DAI HQC Y DUQC THANH PHO HO CHi MINH BO MON GIAI PHAU HQC GIAI PHAU HOC Chuong one Xi cre PEN: CO TAP2 Chi bién: TS.BS. Nguyén Hoang Vai (Tai ban lan thie nhdt, c6 siva chita va bé sung) \€] NHA xuAT BAN y Hoc 2019 Scanned with CamScannerChi bién TS.BS, Nguyén Hoang Vo Tham gia bién sogn GS.TS.BS. Lé Vin Cuéng ThS.BS. Vé Thanh Nghia PGS.TS.BS. Duong Van Hai ThS.BS. Phan Ngge Toan TS.BS. Trang Manh Khéi ThS.BS. Nguyén Phuéc Vinh ThS.BS. Nguyén Truong Ky TS.BS. Nguyén Hoang Vai Thur ky ThS.BS. V6 Thanh Nghia H6i dng thim djnh gifo trinh PGS.TS. Nguyén Ngoc Khéi, BHYD TRHCM Chi tich TS.BS. Nguyén Hoang Vi, DHYD TP.HCM Uy vién TK PGS.TS. Nguyén Van Lam, Trung BHYD Can Tho Phan bign 1 TS. Trin Ding Khoa, Trung DH Y Khoa Pham Ngoc Thach Phan bién 2 PGS.TS. Ng6 Quéc Dat, BHYD TP.HCM Uy vien Quyét dinh Iya chon va sir dung gido trinh “Giai phd hoe - Chuong trinh ¥ da khoa di méi” tai Dai hoc Y Duge TP. Hd Chi Minh s6 513/QD-DHYD ngay 28 thing 02 nam 2019 ca Higu trréng Dai hoc Y Duge TP. Hé Chi Minh, Scanned with CamScannerLOI NOI DAU Thye hign cha truong cia Ban Gidm higu Dai hoc Y Duge va cia Ban Chi nhiém Khoa Y, tir nim hoc 2016 ~ 2017, B6 mén Giai phdu hoc ging day theo chuong trinh di méi cho sinh vién Y da khoa. Bé thugn Igi cho vige hoc tp cla sinh vién, Bé mén bién soan tai ligu theo sat chuong trinh cita timg nam hoc. Chuong trinh Giai phdu hoc nay duge viét thanh hai tap: Tép 1 gdm 18 bai duge danh s6 thit ty tit | dén 18 thuge cée module: Gidi phdu dai cuwong, Ho hip, Ti Tim mach, Tier nigu. Tép 2 gdm 34 bai ti bai s6 19 thude cde module: Tiéu héa, Sinh sin, Co xuong Ahép, Than kinh, Ngi tiét. Cac hinh minh hoa trong tp 2 ciing duge dénh sé thet tr Lién tuc véi t€p 1 va theo sé thir ty ciia bai. Ngoai ra, trong tap 2 nay cdn c6 cdc bai dé phuc vu cho céc ban sinh vién tham khao Khi hgc dén cde chuyén khoa khéc nhu bai Mat, Tai,... ‘NOi dung kién thirc cia mén hoc vé cing Ion trong khi thoi lugng dé hoc trén ging dung 1a cé han nén sinh vin kh6 tiép thu hét n6i dung cia mon hoc. Vi vay, ching t6i hy vong ring b6 sdch nay la ngudn tai ligu dé sinh vign ty hoc mot céch hiéu qua Mic dit ching t6i da rat c6 gang nhung chic chin quyén sdch sé khéng thé khong 6 nhimg thiéu s6t, mong nhan duge ¥ kién déng gép cla Quy Thay C6 va cde ban sinh vién, gitp ching t6i sira chita, bd sung dé b6 sch duge hoan thién hon trong nhimg lan tai ban 16, Xin chan thanh cém on Nha xudt ban Y hoc Chi nhénh Thanh phé Hé Chi Minh 43 gitip ching tdi xudt ban b6 séch nay. Ngdy 20 thang 7 nam 2018 TRUONG BQ MON TS.BS. Nguyén Hoang Vi Scanned with CamScannerMUC LUC MODULE TIEU HOA. Dai cuong hé tigu hoa in Hoang Vit 20. 0 mi 1g — the quan... 21. Da day 22. Rugt non..... 34 23. Dai trang — én Hoang Vii ~ PGS.TS.BS. Duong Van Hai 25, THY sone . 3 TS.BS. Nguyén Hoang Vit 26. Phiic mac va cdc cdu tric nang 46 dng tiéu héa .. 62 GS.TS.BS. Lé Van Cuong MODULE SINH SAN. 75 27. H@ sinh dye ni 76 ThS.BS. Nguyén Phuée Vinh 28, Hé sinh duc nam.... vee ThS.BS. Nguyén Phicéc Vinh MODULE CO XUONG KHOP. 103 29. Xuong dau mi 104 ThS.BS. V Thanh Nghia 30. COt sing... 130 ThS.BS. Vo Thanh Nghia 144 TS.BS. Nguyén Hoang Vi Senses 152, @) co ving dau 6 32. Co than minh... TS.BS. Nguyén Hoang Vi 33. Dai vai - ving vai — cénh tay. : 163 TS.BS. Nguyén Hoang Vit - TS.BS. Trang Manh Khoi Khuyu — cng tay. oe 183 ; TS.BS. Trang Manh Khoi 35. Cé tay — ban tay... 202 TS.BS. Trang Manh Khéi - TS.BS. Nguyén Hoang Vit Scanned with CamScanner36. Dai héng va ving méng. TS.BS. Nguyén Hoang Vii- 37. Khop héng va ving dui. TS.BS. Nguyén Hoang Vii 38. Géi. 259 TS.BS. Nguyén Hoang Vi Cing chén.. 268 . TS.BS. Nguyén Hoang Vi 40. Cé chan va ban chan 286 TS.BS. Nguyén Hoang Vit MODULE THAN KINH .. (4Dpai cuong hé than kinh. 16 TS.BS. Nguyén Hoang Vi 42. Tay gai 2321 GS.TS.BS. Lé Van Cuéng 43. Nao b6.. 328 GS.TS.BS. Lé Van Cuong 44, Mang nio tay . 46 ThS.BS. V6 Thanh Nghia 45. Mach miu nao, 352 TAS.BS. V6 Thanh Nghia 366 GS. TS.BS. Lé Van Cuong 381 GS.TS.BS. Lé Van Cuong 401 46. Cac day than kinh gai séng .. 47. Cac day thin kinh so.. MODULE NOI TIET 48, Tuyén thugng than ThS.BS. Nguyén Phudc Vinh 408 TAS.BS. Phan Ngoc Toan 411 49. Tuyén gidp. 50. Tuyén cfn gidp ThS.BS. Phan Ngoc Toan MODULE GIAC QUAN 51. Mat TS.BS. Neuyén Hoang Via 425 52. Tai... : TS.BS. Neuyén Hoang Vit- PGS.TS.BS. Pham Nave Chat vl Scanned with CamScannerMODULE TIEU HOA 1 Scanned with CamScanner19. DAI CUONG HE TIEU HOA TS.BS. Nguyén Hoang Vit MUC TIEU BAI GIANG 1. M6 té cau tao chung ciia éng tiéu hoa. Gidi thich sw phan bd mach méu ctia éng tiéu hoa. M6 ta phan khu ving bung. Xée dink etic co quan 6 ting phan khu ving bung, tit dé xéc dink cot quan nghi ngé-t6n throng twong ting voi timg vj tri dau hoc chan thieong, vét thong bung. ei] Hé tiéu héa cé nhigm vu tiéu héa thic dn, hap thu chat dinh dudmg va dao thai chat 1u héa va céc co quan tiéu héa phy. Ong tigu_héa dai khoang 5-7 m, bao gdr g, hau, thye quan, da diy, rut non, rugt gia, 6ng hau mén. Cée eo quan tiéu héa phy gdm: rng, ludi, tuyén nude bot, gan, tii mét, tuy. ‘3— Tuyén nuoc bot J Migng Hau Thy quan Gan ‘Tui mat Rudt non ‘Tryc trang ‘Ong hau mén Hinh 19.1. Cac co quan cla hé tisu hoa (Nguén: Shier D, Anatomy and Physiology) Scanned with CamScanner1, CAU TAO CHUNG CUA ONG TIEU HOA Noi chung, thanh cua Ong tiéu hoa c6 cau tao gom bon lép, theo thir ty tir trong ra ngoai 1a: Jép niém mac, tim died niém mac, lop co tron, lop thanh mac. Cau tao nay 66 su thay déi tiyy timg doan cua dng tigu hoa Lép niém mac lét be mat cua long dng tigu hoa gom lop té bio biéu md, lap md lign két va lop co tron mong goi la co niém. Khi lop co niém co rut sé ao ra nhimg ranh, nhimg nép trén bé mat, lam ting dign tich tiép xiic cua 6p niém mac. ‘Tam dudi niém mac la lop mo lién két, chira mach mau, mach bach huyé than kinh va cae tuyén niém mac. ‘ac sgt Lép co tron gém hai tang, tang ngoai 1a co doc, ting trong 1a co vong (riéng da day cn cé thém ting co chéo trong cing). O rudt gia, ting co doc tap trung thanh ba dai c thé thay duge khi nhin dai thé. O mot vai chd, vi dy 6 mén vi, lép co vong day én tao thanh co thit mon vi, co tic dung diéu hoa sy di chuyén thite dn tir da day qua ta trang. Lép thanh mac chinh la phiic mac tang, hign dign 6 thyc quan doan bung, da day, rudt non va rudt gid (ngoai trir tryc tring). Dudi lop thanh mac nay cO tim dirdi thanh mac, la t6 chite lién két thua nim gitra lop co 6 trong va lop thanh mae o ngoai. Nho lop nay ma lop thanh mac c6 thé dé dang duge boc khdi cdu tric bén dudi. C6 tai ligu mé ta tim dui thanh mac thanh mot lop riéng va xem nhu thinh dng teu héa cé nam lép. 2. MACH MAU, THAN KINH CUA ONG TIEU HOA 2.1. Mach mau Vé phdi thai hoc, hé tigu héa duge hinh thanb tir ca ba phan li: rugt trude (foregut), rudt gitra (midgut), rudt sau (higdgut). Ruot trudc tao nén thye quan, da day, phan dau ta tring (dén 16 46 cia éng m§t chu), , tai mat va ty. CAc phan cia rudt trude chia thanh hai p! , phan trén co hoanh va phan duéi co hodnh. Phan trén co hoanh duge cdp mau bai dng mach cha nguc, phan dui co hoanh duge cép mau béi déng mach than tang. Ruot gitta tgo thanh phan cén lai cua té trang, hdng trang, hoi trang, phn phai cia dai trang (tir manh tring dén hét 2/3 phdi cua dai trang ngang) duge cép mau ti dng mach mac treo trang trén. Ruét sau tao thinh 1/3 trai cia dai trang ngang, dai tring xudng, dai trang chau héng (dai trang xich-ma), tngc trang. Cac phan nay duge cép méu boi dong mach mgc treo trang dusi. Phan ln mau tinh mach tir hé tiéu hoa phn duéi co hoanh sé theo tinh mach cira 46 vao gan trade khi vao tinh mach chi duéi dé vé tim. Scanned with CamScanner2.2. Than kinh Cac hoat dng do co van thyc hién nhu cit d6ng cita lu6i, cit dgng nhai hoc giai doan dau cia cit dong nudt duge chi phdi boi cdc spi van dng cia céc day than kinh so s6 V, VII, IX, X, XI, XII va cde soi than kinh tir dam ri cd. Tuyén nuréc bot duige chi phéi béi céc sgi giao cm tit hach cé trén, céc si d6i giao cam tir than kinh so s6 VII va than kinh so 6 IX. Doan duéi thyc quan va toan b6 éng tigu héa duge céu tao béi co tron (trir co that ngoai hau mén), vi vay duge chi phéi béi hé than kinh ty chi (con goi 1a than kinh thye vat, than kinh ty tr)), trong 46 phn 46i giao cdm uu thé hon phan giao cam. _ Cae soi 46i giao cam chi yéu ti thin kinh lang thang (than kinh so sé X) chi phéi hau hét 6ng tiéu héa tir thyc quan dén dai trang ngang. Dai trang xuéng va tryc trang nhén cdc sgi ddi giao cam tir dam r6i ha vi duéi. Hé d6i giao cam cé tac dung gay gian co vong, tang nhu dng va tang tiét dich tiéu héa nén n6i chung la lam ting hoat dng tiéu héa. Hé giao cam 06 téc dung ngugc lai, nghia la ire ché sir tiét dich, giém nhu dong éng tiéu héa, gidt co vong 6 trang thai déng nén n6i chung 1a tre ché qué trinh tiéu héa. Cac si ly tam di tir hach giao cém chau (celiac ganglion) dén da day, gan, tay; cdc sgi tir hach giao cam mac treo trang trén (superior mesenteric ganglion) thi dén rudt non va phan lén Tudt gia; cdc sgi tir hach mac treo tring dui (inferior mesenteric ganglion) dén trac trang. Ngoai ra, & thye quan, da day, ruét cén cé hé théng than kinh néi tai trong thanh cia ching, 46 1 dam réi Meissner nam 6 6p dui niém va dim r6i Auerbach nim gitta céc 16p co tron. Dam réi Meissner c6 vai trd chi phéi lop co niém va sy bai tiét cia cde tuyén trong niém mac, dim r6i Auerbach chi phéi nhu dng va céc cir déng ctia co tron. 3. PHAN KHU VUNG BUNG VA VI TRI CAC CO QUAN HE TIEU HOA Dé thudn tign trong viée mé ta vi tri céc co quan trong 6 bung, vj tri cdc diém dau khi thim khém bénh,... bung duge chia thinh nhiéu ving nhé. Cé hai cach phan chia ving bung phé bién trong lam sang la chia thanh bén ving va chia thanh chin ving. M6t cach téng quat, bung duge chia thanh bén ving la: mot phan te trén phai, mot phan te trén trai, m6t phan te didi phai, m6t phan tw dudi tréi boi dudng ngang qua rén va duéng doc gitra. Vi tri cae co quan trong 6 bung duge mé ta trong bang bén dudi. Chi tiét hon, bung duge chia thinh chin ving boi hai duéng thing doc va hai duéng ngang. Hai diréng doc, cén goi la dug trung din (midclavicular line), di qua diém gitta xuong dén mdi bén; mot duéng ngang di qua diém thdp nbét cia sun suén va mét duéng ngang néi lién hai gai chau trude trén. Chin ving nay cé tén lan lugt li: Scanned with CamScannerG hai bén, tir trén xudng duéi la: viing ha swedn (phai hod trai), ving hong (phai hose trai), ving Ad chdu (phai hode tréi), Viing héng cén goi la viing tht lug, ving mang md. Ving hé chéu cdn goi la ving ben. O gitta, tir trén xudng dudi la ving thugng vi, ving rén, ving he vi. Vang thugng vi He suén trai Ving rén Hong trai Ha vi Hé chau trai Hinh 19.2. Phan khu ving bung A. Chia thanh 4 ving B: Chia thanh 9 ving (Nguén: Saladin, Human Anatomy) PHAN TU TREN PHAI PHAN TU TREN TRAI Thay phai gan Tui mat Da day: phan mon vi Ta trang: doan 1-3 Bau tuy Tuyén thugng than phai Than phai Két trang géc gan Phan trén cia két trang lén Nira phai két trang ngang Thiy trai gan Lach Da day Héng trang va phan trén hdi trang Than va dudi tuy Tuyén thugng than trai Than trai Két trang géc lach Phan trén két trang xuéng Nwa trai két trang ngang PHAN TU’ DU‘! PHAI PHAN TU’ DU'O! TRAIL Manh trang Ruot thiva Hdi trang Phan dui két trang lén Nigu quan phai: doan bung Phan phy phai (ni) Thing tinh (nam) Ti cung (khi to, cd thai) Bang quang (khi day) Két trang chau héng Phan dui két trang xuéng Nigu quan trai: doan bung Phan phy trai (nd) Thing tinh trai (nam) Tir cung (khi to, c6 thai) Bang quang (khi day) Scanned with CamScannerCAU HOI TY LUQNG GIA 1. Thite an trong éng tiéu héa tiép xtic voi A. Lop co tron B. Lép niém mac C. Lop duéi niém mac D. Lép thanh mac 2. Co quan nao sau day thuge eo quan tiéu héa phu? A. Gan B. Hau C. Ta trang D. Ong hau mén 3. Mé ta phan khu ving bung thanh 9 ving, 4. Mot bénh nhén dau 6 ha suém phai, co quan nao sau day duge nghi la c6 lién quan nhat? A. Da diy B. Lich C. Tai mat D. Than pha TAI LIEU THAM KHAO 1. Lé Van Cuong va es (2014). Gidi phdu hoc hé théng, Nha xuiit ban Y hoc TPHCM. 2. Nguyén Quang Quyén va cs (2016). Bai gidng Gidi phdu hoc, tap 1, tap 2, Nha xudt ban Y hoc TPHCM. 3. Martini FH, Timmon MJ, Tallistch MB (2012). Human Anatomy, 7 edition, Benjamin Cummings, New York 4. Moore K.L., et al (2014). Clinically Oriented Anatomy, 7* edition, Lippincott William and Willkins, Philadenphia. 5. Saladin KS (2014). Human Anatomy, 4* edition, McGraw Hill, New York. Scanned with CamScanner20. O MIENG - THU'C QUAN TS.BS. Nguyén Hoang Vit MUC TIEU BAI GIANG 1. M6 ta gidi phau 6 miéng va cdc cdu trite lién quan. 2. M6 ta gidi phdu thyee quéin 3. Xée dinh va gidi thich vj tri ma thie &n hod di vat thudng bi vuéng 6 thc quan. 4. Gidi thich co ché gian tinh mach thc quan trong tang ép luc tink mach cita O miéng (oral cavity), 1a phan dau tién cia éng tiéu héa, c6 nhiém vy ném, nhai, nudt va ndi. G migng cfing dién ra qué trinh tiéu héa héa hgc nhé tac dGng cita nude bot. O migng théng ra ngoai qua khe migng 6 truéc va théng véi hiu qua eo hong 4 phia sau. Eo hong hay eo migng hau (oropharyngeal isthmus) 1a ranh giéi gitta miéng va hau, nim gitra khdu cai mém 6 trén, lung ludi 6 duéi va hai bén 1a cung khau cdi luGi. Phia trén, miéng duge gidi han boi khau ci, Phia duéi migng c6 xuong ham dudi va ludi. Migng duge chia thanh hai phan 1a tién dinh migng va 6 migng chinh. Tién dinh migng 1a m@t khoang hep nim gitra ma, méi va cung rang lgi. O migng chinh la khoang nim gitta khdu cdi va luGi. O migng duge lét bai lop bigu mé lat tang khng simg héa gitip niém mac miéng Khéng bj téc déng gay hai boi thite an Moi tren Khdu cai clrng Khu cai m&m Lwoi ga Hanh nhan khdu cai Moi duéi Hinh 20.1. 0 migng (Nguén: Lewis R. Human Anatomy and Physiology) Scanned with CamScanner1.MA VA MOI Mé (cheek) tao nén thinh bén cia miéng, dugc cu tao bai da, cc co bam da, khéi m6 ma va Iép niém mac lign tuc voi niém mac migng. MOi (lip) gdm o6 méi trén va méi duéi, bao xung quanh khe migng va gép nhau ¢ hai bén goi ld mép méi, Mat trong cia mdi cé him mdi trén va ham méi dudi, néi méi voi nudu rang. Tir ngoai véo, mdi duge céu tgo boi lép da, co van va niém mac. 2. KHAU CAI Khau céi (palate) ngin gitta 6 migng va 6 mai, gdm khdu cdi cing (hard palate) 6 trude va khéu cdi mém (soft palate) lién tye phia sau. Khiu edi etmg durge tao bi mom khdu c4i xuong ham trén va manh ngang xuong khdu cdi, Trén b& m&t khdu c4i cimg 06 nhiing g6 ngang goi li nép khdu cdi. Khéu cai mém duge tao bai co van va m6 tuyén. G Pha sau, gitta kha cdi mém o6 mot nép nhé xuéng dui goi la wdi ga khdu cai, Trong khi nuét, co sé kéo khdu cai mém va lu@i ga khau cdi lén trén, lim déng 16 théng gitra mili va hu, gitp ngan thitc an lén 6 mai. G méi bén ludi ga e6 cung khdu edi ludi (palatoglossal arch) 6 phia trude va cung khéu céi hau (palatopharyngeal arch) 6 phia sau. Gitta hai cung 18 hé hanh nan khdu cai cé hanh nhan khau cdi (palatine tonsils). 3. SAN MIENG San migng la mot ving nim phia duéi phn di dng cita ludi, durge tao chi yéu boi co him méng, co cim méng (xem thém bai Co Dau Cé - module Co Xwwong Khép). Sin migng duge cép mau boi nhénh duéi lui ctia dong mach lui, nhdnh huyét rang dudi cia dng mach ham, nhénh cm cia déng mach mat. 3.1. Co ham méng (mylohyoid) Co ham méng la co chink tgo nén sin 6 migng, nim phia trén bung true co hai than,. Hai co ham mong hinh tam gide, det, bim doc theo duong him mong cia xong him dui va dén bm tn 6 xxong mong. Co him méng cé téc dung nfng sin migng va nang xuong méng én trén, Co ham méng duge van dng boi nhénh ham méng cia thin kinh huyét ring dudi thugc than kinh ham dui. 3.2. Co cim méng (geniohyoid) Co cim méng nim phia trén phin gitta co ham méng, bam tir gai cim dén mat sau than xtrong méng. Dong tic cua co cim méng la nang xuwong méng len trén va kéo xuomg méng ra truéc. Co cim méng duge van dong bai thn kinh gai song cd |. Scanned with CamScanner4. LUOL Ludi nim 6 san migng va chiém gin hét 6 migng chinh khi migng nam. Ludi c6 nhiéu chic nang nhu: ném, tham gia dng téc nhai, nuét, néi. Hai phan ba trudc ludi goi 1a than lui, m6t phan ba sau goi 1a r8 lui. Gitta than va ré ludii 1a ranh tan cing (terminal sulcus) 06 dang chit “V" ma dinh huéng ra sau, Than ludi thon nhé dan vé phia trudc va tan hét bang dinh ludi. R& lz6i dinh vao ndp thanh mén bai ba nép, mét nép gitta va hai nép bén goi la nép Iudi — ndp thanh mén (glossoepiglottic fold). Gitta céc nép cé hai hd ‘nho goi la thung ling nép thanh mén ma xuong hay dj vat c6 thé bj vrdmg 6 day. Mat trén ré ludi cé nhiéu nang bach huyét goi 1a hanh nhén luéi. Mat trén than Iwai lom chém vi 6 nhiéu gai lu6i (lingual papillae). 6 gitta mat dudi than ludi c6 mot nép goi la ham huGi (lingual prenulum), néi lai voi san miéng. Lui duge céu tao béi khung cila ludi va cdc co lus. Khung cia Iwai gm: xuong méng, cAn ludi va vach ludi. Cén ludi nim theo mat phing dimg ngang, bam tir bd trén xuong méng di thing lén va Ian vao bé day ciia Iudi ‘Vach Iuéi nim theo mat phing dimg doc, dinh vao gitta mat trréc cn lu6i va chia cae c4c co Iudi kim hai nhém phai va trai. Co cia Indi gbm hai nhém 1 nhém co ndi tai (intrinsis muscles) va nhém co ngoai lai (extrinsic muscles). Céc co ndi tai bam vao khung cia ludi va tan hét trong ludi, gém mét co doc ludi trén (superior longitudinal muscle), hai co doc ludi duéi (inferior longitudinal muscle), hai co ngang lui (transverse muscle), hai co thang lu6i (verticle muscle). Nhém co ngoai lai la cdc co bam tir cdc cdu tric lan can dén ludi, gdm co cim ludi (genioglossus muscle), co mong ludi (hyoglossus muscle), co tram ludi (styloglossus muscle), co khau c4i luoi (palatoglossus muscle). Ludi durge cép mau boi déng mach ludi, nhanh cia dng mach cinh ngoai (xem Module Tim mach). Céc co & ludi duge van 46ng bai than kinh ha thiét. Cam gic 6 hai phn ba truéc Iwi c6 day thin kinh lui 14 nhénb cia than kinh sinh ba Lim nhiém vu cam gic than thé va thimg nbi thugc than kinh trung gian lim nhiém vu cim gid vi gide. Cém giéc m6t phin ba sau cita luéi c6 cdc day than kinh mat, than kinh thiét hu, than kinh lang thang lam nhiém vu cm gidc vi gidc lin than thé (xem Module Thdn kinh). Scanned with CamScanner‘Sun nap Nép IuGi ndp dui Nép lui ngp ben Thung ling nép thanh mon Hanh nhan khdu cdi Nép khdu cai lwo Than wei Dinh ludi Hinh 20.2. Lui nhin tiv trén (Nguén: Sobotta’s Atlas Human Anatomy) 5, RANG - LOI Loi (gingiva hay gum), cdn goi la nudu, che phi cdc 16 huyét rang cia xuong ham trén va xuong him dudi. Loi duge edu tao béi mé xo va duge phu béi niém mae lign tuc ‘v6i niém mac cia tién dinh migng, khdu cai va sin miéng. Rang (teeth) la cdu tric cimg nhat cua co thé, cé nhiém vu can, xé, nhai. Trong qua trinh phat tridn cita cé thé cé hai loai rang la ring sita (deciduous teeth) va rang vinh vign (permanent teeth). Rang sita xudt hign tir 6 thang tudi dén 2 tudi, déi khi dén 4 tudi. Cé tat ca 20 rang sita, mdi ham c6 10 rang. O mdi bén cia mai ham, tinh tir dung gitta tré ra 1a 2 rang cita, 2 rang nanh, 2 rang céi. Rang cita & ham dui moc dau tién. Rang vinh vién: c6 tat ca 32 ring vinh vién, & mdi bén cia mdi ham theo thir ty tir dung gitra ra la 2 ring cita, | ring nanh, 2 rang tién ham, 3 rang ham (cén goi li ring 6i). Rang vinh vién bat dau thay thé ring sita tir lic 6 tudi va rang sifa sé hodn toan duge thay thé vao khoang 12 tudi. Tuy nhién, ring ham cudi cing, tire rang him thtr ba, cén goi 1a ring khén (wisdom teeth) thuong xuat hién tir 17 dén 25 tudi Mi ring gdm cé phan than rang (crown) nhé Ién trén nudu rang va phan chan rang (root) ch6n trong 1d huy¢t ring. Gidta than ring va chan ring la c6 (neck) rang. 10 Scanned with CamScannerRang duge céu tao béi mét loai mé gan gidng m6 xuong nhung hoi cimg hon xuong, goi li nga ring (dentin). Nga rang bao ly mOt khoang bén trong goi la budng ty ring (dental cavity). Phan budng tiy tuong img véi than rang goi budng than rng (pulp cavity hode coronary cavity); phan budng tiy tuong img véi chan ring goi la éng chan rang (root canal). Ong chan ring mé ra béi mét hay nhiéu 13 goi la 16 dinh chan rang (apical foramen). Qua cac 15 nay cé than kinh, mach mau chui vao budng ty. __Bén ngoai than ring c6 lop men rang (enamel) rat cimg va cé mau tring bong, duge cu tao chai yéu 1a mudi can-xi. Men ring sé khong dugc tai tao hoc thay thé khi bj mai mén hay chan thuong bé vé. Men ring ciing bj mai mon dan theo tuéi. 6 6 rang khong c6 men rang ma c6 lép xwong rang (cementum) méng bao xung quanh, Men rang \ Nga rang ——~ Than rang Budng than rang f [- Nuéu Chan rang ‘Ong chan rang Xuong rang Hinh 20.3. Rang (Nguén: Lewis R. Human Anatomy and Physiology) 6. TUYEN NUGC BOT Co ba cap tuyén nude bot chinh la: tuyén mang tai, tuyén dudi him, tuyén dud ludi, Tuyén mang tai (parotid salivary glands) la tuyén née bot 1én nhat, trong hreng trung binh khoang 20 g. Tuyén cé hinh khong déu, nim tir cung go ma dén ba trade co tte dan chiim va tir mém chim dén mat ngoai co cin, Nude bot tiét ra tir tuyén mang tai durge tap trung vao dng tuyén mang tai, con goi la dng Stensens, roi dd vao tién dinh migng tai vi tri déi dign véi rng ham trén thir hai. Tuyén duéi ham (submandibular salivary glands) nim 6 sin migng, mat trong xuong him dudi, ngay duéi dung ham mong (mylohyoid line). Ong tuyén dusi ham, con goi la éng Wharton, d6 vao dud lui, hai bén ham loi Tuyén durdi ludi (sublingual Iudi, con goi li dng Rivinus, ¢6 nhit alivary glands) nim 6 mat dudi ludi. Ong tuyén dudi dng nho va cing dé vao hai bén ham Ludi. " Scanned with CamScannerNgoai ba cp tuyén trén, con cé nhiéu tuyén nhé nam rai rac trong niém mac ma, niém mac lu6i va khau ci, Chiing tiét nude bot lién tuc gitip lam 4m niém mac migng. THYC QUAN Thue quan (esophagus) la éng eo di ti hiu dén da day, dai khong 25 em, duémg kinh Khong 2 om va dep theo chigu truée sau. Tit ving c6, bat dau & vi tri ngang voi bo dudi ét séng cé 6, thuc quan di qua trung that trén ri trung thét sau, phia sau khi quan va hoi lech trai so v6i duémg gitta. Thye quan di xuyén qua eo hodnh «16 thyze quan clla co nay, ngang voi dét sng ngye 10 dé vao bung vi néi v6i da day 6 tam vi. Trén duéng di, thye quan cé ba ché hep: ché bit chéo cung déng mach chu, ché di phia sau phé quan trai va ché di qua co hodnh. Khi di vao trung that, thytc quan di phia sau tam nbi tri. Vi vay, khi 6 tinh trang lén nbi trai cé thé dé vao thyc quan gay nudt nghen. Vi dudng di cita thyc quan tir ving cd qua ngye réi xuéng bung nén thyre quan duge chia lam ba doan la: thye quan cé, thy quan ngyc va thyc quan bung. Thanh thyc quan duge cu tao boi co tron va co van, G 1/3 trén chi ¢6 co van, & 1/3 git gdm co van va co tron, 6 doan 1/3 duéi chi ¢6 co trom. Tai phiatrén ché néi vei tam vi, mét s6 sgi co hinh thanh co ving dudi thyc quan (lower esophageal sphincter) gitip ngin can djch va thire &n trao nguge tir da day lén thye quan. Ngoai ra, 18 thyc quan cia co hoanh duge giéi han béi hai try cia co hoanh nén cling c6 tac dung gép phin ngn sir trdo thie an va dich vi tir da day Ién thre quan. Niém mac thy quan duge l6t bai lép biéu mé lét ting khéng sig hoa. Lép duéi niém mac cé céc tuyén thyc quan cé chire nang tiét chat nhay lam tron niém mac thy quan. Mach va than kin Dong mach Thue quan cé dugc cdp mau béi cdc nhanh tir déng mach gidp duéi. Thyc quan doan ngye duge cp mau tir dng mach chi ngye qua céc nhanh phé quan, cde nhanh thye quan va cdc déng mach co hoanh. Tinh mach Miu tir niém mac thy quan dé vao dam ri tinh mach duéi niém mac rdi dé vao dam r6i tinh mach sdu cia thyc quan va cudi cing dé vao céc tinh mach quanh thyc quan qua cdc tinh mach xuyén. thyc quan cé, tinh mach thyc quan dé vé tinh mach giap dudi. G thyc quan ngye, tinh mach thyc quan chit yéu dé vao tinh mach don, tinh mach bin don, céc tinh mach 12 Scanned with CamScannergian sum, céc tinh mach phé quan. Tinh mach thyc quan bung dé tinh mach vi trai (tem thém bai Da day). ‘Cung dong mach chi Khi quan ‘ong mach Thyc quan sak chi ngye Co hoanh Da day Bong mach ot cha bung Hinh 20.4. Thyc quan (Nguén: Sobotta's Atlas Human Anatomy) Gidin tinh mgch thyc quén O thie quan bung, cdc tinh mach xuyén dé vao tinh mach vi trai. Trong khi d6, cdc tinh mach xuyén 6 doan cudi quan ngwe thi d6 vao tinh mach don vé tinh mach ban don, tiie Ia vao hé théng tink mach chi (xem bai trong module Tim mach). Tém lai, mau tinh mach doan cudi thuec quan dé vao ca hé théng tinh mach cita va hé tinh mach chit, nghia 1a tai day 06 sy thong thuong gitta hai hé tinh mach cira — chi (portosystemic anastomo- sis). Khi dp luc trong tinh mach ctea tang lén bat thudng (nhw trong xo gan, huyét khéi tinh mach cita), goi la tang dp luc tinh mach ctta (portal hypertension), mau sé khong vé gan theo dicing tinh mach cita ma sé do nguge vé céc tinh mach & thie quan. Hau qua la céic tinh mach duéi niém mac thc quan va céc tinh mach bang hé giita hai hé tinh mach ctra — chii (von da tac sau khi sinh) bj gin, goi ld gidn tinh mach thuc quan (esophageal varices). Hién tugng nay co thé dan dén va cac tinh mach va chdy mau dit dé 13 Scanned with CamScannerCAU HOI TY LUQNG GIA 1. Condo sau day tao nén sin migng? A. Co ham méng, co cm méng B. Co méng ludi, co tram méng C. Co hai than, co cdm méng D. Co méng ludi, co ham méng 2. San miéng dugc cp mau chi yéu béi A. Bong mach mat B. Dong mach hdi C. Déng mach hau lén D. Déng mach ham 3. Cam gide vj gide 6 2/3 trade ludi duge chi phéi boi ‘A. Than kinh ha thigt B. Thin kinh him duéi C. Than kinh thiét hau D, Than kinh trung gian 4. Khau edi cig duge tao than boi A. Xuong ham trén va xuong khau cai B. Xuong him trén va xuong mong C. Xuong khdu cai va xuong gd ma D. Xuong khau cdi va xuong 14 mia 5. Hay giai thich vi sao khi tam ni tréi lon Iai gay nuét nghen? TAI LIEU THAM KHAO 1. Nguyén Quang Quyén (2016). Bai giding Gidi phdu hoc, tap 1, Nha xuat ban Y hoc, TPHCM. 2. Lewis R va es (2001). Human Anatomy and Physiology, Nha xuat bin McGraw Hill, New York. 3. Martini FH va cs (2012). Human Anatomy, 7th edition, Nha xudt bin Benjamin Cummings, New York. 4, Putz R, Pabst R (2008), Sobotta Atlas of Human Anatomy, 14" edition, Elsevier, Munich, 5, Saladin KS (2014). Human Anatomy, 4th edition, Nha xuat ban McGraw Hill, New York. 14 Scanned with CamScanner21. DA DAY MUC TIEU BAI GIANG M6 1a vj tri, hinh thé ngodi ctia da day. . MG ta lién quan ctia da day. . Ma td déng mach va hé bach huyét de day. |. Phiin bigt hai truéng hop thoat vi hodnh, AwWR~ Da day (stomach) 1a doan phinh to nhat cia dng tigu héa, ndi gidta thy qun va rudt non, nim trong 6 bung, sat phia sau vom hoanh tréi va ving thurgng vi, Da day ki mot tang rong va cé hinh dang thay ddi theo tu thé, tudi, gidi, theo lung thtrc an cé trong da day,... 1. HINH THE NGOAI Da day duge mé ta la cé hinh chit J, c6 hai mat truée va sau, hai be cong va hai dau. Tir trén xuéng, da day chia thinh bén ving: ving tam vi, vang day vi, ving than vi, phan hang mén vi. Hai bd bén phai va bén trai cia da day la be cong nhé va ba cong lén. 1.1. Ving tim vj Tam vi (cardia) 1 mOt ving rong khodng 3 cm lién tiép v6i thye quan va théng véi thy quan qua Id tam vj (cardiac orifice). L8 tam vj khéng cé van thye su nén d6i khi dich va thitc an tir da day cé thé di nguge lén thye quan. Lé tam vi nim ngay sau syn suén 7 bén trdi, truéc thin dét sng ngye 10 va Iéch vé bén trai so voi dung gidta khong 2,5 cm. 1.2. Day vi Diy vi (fundus) la phén & phia trén va bén trai so véi tim vi, c6 hinh chém ciu va ngiin v6i thye quin béi mét khuyét goi la khuyét tim vi (cardiac notch). O tw thé dimg, day vj 14 noi chita khéng khi nén trén phim chup X-quang cho thay hinh anh “bong hoi da day”. 1.3. Than vj Than vi (body, corpus) la phan én nhat cia da day, 6 gitta day vi va hang vi, di tir mat phing ngang qua khuyét tam vi dén mat phiing ngang qua khuyét géc (xem bén duéi), 1.4. Phan mén vj Phin mén vi (pyloric part) tiép theo than vi, hep din tir rén xuéng, chia Kam hai phan 14 hang mén vj (pyloric antrum) va phan con lai hep hon goi la éng mén vi (pyloric canal). Ong mén vj dé vao ta tring qua 15 mén vi (pyloric orifice). L8 mén vj nim 6 vi tri 15 Scanned with CamScanner‘wong tng voi dot séng that lumg 1 va 6 bén phai dudng gitta khoang 1,25 em. Co vong & mon vj day lén tao thanh co that mén vi (pyloric sphinter) cé chite nang diéu héa sy da thie an tir da day qua 16 mén vi. 1.5. Ba cong nhé Bo cong nhé (lesser curvature) hoi lm, tao nén bén phai da day. Diém thap nhat cia bo cong nhé 1a khuyét g6c (angular incisure), ranh giGi gitta than vi va phan mon vi. 1.6. Be cong lon BO cong lon (greater curvature) hoi Idi vé bén trai va tao nén bs bén tréi da day. BO cong Ién dai hon ba cong nho, bat dau tir khuyét tam vi dén 16 mén vi. 2. LIEN QUAN 2.1. Lim quan truée O phia trréc, da day lién quan véi thanh ngue 6 trén va thanh bung 6 dudi. G thanh nguc, qua vom hoanh trai, da day lién quan véi céc co quan trong ngye nhwr phoi va mang phdi trdi, tim va mang tim va mot phin thiy tréi gan. G thanh bung, da diy nam ngay sau thanh bung trudc, trong mét tam gidc giéi han béi bo dudi gan, cung suém wai va mat trén dai trang ngang. 2.2. Lién quan sau ‘Mat sau phan day va tam vi lién quan véi tru trai co hoanh, Phan than vi tao nén than trude hau cung mac néi (xem bai Phic mac). Qua hau cung mac néi, mat sau than vj lién quan véi duéi tuy, dng mach va tinh mach lich, than va tuyén thugng than trai, Phan hang mén vj nm truéic mac treo dai trang ngang va qua mac treo nay, da day lién quan géc t4 héng trang. 2.3. Phia bir cong nhé Ba cong nho da day cé mac néi nho bam vao. Phia sau mac néi nho 1a déng mach chi bung, déng mac than tang va dam réi tang. 2.4, Phia bir cong lon Bo cong lm doan day vj thi ép sat vim hoanh trai va lién quan véi lach. Tiép theo, ba cong lim lién quan voi mac néi vj lach va tiép theo la mac néi lim (xem bai Phiic mac). Scanned with CamScannerKhuyét tam vi Day vi Lé tam vi Than vi Ba cong lon LB ynen vi Ong mén vi Hinh 21.1. Mat cdt ding ngang qua da day (Nguén: Sobotta’s Atlas Human Anatomy) 3. CAU TAO VA HiNH THE TRONG Giéng nhwr cau tao chung cua éng tiéu héa, thanh da day c6 bén ldp, tir ngoai vao trong 1a I6p thanh mac, Iép co, lip duéi niém mac, Iép niém mac (xem bai Dai cuong hé tiéu héa). Lép co 6 da day cé cau tao dic biét so véi cdc doan khéc cia éng tiéu héa 1a c6 them tang co chéo 6 trong cing. Sy phan bé cée l6p co ciia da day khong hoan toan gidng nhau giita cdc phan cita da day. Lap co doc da day lién tue véi lop co doc cia thye quan va ta trang, lop nay day nhat 6 bé cong nhé. Lop co vong thi bao kin toan thé da day va diy nhat & mén vi, tao nén co that mén vj nhu da ndi trén. Tang co chéo thi khéng déu, tap trung 6 day vi, di chéo xuéng dudi va huéng vé phia bo cong Ion. Niém mac da day xép thanh cdc nép theo chiéu doc goi la n gastric fugae), thay 16 tir déy vi, thén vj va doc theo bé cong lon. Cac nép & hang vi va gin mén vj sé mat di khi da day cng gian. Trong khi nudt, gidta cdc nép doc 6 ba cong nhé sé tao nén céc ranh goi la ng vi (gastric canal) giup thite an di xu6ng 15 mén vj nhanh hon. vi (gastric fold hode Khi quan sat qua ngi soi da day, ving chuyén tiép gitta niém mac thye quan (co mau héng nhat) va niém mac da day (cé mau dé) goi la duéng “Z”. 4. MACH VA THAN KINH CUA DA DAY 4.1. Dong mach (xem thém bai Déng mach chii trong Module Tim mach). Da day duge cdp mau tir déng mach than tang (celiac trunk). Scanned with CamScannerDong mach than tang xuat phat tir dgng mach chi bung, ngay dudi co hoanh. Ngay sau khi xuat phat, dng mach than tang chia thanh ba nhanh li: dng mach vj trai (left Sastric artery), dong mach gan chung (common hepatic artery) va dong mach lich (splenic artery). Bong mach gan chung lai chia thanh dGng mach gan riéng (proper hepatic artery) va dong mach vj ta trang (gastroduodenal artery). Cac mach mau chinh cia da day hinh thanh hai vong dong mach doc theo hai ba cong ciia da day. G be cong nhé cé déng mach , Xuat phat tir dng mach than tang va dong mach vj phai (right gastric artery), nhdnh cia déng mach gan riéng. O bo cong lin 6 dong mach vi mac néi phai (right gastroepiploic artery), la nhénh cla déng mach vi ta tring va dong mach vj mac néi trai (left gastroepiploic artery) tit dgng mach lich. Ngoai ra, da day cén duge cép mau tir céc déng mach khac nhu déng mach vi ngin (short gastric artery) cp méu cho phan trén bé cong 1én va céc dong mach vi sau (posterior gastric artery) cap méu cho mat sau day vi. Cac déng mach nay xuat phat tir dng mach lich. 6 tam vi cén cé thé duge cdp mau tir cae dOng mach hoanh dusi (inferior phrenic artery) xuat phat tit dong mach chi bung 6 mat duéi co hoanh. 4.2. Tinh mach Cac tinh mach ctia da day di song song dong mach va hau hét dé vé tinh mach cita (Portal vein, hepatic portal vein). Tinh mach cita hinh thanh do sy hgp lin gitra tinh mach lach (splenic vein) va tinh mach mac treo tring trén (right gastroepiploic artery) (xem thém Module Tim mach). Déng mach vitrai Dong mach lach ‘Bong mach Bong mach Vingén visau Bong mach than tang ‘ong mach vi pha Bong mach gan riéng ‘ong mach Vita trang Lach ‘Bong mach vi mac néi trai ‘Dong mach vj mac néi trai Hinh 21.2. Bong mach ciia da day (Nguén: Moore Clinically Oriented Anatomy) 18 Scanned with CamScannerTinh mach vi ngén Tinh mach civa Tinh mach trudc mon vj Tinh mach tach Tinh mach vi mac néi trai Tinh mach mac treo trang duéi cactinn 27 Rupe Tinh mach vi mac néi phai mach ta tuy Tinh mach mac treo trang trén Hinh 21.3. Tinh mach ciia da day (Nguén: Moore Clinically Oriented Anatomy) Cée tinh mach vi phai (right gastric vein) va tinh mach vj trai (left gastric vein) cing 46 vé tinh mach cira. Trude khi dé vao tinh mach cua, tinh mach vi phai con nhan thém mét tinh mach c6 tén 1a tinh mach truée mén vi (prepyloric vein) di len & mat trude mén vj. Tinh mach truéc mén vi kha dé nhin ra va la mgt méc dé xae dinh mén vj trong phau thudt. Cac tinh mach vi ngan (short gastric veins), tinh mach vi mac noi trai (left gastroepiploic vein) dé vé tinh mach tich. Tinh mach vi mac noi phai (right gastroepiploic vein) dé vé tinh mach mac treo trang trén. 4.3, Bach huyét Mach bach huyét & da diy khé phong pha va théng ndi véi mang luéi bach hu cc tang khac & phan trén 6 bung. Noi néi gitta thy quan ~ da day, mach bach huyét lién tue voi mach bach huyét thye quan; ving mén vj thi lién tye voi mach bach huyét cia té trang va tuy. Mach bach huyét di dgc theo cée dng mach da diy, dn luu bach huyét tir mat trude va mat sau da day rdi dé vé chudi hach da day (gastric lymph nodes) 6 bi cong nnhd va chudi hach vi mac néi (gastro-omental lymph nodes) & b& cong lon. Tit 46, bach huyét lai duge dan vé céc hach than tang (celiac lymph node) 4.4. Than kinh (xem thém bai trong Module Than kinh) Da day durgc chi phéi bi than kinh giao cém va déi giao cam. Scanned with CamScanner4.4.1. Giao cam Cae soi giao cam da day xuat phat tir tily ngye 6 dén tay nguc 9 va chi phéi dén da day théng qua céc than kinh tang lén va dam réi tang. Than kinh giao cm ite ché sy tiét dich da day, ire ché sur co bép cita da day nhung lam ting co that co vong mén vi. 4.4.2. Déi giao cam Than kinh d6i giao cdm chi phéi da day bit ngudn tir than than kinh lang thang tre (anterior vagal trunk) va than than kinh lang thang sau (posterior vagal trunk). Than trée cha yéu hinh thanh tir thin kinh lang thang tréi, di mat trude thye quan, qua 16 thyc quan co honh xuéng da day va di doc bd cong nho. Than truée cho nhénh gan (hepatic branch) va nhanh ta trang (duodenal branch) di trong day ching gan té tring (heparodudenal ligament) 16i tiép tuc di dgc theo bé cong nhé va cho céc nhénh vj truée. Than sau, 16n hon than truéc, chi yéu hinh thanh tir than kinh lang thang phai, di 6 ‘mat sau thyc quan, qua 16 thye quan co hoanh réi cling di doc b& cong nhé da day. Than sau cho nhanh tang (celiac branch) di vio dim rdi tang (celiac plexus) ri tiép tue di doc bd cong nhé va cho céc nhanh vj sau (posterior gastric branch). Than kinh di giao cm kich thich su tiét dich da diy, ting co bop cua da day, gay agian co ving mén vj va din truyén cdm giéc dau, cdm gide cing cia da day. Thodt vj hoanh Thodt vj hodnh (hiatus hernia, hiatal hernia) la hién ueong mét phan da day di vio trung thdt qua I6 thee quén cia co hoanh. Thodt vj hodnh thing xéy ra 6 lita tudi trung nién, c6 thé do co hodnh yéu di va I6 thite quan trén co hoanh bi ‘gidn. Cé hai logi thodt vi hhodnh la thodt vi canh thee quan (paraesophageal hiatal hernia) va thodit vj tnegt (sliding hiatal hernia) Trong thodt vi canh the quan, tam vj van 6 vi tri binh thug nhueng mot phan ciia da diy, theimg tai day vj, chui qua 16 the quin co hodnh, phia trade thu quan. Trong treég hop niy, dich va thive dn khang bj trio nguege lén thee quin vi Ib tam vj van & vi tri binh thang. Trong thodt vi trot, thee quan doan bung, tam vi, mt phn day vj tregt lén trén qua 16 thee quén co hoanh. Truong hop nay, dich vée thice an trong da day cé thé tréo ngugc 4én thie quan. Thodt vj tregt thing gap hon thodt vj canh theec quén, Hep m6n vj phi dgi bam sinh Phi dai mén vj bam sinh hay hep mén vj phi dai bam sink (congenital hypertrophic pyloric stenosis) la tink trang co that mon vj day lén bat thuong gay hep 16 mén vj. Khi 6, dich va thiee dn tic da day sé khong qua duege 16 mén vj dé xuéng rugt lim cho bénh nhdn phai nén 61 va dan dan gay céng gian da day, 20 Scanned with CamScannerThy quan Co hoanh, Tam vj Thoat vj canh thyc quan Da day Thoat vj trot Hinh 21.4. Thoat vi hoanh (Nguén: Moore Clinically Oriented Anatomy) CAU HOI TY LUQNG GIA 1. Gtrthé dimg, phan nao cia da day & vi tri cao nhdt? A. Than vi B. Tam vj C. Day vi D. Hang mén vj 2. Mach mau cung cap cho da day chi yéu nim & A. Mat truée than vj B.Mit sau thin vj C. Hai dau (tam vi va mén vi) D. Hai bd cong 3. Lép co véng cua da day day nhat 6 A. Tam vi B. Mon vj C. Bo cong nhé D. Bo cong lon 4. Khi than kinh X bj cét c6 thé din téi A. Da day ting tiét acid B. Da day gim tiét acid C. Da day ting co bop D. Da day bj co nho 5. Hay phan bigt hai truémg hop thoat vj hoanh TAI LIEU THAM KHAO 1. Nguyén Quang Quyén (2016). Bai gidng Giai phdu hoe, tap 2, Nha xudt bin Y hoc, TPHCM. 2. Martini FH va cs (2012). Human Anatomy, 7th edition, Nha xuat bin Benjamin Cummings, New York. 3. Moore K.L., et al (2014). Clinically Oriented Anatomy, 7* edition, Lippincott William and Willkins, Philadenphia. 4, Putz R, Pabst R (2008), Sobotta Atlas of Human Anatomy, 14* edition, Elsevier, Munich. 5. Saladin KS (2014). Human Anatomy, 4th edition, Nha xudt ban McGraw Hill, New York. Standring S (2015). Gray's Anatomy, 41st edition, Elsevier, London, 2 Scanned with CamScanner22. RUQT NON GS.TS.BS. Lé Vin Cuong - TS.BS. Nguyén Hoang Vit MUC TIEU BAI GIANG 1. M6 té vj tri, hinh thé ngodi, hinh thé trong ciia té trang. 2. M6 ta mac treo rugt non 3. M6 té nguyén tiy, dudng di, nhdnh bén ctia déng mach mac treo trang trén. 4. Gidi thich vi sao trong chan thieong bung néu cé tén thuong td tring thi phan ngang dé bj tén thuong cdc phan khic. Theo ding nghia cia tir Latin thi rut non c6 nghia la rut méng (intestinum tenue), 6 vai trd chinh 1a hap thu chat dinh dung. Rudt non thudc ng tigu hoa, gitra da diy va Tudt gia, chiém phan Ién 6 bung, 6 ting duéi mac treo két tring ngang va c6 ba phan la td trang (duodenum), hing trang (jejunum), hdi trang (ileum). Ta trang bat dau tit sau 18 mon vi dén g6c té héng trang (duodenaljejunal flexure). Phin con Iai la hing tring va trang thi héng trang chiém 2/5 chiéu dai, hdi tring tiép theo hdng trang va chiém 3/5. Hdi tring ndi véi manh trang tao nén géc hdi manh tring (ileocecal flexure). TA TRANG ‘Ta trang la phan dau tién va la phan ngin nhat, lon nhat (vé duéng kinh) ciia rudt non. Ta trang cé dang hinh chit “C”, di tir mén vi dén gée té-héng tring, dai khoang 25 cm va chia thanh bén phan Phan trén Phin trén (superior part) thuimg duge goi la D1, nim ngang tir phai sang tri va hoi hung lén trén, gitta m6n vj va ¢6 tii mat, Hai phan ba dau tién cia phan nay hoi phink to va c6 thé di déng, duoc goi la hah td trang. Phan trén t4 trang nam bén phai c6t séng va ngang mite dot séng that lumg 1. Vé lign quan, phan trén ta trang lién quan phia truce voi thay vudng cia gan va tii mat; phia sau-trén véi 18 mac n6i; phia sau véi déng mach vi té trang, éng mat cha, tinh mach cita; phia sau diedi vi dau va 06 tuy. Riéng tinh mach chit duéi cing 6 phia sau nhung cdch t4 tring boi mét l6p mé lign két long leo. Hanh té trang duge phi trong hai 14 phic mac lién tuc véi phite mac tang ctta da day. Bo trén phan nay c6 day ching gan-té tring cia mac néi nho bam. Doan cén lai ciia phan trén thi co dinh va phic mac chi phi 6 mat trude. Phan xudng Phan xudng (descending part) thong dugc goi la D2, ti phan trén m6t géc duge ggi la gdc ta trding trén (con goi Id goi trén td trang). Phan nay di tir c6 ti mat, doc bén phai cOt sng tir dét séng that mg I dén dét séng that hug IIT 22 Scanned with CamScannerhoe ba trén d6t séng thét lung IV. Mat truée phan xudng t4 trang, cb mét doan bi két trang ngang nam vat ngang qua va ching dinh véi nhau bing mé lién két lng Iéo, doan kh6ng cé két trang ngang vat qua thi c6 phic mac phil. Ngoai két trang ngang, mat truéc cia phn xudng ta trang cdn lién quan véi gan, ré mac treo két tring ngang, héng trang. G phia sau o6 than phai, tinh mach chi duéi, co thit lung l6n. Phia trong cita phan xuéng {4 trang 1a dau tuy, éng mat chi va phia ngoai li géc két trang phai. Bén trong phan xuéng té trang cé hai nhi ta trang: Nhi: ta lén (major duodenal papilla) nam 6 thanh sau trong cia phan xudng, cach 15 mén vj khoang 8-10 cm. Tai nhii ta lon cé 18 dé ciia éng mat chi va 6ng tuy chinh. Nhu ta bé (minor duodenal papilla) & phia trén nhi ta lin khodng 2 om va hoi vé phia truée hon so véi nhii ta lén. Tai nh ta bé c6 18 dé cia éng tuy phy. Phan ngang Phin ngang (horizontal pard), hay phan duéi (inferior part), cbn gqi la D3, tiép véi phan xuéng va hop v6i phan xuéng mot goc durge goi la géc td trding dies (cén goi la géi dedi), Phin nay nam vat ngang c6t séng tir phai sang trai va hoi lén trén, giita dét song that lung ITT va d6t s6ng that lung IV, truée tinh mach chi duéi va déng mach cha bung. Vi phan ngang té trang nim ngay truéc cét séng, trong nhing truong hgp chan thuong bung kin, né chu tac déng bai Ie chdn thuong tir phia trudc va cét song tir phia sau nén dé bi chdn thong nhit. Phan lén Phan lén (ascending part), hay D4, lién tiép véi phn ngang, hoi hudng lén trén va sang trdi, bén trai déng mach chu bung, ngang bé trén dét sng thit mg II va néi voi hng trang tao nén géc td-hong trang (duodenojejunal flexure). Hang mén vi Géc ta hng trang Phan xuéng Nha ta lon. Hinh 22.1. Cac phan ciia ta trang (Nguén: Sobotta's Atlas) 23 Scanned with CamScannerMech miu cia ta trang Phan trén ta trang duge cp mau béi d6ng mach trén ta trang, dng mach té tuy trén sau, c6 tie gid con m6 ta mot déng mach nifa la dng mach quat nguge té trang. Cac dong mach nay Ld nhanh ciia dong mach vj ta trang. Mot sé trudng hop, dng mach vj phai cing cung cap mau cho khoang | cm dau cia phan trén ta trang. Sau khi cho cdc nhdnh trén, dng mach vj té trang tiép tyc di xudng, gita t4 trang va dau tuy, roi cho hai nhanh tan 1a déng mach té tuy trén truéc va dong mach vj mac ndi phai. Ca hai nhénh tan nay ciing cho nhigu nhanh nhé dén phan trén td trang. Mau tinh mach ctia phan trén td trang theo tinh mach trén mén vj ho§c tinh mach duéi mén vj. Tinh mach trén mén vj nhan miu tir nita trén cia phan trén va dé vé tinh mach cita hoc tinh mach ta tuy trén sau. Tinh mach duéi mén vj nhn mau tir nira duéi phan trén td trang va dé vé tinh mach vi-mac ndi phai. Mach mau ciia cdc phan can lai cita té tring duge mé ta trong bai Tuy. HONG TRANG VA HOI TRANG 1. KiCH THUGC - V] TRE 1.1. Chiéu dai Chigu dai rudt non thay déi theo timg cé thé, theo gidi, tinh trang truong lye co cia thanh rugt. Chiéu dai cia rudt non & ngudi sng khoang 5 m. Tuy nhién, chiéu dai cia ruét non sé dai hon sau khi tir vong vi mat truong lye co. 1.2. Duong kinh Dusdng kinh rudt non giam dan tir trén xuéng. Nhiing khuc rudt dau cia hdng trang c6 during kinh trung binh khoang 4 cm dén cac khuc rut cudi khoang 2 em, Do 46, nhimg vat la nhu soi mat cé thé di qua hdng trang nhung bi ket & doan cudi hdi trang. 1.3. Vi tri Rust non cuén Iai thanh cdc quai rudt hinh chit U, cdn goi la khiie rudt, mdi khie dai 20-25 cm. C6 14-16 khiic, chia kim hai nhém: mot nhém ndm ngang 6 bén trai 6 bung, m6t nhém nim thang & bén phai 6 bung, riéng, 10-15 cm cudi cing thi Iai nim ngang truéc khi 46 vao manh trang. Trén thyc té, cé m6t quy luat tng quat la 1/3 dau cua rugt non nim 6 ha sudn trai, 1/3 gidta nm 6 trung tam 6 bung va 1/3 cdn lai nim 6 chau hong va hé chau phai, 24 Scanned with CamScanner2. LIEN QUAN Phia trén rudt non lién quan voi két tran; dweéi lién quan v6i cae tang trong chau hong Khi céc tang nay day, cdc quai rudt duge day lén bung va khi céc tang rng, cae khitc rudt lot vio céc khe giita céc tang dé, c6 khi lich xuéng tan ti cling sinh duc tryc trang. Bén Phdi lién quan voi manh trang va két trang lén. Bén irdi lién quan véi két tring xudng. Céc quai ruét nm phia trade két tring xudng va lién quan véi thanh bung truéc nén khi dan xuyén qua héng tréi, rudt non bj thing truée rdi méi toi ka trang, Phia truéc, rugt non lién quan véi than bung trade qua trung gian ciia mac néi lon. Do cdc quai rut khé dai trong khi strc chita cia mac hay khi thanh bung bj xuyén thing, trudc tién, ngoai ra ching con dé lan qu: ig Ngang va mac treo két trang ngang. Phia bé (tryc trang, tang sinh duc, bang quang). 6 bung giéi han nén khi vira mo phic cae quai rugt non o6 khuynh hudng phoi ra ngoai a cdc diém yéu cita thanh bung gay thodt vj. 3. PHAN BIET HONG TRANG VA HOI TRANG Khong c6 ranh gigi r8 rét gidta héng trang va hdi trang. Hong tring c6 thanh day hon, cé mau héng hon va nhigu mach mau hon hdi trang, cdc nép vong & hdng tring nhiéu va lon hon, ce mao trang cling lén hon & héi trang. Héng trang nam 6 quanh rn, doc dudi két tring ngang va truée than tri. Cae quai héi trang nim 6 ving ha vi vA ving chu, phan cudi ciia hdi trang thudng nim & ving chu true co that lumg chéu phai, truéc b6 mach chau phai va hé chau phai dé 48 vao mat trong ché ndi gitta manh trang va két tring lén, Sau day la tom tit mét so diém khéc biét: ~ Duong kinh héng trang hoi lon hon hdi tring ~ Thanh cia héng trang day hon, nhiéu mach mau hon va ¢6 nhii iéu nép vong cao hon la 6 héi trang - M6 bach huyét & héng tring tao nén cdc nang don dc, 6 héi trang la cae mang bach huyét. ~ Cac quai hdng trang nim ngang phia trén trai 6 bung, con céc quai hdi trang nim doe bén phai va phia dudi 4. CAU TAO Thanh rudt non cing c6 cdu tao chung cia dng tigu héa (xem bai Dai cwong he tidu ‘h6a). Tuy nhién, \6p niém mac cua rudt non ¢6 nhiing dc diém riéng phi hgp cho chite nang hap thu ciia rugt. Trén bé mat niém mac c6 rét nhigu nép vong (circular fold) con goi li nhimg nép hinh ligm, nh6 len dén 1/2 hay 2/3 khdu kinh cua long rust. Nép ving cao Khoding & mm va day 25 Scanned with CamScannerkhoang 3 mm, c6 nhiéu & doan dau hdng trang, cing vé phia hdi trang cdc nép nay cang nho dn va bién mat 6 doan cuéi hoi trang. G rugt non cia ngubi ¢6 khong 800 nép vong, ching lam ting dign tich hap thy cia niém mac rudt non lén gap hai Lin va c6 thé thay r qua chyp X-quang ruét non cé thudc can quang. Trén bé mat niém mac ké ca trén mat cae nép vong cé rét nhiéu nim nhé goi li nhung mao (intestinal villi). MGi nhung mao cao 0,5 ~ | mm, bén ngoai la lop biéu mé rudt, bén trong 1a t6 chite lién két c6 chita mach mau va mach bach huyét. Nhung mao lén va cé 86 lugng nhiéu 6 té trang va héng trang, xudng t6i hdi trang sé nho va {t din. Mat 46 ciia nhung mao khoang 10-40 nhung mao trén | mm?. Nhung mao lim ting bé mit niém mac rut lén gap 8 lan. Cau tao chi tiét ctia niém mac rugt dug mé ta trong Mé hoc. 5. MAC TREO RUQT Mac treo rudt non (mesentery) 1a nép phite mac n6i cdc quai rudt non vao thanh bung sau, qua 46 vira dé treo vira dé nudi dudng ru6t vi trong cé chita mach mau. 5.1. RE mac treo RE mac treo (root of mesentery) 1a duréng dinh cita mac treo vao thanh bung sau, di tit géc ta héng tring dén géc hdi manh trang, dai khoang 15 em. Né di chéo tir canh trai dt séng that lung 2, xuéng dudi di phia trréc dét that lung 3, 4 rdi sang phai dén phia truéc khép ciing chau 6 hé chau phai. Vi vay, r8 mac treo Lin lugt di qua phia truée phan ngang tA tring, déng mach chii bung, tinh mach chit dudi, co that lung phai, nigu quan phai va dng mach sinh duc phai. Mac treo ruét non tao nén mét vach chéch xudng dudi va sang phai, chia ting duéi mac treo két trang ngang ciia 6 bung thanh hai khu: khu bén phai théng vdi hé chau phai, khu bén trai thong véi chau héng bé. 5.2. Bi mac treo B& mac treo la noi mac treo gin vao hdng trang, hdi trang. Tai ba mac treo, hai la phiic mac tach xa nhau 7-10 mm dé 6m lay mat ngoai ctia rudt. Chiéu dai ciia bo mac treo bing chiéu dai ruét non nén mac treo phai gap thanh nhiéu nép, mdi nép 1a m6t quai rudt. Chiéu rong cia mac treo 1d khoang cach tir ré dén ba mac treo, thudng lon nhat 6 khoang gira (12-15 cm) va gidm dan 6 hai dau, tai day ré va bd mac treo gan nhau. 5.3. Cu tgo cia mac treo Mac treo do hai lé phic mac 4p sat vao nhau, & gitta hai la clia mac treo c6: - Cc nhanh rudt cia dong mach va tinh mach mac treo tring trén, - Cc bach mach va chudi hach bach huyét. = Cfc nhanh than kinh cua dm réi mac treo tring. 26 Scanned with CamScanner- Té chire mo. Mé phan pl -0 qui luat la Itic dau c6 nhiéu 6 ré mac treo, cing xudng cdc doan duéi mé cang tién gan dén bd mac treo ciia rudt. 6. MACH MAU 6.1. Dong mach Rudt non duge cap mau béi déng mach mac treo trang trén (superior mesenteric artery) (xem thém bai trong module Tim mach). 6.1.1. Nguyén tiy Déng mach mac treo tring trén xudt phat tir mat truée dong mach chi bung, ngay dudi déng mach thin tang, ngang mic dét séng thit lung 1. Cé khi dng mach mac treo trang trén chung than voi déng mach thin tang to thinh than dng mach than tang-mac treo, cling cé thé chung than véi déng mach lich tao thanh than dng mach kich-mac treo hay chung than véi cd dng mach lich vi dng mach gan tgo thinh thdn dng mach gan- lach-mac treo, 6.1.2, Duong di Tur nguyén uy 6 sau tuy va tinh mach lach, déng mach mac treo trang trén bat chéo truéc tinh mach than trai, di xuéng mém méc ciia tuy va trrée phn ngang td trang. Khi di vao mac treo, dng mach mac treo tang trén di bat chéo true déng mach chu bung va tinh mach chi duéi, nigu quan phai va co that lung chau bén phai. Trong ré mac treo, dng, mach bé dudng cong qua phai dén phan cudi cia hoi trang. Dong mach mac treo trang trén & bén trai va hoi phfa sau tinh mach mac treo trang trén trén suét dudng di. Chieu dai ciia dng mach mac treo tring trén khoang 20-25 cm. Dong mach mac treo trang trén xuéng tan cing & vj tri cach goc hoi manh trang khodng 5 cm, tuong img voi géc cita tii thira hdi trang néu cé. 6.1.3. Lién quan Duong di cia déng mach mac treo tring trén duge chia lim bdn doan. 6.1.3.1. Doan sau tuy Doan nay dai khoang 4-5 cm, dng mach nim gitta dng mach chii bung phia sau va tuy 6 true, chung quanh la mét tir gidc tinh mach, cdc canh ciia tir gide khong nam trong, cing mét binh dign. 6 sau phitc mac: bén phai IA tinh mach chit dudi, phia dui la tinh mach than trai. G truée phic mac: bén trai 1a tinh mach mac treo tring duéi, phia trén 1a tinh mach léch. Chung quanh dng mach la d4m réi than kinh va hach bach huyét. a7 Scanned with CamScannerr 6.1.3.2. Doan trén va trubc té trang Khi néng két trang ngang lén thi thdy dng mach xudt hign gitta céc cfu tritc sau: ~ Phia trén la eo tuy. > Bén phai la tinh mach mac treo trang trén. - Bén trai la phan lén cia t4 trang, ~ Phia sau la mom méc tuy va phan ngang td trang. Tinh mach thén trai va phan ngang té trang bj kep giita dng mach chii (phia sau) va 46ng mach mac treo trang trén (phia truéc) nén cé thé bj tdc td tring hoiic lam cham dong mau 6 tinh mach than. 6.1.3.3. Doan trong ré mac treo ru6t Dong mach di gitta ré mac treo ru6t, sau dng mach la khe gitta dng mach chit bung va tinh mach chi duéi, truéc déng mach la cc quai rugt non. 6.1.3.4. Doan trong mac treo Déng mach di vao gitta hai la mac treo rugt theo mt dudng cong Idi sang trai téch ra nhiéu nhénh bén va tn cling bing mét nhénh néi v6i nhanb hai trang cita dong mach hdi két trang. Doan nay rat di déng. 6.1.4, Nhdnh bén Dong mach mgc treo trang trén cho céc nhénh ta tuy dudi, cdc nhénh rust non, dong mach két trang gitta, dng mach két trang phai va déng mach hdi két trang. Dong mach mac treo trang trén cé thé cho nhiing nhénh khée thuéng nhu dng mach tuy mg véi ti 1g 21%, dong mach tuy dudi, déng mach gan phai véi ti 1é 14%. Ngoai ra, dng mach c6 thé cho nhanh déng mach gan chung, d6ng mach két trang giita phy hode cd biét c6 thé cho nhénh d6ng mach léch, dng mach vj té trang, dng mach vj mac ndi phai, e6 khi cho d6ng mach tui mat. 6.1.4.1. Déng mach ta tuy duci Déng mach ta tuy dui (inferior pancreaticoduodenal artery) xuat phat tt dng mach mec treo trang trén, gitta td trang 6 sau va tuy 6 trudc va trén. O day, déng mach chia hai nhénh: dng mach té tuy duéi trude va dong mach t4 tuy didi sau dé néi véi hai nhdnh ong mach té tuy trén trade va dong mach té tuy trén sau tir dng mach vi té tring (xem bai Tuy). Déng mach t4 tyy dui truéc nlm sau mom mic tyy, di én ndi véi ddng mach ta tuy trén truéc, cdp mdu mat truéc cia dau tyy va ta tring. 28 Scanned with CamScannerDéng mach ta tuy duoi sau di bi mau cho mat s chéo phia sau dau tuy va néi voi déng mach ta ty 1 dau tyy va ti tring, 6.1.4.2. Cae dong mach hong trang va hei trang Co khoang 12-20 nhanh dong mach xuat phat ti bén trai dong mach mac treo tring trén di song song voi nhau dén rugt non. Cé hai nhém: nhom trén vao cae quai hdng trang. i 1a cae dong mach hdng tring, nhém dudi vio cite quai hdi tring goi lat cde dGng mach i tring. MGi dong mach rudt sau khi di vio gita hai ki mae treo thi chia Lam hai nln fen va xudng song song véi rudt, ndi véi cde déng mach ké can tgo nén cung déng mach thit 1, ir cung nay cé thé sinh ra cung thir 2, 3, 4. Tir cung déng mach gan rugt nhat c6 nhimg nhénh dong mach thing dén rugt, dong mach thing cita héng trang thing dai khong 3-4 em, & hdi tring khoding 1-3 cm. Theo ly thuyét c6 thé dyra vao sy phan bé cae cung mach trong mac treo dé xite dinh. céc quai rugt. Cac quai rudt diu chi cd mot cung mach, dgng mach thing thi dai va to. Cac quai gitta c6 tir 1 dén 5 cung mach. Cac quai cudi cé it cung, dng mach thing ngin va manh, So ligu Vigt Nam: s6 lugng nhinh dén ruét non & nguoi Viet Nam thay doi tie 8-10 nhénh, trung binh la 9 nhdnh; diong kinh lin nhdt ctia déng mach rugt non la 3,15 mm (Lé Van Cuong). 6.1.4.3. Dong mach hoi két rang Dong mach hoi két tring (iliocolic artery) xuat phat tir bs phai cita d@ng mach mac treo tring trén, céch nguyén uy cua dgng mach mac treo tring trén tir 5-9 cm, dong mach di xuéng sau phic mac thinh bung sau dé dén manh trang. Trén dung di dgng mach bat chéo tinh mach mac treo tring trén va di bie ngang trude co that lug phai, bd mach sinh duc va nigu quan bén phai. Khi dén manh trang, d@ng mach chia lam nam nhanb: DOng mach lén (ascending artery) di én dgc theo bs mac treo ciia két tring lén, ndi mt nhénh cita d6ng mach két trang phai. Déng mach manh trang trude (anterior cecalis artery) dén mat trude manh trang. Dong mach manh trang sau (posterior cecalis artery) dén mat sau manh trang. DéGng mach rugt thira (appendicularis artery) di phia sau hdi trang dén bs ty do ciia mac treo rugt thir, Dong mach héi trang (ileal artery) di dgc theo hi tring dé néi voi nhénh tin cha dng mach mac treo tring trén. 29 Scanned with CamScannerO nguéi Viét Nam, dong mach héi két trang cé ti Ié chung than voi déng mach két irting phai la 6,45%, chiéu dai trung bink cia ding mach hdi két trang la 80 mm va ducéng kinh trung binh la 3 mm (theo Lé Van Cuong). 6.1.4.4, Dong mach két trang phéi Dong mach két trang phai (right colic artery) xuat phat tir bo phai cia dgng mach mac treo tring trén, di qua phia sau phiic mac dé dén phi gitta ciia két trang lén. Trén duromg di dong mach bit chéo phia trude nigu quan va dong mach sinh dyc bén phai, khi dén gan két trang [én thi chia hai nhanh: nhanh lén ndi voi nhanh phai cia dong mach két trang gidta; nhanh xudng néi véi nhanh lén hay nhanh két tring cua dng mach hdi két trang. O nguéi Vigt Nam, déng mach két trang phai cé chiéu dai khong 50 mm va dong kinh trung binh la 2,5 mm. Ti lé déng mach két trang phai chung than v6i dng mach hoi két trang la 6,45%, chung than véi déng mach két trang gitta Ia 24,1%. Co 2% khong co déng mach két trang phai (Lé Van Cuong). 6.1.4.5, Dong mach két trang giita ‘DOng mach két tring gitta (middle colic artery) xuat phat tir mat trudc ca déng mach mac treo tring trén, noi xudt phat céch nguyén iy cia déng mach ta tuy duéi khoang 4cm. Dong mach di vao mac treo két trang ngang va khi céch két tring ngang 6-7 em thi chia Lim hai nhanh phai va trai. Nhdnh phai bé cong doc bo két trang ngang qua phai néi véi nhanh lén cia dong mach két trang phai. Nhénh trai bé cong huéng sang tréi doc két tring ngang dé néi véi nhanh lén ciia d6ng mach két trang trai, O nguéi Viét Nam, déng mach két trang gitta cé chiéu dai trang binh ld 16,8 mm va dug kinh trung binh lé 2,33 mm. Déng mach két trang giita chung than v6i dong mach két trang phdi la 24,1%, CO 12,9% khong cé déng mach két trang gitta. Cé nhanh néi hinh chit H gitta dong mach két trang giita va ding mach két tring phdi Id 7,5%, co 7,5% 6 déng mach két trang gitta phu. Céc nhanh néi cia ding mach mgc treo trang trén Néi v6i déng mach than tang do céc nhanh té tuy duéi néi véi cae nhanh cia dong mach vj td trang. N6i véi déng mach mac treo trang du6i qua d6ng mach két trang gia va déng mach két trang trai. Dic diém ciia dng mach mac treo trang trén & ngudi Vigt Nam: dng mach mac treo trang trén cd nguyén Uy 6 ngang mite 1/3 dudi dét séng that lung 1 va c6 dung kinh 1a 6mm. $6 nhanh bén cia dong mach mac treo trang trén vao rut non trung binh la 9 nhanh, 33,8% déng mach mac treo trang trén cho ba nhanh déng mach hdi két trang, két 30 Scanned with CamScannertrang phai va két tring gitra dén két tring, 24% dong mach két trang phai va dong mach két trang gida chung than voi nhau, 6,45% déng mach hdi két trang va dong mach két trang phai chung than véi nhau, 12,9% khong cho nhanh két tring gitta. 11,29% dong mach mac treo tring trén cho thém mt nhanh két tring gitta phy (ngoai nhanh két trang Aiita da c6) va mét trudng hgp co dng mach két tring phai phy. Dac bigt, c6 hai truong hop déng mach mac treo trang trén cho ra cde nhénh kim nhigm vy thé déng mach than tang (trong trong hop nay ding mach than tang khiém khuyét). 6.2. Tinh mach Cac tinh mach giéng nhwr céc dng mach. Tinh mach mac treo tring trén lén dén phia sau than tuy thi hgp véi tinh mach lich tao thanh tinh mach cita (xem bai Gan) 7. BACH HUYET Cac dudng dan luu bach huyét rudt non co thé tom tat nhu sau: Trong rust: tir cdc mach bach huyét dan dén céc mach niém mac rdi dén dam réi duéi niém, sau 46 dén dam r6i dui thanh mac. sn cdc hach bach huyét doc theo céc mach mau mac treo réi dén cdc hach bach huyét doc theo dGng mach mac treo tring trén va dong mach than tang, sau d6 d6 vé cdc bé dudng trap. 8. THAN KINH Than kinh cung cp cho rugt non c6 nguén géc tir hé than kinh ty chi, gdm thin kinh giao cam va déi giao cam. ‘Than kinh giao cam gém céc hach than kinh giao cdm canh cét séng doan nguc gitta. Cac sgi giao cam truéc hach cé nguén géc tir cdc té bao than kinh & ving chat x4m trung gian bén cla doan ty ngye gitta va di theo céc soi than kinh tang ln va than kinh tang mhé dé dén hach mac treo tring trén. Cac sgi sau hach di cing véi dong mach mac treo tring trén dé vao mac treo va durge phan bé doc theo céc nhanh cita déng mach nay. Cac sgi giao cam lam nhiém vu co mach va tre ché van déng co tron cua rut non. Cae soi truée hach cia thin kinh d6i giao cam di theo than kinh lang thang trade va thin kinh lang thang sau. Nhigm vy cia thin kinh d6i giao cam Ia digu khién sy bai tiét cdc tuyén rudt 6 niém mac va digu khién van d6ng co tron & rudt non. Ngoai ra, tai thinh rugt non cé than kinh ngi tai (xem bai Dai cuong hé tiéu héa). Scanned with CamScanner‘ong mach mac treo trang trén ‘Dong mach té tyy dudi ‘Dong mach mac treo trang dudi ‘Dong mach két trang gidra ‘Déng mach két trang phai Ong mach héi két trang ‘ong mach ng trang Cc dong mach hoi trang Hinh 22.2. Ong mach mac treo trang trén (Nguén: Sobotta’s Atlas) CAU HOI TY LUQNG GIA 1. Ong mat chi va dng tuy 46 vao té trang tai nh ta I6n, nh ta lon nim & A. Phan trén ta trang B. Phan xudng ta tring C. Phan ngang t4 tring D. Phan lén ta trang 2. Phan nao cila ta trang 14 phan di dong? A. Hanh ta tring B. Géc trén ta trang C. Géc dui ta tring D. Phan ngang té trang 3. Trong chén thuong bung néu cé t6n thong ta trang thi pl Jin nao dé bj ton thong nhat? A. Hanh ta tring B. Phan xudng ta trang C. Phan ngang té trang D. Phan lén ta trang, 4. R& mac treo rugt non di qua phia truéc céc cau tric sau day, ngoai tri A. Nigu quan trai B. Tinh mach cha dudi C. Dong mach chu byng D. Phan ngang ta trang 5. Bong mach mac treo tring trén cho cdc nhanh sau, ngoai tri: A. Dong mach ta tuy durdi B. Dong mach hai két tring C. Dong mach két trang giita D. Dong mach két trang trai 32 Scanned with CamScannerTAI LIEU THAM KHAO 2) ae Nguyén Quang Quyén (2016). Bai gidng Gidi phdu hoc, tap 2, Nha xudt ban Y hoc, Thanh pho Hé Chi Minh. Moore K.L., et al (2014). Clinically Oriented Anatomy, 7 edition, Lippincott William and Willkins, Philadenphia. Putz R, Pabst R (2008), Sobotta Atlas of Human Anatomy, 14° edition, Elsevier, Munich. Saladin KS (2014). Human Anatomy, 4th edition, Nha xuat ban McGraw Hill, New York. Skandalakis JE. et al. Skandalakis' surgical anatomy the embryologic and anatomic basic of modern surgery. Standring S (2016). Grays Anatomy, 41st edition, Elsevier, London. 33 Scanned with CamScanner23. DAI TRANG TS.BS. Nguyén Hoang Vii - PGS.TS.BS. Duong Van Hai MUC TIEU BAI GIANG M6 ta hinh thé ngodi, hinh thé trong cée phan ctia dai trang. M6 té nguyén tiy, duedng di, phn nhvinh ctia dong mach mac treo trang duedi. M6 ta tinh mach ciia dai trang. Gidi thich co ché gay gidn tinh mach truc trang khi cé tang dp lee tinh mach ctta, AwNS 1, BAI CUONG Dai trang (large intestine) con goi Li rudt gid, nhung theo tiéng Latin thi cé nghia la rugt day (intestinum crassum), ed chite ning chinh 1a hip thy nuée va dur trir phan. Dai ang go ft ¢ trang va ong hdu mén. Két trang (colon) gdm két trang lén, két trang ngang, két tring xuéng va két trang chdu hong. VE phéi thai, tir két trang lén dén doan 2/3 phai cia két tring ngang c6 ngudn géc tir ru6t gidta vi duge cp miu boi ddng mach mae treo trang trén, tir phan cdn Iai ciia két trang ngang dén hét két trang chau héng c6 nguén géc tir rugt sau va durge cp mau bai déng mach mac treo trang dudi (xem bai Dai cuong hé tigu héa). Vi va . doan két trang tir két trang lén dén hét 2/3 phai cua két tring ngang duge goi li két trang phdi. Phan con lai, tir 1/3 tréi ciia két tring ngang dén hét két trang chau hong goi la kér trang trai. Trén thyc t6, tir “dai trang” va “kér trang” thudng khong durge phan biét ré ring “dai tring” lai duge diing phé bign hon, Do dé, két tring lén throng durge goi la dai tring lén, két trang ngang ciing goi la dai trang ngang, ddng mach h6i két trang cing goi Li dong mach héi dai trang, hay két trang trai duge goi ld dai trang trai, két tring phai throng duge goi la dai trang phai. 2. HINH THE NGOAI Dai trang dai khoaing 1,4-1,8 m, duéng kinh lin nhat 6 doan diu, khoang 7 cm va giam dan dén doan cu Ngoai trir rudt thiza, tryc trang va Ong hau mén, dai trang c nhimg die diém chung inh dang gitip ta phan biét voi rugt non. Dé la: Scanned with CamScanner= Dai ca dge (teniae coli): c6 ba dai ca doc, do co doc cua thinh dai trang tap trang lai, chay doc tir manh trang dén két trang chau héng, + Dai mac treo két trang (mesocolic tenia) & phia sau trong, c6 mac treo két tring ngang va mac treo két trang chau héng bim vio. + Dai mac ndi (omental tenia) & phia sau ngoai. + Dai ty do (free tenia) & phia truse. - Titi phinh két trang (haustra): 1 nhimg tai phinh cia thanh két trang, nam gitta cae dai co dgc, cach nhau bang nhimg ché thit ngang va khéng cé dinh ma thudng xuyén di chuyén, - Cle titi thira mac néi (omental appendices): \a nhimg tii md nho bim vao dai mac néi. Goc két Két trang ngang trang trai Goc két trang phai Két trang lén xuéng HOi trang Két trang Manh trang chau hong Trye tran Rut thiva, ta Hinh 23.1. Cac phan cila dai trang (Nguén: Moore Clinically Oriented Anatomy) 35 Scanned with CamScannerVan hoi Ham van manh trang L6 hoi manh trang —— Hai trang L8 ru6t thir Ruot thira Hinh 23.2. Hinh thé trong ca manh trang (Nguén: Moore Clinically Oriented Anatomy) 3. CAC PHAN CUA DAI TRANG 3.1. Manh trang va rudt thira Manh trang (cecum) la phan dau tién cia dai tring, c6 dang nhu mot cai thi, dai khong 7,5 cm, nim 6 1/4 duéi phai cia 6 bung. Manh trang la tang trong phiic mac, khéng cé mac treo nhung c6 thé di dong. Ruét thia (appendix) dai khoang 6-10 cm, bit mét dau, con dau kia dinh vio mat sau trong ciia manh trang, noi hi ty cia ba dai cc doc, dudi géc hdi manh trang khoang 2-3 cm, Rudt thira cO mac treo rudt thita (meso-appendix), di tit mat sau cia mac treo phan cudi hi trang dén manh trang va dogn dau rugt thira. B& tur do ciia mac treo cd dong mach rudt thita. Manh trang duge cap mau tir déng mach hdi két tring (ileocolic artery), nhanh cia déng mach mac treo trang trén. Dong mach hdi két tring cdn cho nhanh déng mach rugt thira Bach huyét cia manh tring va rugt thita dan vé cdc hach bach huyét 6 mac treo rugt thira va cde hach doc theo déng mach hdi két tring. Bach huyét tir cdc hach nay sé tiép tuc d6 vé cae hach mac treo trang trén (superior mesenteric lymph node) nim quanh dong mach mac treo trang trén. Scanned with CamScannerKét trang lén Két trang Ién (ascending colon) dai khong 8-15 em, lién tye véi manh tring, & bén phai 6 bung, di In dén thiy phai gan thi quit sang trai, tao nén géc két tring phai (right colic flexur), con ggi la két tring gée gan (hepatic flexure). Két tring goc gan nim dudi mit tang ciia gan, khsing xuong sun 9, 10, Mac treo két tring Ién dinh vito phic mac thinh bung sau, tg nén mac dinh két trang phai. Do dé, két tring én goi la tang bj thinh héa hay tang sau phic mac thir phat (secondarily retroperitoneal), Nur vay, két tring lén chi duige phiic mae phii phia trude va hai bén va tro nén 6 dinh, Gidi han ciia mac treo két tring In: 6 érén, bam tir nguyén iy dng mach mac treo tring trén dén phan xuéng ti tring; 6 rong li dudng di cua dng mach mac treo trang trén; 6 died durong chéo di tir ché chia dai dgng mach chu byng dén géc hdi manh trang Gita mat ngoai cita két tring lén va thinh bung tao thanh mét rnh doc, goi la ranh thanh - két trang phai hay ranh canh két tring phai (right paracolic gutter). Ranh nay duong nhign duge lét béi phic mac thanh. Két trang lén va két tring géc gan duge cp mau boi déng mach héi két tring va dong mach két trang phai (xem module Tim mach va bai Ruét non trong module nay). Dong mach khi dén ket tring sé hinh thanh dng mach b& (marginal artery) di song song va gin bd mac treo ciia két trang. Tir déng mach bd, cic nhénh dGng mach thing xudt phat di dén két tring 6 mat trude va mat sau két trang. Tinh mach cia két trang lén 46 vé tinh mach mac treo trang trén. Bach huyét tir két trang lén duge dan vé cdc hach bach huyét két trang phai rdi vé cic hach mac treo trang trén, 3.3. Két trang ngang Két trang ngang (transverse colon) dai trung binh 50 cm, cé khi dén 100 em, la doan dai nhat va di dng nhat, tiép theo géc két tring phai, chay ngang 6 bung, dén lich va bé hudng xudng dudi tao nén géc két trang trai (left colic flexure), con goi la két trang goc lach (splenic flexure). So voi két tring géc gan, két tring géc Lich 6 vj tri cao hon, géc nhon hon va it di déng hon, Két tring géc lich nim phia truéc phan duéi than trai va dinh v6i co hoanh qua day ching hoanh ~ két tring (phrenicocolic ligament). R& mac treo két trang ngang di doc be trurée tuy va lign tue véi phiic mac thanh bung sau (nhitng tdi ligu mé ta tuy chi c6 bé trén va bo didi thi ré mac treo két trang ngang di doc bo dueoi tuy). Két trang ngang va mac treo két trang ngang (transverse mesocolon) thudng vong xudng thap, c6 thé xuéng duéi mite cita mao chau. 37 Scanned with CamScanner