{"id":1623,"date":"2013-03-25T11:36:45","date_gmt":"2013-03-25T11:36:45","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=1623"},"modified":"2013-06-11T08:01:45","modified_gmt":"2013-06-11T08:01:45","slug":"8-miniinvazivni-postupy-v-hrudni-chirurgii-2","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=1623","title":{"rendered":"8 Miniinvazivn\u00ed postupy v hrudn\u00ed chirurgii"},"content":{"rendered":"<h3>8.1 Miniinvazivn\u00ed postupy v hrudn\u00ed chirurgii<\/h3>\n<p style=\"text-align: justify;\">Miniinvazivn\u00ed chirurgick\u00e9 postupy prod\u011blaly na konci minul\u00e9ho stolet\u00ed explozivn\u00ed v\u00fdvoj. Prvotn\u00ed nad\u0161en\u00ed z nov\u00e9 technologie bylo posl\u00e9ze vyst\u0159\u00edd\u00e1no opr\u00e1vn\u011bnou skeps\u00ed danou p\u0159irozen\u00fdmi limity tohoto typu intervence. Tento evolu\u010dn\u00ed proces neminul ani torakochirurgii. Zpo\u010d\u00e1tku se zd\u00e1lo, \u017ee miniinvazivn\u00ed ekvilibristika dok\u00e1\u017ee nahradit klasickou otev\u0159enou chirurgii ve v\u011bt\u0161in\u011b indikac\u00ed. Postupn\u011b se v\u0161ak indikace za\u010daly t\u0159\u00edbit. Lze konstatovat, \u017ee v diagnostice m\u00e1 miniinvaze zelenou. V terapeutick\u00fdch indikac\u00edch existuje opr\u00e1vn\u011bn\u00e1 skepse nad mo\u017enostmi dodr\u017eet axiomy onkologick\u00e9 chirurgie (kompletn\u00ed resekce, dostate\u010dn\u00e1 lymfadenektomie, rekonstrukce). Proto je miniinvazivn\u00ed torakochirurgie bez z\u00e1sadn\u00edch v\u00fdhrad akceptov\u00e1na p\u0159i \u0159e\u0161en\u00ed benign\u00edch onemocn\u011bn\u00ed. Ot\u00e1zka terapeutick\u00fdch intervenc\u00ed je u malign\u00edch nitrohrudn\u00edch afekc\u00ed v\u00edcem\u00e9n\u011b omezena na m\u00e9n\u011b slo\u017eit\u00e9 v\u00fdkony abla\u010dn\u00ed \u010di amputa\u010dn\u00ed. Slo\u017eit\u011bj\u0161\u00ed rekonstruk\u010dn\u00ed v\u00fdkony a zejm\u00e9na rozhodov\u00e1n\u00edm o jejich proveditelnosti si bez direktn\u00ed revize lze p\u0159edstavit jen obt\u00ed\u017en\u011b.<\/p>\n<p style=\"text-align: justify;\">Rozli\u0161ujeme 2 typy miniinvazivn\u00edch hrudn\u00edch operac\u00ed.<\/p>\n<ol>\n<li>Videotorakoskopie (videothoracoscopic surgery \u2013 VTS) je opera\u010dn\u00ed technika prov\u00e1d\u011bn\u00e1 pouze cestou port\u016f zaveden\u00fdch z mal\u00fdch inciz\u00ed, bez pou\u017e\u00edt\u00ed torakotomie. Za kontroly optick\u00e9ho syst\u00e9mu se operuje speci\u00e1ln\u00edmi n\u00e1stroji vyvinut\u00fdmi pro endoskopick\u00e9 v\u00fdkony.<\/li>\n<li>Videoasistovan\u00e1 hrudn\u00ed chirurgie (videoassisted thoracic surgery \u2013 VATS) vyu\u017e\u00edv\u00e1 krom\u011b incizion\u00e1ln\u00edch port\u016f p\u0159\u00edstupovou minitorakotomii. Kombinuje v\u00fdhody otev\u0159en\u00e9 operace (palpa\u010dn\u00ed vjem, i kdy\u017e limitovan\u00fd, mo\u017enost pou\u017eit\u00ed klasick\u00e9ho instrumentaria) a miniinvazivitu (minitorakotomie bez pou\u017eit\u00ed rozv\u011bra\u010de, bez traumatizace interkost\u00e1ln\u00edho prostoru).<\/li>\n<\/ol>\n<p style=\"text-align: justify;\">V z\u00e1jmu maxim\u00e1ln\u00edho benefitu z miniinvazivn\u00edho postupu je t\u0159eba dodr\u017eovat \u0159adu z\u00e1sad:<\/p>\n<ul>\n<li style=\"text-align: justify;\">P\u0159\u00edstup: aby byly zachov\u00e1ny v\u00fdhody miniinvazivn\u00edho p\u0159\u00edstupu, nem\u011bla by b\u00fdt pracovn\u00ed minitorakotomie del\u0161\u00ed ne\u017e 6-8cm a rozv\u011bra\u010d lze akceptovat pouze k distrakci m\u011bkk\u00fdch tk\u00e1n\u00ed.<\/li>\n<li style=\"text-align: justify;\">Chirurgick\u00e1 bezpe\u010dnost v\u00fdkonu: operace nesm\u00ed b\u00fdt hazardem. Preparace jednotliv\u00fdch struktur ve zv\u011bt\u0161en\u00e9m obraze m\u016f\u017ee b\u00fdt stejn\u011b bezpe\u010dn\u00e1, a dokonce p\u0159ehledn\u011bj\u0161\u00ed, ne\u017e je tomu u klasick\u00e9 torakotomie. Srovnateln\u00e9 bezpe\u010dnosti p\u0159i podvazu, p\u0159eru\u0161en\u00ed \u010di uz\u00e1v\u011bru d\u016fle\u017eit\u00fdch struktur m\u016f\u017ee b\u00fdt dosa\u017eeno vyv\u011b\u0161en\u00edm c\u00e9v p\u0159ed staplerovou suturou nebo staplingem nad nalo\u017eenou svorkou tam, kde to anatomick\u00e9 okolnosti dovoluj\u00ed. Podvazy c\u00e9v uzlen\u00e9 extranebo intratorak\u00e1ln\u011b jsou rizikov\u011bj\u0161\u00ed, chyb\u00ed digit\u00e1ln\u00ed kontrola. Klipovat c\u00e9vy se nedoporu\u010duje pro riziko uvoln\u011bn\u00ed klip\u016f. Staplerov\u00fd uz\u00e1v\u011br bronchu i c\u00e9vy je akceptov\u00e1n i v otev\u0159en\u00e9 hrudn\u00ed chirurgii a je pova\u017eov\u00e1n za bezpe\u010dn\u00fd.<\/li>\n<li style=\"text-align: justify;\">Onkologick\u00e1 spolehlivost: souvis\u00ed s indika\u010dn\u00edmi krit\u00e9rii. Pro videoasistovan\u00e9 v\u00fdkony lze indikovat plicn\u00ed tumory ulo\u017een\u00e9 dostate\u010dn\u011b perifern\u011b v pl\u00edci, kter\u00e9 neinfiltruj\u00ed okoln\u00ed struktury, tedy T1, T2, tolerov\u00e1na je velikost do 5 cm v pr\u016fm\u011bru. Malign\u00ed n\u00e1dory mediastina lze \u0159e\u0161it obvykle do velikosti 5 cm, pokud neinfiltruj\u00ed okoln\u00ed struktury.<\/li>\n<li style=\"text-align: justify;\">U malign\u00edch l\u00e9z\u00ed je malign\u00ed mediastin\u00e1ln\u00ed lymfadenopatie obvyklou kontraindikac\u00ed VTS\/VATS.Pokud nen\u00ed lymfogenn\u00ed diseminace p\u0159edopera\u010dn\u011b-verifikov\u00e1na, je mediastin\u00e1ln\u00ed lymfadenektomie ne-d\u00edlnou sou\u010d\u00e1st\u00ed otev\u0159en\u00e9 stejn\u011b jako miniinvazivn\u00ed operace.<\/li>\n<li style=\"text-align: justify;\">Kr\u00e1tkodob\u00e9 efekty VATS resekc\u00ed: na v\u011bt\u0161\u00edch sestav\u00e1ch byly prok\u00e1z\u00e1ny tyto pozitivn\u00ed vlivy mini-invazivn\u00edch postup\u016f: men\u0161\u00ed poopera\u010dn\u00ed bolesti,men\u0161\u00ed redukce ventila\u010dn\u00edch parametr\u016f po identick\u00e9m rozsahu operace a d\u0159\u00edv\u011bj\u0161\u00ed n\u00e1vrat do norm\u00e1ln\u00edho \u017eivota.<\/li>\n<li style=\"text-align: justify;\">Dlouhodob\u00e9 v\u00fdsledky: na v\u011bt\u0161\u00edch sestav\u00e1ch VTS\/ VATS operac\u00ed jsou referov\u00e1ny minim\u00e1ln\u011b stejn\u00e9, v n\u011bkter\u00fdch p\u0159\u00edpadech i lep\u0161\u00ed dlouhodob\u00e9 v\u00fdsledky (2let\u00e9, 5let\u00e9 p\u0159e\u017eit\u00ed, po\u010det recidiv, doba do recidivy). Jako d\u016fvody se uv\u00e1d\u011bj\u00ed selekce (nejde o randomizovan\u00e9 soubory) a men\u0161\u00ed z\u00e1sah do imunitn\u00edho syst\u00e9mu (imunodeficit indukovan\u00fd klasick\u00fdm opera\u010dn\u00edm v\u00fdkonem je v\u011bt\u0161\u00ed ne\u017e po VATS operaci).<\/li>\n<li style=\"text-align: justify;\">N\u00e1klady: n\u00e1klady na materi\u00e1l spot\u0159ebovan\u00fd p\u0159i operaci jsou vy\u0161\u0161\u00ed, ale \u010d\u00e1ste\u010dn\u011b redukovateln\u00e9 men\u0161\u00edmi n\u00e1klady na krat\u0161\u00ed hospitalizaci a rychlej\u0161\u00edm n\u00e1vratem do b\u011b\u017en\u00e9ho \u017eivota.<\/li>\n<\/ul>\n<h3>8.2 Kontraindikace VTS\/VATS operac\u00ed<\/h3>\n<p style=\"text-align: justify;\">Krom\u011b obecn\u00fdch kontraindikac\u00ed celkov\u00fdch, intern\u00edch a pneumologick\u00fdch je t\u0159eba dodr\u017eovat kontraindikace speci\u00e1ln\u011b v\u00e1zan\u00e9 na minim\u00e1ln\u011b invazivn\u00ed nitrohrudn\u00ed operativu. Jsou absolutn\u00ed a relativn\u00ed.Absolutn\u00ed:<\/p>\n<ul>\n<li>nemo\u017enost selektivn\u00ed ventilace,<\/li>\n<li>malign\u00ed mediastin\u00e1ln\u00ed lymfadenopatie,<\/li>\n<li>lok\u00e1ln\u011b pokro\u010dil\u00fd n\u00e1dor,<\/li>\n<li>pl\u00e1novan\u00e1 rekonstrukce (tracheoplastika, bronch\u00ed plastika, angioplastika),<\/li>\n<li>obliterace pleur\u00e1ln\u00ed dutiny ne\u0159e\u0161iteln\u00e1 adheziol\u00fdzou,<\/li>\n<li>v\u00e1\u017en\u00e1 koagulopatie.<\/li>\n<\/ul>\n<p>Relativn\u00ed:<\/p>\n<ul>\n<li>p\u0159edchoz\u00ed operace,<\/li>\n<li>p\u0159edchoz\u00ed induk\u010dn\u00ed terapie (zejm\u00e9na radioterapie).<\/li>\n<\/ul>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_2291.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 13 \u2013 N\u00e1hrada perikardu bovinn\u00ed z\u00e1platou\" alt=\"Obr. 13 \u2013 N\u00e1hrada perikardu bovinn\u00ed z\u00e1platou\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_2291.png\" width=\"200\" height=\"155\" \/><\/a><p class=\"wp-caption-text\">Obr. 13<br \/>N\u00e1hrada perikardu bovinn\u00ed z\u00e1platou<\/p><\/div>\n<p style=\"text-align: justify;\">Obecn\u00e9 principy miniinvazivn\u00edch operac\u00ed z\u016fst\u00e1vaj\u00ed poplatn\u00e9 postup\u016fm vypracovan\u00fdm pro otev\u0159en\u00e9 operace. Zvl\u00e1\u0161tn\u00ed pozornost zasluhuje polohov\u00e1n\u00ed pacienta z d\u016fvodu dostate\u010dn\u00e9 p\u0159ehlednosti opera\u010dn\u00edho pole. Zat\u00edmco u klasick\u00fdch operac\u00ed je \u010dasov\u00e1 posloupnost jednotliv\u00fdch opera\u010dn\u00edch krok\u016f d\u00e1na pom\u011brn\u011b pevn\u011b a ov\u011b\u0159ena \u010dasem, videotorakoskopick\u00fd \u010di asistovan\u00fd postup m\u00e1 ur\u010ditou variabilitu danou limitovan\u00fdm p\u0159\u00edstupem a nutnost\u00ed st\u0159\u00eddat p\u0159\u00edstupov\u00e9 cesty pro optiku a pracovn\u00ed n\u00e1stroje k udr\u017een\u00ed p\u0159ehlednosti v opera\u010dn\u00edm poli. Ur\u010dit\u00e9 z\u00e1sady pro volbu pozice port\u016f, instrument\u00e1ria a jist\u00fd \u010dasov\u00fd \u0159\u00e1d plat\u00ed i pro jednotliv\u00e9 typy VTS\/VATS operac\u00ed. Optick\u00e1 explorace hrudn\u00edku a posouzen\u00ed obecn\u00e9 i torakoskopick\u00e9 resekability se prov\u00e1d\u00ed jedn\u00edm z pracovn\u00edch port\u016f. Prvn\u00ed 10mm port se zakl\u00e1d\u00e1 obvykle v 6. mezi\u017eeb\u0159\u00ed v p\u0159edn\u00ed axil\u00e1rn\u00ed \u010d\u00e1\u0159e, p\u0159ed okrajem m. latissimus dorsi, po posouzen\u00ed lok\u00e1ln\u00edho n\u00e1lezu se p\u0159id\u00e1vaj\u00ed dal\u0161\u00ed vstupy. P\u0159\u00edpadn\u00e1 minitorakotomie je vedena p\u0159\u00edmo nad hlavn\u00edm interlobiem (obvykle 5. mezi\u017eeb\u0159\u00edm p\u0159ed doln\u00edm \u00fahlem lopatky, 4. mezi\u017eeb\u0159\u00edm v p\u0159\u00edpad\u011b horn\u00ed lobektomie vpravo), m\u016f\u017ee nahrazovat prvn\u00ed port. Dal\u0161\u00ed 2 porty (10mm) se punktuj\u00ed za optick\u00e9 kontroly a dodr\u017een\u00ed principu triangulace tak, aby se optika a opera\u010dn\u00ed n\u00e1stroje nek\u0159\u00ed\u017eily. Dodate\u010dn\u00e9 porty (5mm) pro n\u00e1stroje pot\u0159ebn\u00e9 k manipulaci a trakci za nitrohrudn\u00ed struktury lze zalo\u017eit v pot\u0159ebn\u00fdch m\u00edstech (obr. 1).<\/p>\n<p>Eventu\u00e1ln\u00ed inici\u00e1ln\u00ed adheziol\u00fdza se prov\u00e1d\u00ed v z\u00e1jmu dokonal\u00e9ho p\u0159ehledu v operovan\u00e9m hrudn\u00edku.<\/p>\n<h3>8.3 Obecn\u00e9 principy VTS\/VATS operac\u00ed<\/h3>\n<h4>8.3.1 Diagnostick\u00e1 VTS<\/h4>\n<p>Videotorakoskopie je v\u00fdte\u010dn\u00fd pomocn\u00edk k ov\u011b\u0159en\u00ed povahy pleur\u00e1ln\u00edch v\u00fdpotk\u016f, povrchov\u00fdch plicn\u00edch, pleur\u00e1ln\u00edch a mediastin\u00e1ln\u00edch l\u00e9z\u00ed. V \u0159ad\u011b p\u0159\u00edpad\u016f lze vysta\u010dit se 2 porty (jeden pro optiku, druh\u00fd pro odb\u011br vzorku z pleury, mediastina). D\u016fle\u017eit\u00e9 je polohov\u00e1n\u00ed pacienta: poloha na z\u00e1dech s hrudn\u00edkem podlo\u017een\u00fdm do 30\u00b0 je vhodn\u00e1 pro revizi p\u0159edn\u00edho mediastina. V\u011bt\u0161ina plicn\u00edch biopsi\u00ed se prov\u00e1d\u00ed v later\u00e1ln\u00ed poloze. Pro revizi zadn\u00edho mediastina, paravertebr\u00e1ln\u00edho prostoru a zadn\u00edho kostofrenick\u00e9ho \u00fahlu je vhodn\u00e1 later\u00e1ln\u00ed pozice vyklon\u011bn\u00e1 o 30\u00b0 na b\u0159icho. Mal\u00e9 \u00fatvary z mediastina lze odstranit cel\u00e9, z objemn\u00fdch neohrani\u010den\u00fdch \u00fatvar\u016f se biopsie prov\u00e1d\u00ed ost\u0159e po prot\u011bt\u00ed mediastin\u00e1ln\u00ed pleury (obr. 2).<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_231.jpg\"><img decoding=\"async\" title=\"Obr. 2 \u2013 Exstirpace preaort\u00e1ln\u00ed uzliny\" alt=\"Obr. 2 \u2013 Exstirpace preaort\u00e1ln\u00ed uzliny\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_231.jpg\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 2<br \/>Exstirpace preaort\u00e1ln\u00ed uzliny<\/p><\/div><\/td>\n<td style=\"border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_2321.png\"><img decoding=\"async\" title=\"Obr. 3 \u2013 Staplerov\u00e1 biopsie pro diseminovan\u00fd plicn\u00ed proces\" alt=\"Obr. 3 \u2013 Staplerov\u00e1 biopsie pro diseminovan\u00fd plicn\u00ed proces\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_2321.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 3<br \/>Staplerov\u00e1 biopsie pro diseminovan\u00fd plicn\u00ed proces<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_2331.png\"><img decoding=\"async\" title=\"Obr. 4 \u2013 Extrakce projektilu z pleur\u00e1ln\u00ed dutiny\" alt=\"Obr. 4 \u2013 Extrakce projektilu z pleur\u00e1ln\u00ed dutiny\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_2331.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 4<br \/>Extrakce projektilu z pleur\u00e1ln\u00ed dutiny<\/p><\/div><\/td>\n<td style=\"border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_2341.png\"><img decoding=\"async\" title=\"Obr. 5 \u2013 Princip horn\u00ed hrudn\u00ed sympatektomie (resekce 2. a 3. ganglia)\" alt=\"Obr. 5 \u2013 Princip horn\u00ed hrudn\u00ed sympatektomie (resekce 2. a 3. ganglia)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_2341.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 5<br \/>Princip horn\u00ed hrudn\u00ed sympatektomie<br \/>(resekce 2. a 3. ganglia)<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Proveden\u00ed plicn\u00ed biopsie odpov\u00edd\u00e1 n\u00e1lezu. Numul\u00e1rn\u00ed l\u00e9ze p\u0159i povrchu lze sn\u00e9st ost\u0159e a resek\u010dn\u00ed linii o\u0161et\u0159it koagulac\u00ed. K lokalizaci hlub\u0161\u00edch l\u00e9z\u00ed m\u016f\u017ee pomoci barevn\u00e9 zna\u010den\u00ed p\u0159edopera\u010dn\u011b, takov\u00e9 biopsie je stejn\u011b jako v\u011bt\u0161\u00ed nec\u00edlen\u00e9 biopsie plicn\u00edho parenchymu mo\u017en\u00e9 prov\u00e1d\u011bt endostaplery (obr. 3).<\/p>\n<p>Biopsie pleury je obvykle snadn\u00e1 pomoc\u00ed bioptick\u00fdch kle\u0161t\u00ed \u010di na zp\u016fsob parci\u00e1ln\u00ed pleurektomie. V\u00fdpotek k bakteriologick\u00e9mu \u010di cytologick\u00e9mu vy\u0161et\u0159en\u00ed ods\u00e1v\u00e1me kanylou na za\u010d\u00e1tku operace. V p\u0159\u00edpad\u011b difuzn\u00edho posti\u017een\u00ed pleury karcin\u00f3zou lze v jedn\u00e9 dob\u011b prov\u00e9st talkovou pleurod\u00e9zu. Obr. 4 ukazuje extrakci projektilu z pleur\u00e1ln\u00ed dutiny.<\/p>\n<h4>8.3.2 VTS sympatektomie<\/h4>\n<p style=\"text-align: justify;\">Torakoskopick\u00e1 sympatektomie je na rozd\u00edl od klasick\u00e9 otev\u0159en\u00e9 operace jednodu\u0161\u0161\u00ed a p\u0159ehledn\u011bj\u0161\u00ed. Jedn\u00e1 se o odstran\u011bn\u00ed (destrukci) krani\u00e1ln\u00ed \u010d\u00e1sti hrudn\u00edho sympatick\u00e9ho provazce, kter\u00e9 m\u00e1 v\u00fdborn\u00fd terapeutick\u00fd efekt nap\u0159. u palm\u00e1rn\u00ed \u010di axil\u00e1rn\u00ed hyperhidr\u00f3zy nebo u Raynaudovy nemoci, kde selh\u00e1v\u00e1 konzervativn\u00ed l\u00e9\u010dba (antidepresiva, beta-blok\u00e1tory, cholinergn\u00ed prepar\u00e1ty). Hrudn\u00ed sympatikus je paravertebr\u00e1ln\u011b ulo\u017een\u00fd nervov\u00fd provazec se v\u0159azen\u00fdmi ganglii. Prvn\u00ed ganglion (Th1) odpov\u00edd\u00e1 za pocen\u00ed a chlad obli\u010deje, ruky a mal\u00e9 \u010d\u00e1sti axily, spolu s 8. cervik\u00e1ln\u00edm gangliem (C8) tvo\u0159\u00ed ganglion stellatum, odpov\u011bdn\u00e9 za o\u010dn\u00ed a pupil\u00e1rn\u00ed reflexy. G. stellatum mus\u00ed b\u00fdt \u0161et\u0159eno, jeho poran\u011bn\u00ed m\u016f\u017ee zp\u016fsobit mi\u00f3zu, pt\u00f3zu a enoftalmus (Hornerova tri\u00e1da). Druh\u00e9, t\u0159et\u00ed a \u010dtvrt\u00e9 ganglion (Th2\u2013Th4) se pod\u00edl\u00ed na hyperhidr\u00f3ze, chladu horn\u00edch kon\u010detin a rudnut\u00ed obli\u010deje v sestupn\u00e9 m\u00ed\u0159e (obr. 5).<\/p>\n<p style=\"text-align: justify;\">Pro kraniofaci\u00e1ln\u00ed hyperhidr\u00f3zu a rudnut\u00ed v obli\u010deji je indikov\u00e1na Th2 sympatektomie, pro palm\u00e1rn\u00ed a axil\u00e1rn\u00ed hyperhidr\u00f3zu jsou resekov\u00e1na ganglia Th3\u2013Th4.<\/p>\n<p style=\"text-align: justify;\">V p\u0159\u00edpad\u011b v\u00fdrazn\u00e9 kombinovan\u00e9 symptomatologie se prov\u00e1d\u00ed hrudn\u00ed sympatektomie v rozsahu Th1\u2013Th4, odstra\u0148uje se tedy doln\u00ed t\u0159etina ganglion stellatum a dal\u0161\u00ed 3 hrudn\u00ed ganglia. Vzhledem k obecn\u011b dobr\u00e9mu p\u0159ehledu v opera\u010dn\u00edm poli se s v\u00fdhodou pou\u017e\u00edvaj\u00ed minitorakoskopick\u00e9 n\u00e1stroje (t\u0159\u00ed nebo p\u011btimilimetrov\u00e1 optika a t\u0159\u00edmilimetrov\u00e9 n\u00e1stroje). Pokud nejsou v hrudn\u00edku sekund\u00e1rn\u00ed zm\u011bny, lze sympatikus vyhledat pom\u011brn\u011b snadno paravertebr\u00e1ln\u011b, druh\u00e9 \u017eebro je obvykle prvn\u00ed z\u0159eteln\u011b patrn\u00e9 \u017eebro a slou\u017e\u00ed jako vod\u00edtko k lokalizaci ganglia Th2, kter\u00e9 je pod jeho dist\u00e1ln\u00ed hranou. Po pleurotomii je provazec vyzvednut ze sv\u00e9ho l\u016f\u017eka a za pe\u010dliv\u00e9ho p\u0159eru\u0161en\u00ed komunikuj\u00edc\u00edch sympatick\u00fdch vl\u00e1ken v pot\u0159ebn\u00e9m rozsahu resekov\u00e1n. Pe\u010dliv\u00e1 hemost\u00e1za je nezbytn\u00e1, v\u00fdkon kon\u010d\u00ed obvykle zalo\u017een\u00edm jednoho dr\u00e9nu. Operace se v\u011bt\u0161inou prov\u00e1d\u00ed oboustrann\u011b v jedn\u00e9 anestezii, v\u00fdrazn\u00fd a dlouhodob\u00fd efekt lze o\u010dek\u00e1vat a\u017e u 90 % operovan\u00fdch. P\u0159ed propu\u0161ten\u00edm je t\u0159eba vylou\u010dit poopera\u010dn\u00ed bradykardii a Horner\u016fv syndrom. Z d\u016fvodu mo\u017en\u00e9 kompenzatorn\u00ed hyperhidr\u00f3zy zad n\u011bkte\u0159\u00ed auto\u0159i doporu\u010duj\u00ed sympatick\u00fd provazec pouze klipovat. P\u0159i v\u00fdrazn\u00fdch pot\u00ed\u017e\u00edch lze klipy odstranit reoperac\u00ed.<\/p>\n<h4>8.3.3 VTS\/VATS operace v mediastinu<\/h4>\n<p>Pro operace v p\u0159edn\u00edm mediastinu pou\u017e\u00edv\u00e1me semilater\u00e1ln\u00ed polohu nemocn\u00e9ho, porty zakl\u00e1d\u00e1me krani\u00e1ln\u011bji: v 3.\u20135. mezi\u017eeb\u0159\u00ed v p\u0159edn\u00edch a st\u0159edn\u00edch axil\u00e1rn\u00edch \u010dar\u00e1ch v triangul\u00e1rn\u00ed pozici (obr. 6).<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_2361.png\"><img decoding=\"async\" title=\"Obr. 6 \u2013 Pozice port\u016f pro operaci v p\u0159edn\u00edm mediastinu\" alt=\"Obr. 6 \u2013 Pozice port\u016f pro operaci v p\u0159edn\u00edm mediastinu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_2361.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 6<br \/>Pozice port\u016f pro operaci v p\u0159edn\u00edm mediastinu<\/p><\/div><\/td>\n<td style=\"border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_2371.png\"><img decoding=\"async\" title=\"Obr. 7 \u2013 Exstirpace perikardi\u00e1ln\u00ed cysty\" alt=\"Obr. 7 \u2013 Exstirpace perikardi\u00e1ln\u00ed cysty\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_2371.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 7<br \/>Exstirpace perikardi\u00e1ln\u00ed cysty<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">N\u00e1dory a cysty p\u0159edn\u00edho mediastina lze touto cestou odstranit stejn\u011b jako thymomy, pokud nep\u0159er\u016fstaj\u00ed do okoln\u00edch struktur (Masaoka I, II) a nejsou v\u011bt\u0161\u00ed ne\u017e 5 cm (konsenzus). V p\u0159\u00edpad\u011b thymom\u016f a myastenie je nezbytn\u00e9 kompletn\u00ed odstran\u011bn\u00ed tk\u00e1n\u011b thymu, kter\u00e9 vy\u017eaduje preparaci nad \u00farove\u0148 lev\u00e9 brachiocefalick\u00e9 \u017e\u00edly a kontrolu protilehl\u00e9 strany (nebezpe\u010d\u00ed poran\u011bn\u00ed br\u00e1ni\u010dn\u00edho nervu). Proto n\u011bkdy b\u00fdv\u00e1 volen oboustrann\u00fd p\u0159\u00edstup. N\u00e1dory do velikosti 5 cm lze extrahovat roz\u0161\u00ed\u0159en\u00fdm portem, v\u017edy v ochrann\u00e9m obalu. Benign\u00ed cysty (perikardi\u00e1ln\u00ed, bronchi\u00e1ln\u00ed) lze v\u011bt\u0161inou vypreparovat tup\u011b, m\u00e1lokdy maj\u00ed v\u00fdznamn\u011bj\u0161\u00ed c\u00e9vn\u00ed z\u00e1soben\u00ed, stopka b\u00fdv\u00e1 avaskul\u00e1rn\u00ed, lze ji o\u0161et\u0159it koagulac\u00ed, klipem, Ligasure \u010di harmonick\u00fdm skalpelem (obr. 7). \u00dazkou komunikaci s perikardem nen\u00ed t\u0159eba uzav\u00edrat.<\/p>\n<p style=\"text-align: justify;\">L\u00e9ze zadn\u00edho mediastina jsou l\u00e9pe p\u0159\u00edstupn\u00e9 v later\u00e1ln\u00ed torakotomick\u00e9 poloze sklopen\u00e9 na b\u0159icho tak, aby pl\u00edce po desuflaci z\u016fstala le\u017eet na p\u0159edn\u00edm odd\u00edlu hemitoraxu. Pracovn\u00ed porty pak zav\u00e1d\u00edme v p\u0159edn\u00ed axil\u00e1rn\u00ed \u010d\u00e1\u0159e ve vy\u0161\u0161\u00edch mezi\u017eeb\u0159\u00edch pro operace v horn\u00edm zadn\u00edm mediastinu (2. a 4. mezi\u017eeb\u0159\u00ed) a kaud\u00e1ln\u011bji p\u0159i operac\u00edch supradiafragmaticky (4. a 6. mezi\u017eeb\u0159\u00ed). Triangulaci zabezpe\u010duje trokar pro optiku ulo\u017een\u00fd dorz\u00e1ln\u011bji (za zadn\u00ed axil\u00e1rn\u00ed \u010darou, obvykle o mezi\u017eeb\u0159\u00ed kaud\u00e1ln\u011bji ne\u017e pracovn\u00ed porty).<\/p>\n<h4>8.3.4 Miniinvazivn\u00ed chirurgie spont\u00e1nn\u00edho pneumotoraxu<\/h4>\n<p style=\"text-align: justify;\">Obvyklou indikac\u00ed chirurgick\u00e9 intervence u spont\u00e1nn\u00edho pneumotoraxu je 1. recidiva kolapsu pl\u00edce, operace prvn\u00ed epizody nereaguj\u00edc\u00ed na konzervativn\u00ed l\u00e9\u010dbu (hrudn\u00ed dren\u00e1\u017e) a prevence recidivy u nemocn\u00fdch v pracovn\u00edm \u010di sportovn\u00edm riziku (letci, pot\u00e1p\u011b\u010di).<\/p>\n<p style=\"text-align: justify;\">Operace prob\u00edh\u00e1 v later\u00e1ln\u00ed torakotomick\u00e9 poloze,2 porty zav\u00e1d\u00edme v p\u0159edn\u00ed axil\u00e1rn\u00ed \u010d\u00e1\u0159e (4. a 6. mezi\u017eeb\u0159\u00ed) a jeden v 7. mezi\u017eeb\u0159\u00ed v zadn\u00ed axil\u00e1rn\u00ed linii tak, aby mohla b\u00fdt po relokaci optiky o\u0161et\u0159ena cel\u00e1 plocha pariet\u00e1ln\u00ed a br\u00e1ni\u010dn\u00ed pleury. Operace za\u010d\u00edn\u00e1 p\u00e1tr\u00e1n\u00edm po bul\u00e1ch a bublin\u00e1ch, obvykle jsou lokalizov\u00e1ny v apexu, ne v\u017edy jsou nalezeny, pomoci m\u016f\u017ee vodn\u00ed zkou\u0161ka (pono\u0159en\u00ed podez\u0159el\u00e9ho \u00faseku pl\u00edce pod hladinu fyziologick\u00e9ho roztoku a \u010d\u00e1ste\u010dn\u00e1 insuflace pl\u00edce). Patologickou plicn\u00ed tk\u00e1\u0148 je t\u0159eba resekovat pomoc\u00ed endostapler\u016f nebo pro\u0161\u00edt (obr. 8).<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_2391.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 8 \u2013 Resekce apexu pl\u00edce endostaplerem\" alt=\"Obr. 8 \u2013 Resekce apexu pl\u00edce endostaplerem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_2391.png\" width=\"200\" height=\"188\" \/><\/a><p class=\"wp-caption-text\">Obr. 8<br \/>Resekce apexu pl\u00edce endostaplerem<\/p><\/div><\/td>\n<td style=\"border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_2401.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 9 \u2013 Pleurabraze diafragmatick\u00e9 plery\" alt=\"Obr. 9 \u2013 Pleurabraze diafragmatick\u00e9 plery\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_2401.png\" width=\"200\" height=\"159\" \/><\/a><p class=\"wp-caption-text\">Obr. 9<br \/>Pleurabraze diafragmatick\u00e9 plery<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_2411.png\"><img decoding=\"async\" title=\"Obr. 10 \u2013 Videotorakoskopick\u00e1 pleurektomie\" alt=\"Obr. 10 \u2013 Videotorakoskopick\u00e1 pleurektomie\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_2411.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 10<br \/>Videotorakoskopick\u00e1 pleurektomie<\/p><\/div><\/td>\n<td style=\"border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">V z\u00e1jmu prevence recidivy pneumotoraxu je nem\u00e9n\u011b d\u016fle\u017eit\u00e1 \u0159\u00e1dn\u00e1 pleurod\u00e9za. Lze j\u00ed dos\u00e1hnout chemicky, mechanicky (abraze kart\u00e1\u010dkem, speci\u00e1ln\u00ed kuli\u010dkou, smotkem polypropylenov\u00e9 s\u00ed\u0165ky) nebo proveden\u00edm pleurektomie (obr. 9).<\/p>\n<p style=\"text-align: justify;\">Za p\u0159im\u011b\u0159en\u00fd kompromis mezi n\u00e1ro\u010dnost\u00ed operace, krv\u00e1cen\u00edm a spolehlivost\u00ed procedury se pova\u017euje apik\u00e1ln\u00ed pleurektomie do v\u00fd\u0161e 3. nebo 4. mezi\u017eeb\u0159\u00ed a pleuroabraze zbyl\u00e9 kost\u00e1ln\u00ed a diafragmatick\u00e9 pleury (obr. 10). Chemick\u00e1 pleurod\u00e9za (talk\u00e1\u017e) se pou\u017e\u00edv\u00e1 jen v p\u0159\u00edpad\u011b sekund\u00e1rn\u00edch pneumotorax\u016f zp\u016fsoben\u00fdch generalizovanou malignitou nebo p\u0159i selh\u00e1n\u00ed v\u00fd\u0161e uveden\u00e9ho postupu.<\/p>\n<h4>8.3.5 Anatomick\u00e9 plicn\u00ed resekce<\/h4>\n<p style=\"text-align: justify;\">Tyto operace prov\u00e1d\u00edme videoasistovan\u011b se zalo\u017een\u00edm pomocn\u00e9 minitorakotomie ulo\u017een\u00e9 nad pr\u016fb\u011bhem interlobia. Minitorakotomie dovoluje pou\u017eit\u00ed klasick\u00fdch n\u00e1stroj\u016f, usnad\u0148uje zvl\u00e1d\u00e1n\u00ed opera\u010dn\u00edch komplikac\u00ed (krv\u00e1cen\u00ed), z\u00e1v\u011brem operace pak slou\u017e\u00ed k extrakci prepar\u00e1tu (v ochrann\u00e9m obalu). Jsou popisov\u00e1ny kompletn\u011b torakoskopicky proveden\u00e9 lobektomie s odstran\u011bn\u00edm prepar\u00e1tu axil\u00e1rn\u00ed nebo subkost\u00e1ln\u00ed inciz\u00ed p\u0159es br\u00e1nici, benefit takov\u00fdch modifikac\u00ed je sporn\u00fd.<\/p>\n<p style=\"text-align: justify;\">Pro preparaci hilov\u00fdch struktur se nab\u00edz\u00ed klasick\u00e9 instrumentarium \u2013 pravo\u00fahl\u00fd disektor, pinzeta, koagulace s del\u0161\u00edm n\u00e1stavcem. Absence digit\u00e1ln\u00edho vjemu je nahrazena zv\u011bt\u0161en\u00fdm obrazem a mo\u017enost\u00ed pohledu z libovoln\u00e9ho \u00fahlu 30\u00b0 optikou. K preparaci interlobia lze pou\u017e\u00edt ostr\u00fd postup, koagulaci nebo harmonick\u00fd skalpel. Aplikace stapleru u nekompletn\u011b vytvo\u0159en\u00e9ho interlobia je obvykl\u00e1 a bezpe\u010dn\u00e1 a\u017e po identifikaci c\u00e9v a pr\u016fdu\u0161ky. C\u00e9vy se o\u0161et\u0159uj\u00ed c\u00e9vn\u00edmi endostaplery. P\u0159ed nalo\u017een\u00edm stapleru je nezbytn\u00e9 vypreparovat dostate\u010dn\u00fd \u00fasek c\u00e9vy. V\u00fdhodn\u00e9 je vyv\u011b\u0161en\u00ed c\u00e9vy nebo zaji\u0161t\u011bn\u00ed c\u00e9vy centr\u00e1ln\u011b svorkou (nen\u00ed nutn\u00e9 v interlobiu, extrapulmon\u00e1ln\u011b je mo\u017en\u00e9 i p\u0159es perikard v z\u00e1jmu dosa\u017een\u00ed kr\u00e1tk\u00e9ho pah\u00fdlu). K o\u0161et\u0159en\u00ed slab\u0161\u00ed pr\u016fdu\u0161ky lze pou\u017e\u00edt endostapler. V p\u0159\u00edpad\u011b hlavn\u00edho bronchu nebo siln\u011bj\u0161\u00ed tk\u00e1n\u011b bronchu je nezbytn\u00e9 pou\u017e\u00edt stapler s dostate\u010dnou d\u00e9lkou svorek. Rizikovou suturu lze p\u0159e\u0161\u00edt pokra\u010duj\u00edc\u00edm stehem, kontrola t\u011bsnosti je nutn\u00e1. Po uvoln\u011bn\u00ed pl\u00edce (prot\u011bt\u00ed lig. pulmonale, dokon\u010den\u00ed preparace interlobia) n\u00e1sleduje odstran\u011bn\u00ed resekovan\u00e9 pl\u00edce minitorakotomi\u00ed v plastikov\u00e9m steriln\u00edm s\u00e1\u010dku. Pro VATS mediastin\u00e1ln\u00ed lymfadenektomii plat\u00ed stejn\u00e9 z\u00e1sady jako p\u0159i klasick\u00e9m p\u0159\u00edstupu. Po odstran\u011bn\u00ed pl\u00edce se mediastinum, event. plicn\u00ed hilus a oblast ,,samp\u201c uzlin zp\u0159\u00edstupn\u00ed optice i n\u00e1stroj\u016fm. Dren\u00e1\u017e hrudn\u00edku (2 dr\u00e9ny \u2013 apik\u00e1ln\u011b a baz\u00e1ln\u011b po lobektomii, respektive jeden po pneumonektomii) je zakl\u00e1d\u00e1na cestou inciz\u00ed pro porty. Suturou minitorakotomie kon\u010d\u00ed v\u00fdkon. Aproxim\u00e1tor ani perikost\u00e1ln\u00ed stehy se nepou\u017e\u00edvaj\u00ed.<\/p>\n<h6>VATS pneumonektomie<\/h6>\n<p style=\"text-align: justify;\">Po\u0159ad\u00ed krok\u016f u pneumonektomi\u00ed se li\u0161\u00ed oproti otev\u0159en\u00e9mu postupu. Jako prvn\u00ed struktura plicn\u00edho hilu mus\u00ed b\u00fdt o\u0161et\u0159ena horn\u00ed plicn\u00ed \u017e\u00edla. To usnadn\u00ed p\u0159\u00edstup, preparaci a bezpe\u010dn\u00e9 o\u0161et\u0159en\u00ed plicnice. Posledn\u00edc\u00e9vn\u00ed strukturou o\u0161et\u0159enou p\u0159i VATS pneumonektomii je doln\u00ed plicn\u00ed \u017e\u00edla. Po uvoln\u011bn\u00ed pl\u00edce a doln\u00edho kompartmentu mediastin\u00e1ln\u00edch uzlin (uzliny pozice 7\u20139) od mediastina je nakonec o\u0161et\u0159ena hlavn\u00ed pr\u016fdu\u0161ka. N\u00e1sleduje sampling uzlin skupin 2\u20136.Indikace videoasistovan\u00e9 pneumonektomie by m\u011bly b\u00fdt naprosto raritn\u00ed, v\u017edy by m\u011bla b\u00fdt relevantn\u00ed explorac\u00ed vylou\u010dena mo\u017enost men\u0161\u00ed resekce (bronchoplastick\u00fd nebo angioplastick\u00fd parenchym \u0161et\u0159\u00edc\u00ed v\u00fdkon).<\/p>\n<h6>VATS lobektomie<\/h6>\n<p style=\"text-align: justify;\">Popis jednotliv\u00fdch lobektomi\u00ed mus\u00ed b\u00fdt dopln\u011bn vzhledem k obt\u00ed\u017en\u011bj\u0161\u00ed orientaci v opera\u010dn\u00edm polio stru\u010dn\u00fd n\u00e1stin man\u00e9vr\u016f slou\u017e\u00edc\u00edch k identifikaci d\u016fle\u017eit\u00fdch struktur a k jejich bezpe\u010dn\u00e9mu o\u0161et\u0159en\u00ed v nej\u010dast\u011bji u\u017e\u00edvan\u00e9m po\u0159ad\u00ed krok\u016f.<\/p>\n<ul>\n<li style=\"text-align: justify;\"><strong>Horn\u00ed lobektomie vpravo<\/strong><br \/>\nHorn\u00ed lobektomie za\u010d\u00edn\u00e1 p\u0159eru\u0161en\u00edm v\u011btv\u00ed horn\u00ed plicn\u00ed \u017e\u00edly pro horn\u00ed lalok. Tak je zjedn\u00e1n p\u0159\u00edstupk apikoanteriorn\u00edmu kmenu prav\u00e9 plicnice. Jeho o\u0161et\u0159en\u00ed nebo o\u0161et\u0159en\u00ed jednotliv\u00fdch segment\u00e1ln\u00edch tepen pro apik\u00e1ln\u00ed a p\u0159edn\u00ed segment je dal\u0161\u00edm krokem resekce. N\u00e1sleduje preparace hlavn\u00edho interlobia nad plicn\u00ed tepnou a izolace odstupu tepny pro zadn\u00ed segment horn\u00edho laloku, jej\u00ed p\u0159eru\u0161en\u00ed je mo\u017en\u00e9 a\u017e po bezpe\u010dn\u00e9m ov\u011b\u0159en\u00ed topografie tepenn\u00e9ho z\u00e1soben\u00ed st\u0159edn\u00edho a doln\u00edho laloku. Rozd\u011blen\u00ed zadn\u00ed \u010d\u00e1sti interlobia se prov\u00e1d\u00ed tupou preparac\u00ed, elektrokoagulac\u00ed, harmonick\u00fdm skalpelem nebo line\u00e1rn\u00edm staplerem v linii mezi zadn\u00ed hranou plicn\u00ed tepny mezi odstupy 2. a 6. segment\u00e1ln\u00ed arterie a zadn\u00ed \u010d\u00e1st\u00ed plicn\u00edho hilu ve v\u00fd\u0161i doln\u00ed hrany horn\u00ed lob\u00e1rn\u00ed pr\u016fdu\u0161ky. Preparace a identifikace avaskul\u00e1rn\u00ed z\u00f3ny interlobia mezi horn\u00edm a st\u0159edn\u00edm lalokem b\u00fdv\u00e1 v\u011bt\u0161inou obt\u00ed\u017en\u011bj\u0161\u00ed, d\u011bje se v linii mezi p\u0159edn\u00ed hranou plicnice nad odstupem tepen pro st\u0159edn\u00ed lalok a soutokem \u017eil horn\u00edho a st\u0159edn\u00edho laloku. Pou\u017eit\u00ed endostapleru zde m\u00e1 pln\u00e9 opr\u00e1vn\u011bn\u00ed, pokud je ov\u011b\u0159eno, \u017ee \u017e\u00edly st\u0159edn\u00edho laloku, segment\u00e1ln\u00ed tepny st\u0159edn\u00edho laloku a st\u0159edn\u00ed lob\u00e1rn\u00ed bronchus z\u016fstanou mimo bran\u017ee n\u00e1stroje. Horn\u00ed lob\u00e1rn\u00ed bronchus uvoln\u011bn\u00fd tupou preparac\u00ed pak m\u016f\u017ee b\u00fdt uzav\u0159en a p\u0159eru\u0161en endostaplerem. Po extrakci laloku v plastikov\u00e9m vaku se je\u0161t\u011b provede lymfadenektomie uzlin plicn\u00edho hilu a mediastina, p\u0159eru\u0161\u00ed se doln\u00ed plicn\u00ed ligamentum a st\u0159edn\u00ed lalok se fixuje stehem k doln\u00edmu pro prevenci torze. N\u00e1sleduje zaveden\u00ed hrudn\u00edch dren\u016f do kupuly pleur\u00e1ln\u00ed a nad br\u00e1nici cestou pracovn\u00edch port\u016f.<\/li>\n<li style=\"text-align: justify;\"><strong>St\u0159edn\u00ed lobektomie<\/strong><br \/>\nPrvn\u00edm krokem je preparace p\u0159edn\u00ed \u010d\u00e1sti hlavn\u00edho interlobia a\u017e po plicn\u00ed tepnu a identifikace jednotliv\u00fdch odstup\u016f tepny v interlobiu. N\u00e1sleduje p\u0159eru\u0161en\u00ed segment\u00e1ln\u00edch tepen st\u0159edn\u00edho laloku. V\u00fdkon pokra\u010duje identifikac\u00ed a p\u0159eru\u0161en\u00edm \u017eil st\u0159edn\u00edho laloku a transsekc\u00ed vedlej\u0161\u00edho interlobia v linii mezi soutokem \u017eil horn\u00edho a st\u0159edn\u00edho laloku a p\u0159edn\u00ed hranou plicn\u00ed tepny v hlavn\u00edm interlobiu ve v\u00fd\u0161i pah\u00fdl\u016f o\u0161et\u0159en\u00fdch arteri\u00ed st\u0159edn\u00edho laloku. Tup\u00e1 preparace st\u0159edn\u00edho bronchu dovoluje jeho o\u0161et\u0159en\u00ed endostaplerem. N\u00e1sleduje extrakce resek\u00e1tu, odstran\u011bn\u00ed uzlin interlobia, prot\u011bt\u00ed pulmon\u00e1ln\u00edholigamenta, dokon\u010den\u00ed lymfadenektomie a typick\u00e1dren\u00e1\u017e.<\/li>\n<li style=\"text-align: justify;\"><strong>Doln\u00ed lobektomie vpravo i vlevo<\/strong><br \/>\nPrvn\u00ed krok spo\u010d\u00edv\u00e1 v identifikaci plicn\u00ed tepny v hlavn\u00edm interlobiu, jej\u00edm vyv\u011b\u0161en\u00ed a p\u0159eru\u0161en\u00ed.Po prot\u011bt\u00ed lig. pulmonale se endostaplerem pro\u0161ije a p\u0159eru\u0161\u00ed doln\u00ed plicn\u00ed \u017e\u00edla. Pr\u016fdu\u0161ka se o\u0161et\u0159\u00ed endostaplerem v interlobiu pod odstupem st\u0159edn\u00edho bronchu, resp. pod odstupem horn\u00edho bronchu vlevo. Po extrakci prepar\u00e1tu n\u00e1sleduje lymfadenektomie. Zaveden\u00ed 2 hrudn\u00edch dren\u016f v typick\u00e9 lokalizaci kon\u010d\u00ed v\u00fdkon.<\/li>\n<li style=\"text-align: justify;\"><strong>Horn\u00ed lobektomie vlevo<\/strong><br \/>\nTuto operaci lze za\u010d\u00edt preparac\u00ed plicn\u00ed tepny v interlobiu a p\u0159eru\u0161en\u00edm lingul\u00e1rn\u00edch tepen nebo tepen pro zadn\u00ed segment horn\u00edho laloku. Z p\u0159edn\u00edho p\u0159\u00edstupu se p\u0159eru\u0161\u00ed horn\u00ed plicn\u00ed \u017e\u00edla. O\u0161et\u0159en\u00ed apik\u00e1ln\u00edch a p\u0159edn\u00edch segment\u00e1ln\u00edch tepen pak m\u016f\u017ee b\u00fdt snaz\u0161\u00ed zep\u0159edu, pokud tomu tak nen\u00ed, je nutn\u00e9 jejich o\u0161et\u0159en\u00ed zezadu pr\u016fdu\u0161ky cestou interlobia po event. p\u0159eru\u0161en\u00ed tepen zadn\u00edho segmentu horn\u00edho laloku. Po transsekci p\u0159edn\u00ed i zadn\u00ed \u010d\u00e1sti interlobia n\u00e1sleduje preparace horn\u00ed lob\u00e1rn\u00ed pr\u016fdu\u0161ky a jej\u00ed uz\u00e1v\u011br a p\u0159eru\u0161en\u00ed po odta\u017een\u00ed plicn\u00ed tepny.<br \/>\nResek\u00e1t je extrahov\u00e1n op\u011bt v plastikov\u00e9m vaku. N\u00e1sleduje prot\u011bt\u00ed lig. pulmonale, lymfadenektomie a zalo\u017een\u00ed dr\u00e9n\u016f.<\/li>\n<\/ul>\n<h3>8.4 Literatura<\/h3>\n<ol>\n<li style=\"text-align: justify;\">Becker HD, Hohenberger W, Junginger T, Schlag PM, editors. Chirurgick\u00e1 onkologie. Praha: Grada Publishing; 2005.<\/li>\n<li style=\"text-align: justify;\">Cahan WG, Watson WL, Pool JL. Radical pneumonectomy. J Thorac Surg. 1951;22:476\u2013483.<\/li>\n<li style=\"text-align: justify;\">Fanta J, Votruba J, Neuwirth J. Chirurgick\u00e1 l\u00e9\u010dba emfyz\u00e9mu plic. Praha: Grada Publishing; 2004.<\/li>\n<li style=\"text-align: justify;\">Ginsberg RA. Atlas of clinical oncology. Lung cancer. Hamilton: BC Decker Inc; 2002.<\/li>\n<li style=\"text-align: justify;\">Grunenwald DH. Surgery for advanced stage lung cancer. Semin Surg Oncol. 2000;18:137\u2013142.<\/li>\n<li style=\"text-align: justify;\">Klein J. Chirurgie karcinomu plic. Praha: GradaPublishing; 2006.<\/li>\n<li style=\"text-align: justify;\">Kolek V, Va\u0161\u00e1k V. Pneumologie. Praha: Maxdorf;2010.<\/li>\n<li style=\"text-align: justify;\">Mathisen DJ, Grillo HC. Carinal resection forbronchogenic carcinoma. J Thorac Cardo VascSurg. 1991;102:16\u201323.<\/li>\n<li style=\"text-align: justify;\">Nakahara H, Ohno K, Matsumura A. Extendedoperation for lung cancer invading the aortic archand superior vena cava. J Thorac Cardiovasc Surg.1989;97:428\u2013433.<\/li>\n<li style=\"text-align: justify;\">Pafko P, Haru\u0161iak S, et al. Praktick\u00e1 chirurgie tra-chey. 1 vyd\u00e1n\u00ed. Praha: Gal\u00e9n; 2001.<\/li>\n<li style=\"text-align: justify;\">Pafko P, Lischke R, et al. Plicn\u00ed chirurgie. Opera\u010d-n\u00ed manu\u00e1l. 1. vyd\u00e1n\u00ed. Praha: Gal\u00e9n; 2010.<\/li>\n<li style=\"text-align: justify;\">Pearson GF, Cooper JD, Deslauriers J, Ginsberg RJ, Hiebert CA, Patterson GA, Urschel HC. Thoracic surgery. New York: Churchil Livingstone; 2002,<\/li>\n<li style=\"text-align: justify;\">Pitz CC, Brutel de la Riviere A, van Swieten HA, Westermann CJJ, Lammers JWJ, Bosch JMM. Results of surgical treatment of T4 non-small cell lung cancer. Europ J Cardio Thorac Surg. 2003;24:1013\u20131018.<\/li>\n<li style=\"text-align: justify;\">Pichlmaier H, Schildberg FW. Thoraxchirurgie.Heidelberg: Springer; 2006.<\/li>\n<li style=\"text-align: justify;\">Price-Thomas C. Conservative resection of thebronchial tree. J R Coll Sulg Edinb. 1956;1:169\u2013173.<\/li>\n<li style=\"text-align: justify;\">Proch\u00e1zka J. Resekce plic. Praha. SZN; 1954.<\/li>\n<li style=\"text-align: justify;\">Rendina EA, Venuta F, De Giacomo T, CicconeAM, Ruvolo G, Coloni GF, Ricci C. Inductionchemotherapy for T4 centrally located non-smalllung cancer. J Thorac Cardiovasc Surg. 1999;117:225\u2013229.<\/li>\n<li style=\"text-align: justify;\">\u0158eh\u00e1k F, \u0160mat V Chirurgie plic a mediastina. Pra-ha: Avicenum; 1986.<\/li>\n<li style=\"text-align: justify;\">Sch\u00fctzner J, Smat V, et al. Myasthaemia gravis.1. vyd\u00e1n\u00ed. Praha: Gal\u00e9n; 2005.<\/li>\n<li style=\"text-align: justify;\">Stolz A, Pafko P. Komplikace v hrudn\u00ed chirurgii.1. vyd\u00e1n\u00ed. Praha: Grada Publishing; 2010.<\/li>\n<li style=\"text-align: justify;\">Tsuchiya R, Asamura H, Kondo H. Extended re-section of the left atrium, reat vessels, or both forlung cancer. Ann Thorac Surg. 1994;57:960\u2013965.<\/li>\n<li style=\"text-align: justify;\">Vomela J. Mediastinitis acuta, diagnostika a te-rapie. 1. vyd\u00e1n\u00ed. Brno: Acta facultatis MedicaeUmiversitatis Brunensis Masarykianae (Sborn\u00edkprac\u00ed l\u00e9ka\u0159sk\u00e9 fakulty \u010d. 116 Masarykovy Univer-sity Brno); 2000.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>8.1 Miniinvazivn\u00ed postupy v hrudn\u00ed chirurgii Miniinvazivn\u00ed chirurgick\u00e9 postupy prod\u011blaly na konci minul\u00e9ho stolet\u00ed explozivn\u00ed v\u00fdvoj. Prvotn\u00ed nad\u0161en\u00ed z nov\u00e9 technologie bylo posl\u00e9ze vyst\u0159\u00edd\u00e1no opr\u00e1vn\u011bnou skeps\u00ed danou p\u0159irozen\u00fdmi limity tohoto typu intervence. Tento evolu\u010dn\u00ed proces neminul ani torakochirurgii. Zpo\u010d\u00e1tku se zd\u00e1lo, \u017ee miniinvazivn\u00ed ekvilibristika dok\u00e1\u017ee nahradit klasickou otev\u0159enou chirurgii ve v\u011bt\u0161in\u011b indikac\u00ed. Postupn\u011b se v\u0161ak [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1347,"menu_order":40,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-1623","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1623","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1623"}],"version-history":[{"count":9,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1623\/revisions"}],"predecessor-version":[{"id":1854,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1623\/revisions\/1854"}],"up":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1347"}],"wp:attachment":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1623"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}