LIEU CAT RUOT THA NOI SOI CO AN TOAN TREN BENH NHAN MANG THAI HAY KHONG?

Nguyen Tan Cng*, Tran Phung Dung Tien*, Le Chau Hoang Quoc Chng*, Nguyen Tr Hien**, o Hu Liet**
TOM TAT at van e: au bung cap tren benh nhan co thai at ra van e kho khan trong chan oan va thach thc trong ieu tr. Viem ruot tha cap la nguyen nhan ngoai khoa thng gap nhat tren benh nhan co thai. Trc ay co thai la chong ch nh tuyet oi cua mo noi soi, tuy nhien, gan ay phau thuat noi soi ngay cang c ap dung nhieu tren benh nhan co thai va cho thay co ket qua tot. Muc tieu: anh gia ket qua cat ruot tha tren benh nhan co thai. Phng phap nghien cu: anh gia ket qua nhng trng hp cat ruot tha noi soi tren benh nhan co thai thc hien t 01/2001 en 7/2004, so sanh vi nhng trng hp mo m cat ruot tha tren benh nhan co thai thc hien t 01/2000 en 12/2003. Ket qua: co 41 trng hp mo noi soi cat ruot tha va 36 trng hp mo m cat ruot tha. Trong 41 trng hp mo noi soi co 9 trng hp ba thang au, 19 ba thang gia va 13 ba thang cuoi. Trong o co 6 trng hp viem phuc mac do ruot tha v. Trong nhom mo m co12 trng hp trong ba thang au, 21 ba thang gia va 3 ba thang cuoi. Co 2 trng hp say thai trong nhom mo m, 01 trng hp say thai trong nhom mo noi soi. Trong nhom mo m co 01 trng hp b nhiem trung vet mo, trong 06 trng hp viem phuc mac toan bo c mo noi soi co 01 trng hp (16,66%) b tac ruot do dnh sau mo. Nhom mo noi soi co thi gian nam vien va thi iem co trung tien tr lai ngan hn so vi nhom mo m. Ket luan: cat ruot tha noi soi tren benh nhan co thai co the thc hien an toan nh trong mo m, co ket qua tot trong ca ba tam ca nguyet. Li iem cua phau thuat noi soi la khi chan oan khong chnh xac van co the x ly c thng ton qua noi soi ma khong can m rong thanh ng mo ln hoac them ng mo ln khac. Thi gian hoi phuc va thi gian nam vien ngan hn mo m. SUMARY

IS IT SAFE TO PERFORM LAPAROSCOPIC APPENDECTOMY DURING PREGNANCY ?

Nguyen Tan Cuong*, Tran Phung Dung Tien*, Le Chau Hoang Quoc Chuong*, Nguyen Tri Hien**, Do Huu Liet** Background: the acute abdomen in the pregnant patient poses a difficult diagnostic and therapeutic challenge to the surgeon. Acute appendicitis is the most common extra-uterine surgical emergency requiring urgent surgical intervention during pregnancy. Once an absolute contraindication in pregnancy, laparoscopy has been increasingly used in last recent years. Objectives: evaluate result of laparoscopic appendectomy during pregnancy. Methods: compare results of the laparoscopic appendectomy group from 01/2001 to 7/2004 with the open appendectomy group from 01/2000 to 7/2004 during pregnancy

Results: 41 cases were perform by laparoscopic appendectomy and 36 by open appendectomy. Among laparoscopic group, 9 were in the first trimester, 19 in the second trimester and 13 in the last trimester, there were 06 cases of difused peritonitis, one case aborted after surgery, one had postoperative adhensive small intestine obstruction, no incisional infection was encountered. Among open group, 12 were in the first trimester, 21 in the second trimester and 3 in the last trimester, two abortions, one incisional infection. Length of hospital stay in the laparoscopic group is shorter than in the open group. Conclusions: Laparoscopic appendectomy in pregnant women may be as safe as open appendectomy. It is technically feasible in all trimesters of pregnancy. The prominent advantage of laparoscopy was the unecessity to convert to open surgery or changing the incision line when incorrect diagnosis being made. Length of hospital stay is shorter than in open appendectomy. * Bo mon ngoai tong quat ai hoc Y dc TP.Ho Ch Minh * * Khoa ngoai Tieu hoa Gan mat BV Ch Ray

au bung cap rat thng gap tren benh nhan co thai. Cac tnh trang au bung lien quan en thai ky nh cac thay oi sinh ly va giai phau khi co thai, thai ngoai t cung, say thai la thng gap nhat. Viem ruot tha la cap cu ngoai khoa thng gap nhat tren benh nhan co thai, t le 1/1500 thai phu va chia eu cho ca ba tam ca nguyet. Trong o kha nang chan oan ung ch la 75%. T le say thai, sinh non sau mo 514%. Tnh trang bung cap cu tren benh nhan co thai at ra van e rat kho trong chan oan va ieu tr. Cac trieu chng c nang nh chan an, buon oi va oi cung la trieu chng cua co thai. T cung to ay cac tang khac - trong o co ruot tha - khoi v tr thong thng va ngan khong cho mac noi ln di chuyen en vung b viem. Cac xet nghiem mau va nc tieu khong ang tin cay, tang bach cau co the b qui cho la do co thai. Khi thai to, c thanh bung cang dan, do o phan ng thanh bung va co cng thanh bung khong ro. Phau thuat vien chang nhng ch cha tr cho ngi me ma con phai bao ton s song cua thai nhi. Chan oan khong chnh xac a en ch nh mo khong can thiet cung co the anh hng khong tot en s phat trien cua thai nhi, trong khi s cham tre trong chan oan lam tang kha nang v ruot tha, gay tang t le bien chng va t vong tren me va con.. T vong do viem ruot tha tren benh nhan co thai la t vong do chan oan tre(Balber 1908). Do o chan oan chnh xac va can thiep phau thuat sm la thiet yeu cho viec cu song ca me va thai. OI TNG VA PHNG PHAP Thiet ke nghien cu Can thiep lam sang vi nhom chng hoi cu.

anh gia ket qua 41 trng hp mo cat cat ruot tha noi noi soi tren benh nhan co thai thc hien t 01/2001 en 7/2004, so sanh vi ket qua hoi cu 36 trng hp mo m cat ruot tha thc hien t 01/2000 en 12/2003. oi tng Nhng benh nhan co thai c chan oan viem ruot tha nhap khoa cap cu benh vien Ch Ray. Tieu chuan loai tr: - Nhng benh nhan co benh ly i kem ve ho hap, tim mach, tiet nieu, huyet hoc la chong ch nh mo noi soi. - Benh nhan co chan oan trc mo la viem ruot tha cap nhng khi mo ra la benh ly khac. Phng phap tien hanh oi vi nhng trng hp mo noi soi - Nhng benh nhan co thai vi chan oan viem ruot tha eu c sieu am, kham san khoa va dung thuoc giam go t cung (salbutamol) trc mo. - Tat ca eu c gay me noi kh quan. - S dung 3 trocar, trocar au tien 10mm at tren hoac di ron tuy theo tuoi thai va theo phng phap m Hasson. CO2 c bm vao o bung vi ap lc 8-12mmHg. Hai trocar con lai (10mm va 5mm) c at di s quan sat trc tiep cua knh soi, at hai ho chau khi thai nho, khi thai to se at ha sn phai va ho chau phai hoac ha sn phai va thng v. - Sau mo benh nhan c dung thuoc giam go t cung, sieu am lai va kham san khoa. Trc khi xuat vien, se sieu am va kham san khoa lan na. - Theo doi hau phau cac dien bien: thi iem trung tien, tnh trang vet mo, go t cung, ra huyet am ao, say thai, sinh non, thi gian dung thuoc giam au sau mo, tnh trang bung, thi iem xuat vien. - Benh nhan c theo doi tiep tuc en khi sanh qua th t, ien thoai trc tiep. KET QUA Trong thi gian t 01/2001 en 7/2004 chung toi thc hien c 41 trng hp cat ruot tha noi soi benh nhan co thai. Trong o co 9 trng hp ba thang au, 19 ba thang gia va 13 ba thang cuoi. Co 22 trng hp con so, 19 con ra. Trong 36 trng hp mo m thc hien t 01/2000 en 12/2003, co 12 trng hp ba thang au, 21 ba thang gia va 3 ba thang cuoi. Trong o 17 trng hp con so,19 con ra. Trong nhom mo noi soi co 35 trng hp viem ruot tha cha v, 06 trng hp ruot tha v gay viem phuc mac. Thi gian mo noi soi trung bnh 51,46 22,97 phut (15 120 phut), thi gian mo m trung bnh 56,25 31,11 phut (20-170 phut) 3

Cac dau hieu sieu am gi y viem ruot tha nh: ruot tha to an khong xep, co soi phan trong long ruot tha, co dau hieu hoai t, co dch khu tru ho chau phai hay vung manh trang. Trong nhom mo noi soi co 28 trng hp (68,3%) co dau hieu gi y tren sieu am ve viem ruot tha, con trong nhom mo m co 23 trng hp (63,9%) co dau hieu nay. Bang 1: tom tat tnh trang benh nhan Noi soi Mo m p N=41 N=36 Tuoi me (nam) 27,59 5,55 27,53 5,74 0,96 4 Tuoi thai (tuan) 22,2 8,64 18,81 8,76 0,92 Thi gian au 40,12 35,96 37,06 32,70 0,69 8 So lng bach cau 13994,63432 13794,44502 0,85 5,09 8,24 4 Dau hieu viem ruot tha 28 23 0,68 tren sieu am 3 Thi gian mo 51,46 22,97 56,25 31,11 0,44 1 Thi gian dung thuoc giam 1,71 1,05 2,06 1,58 0,25 au(ngay) 5 Thi iem trung tien 1,56 0,50 2,06 0,71 0,0 (ngay) 1 Xuat huyet am ao Tang cn go t cung Say thai 1 2 0,48 1 Sinh non 0 0 Nhiem trung vet mo 1 0 Thi gian hau phau 3,29 1,45 4,08 1,86 0,0 (ngay) 4 Thi iem co trung tien tr lai trong nhom mo noi soi la 1,560,5 ngay, trong nhom mo m la 2,060,71 ngay, p=0,01, khac biet co y ngha thong ke. Thi gian hau phau trong nhom mo noi soi 3,291,45 ngay ngan hn trong nhom mo m (4,081,86 ngay), p=0,04, khac biet co y ngha thong ke. Trong nhom mo noi soi co 01 trng hp b say thai: benh nhan 27 tuoi, thai 24 tuan, au bung trc nhap vien 02 ngay, sot nhe, bach cau 12500/mm3, an au ho chau phai, sieu am co t dch ho chau phai, khong thay hnh anh ruot tha. Benh nhan c theo doi tai mot benh vien phu san vi chan oan doa say thai cha loai tr viem ruot tha cap,

benh nhan khong c dung salbutamol v b d ng. Sau o hoi chan vi khoa ngoai BV Ch Ray va c chan oan viem ruot tha cap/thai 24 tuan doasay, co ch nh mo noi soi cap cu nhng tien lng say thai cao v khong dung c salbutamol cho benh nhan. Khi soi vao o bung thay co nhieu dch uc va gia mac khap bung, ruot tha hoai t v than. X tr: hut sach dch mu, cat ruot tha, ti ra o bung qua noi soi, dan lu di gan va Douglas, sau mo khong dung salbutamol. Hau phau gi 28, benh nhan au quan bung, ra huyet am ao va say thai t nhien. Benh nhan nam vien them 02 ngay, xuat vien on, khong tai bien nao khac. Trong nhom mo m co 02 trng hp say thai. Mot trng hp viem ruot tha sung huyet/thai 24 tuan. Mot trng hp song thai 27 tuan, benh nhan 21 tuoi, con so, au bung trc nhap vien 12 gi, sot, bach cau 19000/mm3, N 90,5%, sieu am ghi nhan co dch vung ho chau phai, hong phai, hong trai, ha sn trai, co hai thai song khoang 27 tuan, c ch nh mo vi chan oan viem ruot tha cap/ song thai 27 tuan. Vao o bung ng McBurney, ghi nhan co dch uc va gia mac ho chau phai va tieu khung, ruot tha khong viem, co dch uc t ha sn phai chay xuong. Keo dai ng mo len en ha sn phai e kiem tra, gan tui mat, da day bnh thng, thay dch uc t thng v va ha sn trai chay qua. Quyet nh m them ng gia tren ron, kiem tra khong ghi nhan co sang thng na bung trai. Benh nhan dc ra bung va at 2 ong dan lu hong phai va di gan, chan oan sau mo la vpm nguyen phat. Sau mo 10 gi, benh nhan tang go, ra huyet am ao va say thai. Benh nhan xuat vien sau 6 ngay. BAN LUAN au bung do nguyen nhan ngoai khoa tren benh nhan co thai tng oi t gap.Ngi bac s phau thuat gap kho khan trc hai la chon: hoac tien hanh cuoc mo khong can thiet, hoac chan oan va ieu tr cham tre khien tang bien chng tren me va tang t le say thai, sinh non. S thay oi trieu chng c nang va thc the tren benh nhan co bung ngoai khoa do s thay oi giai phau va sinh ly trong thai ly gop them phan lam lan va kho khan cho chan oan.[4,18,19,20,26] Viem ruot tha la cap cu ngoai khoa thng gap nhat benh nhan co thai. T le mo bung trang len en 20-35%, trong khi o t le nay ch khoang 5-10% nhom benh nhan cung tuoi khong mang thai. Co s kho khan trong chan oan la do: cac trieu chng c nang nh chan an, buon oi, oi cung gap khi co thai; v tr ruot tha thay oi khi thai to, trong 5

tam ca nguyet gia ruot tha se b ay len ngang ron, va co the len en ha sn phai khi thai tam ca nguyet cuoi; phan ng thanh bung va co cng khong ro khi thai to do c thanh bung cang dan. Cac xet nghiem ve mau va nc tieu khong ang tin cay; co s han che s dung cac phng tien chan oan nh X quang quang, CT scan v nguy c gay quai thai. Khi ruot tha v nguy c viem phuc mac toan bo rat cao do t cung tang co ay dch lan xa va ngan khong cho mac noi ln di chuyen en vung b viem. Ngoai ra con co nhieu benh ly khac co kha nang nham lan vi viem ruot tha tren benh nhan co thai.[2,3,6,7,11] Bang 2: nhng benh ly co bieu hien giong viem ruot tha[11] San khoa Khong san khoa Thai ngoai t cung Viem be than Doa say thai Viem tui mat Nhau bong non Viem tuy Sanh non Viem da day, ruot au day chang tron Soi than Viem mang oi Tac ruot Xoan phan phu Viem phan phu T le say thai sau mo t 5-14%, t le nay la 1,5% khi ruot tha cha v nhng tang len en 35% neu ruot tha a v. Soi o bung ong gop mot mo thc chan oan va ieu tr mi vao cac benh ly khac nhau vung bung va tieu khung. Do s thanh cong cua phau thuat noi soi tren benh nhan khong co thai, ngay nay ngi ta m rong ch nh vao benh nhan co thai. a co thi co thai la chong ch nh tuyet oi cua mo noi soi, trong nhng nam gan ay soi o bung a c s dung an toan trong ieu tr cac benh ly vung tieu khung tren benh nhan co thai. Soi o bung giup xac nh nguyen nhan cua au bung, tranh c s cham tre trong chan oan. Thai phu co the thu hng nhng li ch cua phau thuat noi soi nh phuc hoi sm sau mo, giam s dung thuoc giam au sau mo, an uong lai sm, thi gian nam vien ngan, vet mo nho, giam nguy c nhiem trung vet mo, thoat v vet mo so vi mo m.[6,7,12,18,25,26] Li the khac cua phau thuat noi soi: giam sang chan phau thuat, giam s va cham t cung trong qua trnh phau thuat, giup giam t le say thai, sinh non. Trong nghien cu nay khong co s khac biet ve tuoi me, tuoi thai, thi gian au trc mo, so lng bach cau, thi gian mo, thi gian s dung thuoc giam au sau mo, cac bien

chng lien quan en thai phu va thai nhi gia nhom mo noi soi va nhom mo m. Ve viec at trocar, at trocar au tien theo phng phap m Hasson la an toan nhat. T cung to la yeu to can quan tam khi mo noi soi tren benh nhan co thai. ay t cung se ngang mc xng mu khi thai c 12 tuan, va ngang ron khi thai 20 tuan, do o co nguy c gay ton thng t cung va cac mach mau tren thanh t cung cung nh thai nhi khi choc kim Veress e bm kh CO2 mu. Viec nay co the a en tran kh trong thanh t cung va thuyen tac kh[4,18,25]. Trong nghien cu nay khong co trng hp nao ton thng t cung do viec at trocar. Van e bm kh o bung: ap lc cho phep khi bm kh trong mo noi soi benh nhan co thai la khong qua 15mmHg[21,22,24,26], ay chung toi bm kh vi ap lc t 812mmHg. Ap lc o bung a cao do t cung to nen viec bm kh co the gap kho khan va o bung co the khong dan u rong cho cuoc mo, nhat la trong ba thang cuoi thai ky. Thoat tien phau thuat noi soi c khuyen cao ch nen ap dung cho thai tam ca nguyet gia, v cha ro tac dung cua CO2 len thai trong tam ca nguyet au (la giai oan hnh thanh cac c quan cua s song), con trong tam ca nguyet cuoi th t cung to se gay kho khan cho cuoc mo. Gan ay a co mot so bao cao ve phau thuat noi soi cat tui mat, cat ruot tha, u buong trng tren benh nhan co thai trong ba thang au va ba thang cuoi an toan [4,1120,23]. Trong nghien cu nay co 13 trng hp cat ruot tha noi soi trong ba thang cuoi an toan. Khi bm CO2 vao o bung, CO2 gay tang than huyet cap tnh mc o va phai va co s toan ho hap tren ngi me. Phoi thai hap thu CO2 t mau me qua ong mach t cung, va v pH mau thai cung ngang bang pH mau me, nen cung co s toan ho hap nhe ghi nhan phoi thai. Tuy nhien, tnh trang toan huyet nay co the co the ieu chnh bang s tang thong kh cua ngi me, hn na co mot khoang thi gian trong gia tnh trang toan huyet va s gia tang ap suat phan CO2 cuoi th th ra, do o CO2 thai rat t thay oi4,8,18]. Viec theo doi sat tnh trang huyet ong cua thai phu vi may o CO2 trong mau me (Capnography) - va tot hn la kh mau ong mach - la ieu can thiet. Can tham van y kien bac s san khoa trc mo. Mot nghien cu tren cu thay rang du co s giam toc o ti mau qua nhau, nhng ap lc ti mau cho thai, pH va kh mau thai khong b anh hng bi bm hi CO2 trong khoang thi gian 60 phut. Tac gia ket luan rang dong mau qua nhau thai van hieu qua khi ap lc bm hi trong bung meen 20mmHg trong vong 01 gi,khong co tac hai lau dai nao ghi nhan c tren cu con.[1,11] 7

Ve mat chan oan, soi o bung giup quan sat trc tiep ruot tha va khang nh ruot tha co viem hay khong. Trong mot so trng hp, khi soi vao o bung, khong phai viem ruot tha ma la nhng benh ly khac nh viem tui mat, thung da day, u nang buong trng xoanco the x ly c qua noi soi ma khong can chuyen oi thanh ng mo ln. Nh trong nhom mo m cua chung toi , co mot trng hp viem phuc mac nguyen phat, du a keo dai ng mo Mc Burney en ha sn phai van phai i them ng gia tren ron e tham sat toan o bung, neu la mo noi soi co the quan sat c toan o bung va benh nhan co the khong b say thai. Trong nghien cu nay, co s khac biet co y ngha thong ke ve thi iem co trung tien tr lai va thi gian hau phau gia nhom mo noi soi va nhom mo m. ay la li iem quan trong khac cua mo noi soi, giup benh nhan nhanh chong tr lai sinh hoat bnh thng, giam chi ph ieu tr. Ngoai ra con mot li iem na cua mo noi soi la khong b thoat v vet mo, trong khi ay la mot nguy c rat ln oi vi mo m, nhat la khi thai phat trien dan an tam ca nguyet th 3. oi vi nhng trng hp viem phuc mac ruot tha, khi a thanh thao vi cat ruot tha viem cap, phau thuat vien co the m rong ch nh sang nhng trng hp viem phuc mac ruot tha. Phau thuat vien co kinh nghiem co the mo thanh cong khoang 75% trng hp viem phuc mac ruot tha[5,17]. Trong nghien cu nay co 06 trng hp viem phuc mac toan bo do ruot tha v tren benh nhan co thai c mo noi soi, trong o 05 trng hp (83,34%) co ket qua tot khong tai bien va bien chng cho ca me va con, 01 trng hp b tac ruot sm sau mo. KET LUAN Phau thuat cat ruot tha noi soi tren benh nhan co thai co the thc hien an toan nh mo m va co nhng u iem ro rang so vi mo m la thi gian hoi phuc va thi gian nam vien ngan hn. Co ket qua tot trong ca ba tam ca nguyet. Khi chan oan sai van co the x tr c qua noi soi ma khong can chuyen thanh ng mo ln hoac them ng mo ln khac, do o giam thieu nguy c nhiem trung vet mo, thoat v vet mo tren me va giam nguy c say thai, sinh non. Phau thuat nen c tien hanh bi mot phau thuat vien noi soi co kinh nghiem. Can theo doi sat tnh trang me va thai.
TAI LIEU THAM KHAO 1. Antinio M.Cruz, Lucy C.Southerland, Tanya Duke, et al. Intraamniotic pressure, and cardiopulmonary effects. Anesthesiology, 1996;85:1395-1042.

2. Andersen B, Nielsen TF. Appendicitis in pregnancy : dianogsis, managemence and complications. Acta Obstet Gynecol Scand, 1999;78(9):758-762. 3. Affleck DG, Handrahan DL, Egger MJ, Price RR. The laposcopic managemence of appendicitis and cholelithiasis during pregnancy. J Am Surg,1999;176(6):523-529. 4. A.T.Gurbuz, M.E Peetz. The acute abdomen in the pregnant patient, is there a role for laparoscopy ? Surg Endosc, 1997;11:98-102. 5. o Minh ai, Nguyen Hoang Bac, Nguyen Tan Cng, Nguyen nh Tng Lan. Phau thuat noi soi ieu tr viem phuc mac ruot tha. Y hoc TPHCM, 2003; 7 (1):95-99. 6. Haya Al Fozan, Togas Tulandi. Safety and risk of laparoscopy in pregnancy. Current opinion in obstetrics and gynecology, 2002;14:375-379. 7. Howard T. Sharp. The acute abdomen during pregnancy. Clinical Obstetrics and Gynecology, 2002;45:553-561. 8. Hunter JG, Swanstrom L, Thornburg K. Carbondioxide pneumoperitoneum induces fetal acidosis in a pregnant ewe model. Surg Endoscopy, 1995;9:272-279. 9. Kevin P. Lally, Charles S. Cox Jr, Richard J, Andrassy. Appendix. In: Sabistons Texbook of Surgery. 16th ed. W.B. Saunders Company, 2001:917-929. 10. Kodali Bhavani-Shankar, Richard A. Steinbrook, David C. Brooks, Sanjay Datta. Arterial to end-tidal carbondioxide pressure difference during laparoscopic surgery in pragnancy. Anesthesiology, 2000;93:370-373. 11. Lt Col S Chawla, Lt Cd Shakti Vardhan. Brig SS Jog. Appendicitis during pregnancy. MJAFI, 2003;59:212-215. 12. Marcelo Andreoli, Michael Servakov, Paul Meyers, and William J Mann. Laparoscopic surgery during pregnancy. J Am Assoc Gynecol Laparosc, 1999;6(2):229-233 13. Mazen Bisharah, Togas Tulandi. Laparoscopic surgery in pregnancy. Clinical Obstetrics and Gynecology, 2003;46(1):92-97. 14. Mohammad Fatum, Nathan Rojansky. Laparoscopic surgery during pregnancy. Obstetric and Gynecologic Survey, 2001;56:50-59. 15. Myriam J. Curet, Douglas Allen, Robert K.Josloff, et al. Laparoscopy during pregnancy. Arch Surg, 1996;131:546-551. 16. Nguyen Hoang nh, Nguyen Tan Cng. Phau thuat cat ruot tha qua noi soi o bung. Y hoc TPHCM, 1997;4(1):16-24. 17. Nguyen Hoang nh, Nguyen Tan Cng, Nguyen Hoang Bac, Pham Van Nhan, o Minh ai. anh gia mc o an toan va hieu qua cua cat ruot tha noi soi. Ngoai khoa so 4, 2001:6-10 18. Nguyen Tan Cng, o Hu Liet, Tran Chanh Tn. Ket qua bc au cat ruot tha noi soi tren benh nhan co thai. Y hoc TPHCM,2003;7(1):105-112. 19. Reich H, Hunter JG. Is it safe to perform laparoscopic appendectomy during pregnancy ? Laparosc focus, 1992;1:11-12. 20. Rizzo AG. Laparoscopic surgery in pregnancy: longterm follow up.J Laparoendosc Adv Surg Tech A, 2003;13(1):11-15. 21. Rosemary A. Kozar and Joel J.Roslyn. The appendix. In:Principles of surgery. Edited by Seymour I. Schwartz. 17th ed. Mc Graw-Hill,1999: 22. R. Scott Jones. Acute Abdomen. In: Sabistons Textbook of surgery. 16th ed. W.B. Saunders Company, 2001:813-814. 23. S.Lyass, A.Pikarsky, V.H. Eisenberg, U.Elchalal, J.G.Schenker, P.Reissman. Is laparoscopic appendectomy safe in pregnant women ? Surg Endosc, 2001;15:377-379.

24. SAGES guidelines for laparoscopic surgery during pregnancy. Society of American gastrointestinal Endoscopic Suegeons, October 2000. SAGES publication 0023. 25. Tran Phung Dung Tien. So sanh ket qua bc au gia cat ruot tha noi soi va mo m benh nhan co thai. Y hoc TPHCM,2003;7(4):351-355. 26. Van Dorsten. Dianogtic and operative lapascopy. In: Operative Obstetrics. 2nd ed. Mc Craw-Hill 2002:453-474.

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