i trng xch-ma ma tr xung.

o CT l phng tin chn on c chn la chn on xc nh nguyn nhn (ung th i trng) trn BN c hi chng tc rut hay vim phc mc. X-quang i trng c ch nh hn ch trong tc i trng do ung th i trng. Khi nghi ng ung th i trng thng, chng ch nh chp X-quang i trng vi Barium. 2.1.2-Ung th trc trng: BN b ung th trc trng c hai triu chng chnh l tiu mu (60%) v thay i thi quen i tiu (43%). Khi bnh tin trin, BN c th c: o au do khi u gy bn tc hay tc rut, do khi u xm ln vo m ri thn kinh vng chu v trc xng cng, do thng khi u gy vim phc mc.

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o Tiu khng t ch, do khi u xm ln vo c tht hu mn. o Tiu gt but, do khi u xm ln vo bng quang. Thm trc trng l thao tc quan trng v c tnh cch bt buc trc bt k biu hin bt thng no ca vng hu mn-trc trng. Mc ch ca vic thm khm hu mn trc trng l nhm: o Pht hin khi u trc trng o nh gi tng i mc xm ln vo c quan ln cn o nh gi chc nng c tht o nh gi kh nng bo tn c tht BN b ung th trc trng c th nhp vin v hi chng tc rut. Chn on tc rut do ung th trc trng bao gm: o Hi chng tc rut thp o Thm trc trng c th s c khi u bt lng trc trng. Nu khi u nm 2/3 trn, thm khm trc trng c th khng s ng khi u, nhng du hiu mu bm theo gant rt c gi tr trong chn on. o X-quang bng khng sa son: chng hi rut non v ton b khung i trng (chn on phn bit: lit rut). o Cng ging nh trng hp tc rut do ung th i trng, CT l phng tin chn on c la chn cho tc rut do ung th trc trng. Ni soi trc trng vi ng soi cng c th c ch nh thay cho CT. Khng c ch nh chp Xquang i trng khi lm sng chn on tc rut do ung th trc trng. o Cn ch l nu thm khm trc trng s c khi u bt lng trc trng, ngoi X-quang bng khng sa son, khng cn thit phi ch nh thm bt c phng tin chn on no khc. 2.2-Chn on phn bit: Tu theo triu chng khi BN nhp vin, cc chn on phn bit c th l: o au bng qun, thiu mu, tiu mu bm hay mu : Polyp i trc trng Vim ti tha i trng Vim i trng mn Hi chng Rendu-Osler-Weber Tr Lc ni mc t cung o Khi u bng: Lao hi manh trng Ung th d dy Ung th gan Ung th tu

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o Hi chng tc rut: Xon i trng Hi chng Ovilgie o Hi chng vim phc mc: Vim phc mc rut tha Thng lot d dy-t trng 2.3-Chn on cn lm sng: 2.3.1-X-quang i trng vi Barium: Hnh nh: o Khi nh vo lng i trng vi ng b khng u o Lng i trng b hp li (hnh 4,5) pht hin khi u giai on sm, cn chp i quang kp. Hn ch ca X-quang i trng trong chn on ung th i trng: o Kh pht hin ung th giai on sm v kh chn on phn bit vi polyp i trng o Kh pht hin c tn thng vng hi-manh trng v bng trc trng chnh xc ca X-quang i trng trong chn on ung th i trng l 70-85%.

Hnh 5- Hnh nh ung th i trng trn X- Hnh 6- Hnh nh ung th i trng qua ni soi quang i trng i trng

2.3.2-Ni soi i trc trng km sinh thit (hnh 6): L tiu chun vng trong chn on v tm sot cc bnh l c tnh ca i trc trng. ng soi cng c s dng chn on v sinh thit tn thng trc trng. ng soi mm c s dng chn on v sinh thit tn thng khung i trng. ng soi mm c chiu di ngn (60 cm) dng soi i trng xch-ma hin nay t c ch nh. 230

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2.3.3-CT (hoc MRI): t khi c ch nh chn on xc nh ung th i trng, tr cc trng hp sau: o BN khng chp nhn ni soi i trng o BN khng gi c bart o Tc rut do u i trng o Thng u i trng Hnh nh ca ung th i trng trn CT (hnh 7): o Khi c m m mm, nh vo lng i trng o Dy thnh i trng (> 6mm) o Hp lng i trng Ch nh ph bin nht ca CT: o nh gi giai on ung th i trng o Pht hin ung th ti pht hay di cn

Hnh 7- Hnh nh ung th i trng trn CT: A-ung th i trng ngang, B-ung th ch ni xchma-trc trng

2.3.4-Siu m qua ng trc trng: Hin nay l phng php c chn la nh gi mc xm ln qua thnh trc trng ( chnh xc 72-94%) v nh gi di cn hch vng ( chnh xc 73-86%). 2.3.5-Chp cng hng t qua ng trc trng (endorectal surface-coil MRI): C gi tr tng ng hay cao hn siu m qua ng trc trng trong vic nh gi mc xm ln qua thnh trc trng v nh gi di cn hch vng. 2.3.6-Siu m bng: Siu m c ch nh pht hin di cn gan. Hnh nh di cn gan trn siu m l cc khi echo dy ri rc trong nhu m gan. 2.3.7-PET:

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PET t khi c ch nh trc phu thut. Sau phu thut, c th phn bit ung th ti pht hay so x ti vng ming ni, PET l ch nh u tin. 2.3.8-CEA: CEA t khi tng BN ung th i trng km bit ho. Nu tng trc phu thut, CEA c th c dng nh gi mc trit cn ca cuc phu thut v pht hin ung th ti pht. Cn nh rng CEA cng tng trong mt s trng hp khc (bnh l gan mt tu, ht thuc l) 2.3.9-CEA scan: CEA scan i khi c ch nh pht hin di cn xa. Phng php chp lp lnh xmin dch ny s dng cc khng th ca CEA c nh du ng v phng x pht hin cc t chc sn xut CEA trong c th. Vai tr ca CEA scan trong vic pht hin di cn xa cn ang c bn lun. 2.4-Thi chn on: BN b ung th i trc trng c th nhp vin v cc bnh cnh lm sng sau: o Khi u bng o Hi chng thiu mu km st cn o Hi chng ri lon tiu ho di o Hi chng xut huyt tiu ho di o Hi chng tc rut o Hi chng vim phc mc o Di cn th pht gan, phi..c pht hin tnh c chn on xc nh ung th i trc trng, ni soi i trc trng (ng soi mm hay cng, tu thuc vo tn thng nm thp trc trng hay cao trn khung i trng) l ch nh u tin v c tnh cch bt buc. Ni soi gip chn on xc nh v hnh nh cng nh v gii phu bnh, v y l phng tin duy nht c th tin hnh sinh thit khi u. i vi BN b ung th trc trng, ngay c sau khi c ni soi ng soi cng, BN cng cn c ni soi ton b khung i trng vi ng soi mm pht hin cc tn thng c tnh ng phi hp. CT hay MRI c th c ch nh chn on xc nh ung th i trc trng thay th cho ni soi, nu BN khng hp tc tin hnh ni soi, BN c cc chng ch nh ni soi (bnh l ti tha i trng, khi u i trng thng). Vai tr chnh ca CT hay MRI l nh gi giai on ung th i trng sau khi c chn on xc nh. i vi BN b ung th trc trng, ngoi CT v MRI, siu m qua ng trc trng (v gn y l MRI qua ng trc trng) cng c th c ch nh v c xem l phng tin nh gi mc xm ln ca khi u qua thnh trc trng chnh c chnh xc cao nht. tm kim cc di cn xa, cc xt nghim sau y c th c ch nh: o X-quang ngc thng o Siu m bng o Xt nghim chc nng gan o PET 232

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o CEA scan o X hnh xng o CT s no Ngay c khi t c gi tr chn on, CEA cng nn c xt nghim cho tt c cc BN b ung th i trc trng, lm c s cho vic theo di v nh gi tin lng sau ny. Khi BN nhp vin v hi chng tc rut thp, X-quang bng khng sa son l ch nh trc tin. X-quang bng xc nh c tc i trng nhng khng chn on c nguyn nhn. Hn na, X-quang khng phn bit c tc on cui ca i trng v trc trng vi hi chng gi tc i trng cp (hi chng Ovilgie). gii quyt c cc vn nu trn, cn phi c CT bng. Phi rt cn thn khi ch nh chp X-quang i trng i vi nhng BN c hi chng tc rut thp. nhng BN c st, bch cu tng, bng n au khu tr, chng ch nh chp X-quang i trng. Nu thm khm trc trng s c khi u bt lng trc trng, ngoi X-quang bng khng sa son, khng cn thit phi ch nh thm bt c phng tin chn on no khc. Khi lm sng nghi ng khi u i trng thng, CT l phng tin chn on c chn la trc tin. iu cn ch l BN c khi u thng km tc i trng thng nhanh chng ri vo trng thi sc nhim trng nhim c v d hu s rt nng n nu khng c can thip phu thut kp thi. Thng thng vic thm khm lm sng trn nhng BN nh th a ra quyt nh can thip phu thut ngay m khng cn phi tn thi gian lm CT bng, thm ch c siu m bng. 2.5-nh gi giai on: C nhiu cch phn loi ung th i trc trng. Phn loi c in nht l phn loi ca Dukes, c p dng ph bin trong nhng nm ca thp nin 30. Trong nhng nm tip theo sau , c nhiu ci bin t phn loi ca Dukes, trong phi k n phn loi ca Astler-Coller (ph bin trong nhng nm thp nin 50) (hnh 8) v MAC (ci bin ca phn loi ca Astler-Coller)

Hnh 8- nh gi giai on ung th i trc trng theo Astler-Coller

Ngy nay, phn loi c p dng ph bin nht l phn loi theo TNM ca American Joint Committee on Cancer (AJCC) and the International Union against Cancer (UICC). Khi u: o Tis: carcinoma in situ

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o T1: carcinoma xm ln ti lp di nim mc o T2: carcinoma xm ln ti lp c o T3: carcinoma xm ln qua lp c nhng cha qua lp thanh mc (hay xm ln vo m quanh trc trng phn ngoi phc mc) o T4: carcinoma xm ln vo cc tng, cu trc ln cn hay thng Hch: o N0: cha di cn hch vng o N1: di cn 1-3 hch vng o N2: di cn 4 hch vng tr ln Di cn xa: o M0: cha di cn xa. o M1: di cn xa nh gi giai on ung th i trc trng theo AJCC (bng 2):
Giai on 0 I IIA IIB IIIA IIIB IIIC IV T is 1 2 3 4 1-2 3-4 Bt k Bt k N 0 0 0 0 0 1 1 2 Bt k M 0 0 0 0 0 0 0 0 1 Dukes* A A B B C C C MAC** A B1 B2 B3 C1 C2/C3 C1/ C2/C3 D

(*) Dukes: Phn loi theo Cuthbert Dukes (**) MAC: Ci bin ca phn loi theo Astler-Coller 3-iu tr ung th i trng: 3.1-Cc phng php iu tr: 3.1.1-Phu thut ct i trng: Ct i trng l phng php duy nht iu tr ung th i trng. Ct i trng qua ni soi ci thin cht lng cuc sng ca BN mt thi gian ngn sau m (t au) nhng kt qu lu di ca ct i trng qua ni soi so vi m m ang c nghin cu. Chun b trc m ct i trng: o Chun b i trng: Ngy nay, chun b i trng vi polyethylene glycol (PGE) v natri phosphate hin nay thay th phng php tht tho i trng c in. Natri phosphate lm cho BN d chu hn nhng c th gy ri lon nc v in gii (tng natri v phosphate, gim kali v canxi huyt tng). Khng sinh: Erythromycin base 1 gm x 3 (U) v neomycine 1 gm x 3 (U)

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Ciprofloxacin 400 mg x 2 (U) Metronodazole 500 mg x 3 (U) o Cho khng sinh d phng: cephalosporin, th h 2 hay 3, c ph tr vi khun ym kh. Nguyn tc phu thut ct i trng do ung th i trng: o Khc vi ct i trng trong cc bnh l lnh tnh ca i trng, ct i trng trong ung th i trng l ct theo s phn b ca ng mch chnh cung cp mu cho on i trng c khi u (hnh 9). o Cc nguyn tc khc ging nh ct i trng trong cc bnh l lnh tnh ca i trng: Phi chun b tt i trng trc m Sau khi ct, hai u i trng cn li phi c ti mu tt Ni i trng k u nu i trng c chun b tt

Hnh 9- S khc nhau trong gii hn ct i trng trong ung th i trng (a) v trong cc bnh l lnh tnh ca i trng (b)

Cc bc chnh trong phu thut ct i trng trong ung th i trng: o nh gi giai on: nh gi khi u (v tr, kch thc, mc xm ln) nh gi di cn hch (v tr, s lng) nh gi di cn xa (xoang bng, gan) o Tm v kp ct cung mch chnh cung cp mu cho on i trng c khi u o Di ng i trng

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o Ct on i trng tng ng vi ng mch c tht, sao cho hai mp ct vn c ti mu tt. o Ni hai u i trng hay lm hu mn nhn to i trng. K thut khng ng n (no touch) khng ci thin tin lng ca cn bnh. Bin chng sau m: ngoi cc bin chng ngoi khoa ni chung, c hai bin chng cn c nhn mnh: o Cc bin chng nhim trng: nhim trng vt m, p-xe tn lu o X/d ming ni i trng Cc bin chng khc, lin quan n phu thut: o Tn thng t trng o Tn thng niu qun o Tn thng lch o Tn thng mch mu: mc treo trng trn, mc treo trng di, t tu, v mc ni phi o Tn thng niu qun o Tn thng m ri thn kinh h v Cc phng php ct i trng: o Ct i trng trit cn (hnh 10): Ct i trng tri: ct i trng xch-ma, i trng xung v i trng ngang bn tri Ct i trng tri m rng: ct i trng xch-ma, i trng xung v i trng ngang Ct i trng phi: ct 10 cm cui hi trng, manh trng, i trng ln v i trng ngang bn phi Ct i trng phi m rng: ct 10 cm cui hi trng, manh trng, i trng ln v i trng ngang Ct ton b i trng: ct 10 cm cui hi trng, manh trng, i trng ln, i trng ngang, i trng xung, i trng xch-ma, mt phn hay ton b trc trng. o Ct on i trng (khi u cha c di cn hch hay ct i trng c tnh cht thuyn gim): Ct hi-manh trng Ct i trng gc gan Ct i trng ngang Ct i trng gc lch Ct i trng xch-ma

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Hnh 10- Cc phng php ct i trng trit cn

3.1.2-Ho tr: T giai on III ca ung th trc trng, ho tr b tc lm ci thin tin lng sng ca BN b ung th i trng. Cc phc : o AIO (acid folic, fluorouracil, irrinotecan): irrinotecan (100 mg/m2) TTM trong 2 gi ngy 1, leucovorin (500 mg/m2) TTM trong 2 gi ngy 1, sau fluorouracil (2000 mg/m2) TTM trong 24 gi. Liu trn cho mi tun v cho lin tc 4 tun trong mi nm. o FOLFOX4 (oxaliplatin, leucovorin, fluorouracin): oxaliplatin (85 mg/m2) TTM trong 2 gi ngy 1, leucovorin (200 mg/m2) TTM trong 2 gi trong ngy 1 v 2, sau fluorouracil (400 mg/m2) TM bolus v ri fluorouracil (600 mg/m2) TTM trong 22 gi ngy 1 v 2. Liu trn lp li mi 2 tun.

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o FOLFOX6 (oxaliplatin, leucovorin, fluorouracin): oxaliplatin (85-100 mg/m2) TTM trong 2 gi ngy 1, leucovorin (400 mg/m2) TTM trong 2 gi ngy 1, sau fluorouracil (400 mg/m2) TM bolus v ri fluorouracil (2400-3000 mg/m2) TTM trong 46 gi. Lp li mi 2 tun. o FOLFIRI (acid folic, fluorouracil, irrinotecan): irrinotecan (180 mg/m2) TTM trong 2 gi ngy 1, leucovorin (400 mg/m2) TTM trong 2 gi ngy 1, sau fluorouracil (400 mg/m2) TM bolus ngy 1 v ri fluorouracil (2400-3000 mg/m2) TTM trong 46 gi. Lp li mi 2 tun. o IFL (Saltz) (irrinotecan, fluorouracin, leucovorin): irrinotecan (125 mg/m2), fluorouracil (500 mg/m2), leucovorin (20 mg/m2) TM bolus. Lp li mi tun trong 4 tun cho mi 6 tun. o NCCTG (fluorouracin, levamisole): fluorouracil (450 mg/m2) TM bolus mi ngy t ngy 1-5 mi tun trong 4 tun, kt hp vi levamisole 50 mg ung 3 ln mi ngy trong 3 ngy lin tip cho mi 2 tun. o NCCTG (fluorouracin, leucovorin liu thp): fluorouracil (450 mg/m2), leucovorin (20 mg/m2) TM bolus mi ngy trong 5 ngy cho mi 4 tun. o NSABP (fluorouracin, leucovorin liu cao): fluorouracil (500 mg/m2), leucovorin (500 mg/m2) TM bolus mi tun trong 6 tun cho mi 8 tun. 3.1.3-X tr: X tr thuyn gim: hin ti cha c vai tr tiu chun trong iu tr b tc sau phu thut ct i trng. 3.2-Ch nh: Giai on I: ct i trng Giai on II: o Ct i trng o Khng iu tr b tc, tr khi BN ang nm trong nhm nghin cu Giai on III: o Ct i trng trit cn o Ho tr b tc sau m vi fluorouracil (5-FU) v leucovorin trong 6 thng (phc NCCTG hay NSABP) o X tr b tc: hin ti cha c vai tr tiu chun trong iu tr b tc sau phu thut ct i trng trit cn. Giai on IV: o Ct on i trng nu khi u c th ct c o Ni tt qua ch tc nghn hay chy mu. o Ct b khi di cn bit lp (gan, phi, bung trng) dnh cho mt s BN chn lc. o Ring khi di cn gan khng ct c: hu khi u bng nhit, bng sng cao tn hay ho tr qua ng mch gan.

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o Ho tr thuyn gim: cc phc kt hp 5-FU v leucovorin vi irrinotecan (FOLFIRI, AIO, IFL) hoc oxaliplatin (FOLFOX4, FOLFOX6) c xem nh cc phc chun. 3.3-iu tr tc rut do ung th i trng: Ch nh: o Bn tc i trng: tht tho, nu thnh cng: sp xp m chng trnh o Tc i trng hon ton hay tht tho tht bi: phu thut bn khn o Tc i trng, do v manh trng: phu thut cp cu Chun b trc m: o iu chnh ri lon nc v in gii o iu tr cc bnh l ni khoa nu c o Truyn mu Hb > 9 g/dL o Cho khng sinh o t thng d dy (nu phu thut cp cu hay bn khn) Phng php phu thut: tu vo nh gi giai on trong lc phu thut v ton trng ca BN, c th lm hu mn nhn to trn dng, ni tt i trng, ct rng hay ct on i trng c khi u. Sau khi ct i trng, nu u ct trn hi trng, c th ni hai u ngay. Nu u ct trn i trng, c th a hai u ra ngoi hoc ni ngay sau khi ra i trng trn bn m (hnh 11).

Hnh 11- Ra i trng trn bn m: sau khi ct i trng, u xa ca i trng c ni vi mt ng c khu knh ln (loi ng th ca my gy m). u kia ca ng nm trong mt chu t di sn, cnh bn m. Ct rut tha, lun thng Foley qua gc rut tha. Truyn dung dch mui sinh l (NaCl 0,9% hay Ringer Lactate) vo i trng qua thng Foley. Vut nh dc theo khung i trng y phn theo ng vo chu.. Sau khi ra sch i trng, rt b thng Foley v ng ra, khu buc gc rut tha, ni i trng.

3.4-iu tr ung th i trng thng: Nguyn tc iu tr: o Hi sc nhanh vi dch truyn o Khng sinh: cephalosporin th h ba kt hp aminoglycoside v metronidazole 239

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o Phu thut khn cp Ni dung phu thut: ct on i trng c khi u, a hai u ra ngoi lm hu mn nhn to, ra bng, dn lu xoang bng. 4-iu tr ung th trc trng: 4.1-Cc phng php iu tr: 4.1.1-Phu thut: 4.1.1.1-Phu thut ct khi u:

Hnh 12- Phu thut ct khi u bo tn trc trng trong ung th trc trng

Phu thut ct khi u l loi phu thut bo tn trc trng. Phu thut c th thc hin qua ng hu mn (hnh 12) hay qua ng xng ct (tip cn trc trng t pha sau) Ch nh: o Khi u T1, 1/3 di trc trng. i khi c th c ch nh cho khi u 1/3 gia trc trng (phu thut ny cn c gi l ct khi u trc trng qua ng hu mn qua ni soi) o Khng chim qu 1/3 chu vi thnh trc trng o bit ho: tt hay trung bnh o C siu m qua ni soi v khng pht hin hch di cn (0-12% khi u T1 c di cn hch). K thut: o Ct ton b thnh trc trng c khi u, cch b ngoi khi u 1 cm. o Khu li thnh trc trng. Nu ct khi u qua ng hu mn, c th h mp ct. Kt qu: t l ti pht ti ch 0-40%. 4.1.1.2-Phu thut ct trc: Cn gi l phu thut bo tn c tht. C hai loi phu thut bo tn c tht: phu thut ct trc v phu thut ct trc thp. Phu thut c gi l ct trc thp nu sau khi ct, ming ni trc trng nm bn di ngch trc trng-bng quang. Ch nh: khi u 2/3 trn ca trc trng. Mt s nguyn tc chnh v mt k thut: 240

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o Di ng trc trng, i trng xch-ma, ln ti i trng gc lch. o Tht v ct ng mch mc treo trng di o Phi trn khi u: ct ti ni gip gia i trng xch-ma v i trng xung (hnh 13).

Hnh 13- Gii hn ct on i trc trng trong phu thut ct trc

o Phi di khi u: i vi khi u 1/3 trn trc trng: gii hn di ( ct trc trng v mc treo trc trng) cch khi u 5 cm. i vi khi u 1/3 gia trc trng:

Hnh 14- Gii hn ct b ton b mc treo trc trng trong phu thut ct trc

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Gii hn di ct trc trng cch khi u ti thiu 2 cm (i vi t bo ung th c bit ho tt) hay 5 cm (i vi t bo ung th c bit ho km). Gii hn di ct mc treo trc trng l 5 cm. Mt s phu thut vin ngh ct b ton b mc treo trc trng (TME-total mesorectal excision) gim thiu t l ti pht ti ming ni sau m (hnh 14). o Nu ming ni nm bn di ngch trc trng-bng quang, c th cn to hnh i trng lm gim s ln i tiu hng ngy. To hnh i trng c th l to ti ch J (J pouch) hay x dc khu ngang on i trng cch ming ni 6 cm (hnh 15).

Hnh 15- K thut to hnh i trng (A-x dc khu ngang, B-to ti i trng hnh ch J) lm gim s ln i tiu hng ngy trong phu thut ct trc.

Hnh 16- K thut ni i trc trng bng stapler trong phu thut ct trc.

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o Ni i trng trc trng cn li, bng stapler vng hay bng tay (hnh 16,17). Nu mp ct di st b trn ng hu mn, ni trc trng vi ng hu mn qua ng hu mn. Bin chng sau m: o Quan trng nht l x-d ming ni. T l x d ming ni sau phu thut bo tn c tht kh cao: 15% (3-11% nu ming ni 1/3 gia trc trng, 20% nu ming ni 1/3 di trc trng). V l do ny, nhiu phu thut vin m hu mn nhn to hi trng tm thi nu ming ni 1/3 di, dc bit nu BN c x tr hay ho tr trc m. Khng c s khc bit v x-d ming ni gia ni bng stapler hay bng tay. o Cc bin chng khc: B tiu tm thi Lit dng

Hnh 17- Cc phng php ni i-trc trng bng stapler trong phu thut ct trc: A-ni tn-tn, mi khu ti, B-ni tn tn sau hai ln ng stapler,C-ni tn bn sau khi to hnh i trng thnh ti ch J.

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4.1.1.3-Phu thut ct trc trng qua ng bng v tng sinh mn (phu thut Miles) (hnh 18): Ch nh: o Ung th trc trng 1/3 di o Khng th thc hin phu thut bo tn c tht (u xm ln c tht hay vo vng chu, ri lon chc nng c vng c sn trc phu thut) Ni dung: cuc phu thut c thc hin bi hai kp: o -kp phu thut ng bng: Di ng i trng xch-ma v trc trng Ct hai dy chng bn ca trc trng Ct ngang ni gip gia i trng xch-ma v i trng xung, ng tm u di, a u trn ra ngoi lm hu mn nhn to. o -kp phu thut ng tng sinh mn: Khu kn ng hu mn Ct dy chng hu mn-cng, vo khoang trc xng cng Ct c nng hu mn Tch trc trng ra khi tin lit tuyn hay m o, rt b trc trng ra ngoi Khu li tng sinh mn Bin chng: o Chy mu l bin chng ng ngi nht, nht l chy mu t m ri tnh mch trc xng cng. o B tiu o Lit dng o Tn thng bng quang, ti tinh, niu o 4.1.1.4-Phu thut on chu: Ni dung ca phu thut on chu: ct b trc trng km theo cc tng ln cn (bng quang, tin lit tuyn, t cung, bung trng, thnh sau m o). 4.1.1.5-Hu mn nhn to: Ch nh: o Tc rut do ung th trc trng, khi u cn ct b c: lm hu mn nhn to i trng xch-ma. Sau 2 tun tin hnh phu thut trit . o Khi u khng th ct b c: hu mn nhn to i trng ngang. 244

Hnh 18- Gii hn ct on i trc trng trong phu thut Miles

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4.1.2-X tr: Khc vi ung th i trng, x tr c vai tr kh quan trng trong iu tr ung th trc trng. X tr trong lng trc trng: o Ch nh tng t nh ct khi u qua ng hu mn. o Mc tiu: s dng tia x c cng cao, tp trung vo mt vng nh trn thnh trc trng, ni c khi u. Qu trnh iu tr c chia thnh vi t. Thi gian iu tr trung bnh ca phng php ny l 60 ngy, vi tng liu chiu x 9-15 Gy. o Kt qu: t l ti pht ti ch 30%, t l sng 5 nm: 76%. X tr b tc trc m: o u im: gim giai on khi u, tng kh nng phu thut, tng kh nng bo tn c tht, gim nguy c ti pht sau m. o Nhc im: tr hon cuc phu thut, lm cho vic nh gi giai on tr nn khng chnh xc, lm tng nguy c xy ra bin chng sau m. X tr sau m: o u im: BN c phu thut kp thi, vic nh gi giai on chnh xc, gim nguy c ti pht sau m. o Khuyt im: khng kim sot c s gieo rc t bo ung th trong thi gian phu thut; m bu st b thiu mu s t nhy vi tia x; nu c bin chng phu thut, x tr b tc s b tr hon. Cha c bng chng r rng ca vic ci thin tin lng sng ca x tr b tc trc hay sau m. Tuy nhin, x tr b tc (trc hay sau m) lm gim r rt t l ti pht ti ch. 4.1.3-Ho tr: (xem phn iu tr ung th i trng) 4.2-Ch nh: 4.2.1-Giai on 0: C th chn la mt trong 4 phng php sau: 1. Ct khi u qua ng hu mn 2. Ct khi u qua ng xng ct 3. X tr trong lng trc trng 4. X tr vng 4.2.2-Giai on I: C th chn la mt trong 3 phng php sau: 1. Phu thut ct trc 2. Phu thut ct trc trng qua ng bng v tng sinh mn 3. Phu thut ct khi u (ng ng hu mn, ng xng ct). Phu thut ct khi u (vi b ct khng c t bo ung th) kt hp ho-x b tc sau m, theo mt s

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tc gi, cho kt qu tng ng phu thut ct trc v phu thut ct trc trng qua ng bng v tng sinh mn 4.2.3-Giai on II: C th chn la mt trong 3 phng php sau, kt hp vi ho-x b tc sau m: 1. Phu thut ct trc 2. Phu thut ct trc trng qua ng bng v tng sinh mn 3. Phu thut on chu 4.2.4-Giai on III: C th chn la mt trong 4 phng php sau, kt hp vi x tr trc m v ho-x b tc sau m: 1. Phu thut ct trc 2. Phu thut ct trc trng qua ng bng v tng sinh mn 3. Phu thut on chu 4. Ho-x thuyn gim 4.2.5-Giai on IV: C th chn la mt trong 4 phng php sau, kt hp vi ho-x b tc sau m: 1. Ct ni on trc trng c khi u vi tnh cch thuyn gim, ni tt qua khi u hay lm hu mn nhn to trn dng 2. Ct cc khi di cn bit lp gan, phi, bung trng 3. Ho-x thuyn gim 4.2.6-Ung th trc trng ti pht: 1. Ct khi u ti ch vi mc ch trit cn hay thuyn gim 2. Ct cc khi di cn bit lp gan, phi, bung trng 3. X tr thuyn gim 4. Ho tr thuyn gim 5. Ho-x thuyn gim 6. t stent qua ch hp qua ni soi 4.3-Kt qu v tin lng: T l sng sau 5 nm: o Giai on I: 90% o Giai on II: 75% o Giai on III: 50% o Giai on IV (nu c di cn xa): 5% T l ti pht: 5-30%. Ti pht thng xy ra trong 2 nm u sau phu thut. Thng l ti pht ti ch. 5-Tm sot ung th i trc trng:

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Cc phng tin tm sot ung th trc trng: o Xt nghim tm mu n trong phn o X-quang i trng o Ni soi trc trng, ng soi cng o Ni soi i trng xch-ma o Ni soi khung i trng: hin nay l phng tin c ch nh ph bin nht BN trn 60 tui, BN b vim lot i trng trn 10 nm: ni soi i trng mi 3-5 nm BN c hi chng a polyp: o Hi chng Lynch (HNPCC): Ni soi i trng mi 2 nm, bt u t nm 20 tui, sau mi nm khi tui trn 40. Siu m qua ng m o v sinh thit nim mc t cung mi 1-2 nm, bt u t nm 25-35 tui. Siu m h niu v xt nghim nc tiu mi 1-2 nm, bt u t nm 3035 tui. o Hi chng FAP: Ni soi i trng mi nm, bt u t nm 10 tui Ni soi d dy-t trng mi 1-3 nm, bt u t nm 20-25 tui Thm khm tuyn gip v h thn kinh trung ng hng nm 6-K thut phu thut: 6.1-Phu thut ct i trng phi ni soi:

BN c t t th nm nga, hai chn dng. Phu thut vin ng gia hai chn BN hay bn tri. Cc trocar c t nh trong hnh.

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Xoay bn m cho u BN thp hn chn v bn tri thp hn bn phi. Vn mc ni ln ln trn i trng ngang. y i trng ngang ln tng trn xoang bng. Vn quai hi trng cui xung hc chu v y cc quai rut non sang bn tri xoang bng. Trc tin quan st t trng qua mc treo i trng ngang. T trng nm bn phi ca b mch mc treo trng trn. Ko vng hi manh trng sang pha trc-bn. Tm b mch hi-i trng. B mch ny c v tr gii phu tng i c nh, v trong 90% cc trng hp, ng mch i trng phi xut pht t b mch ny. on u b mch hi-i trng nm ngay bn di t trng. To hai ca s bn trn v di b mch hi-i trng. Tch dc theo b mch n ni xut pht ca n. Kp ct b mch hi-i trng bng clip, stapler, LigaSure, SonoSureTr trng hp kp ct bng clip, cc trng hp cn li c th kp ct ng v tnh mch cng lc. Kp mt mp phc mc ca mc treo i trng ngang bn trn t trng, bt u di ng i trng ngang t trong ra phi ngoi. Tch t trng v u tu ra khi mc treo i trng ngang. Cn thn khng lm tn thng tnh mch i trng gia hay tnh mch t tu di. Nu bc ny kh khn, c th di ng i trng ngang t phi trn v t gc gan v pha ng gia.

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Mch mu trc tin bn phi b mch i trng gia l tnh mch i trng phi. Tnh mch i trng phi s hp vi tnh mch v-mc ni phi to thnh thn tnh mch v-i trng Henle, vo tnh mch mc treo trng trn. Kp ct tnh mch i trng phi v cha li tnh mch v-mc ni phi. Nu c ng mch i trng phi i song song vi tnh mch, kp ct ng mch cng vi tnh mch. Rch l phc mc ngay trn gc ca b mch i trng gia. C lp v kp ct nhnh phi ca b mch i trng gia. Nu ct i trng phi m rng, c lp v kp ct b mch i trng gia. ng mch i trng gia thng khng c nh v mt gii phu: trong 46% cc trng hp, ng mch phn hai nhnh phi v tri nh kinh in. Trong cc trng hp cn li, ng mch c th ch c mt thn chnh, hay phn thnh ba nhnh cung cp mu cho i trng ngang.

Nhc mc treo i trng ngang ln, bt u bc tch di ng i trng t t trng ra phi ngoi. Ch mt phng bc tch phi phi trc ca mc sau phc mc Toldt (mc Toldt). Nu bc tch ng mt phng bc tch, niu qun, nm pha sau mc Toldt, s khng b tn thng. Vic bc tch i dn ra phi ngoi, n pha sau ca i trng gc gan, i trng ln v manh trng th ngng li.

Nhc quai hi trng tn ra khi hc chu v ko ra trc v ln trn, thy ni tip xc gia quai hi trng tn v phc mc sau. Rch l phc mc, tch quai hi trng tn ra khi phc mc sau. Khi mt phng bc tch t di ln gp mt phng bc tch ban u 249

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th tip tc rch l phc mc vng quanh rut tha, manh trng, i trng ln ti i trng gc gan. Tch mc ni ln ra khi i trng ngang, bt u t bn tri sang bn phi. Khi h i trng gc gan, c th thay i t th BN (cho BN nm u cao) v phu thut vin chuyn sang ng pha bn tri BN. Kp gi rut tha. M bng ng gia trn rn, bt u t l trocar rn hng ln thng v. ng m bng di khong 5 cm l , nhng c th thay i tu thuc vo kch thc ca khi u. Lng mt bao che vt m khng cho t bo ung th gieo rc ln vt m. a on i trng phi v hi trng tn c bc tch di ng ra ngoi. Kp ct hi trng. Kp ct mc treo hi trng cho n v tr cung mch hi-i trng ct trc . Kp ct nhnh ng mch b ca i trng ngang. Kp ct i trng ngang pha di khi u 5-10 cm. Ni hi i trng ngang bng my hay bng tay sau a vo li xoang bng. ng bng. 6.2-Phu thut ct i trng xch-ma ni soi: T th BN tng t nh trong phu thut ct i trng phi, nhng pha bn tri c nng ln cao. Cc trocar c t nh trong hnh v. Trong thi gian u, phu thut vin ng pha bn phi BN, v ngi ph ng pha bn tri. Khi di ng gc lch, phu thut vin ng gia hai chn BN, v ngi ph ng bn phi.

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i trng xch-ma c kp v ko ra khi hc chu. Ngi ph gi chc i trng sao cho mc treo i trng xch-ma cng ra theo hng trc-bn. Trc tin tm ng mch mc treo trng di. To mt mt phng bc tch ngay sau ng mch mc treo trng di. y l mt phng v mch v nm trc mc Toldt. Tt nht l bt u bc tch t xng cng. Rch l phc mc mc treo i trng xch-ma. Tch m ti h v phi v tri ra khi mc treo i trng xch-ma. Bt buc phi tm niu qun tri. Nu khng tm thy niu qun tri trong lc to mt phng bc tch t trong ra ngoi, phi tm niu qun tri phi trn ng mch mc treo trng di. Nu khng tm thy niu qun tri, phi di ng i trng t pha ngoi vo. C lp, kp ct ng mch mc treo trng di ngay sau ni xut pht ca n t ng mch ch. Tm, c lp v kp ct tnh mch mc treo trng di v tr cao ca n.

Tip tc tch v qut mt sau mc treo i trng ra khi mc Toldt bn di. Nu i ng mt phng bc tch, s khng thy lp m quanh thn ng thi thy niu qun v b mch sinh dc nm phi sau mc Toldt. Mt phng bc tch s tin dn ra ngoi, hng v thnh bng.

i trng xch-ma c ko v pha gia bng thy c np phc mc gia n v thnh bng bn. Nu bc tch y t trong ra, l phc mc ny s rt mng.

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Rch l phc mc t di hng dn ln gc lch. Tch mc ni ln ra khi i trng ngang, bt u t bn phi sang bn tri. Vo hu cung mc ni. Tch i trng gc lch ra khi phc mc sau. Cng vic bc tch ny kh phc tp. C th dng dao ct siu m hn ch s chy mu. Sau khi c tch ra khi ui tu, i trng gc lch di ng hon ton. Kp ct ngang vng ni xch-ma trc trng bng stapler qua cng trocar 12 cm vng bng di. M bng mt ng nh h chu tri hay ng gia. di ca ng m bng thay i ph thuc vo kch thc khi u. Lng mt bao che vt m khng cho t bo ung th gieo rc ln vt m. a i trng xch-ma ra ngoi. Ti thiu 15 cm i trng trn khi u phi nm bn ngoi thnh bng. Kp ct nhnh ng mch b ca i trng, ct ngang i trng pha trn khi u. Khu mi ti u i trng. t cht v phn e ca stapler vng ni tn tn (circular EEA stapler). Xit mi ch khu, a i trng vo li xoang bng. Bm hi li xoang bng. Tin hnh ni i-trc trng bng stapler di s quan st qua ng soi. Kim tra kn ca ming ni bng cch thc sau: bm nc vo hc chu cho ngp ming ni. Kp on i trng pha trn ming ni. Bm hi on i trng bn di qua ng soi trc trng hay i trng xch ma. Nu khng thy hi thot qua ming ni th ming ni t yu cu v kn. Trc khi kt thc cuc m, phi quan st xoang bng bo m rut non khng chui qua phi sau i trng tri. 6.3-Phu thut Miles: -kp ng bng: sau khi di ng i trng xung t i trng xch-ma ln ti i trng gc lch, tm v tht ng mch mc treo trng di. Mc treo i trng xch-ma c ct t trn xung di. Khi ti gii hn gia i trng xch-ma v trc trng, phc mc hai bn trc trng c ct t sau ra trc. Tip tc ct np phc mc gia trc trng v bng quang (nam) hay m o (n).

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Tch mt sau trc trng ra khi xng cng. Vic tch c th thc hin bng tay hay bng dao in. Ch din bc tch i gia mc chu tng v mc chu thnh.

pha trc, trc trng c tch ra khi bng quang v ti tinh (nam). Din bc tch i pha sau mc Denonvillier. Nu n, trc trng c tch ra khi m o. Sau khi bc tch pha trc v sau trc trng, trc trng ch cn c c nh vo xng chu bi hai dy chng bn. Trong hai dy chng bn ny c cc nhnh tr gia xut pht t ng mch chu trong.

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Ct hai dy chng bn

Ct ngang i trng, ni gip gia i trng xung v xch-ma. u trn c a ra ngoi lm HMNT. u di c ng tm sau c a ra ngoi qua ng tng sinh mn.

Khu hai mp phc mc sn chu. on i trng v trc trng c ct b nm bn di mp phc mc ny. ng bng . Cng vic ca -kp ng bng kt thc.

-kp ng tng sinh mn: hai chn BN c k theo t th ph khoa. Trc tin khu kn hu mn. Rch da hnh qu trm quanh hu mn.

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Ct m m hai bn hu mn (trong h ngitrc trng). Trong m m hai bn c b mch tr di. B mch tr di c buc ring.

Ct dy chng cng-trc trng vo khoang trc xng cng, trc mc chu thnh. Khng i qu st vo mt trc xng cng v c th lm chy mu m ri tnh mch trc xng cng.

Ct c nng hu mn hai bn.

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Trc trng gi ch cn c nh pha trc vi niu o sau bi c trc trngniu o. Ct c trc trng-niu o s gii phng hon ton trc trng. Li u trn ca i trng ra ngoi s lm cho cng on cui cng ny c thc hin d dng hn.

Khu da tng sinh mn. Dn lu c th c t qua vt m hay cnh vt m.

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