{"id":2516,"date":"2013-05-21T09:44:30","date_gmt":"2013-05-21T09:44:30","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=2516"},"modified":"2013-06-11T16:11:30","modified_gmt":"2013-06-11T16:11:30","slug":"2-diagnostika-a-lecba-onemocneni-zlucniku-2","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=2516","title":{"rendered":"2 Diagnostika a l\u00e9\u010dba onemocn\u011bn\u00ed \u017elu\u010dn\u00edku"},"content":{"rendered":"<h4>2.1 \u00davod<\/h4>\n<p style=\"text-align: justify;\">Cholecystektomie pat\u0159\u00ed k nej\u010dast\u011bj\u0161\u00edm operac\u00edm na chirurgick\u00fdch pracovi\u0161t\u00edch. Po\u010d\u00edt\u00e1 se k v\u00fdkon\u016fm st\u0159edn\u011b obt\u00ed\u017en\u00fdm a od roku 1892, kdy ji Langenbuch provedl poprv\u00e9, se na technice prakticky nic nezm\u011bnilo. Po 100 letech v roce 1987 prof. Mouret v Lyonu ve Francii zah\u00e1jil laparoskopickou cholecystektomi\u00ed revoluci v technice operov\u00e1n\u00ed. Pr\u00e1v\u011b cholecystektomie se uk\u00e1zala jako nejvhodn\u011bj\u0161\u00ed operace k prosazen\u00ed laparoskopick\u00e9 metody.<\/p>\n<p style=\"text-align: justify;\">Dnes v\u0161eobecn\u011b uzn\u00e1van\u00e9 v\u00fdhody laparoskopick\u00e9 operace \u2013 m\u00e9n\u011b bolesti po operaci, rychlej\u0161\u00ed rekonvalescence, krat\u0161\u00ed hospitalizace, lep\u0161\u00ed kosmetick\u00fd efekt \u2013 p\u0159iv\u00e1d\u011bly z po\u010d\u00e1tku pacienty na ta pracovi\u0161t\u011b, kter\u00e1 s touto metodou za\u010dala. Prudk\u00fd \u00fabytek cholecystektomi\u00ed na chirurgi\u00edch, kde nem\u011bli laparoskopickou aparaturu, pak p\u0159esv\u011bd\u010dil v\u0161echny chirurgy, \u017ee bez laparoskopick\u00e9ho operov\u00e1n\u00ed se nelze obej\u00edt.Prvn\u00ed laparoskopick\u00e1 operace v \u010desk\u00fdch zem\u00edch, laparoskopick\u00e1 cholecystektomie, byla provedena \u010desk\u00fdmi chirurgy dne 20. z\u00e1\u0159\u00ed 1991 v \u010cesk\u00fdch Bud\u011bjovic\u00edch.<\/p>\n<h4>2.2 Klinick\u00fd obraz a diagnostika choleliti\u00e1zy<\/h4>\n<p style=\"text-align: justify;\">Cholecystoliti\u00e1za m\u00e1 v podstat\u011b dv\u011b p\u0159\u00edznakov\u00e9 formy:\u00a01. forma dyspeptick\u00e1,2. forma kolikov\u00e1.<\/p>\n<ol>\n<li style=\"text-align: justify;\">Forma dyspeptick\u00e1 \u2013 je prov\u00e1zena souborem nespecifick\u00fdch p\u0159\u00edznak\u016f \u2013 nep\u0159\u00edjemn\u00fd a bolestiv\u00fd tlak v nadb\u0159i\u0161ku, sp\u00ed\u0161e v prav\u00e9m pod\u017eeb\u0159\u00ed. D\u00e1le nauzea, zvracen\u00ed, nad\u00fdm\u00e1n\u00ed,\u2026 Klinicky se projevuje bolestivost\u00ed v prav\u00e9m pod\u017eeb\u0159\u00ed p\u0159i palpaci. Typick\u00fd je p\u0159\u00edznak Murphyho \u2013 bolestiv\u00e1 reakce pacientap\u0159i palpaci pod prav\u00fdm obloukem \u017eebern\u00edm p\u0159i sou\u010dasn\u00e9m nadechnut\u00ed.<\/li>\n<li style=\"text-align: justify;\">Forma kolikov\u00e1 \u2013 \u017elu\u010dov\u00e9 koliky. Kolikovit\u00e9 bolesti mohou b\u00fdt vyprovokov\u00e1ny j\u00eddlem, stresem, p\u0159ev\u00e1\u017en\u011b je p\u0159\u00ed\u010dinou uz\u00e1v\u011br cystiku kamenem. Projevuj\u00ed se k\u0159e\u010dovit\u00fdmi bolestmi v prav\u00e9m pod\u017eeb\u0159\u00ed \u010dasto vyst\u0159eluj\u00edc\u00ed do prav\u00e9ho ramenn\u00edho kloubu.<\/li>\n<\/ol>\n<p style=\"text-align: justify;\">Ob\u011b tyto formy choleliti\u00e1zy se mohou komplikovat a m\u011bnit klinick\u00fd obraz. Jednou z komplikac\u00ed je z\u00e1n\u011bt, od prost\u00e9 cholecystitidy po empy\u00e9m \u017elu\u010dn\u00edku, pericholecystick\u00fd infiltr\u00e1t, a dokonce perforaci \u017elu\u010dn\u00edku s bili\u00e1rn\u00ed peritonitidou. Dal\u0161\u00ed komplikac\u00ed m\u016f\u017ee b\u00fdt ikterus \u2013 konkrement v choledochu nebo \u00fatlak \u017elu\u010dov\u00fdch cest nap\u0159\u00edklad z\u00e1n\u011btliv\u00fdm infiltr\u00e1tem. Z\u00e1n\u011bt m\u016f\u017ee pokra\u010dovat na \u017elu\u010dov\u00e9 cesty s typickou cholangoitidou \u2013 vysok\u00e9 teploty, t\u0159esavky.<\/p>\n<p style=\"text-align: justify;\">Diagnostika cholecystoliti\u00e1zy mus\u00ed b\u00fdt ze strany l\u00e9ka\u0159e velmi aktivn\u00ed. Z\u00e1kladn\u00ed diagnostickou metodou je sonografick\u00e9 vy\u0161et\u0159en\u00ed dutiny b\u0159i\u0161n\u00ed, prost\u00fd rtg sn\u00edmek b\u0159icha a komplexn\u00ed laboratorn\u00ed vy\u0161et\u0159en\u00ed. <b>V\u0161echny tyto metody prov\u00e1d\u00edme v\u017edy u ka\u017ed\u00e9 n\u00e1hl\u00e9 p\u0159\u00edhody b\u0159i\u0161n\u00ed.<\/b><\/p>\n<p style=\"text-align: justify;\">D\u016fvod je prost\u00fd \u2013 jedna t\u0159etina pacient\u016f m\u00e1 cholecystoliti\u00e1zu, ale to je\u0161t\u011b neznamen\u00e1, \u017ee cholecystoliti\u00e1za je p\u0159\u00ed\u010dinou pot\u00ed\u017e\u00ed pacienta. Podrobn\u011bj\u0161\u00ed rozbor diagnostick\u00fdch metod viz kapitola Indikace.<\/p>\n<h4>2.3 Indikace a kontraindikace operace<\/h4>\n<p style=\"text-align: justify;\">K laparoskopick\u00e9 cholec ystektomii indikujeme symptomatickou cholecystoliti\u00e1zu na podklad\u011b laboratorn\u00edho vy\u0161et\u0159en\u00ed a sonografick\u00e9ho vy\u0161et\u0159en\u00ed \u017elu\u010dn\u00edku a \u017elu\u010dov\u00fdch cest. Indikace se prakticky neli\u0161\u00ed od indikace k otev\u0159en\u00e9 cholecystektomii. U sonografick\u00e9ho vy\u0161et\u0159en\u00ed vy\u017eadujeme popis \u0161\u00ed\u0159e st\u011bny \u017elu\u010dn\u00edku, obsahu \u017elu\u010dn\u00edku, jeho velikost a d\u00e1le \u0161\u00ed\u0159i choledochu. Tam, kde je \u0161\u00ed\u0159e choledochu v\u011bt\u0161\u00ed ne\u017e 8 mm, je n\u00e1lez suspektn\u00ed z choledocholiti\u00e1zy a indikujeme endoskopickou retrogr\u00e1dn\u00ed cholangiopan\u00a0kreatografii (ERCP) s eventu\u00e1ln\u00ed extrakc\u00ed konkrement\u016f.<\/p>\n<p style=\"text-align: justify;\">O \u00faloze ERCP v l\u00e9\u010db\u011b choledocholiti\u00e1zy se zm\u00edn\u00edme je\u0161t\u011b d\u00e1le. Dnes m\u016f\u017eeme \u0159\u00edci, \u017ee 95% pacient\u016f se symptomatickou cholecystoliti\u00e1zou m\u016f\u017ee b\u00fdt indikov\u00e1no k laparoskopick\u00e9 cholecystektomii. P\u016fvodn\u011b stanoven\u00e1 krit\u00e9ria relativn\u00edch kontraindikac\u00ed \u2013 svra\u0161t\u011bl\u00fd \u017elu\u010dn\u00edk, obezita, siln\u011bj\u0161\u00ed st\u011bna \u017elu\u010dn\u00edku ne\u017e 7 mm, sr\u016fsty po p\u0159edchoz\u00edch operac\u00edch v nadb\u0159i\u0161ku \u2013 dnes ji\u017e v\u0161eobecn\u011b neplat\u00ed.<\/p>\n<p style=\"text-align: justify;\">Z\u00e1le\u017e\u00ed na technick\u00e9m vybaven\u00ed pracovi\u0161t\u011b, na vysp\u011blosti operat\u00e9ra, co pova\u017euje je\u0161t\u011b za indikaci a co za kontraindikaci k laparoskopick\u00e9 cholecystektomii.<\/p>\n<p style=\"text-align: justify;\">Laparoskopick\u00e1 cholecystektomie se prov\u00e1d\u00ed i v t\u011bhotenstv\u00ed. Laparoskopickou cholecystektomii mohou podstoupit pacienti s akutn\u00ed cholecystitidou a enormn\u011b ob\u00e9zn\u00ed. Cholecystoenter\u00e1ln\u00ed p\u00ed\u0161t\u011bl m\u016f\u017ee b\u00fdt rovn\u011b\u017e vy\u0159e\u0161ena laparoskopicky p\u0159i znalosti pr\u00e1ce s endostaplery a endostehem.<\/p>\n<p style=\"text-align: justify;\">Absolutn\u00ed kontraindikace k laparoskopick\u00e9 cholecystektomii prakticky nen\u00ed, v\u017edy je t\u0159eba pacienta posuzovat individu\u00e1ln\u011b ve spolupr\u00e1ci s anesteziologem.<\/p>\n<h4>2.4 Laparoskopick\u00e1 cholecystektomie<\/h4>\n<h5>2.4.1 Technika operace<\/h5>\n<h6>Ulo\u017een\u00ed pacienta<\/h6>\n<p>V z\u00e1sad\u011b existuj\u00ed dva zp\u016fsoby operace:<\/p>\n<ul>\n<li style=\"text-align: justify;\">Zp\u016fsob \u201eamerick\u00fd\u201c, kdy pacient le\u017e\u00ed na z\u00e1dech,\u00a0operat\u00e9r stoj\u00ed vlevo od pacienta, \u201e asistent-kameraman\u201c po jeho lev\u00e9 ruce a dal\u0161\u00ed asistence naproti operat\u00e9ra. Instrument\u00e1\u0159ka stoj\u00ed vpravo od doln\u00edch kon\u010detin operovan\u00e9ho, dva monitor y jsou pak po stran\u00e1ch hlavy pacienta. Tato metoda umo\u017e\u0148uje operat\u00e9rovi pracovat jen s jedn\u00edm n\u00e1strojem, co\u017e je v\u00fdhodn\u00e9 pro obdob\u00ed, kdy chirurg s laparoskopick\u00fdmi operacemi za\u010d\u00edn\u00e1. Asistence pak p\u0159idr\u017euje \u017elu\u010dn\u00edk za fundus a infundibulum \u017elu\u010dn\u00edku. I u tohoto zp\u016fsobu v\u0161ak operat\u00e9r m\u016f\u017ee pracovat obouru\u010d, co\u017e umo\u017e\u0148uje mnohem jemn\u011bj\u0161\u00ed techniku operov\u00e1n\u00ed (obr. 1a).<\/li>\n<li style=\"text-align: justify;\">Zp\u016fsob \u201efrancouzsk\u00fd\u201c, kdy pacient le\u017e\u00ed na z\u00e1dech s abdukovan\u00fdmi doln\u00edmi kon\u010detinami, operat\u00e9r pak stoj\u00ed mezi nohama pacienta a operuje obouru\u010dnou technikou. Asistence dr\u017e\u00edc\u00ed kameru stoj\u00ed na lev\u00e9 stran\u011b opera\u010dn\u00edho stolu, asistence dr\u017e\u00edc\u00ed fundus \u017elu\u010dn\u00edku stoj\u00ed na prav\u00e9 stran\u011b opera\u010dn\u00edho stolu (obr. 1b).<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Dnes se jednozna\u010dn\u011b operuje obouru\u010dn\u011b stejn\u011b jako u klasick\u00e9 operace. Asistent je jen jeden, nebo dokonce chirurg operuje s\u00e1m s instrument\u00e1\u0159kou.<\/p>\n<h6>Zaveden\u00ed trokar\u016f<\/h6>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" 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\/05\/Image_093.png\"><img decoding=\"async\" title=\"Obr. 1a \u2013 Z\u00e1kladn\u00ed poloha nemocn\u00e9ho na z\u00e1dech Obr. 1b \u2013 Poloha nemocn\u00e9ho s abdukovan\u00fdmi doln\u00edmi kon\u010detinami\" alt=\"Obr. 1a \u2013 Z\u00e1kladn\u00ed poloha nemocn\u00e9ho na z\u00e1dech Obr. 1b \u2013 Poloha nemocn\u00e9ho s abdukovan\u00fdmi doln\u00edmi kon\u010detinami\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_093.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 1a \u2013 Z\u00e1kladn\u00ed poloha nemocn\u00e9ho na z\u00e1dech<br \/>Obr. 1b \u2013 Poloha nemocn\u00e9ho s abdukovan\u00fdmi doln\u00edmi kon\u010detinami<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" 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\/05\/Image_095.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 13px; line-height: 19px; text-align: justify;\" title=\"Obr. 2 \u2013 Mo\u017enosti um\u00edst\u011bn\u00ed trokar\u016f p\u0159i laparoskopick\u00e9 cholecystektomii\" alt=\"Obr. 2 \u2013 Mo\u017enosti um\u00edst\u011bn\u00ed trokar\u016f p\u0159i laparoskopick\u00e9 cholecystektomii\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_095.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 2 \u2013 Mo\u017enosti um\u00edst\u011bn\u00ed<br \/>trokar\u016f p\u0159i laparoskopick\u00e9 cholecystektomii<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Obvykl\u00e9 um\u00edst\u011bn\u00ed trokar\u016f je uk\u00e1z\u00e1no na obr\u00e1zc\u00edch n\u00ed\u017ee (obr. 2). Zav\u00e1d\u011bn\u00ed trokar\u016f z\u00e1vis\u00ed na zvyklostech pracovi\u0161t\u011b. Nejprve vedeme drobnou ko\u017en\u00ed incizi pod nebo nad pupkem v d\u00e9lce asi 10 mm. Po vyzvednut\u00ed st\u011bny b\u0159i\u0161n\u00ed za ko\u017en\u00ed \u0159asu kolmo zav\u00e1d\u00edme Veressovou jehlu do dutiny b\u0159i\u0161n\u00ed. Po dosa\u017een\u00ed nastaven\u00e9ho nitrob\u0159i\u0161n\u00edho tlaku CO2 na 11\u201312 mm Hb zav\u00e1d\u00edme stejnou inciz\u00ed 10mm trokar pro optiku s videokamerou. Sami u laparoskopick\u00e9 cholecystektomie pou\u017e\u00edv\u00e1me kovov\u00fdch trokar\u016f. Prvn\u00ed trokar zav\u00e1d\u00edme v oblasti pupku \u201enaslepo\u201c \u0161ikmo proti br\u00e1nici a po \u201enap\u00edchnut\u00ed\u201c vyzvedneme trokarem st\u011bnu b\u0159i\u0161n\u00ed a pronik\u00e1me tlakem na trokar d\u00e1le do dutiny b\u0159i\u0161n\u00ed, neproch\u00e1z\u00edme tedy kolmo st\u011bnou b\u0159i\u0161n\u00ed. Na zav\u00e1d\u011bn\u00ed tohoto trokaru se pod\u00edlej\u00ed ob\u011b ruce operat\u00e9ra, prav\u00e1 ruka udr\u017euje\u00a0sm\u011br zav\u00e1d\u011bn\u00ed a slou\u017e\u00ed tak\u00e9 jako \u201ezar\u00e1\u017eka\u201c p\u0159i proniknut\u00ed st\u011bnou. Pokud pou\u017e\u00edv\u00e1me plastick\u00fd trokar s pru\u017en\u00fdm krytem, mus\u00edme proch\u00e1zet st\u011bnou b\u0159i\u0161n\u00ed kolmo. P\u0159i tzv. otev\u0159en\u00e9 technice zaveden\u00ed trokar\u016f postupn\u011b incidujeme v\u0161echny vrstvy st\u011bny b\u0159i\u0161n\u00ed v\u010detn\u011b peritonea a zav\u00e1d\u00edme trokar s tup\u00fdm mandr\u00e9nem. M\u00edsto incize kolem trokaru ut\u011bs\u0148ujeme stehem. Pak p\u0159ipojujeme hadi\u010dku insuflace a zav\u00e1d\u00edme bu\u010f rovnou, nebo \u0161ikmou optiku (preferujeme \u0161ikmou).Po p\u0159ehl\u00e9dnut\u00ed dutiny b\u0159i\u0161n\u00ed za optick\u00e9 kontroly zav\u00e1d\u00edme hlavn\u00ed pracovn\u00ed trokar asi 2cm pod processus xiphoideus (10 mm), v\u017edy vpravo od ligamentum teres hepatis. Dva 5mm trokary pak zav\u00e1d\u00edme v prav\u00e9m pod\u017eeb\u0159\u00ed, jeden t\u011bsn\u011b pod obloukem v p\u0159edn\u00ed axil\u00e1rn\u011b \u010d\u00e1\u0159e, druh\u00fd v \u010d\u00e1\u0159e medioklavikul\u00e1rn\u00ed v \u00farovni poloviny vzd\u00e1lenosti mezi pupkem a \u017eebern\u00edm obloukem. Tyto dva 5mm trokary slou\u017e\u00ed k zaveden\u00ed n\u00e1stroj\u016f, k dr\u017een\u00ed a manipulaci se \u017elu\u010dn\u00edkem. Po zaveden\u00ed trokar\u016f upravujeme polohu nemocn\u00e9ho s opera\u010dn\u00edm stolem do anti-Trendelenburgovy polohy (asi 20 st.) a nakl\u00e1n\u00edme asi 15 st. doleva. Touto polohou kli\u010dky st\u0159evn\u00ed uvoln\u00ed subhepat\u00e1ln\u00ed prostor. <strong>Zaveden\u00ed tro\u00adkar\u016f<\/strong> je v\u017edy individu\u00e1ln\u00ed dle pot\u0159eby \u2013 nen\u00ed nutn\u00e9 dodr\u017eovat v\u00fd\u0161e uveden\u00fd postup.<\/p>\n<p style=\"text-align: justify;\">Kle\u0161t\u011bmi zaveden\u00fdmi trokarem v p\u0159edn\u00ed \u010d\u00e1\u0159e axil\u00e1rn\u00ed dr\u017e\u00edme fundus \u017elu\u010dn\u00edku, kle\u0161t\u011bmi zaveden\u00fdmi trokarem v \u010d\u00e1\u0159e medioklavikul\u00e1rn\u00ed pak dr\u017e\u00edme infundibulum \u017elu\u010dn\u00edku (obr. 3).<\/p>\n<p style=\"text-align: justify;\">Operat\u00e9r dr\u017e\u00ed levou rukou infundibulum a manipuluje s kr\u010dkem \u017elu\u010dn\u00edku tak, jak pot\u0159ebuje. Hlavn\u00edm pracovn\u00edm trokarem pod processus xiphoideus zav\u00e1d\u00edme opera\u010dn\u00ed n\u00e1stroje, opera\u010dn\u00ed kle\u0161t\u011b, n\u016f\u017eky, koagula\u010dn\u00ed h\u00e1\u010dek, eventu\u00e1ln\u011b sac\u00ed a v\u00fdplachovou kanylu, ultrasonografick\u00e9 n\u00e1stroje.<\/p>\n<h6>Uvoln\u011bn\u00ed \u017elu\u010dn\u00edku<\/h6>\n<p style=\"text-align: justify;\">Fundus \u017elu\u010dn\u00edku mobilizujeme sm\u011brem ventr\u00e1ln\u00edm a krani\u00e1ln\u00edm, t\u00edm zp\u0159ehled\u0148ujeme oblast Calotova troj\u00faheln\u00edku. Pokud jsou v oblasti \u017elu\u010dn\u00edku adheze, nej\u010dast\u011bji omenta se st\u011bnou \u017elu\u010dn\u00edku, tyto rozru\u0161ujeme. Je-li st\u011bna \u017elu\u010dn\u00edku napjat\u00e1 a nelze ji uchopit do kle\u0161t\u00ed \u2013 hydrops nebo empy\u00e9m, prov\u00e1d\u00edme punkci \u017elu\u010dn\u00edku. Silnou jehlu zav\u00e1d\u00edme samotn\u00fdm vpichem\u00a0p\u0159es st\u011bnu b\u0159i\u0161n\u00ed pod prav\u00fdm \u017eebern\u00edm obloukem a do lumen \u017elu\u010dn\u00edku pronik\u00e1me v oblasti fundu. Po dokon\u010den\u00ed punkce a odstran\u011bn\u00ed jehly uzav\u00edr\u00e1me punk\u010dn\u00ed otvor bran\u017eemi \u00fachopov\u00fdch kle\u0161t\u00ed.<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff; width: 50%;\" 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\/05\/Image_096.png\"><img decoding=\"async\" title=\"Obr. 3 \u2013 Prot\u011bt\u00ed viscer\u00e1ln\u00edho peritonea Obr. 4a \u2013 Izolace ductus cysticus pomoc\u00ed n\u016f\u017eek\" alt=\"Obr. 3 \u2013 Prot\u011bt\u00ed viscer\u00e1ln\u00edho peritonea Obr. 4a \u2013 Izolace ductus cysticus pomoc\u00ed n\u016f\u017eek\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_096.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 3 \u2013 Prot\u011bt\u00ed viscer\u00e1ln\u00edho peritonea<br \/>Obr. 4a \u2013 Izolace ductus cysticus pomoc\u00ed n\u016f\u017eek<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" 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\/05\/Image_098.png\"><img decoding=\"async\" title=\"Obr. 4b \u2013 Klipov\u00e1n\u00ed ductus cysticus\" alt=\"Obr. 4b \u2013 Klipov\u00e1n\u00ed ductus cysticus\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_098.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 4b \u2013 Klipov\u00e1n\u00ed ductus cysticus<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" 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\/05\/Image_100.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 13px; line-height: 19px; text-align: start;\" title=\"Obr. 5 \u2013 Uvoln\u011bn\u00ed \u017elu\u010dn\u00edku z l\u016f\u017eka po prot\u011bt\u00ed ductus\" alt=\"Obr. 5 \u2013 Uvoln\u011bn\u00ed \u017elu\u010dn\u00edku z l\u016f\u017eka po prot\u011bt\u00ed ductus\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_100.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 5 \u2013 Uvoln\u011bn\u00ed \u017elu\u010dn\u00edku z l\u016f\u017eka po prot\u011bt\u00ed ductus<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" 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\/05\/Image_099.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 13px; line-height: 19px; text-align: start;\" title=\"Obr. 6 \u2013 Dokon\u010den\u00ed izolace \u017elu\u010dn\u00edku z l\u016f\u017eka pomoc\u00ed n\u016f\u017eek\" alt=\"Obr. 6 \u2013 Dokon\u010den\u00ed izolace \u017elu\u010dn\u00edku z l\u016f\u017eka pomoc\u00ed n\u016f\u017eek\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_099.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 6 \u2013 Dokon\u010den\u00ed izolace \u017elu\u010dn\u00edku z l\u016f\u017eka pomoc\u00ed n\u016f\u017eek<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>Preparace v Calotov\u011b troj\u00faheln\u00edku<\/h6>\n<p style=\"text-align: justify;\">Pomoc\u00ed h\u00e1\u010dkov\u00e9 elektrody nebo prepara\u010dn\u00edch n\u016f\u017eek izolujeme ductus cysticus, za\u010d\u00edn\u00e1me v\u017edy u kr\u010dku \u017elu\u010dn\u00edku (obr. 4a).<\/p>\n<p style=\"text-align: justify;\">Pou\u017e\u00edv\u00e1me-li k preparaci h\u00e1\u010dkov\u00e9 elektrody, sna\u017e\u00edme se vyvarovat koagulace pro mo\u017en\u00e9 tepeln\u00e9 poran\u011bn\u00ed spole\u010dn\u00e9ho \u017elu\u010dovodu. Sami jsme u\u017e\u00edvali k t\u00e9to\u00a0preparaci h\u00e1\u010dkov\u00e9 elektrody. Pozd\u011bji jsme p\u0159e\u0161li v t\u00e9to oblasti na preparaci pomoc\u00ed n\u016f\u017eek, nebo\u0165 se n\u00e1m zd\u00e1, \u017ee pr\u00e1ce s nimi je jemn\u011bj\u0161\u00ed a p\u0159esn\u011bj\u0161\u00ed. Dnes se s oblibou pou\u017e\u00edvaj\u00ed sonografick\u00e9 n\u00e1stroje, kter\u00e9 riziko tepeln\u00e9ho poran\u011bn\u00ed sni\u017euj\u00ed na minimum. P\u0159i preparaci v Calotov\u011b troj\u00faheln\u00edku je v\u00fdhodn\u00e9 kle\u0161t\u011bmi dr\u017e\u00edc\u00edmi infundibulum \u017elu\u010dn\u00edku manipulovat touto \u010d\u00e1st\u00ed zleva doprava a naopak, co\u017e n\u00e1m umo\u017en\u00ed lep\u0161\u00ed expozici duktus cysticus.Pomoc\u00ed prepara\u010dn\u00edch n\u016f\u017eek nebo h\u00e1\u010dkov\u00e9 elektrody obch\u00e1z\u00edme duktus cysticus, abychom z\u00edskali dostate\u010dn\u00fd prostor k nalo\u017een\u00ed klip\u016f. Zde je d\u016fle\u017eit\u00e9 vid\u011bt, \u017ee ductus cysticus navazuje na kr\u010dek \u017elu\u010dn\u00edku, aby nedo\u0161lo k z\u00e1m\u011bn\u011b duktus cysticus za duktus choledochus.<\/p>\n<p style=\"text-align: justify;\">Pokud jsou v t\u00e9to oblasti t\u011b\u017ek\u00e9 z\u00e1n\u011btliv\u00e9 zm\u011bny, m\u016f\u017eeme naopak preparovat duktus cysticus centr\u00e1ln\u011b a\u017e k junkci ductus hepaticus, abychom m\u011bli jistotu, \u017ee neizolujeme spole\u010dn\u00fd \u017elu\u010dovod. N\u011bkdy je tato f\u00e1ze operace velmi jednoduch\u00e1, jindy velmi slo\u017eit\u00e1. Ductus cysticus klipujeme dv\u011bma klipy centr\u00e1ln\u011b bl\u00ed\u017ee choledochu a jedn\u00edm klipem perifern\u011b (obr. 4b).Pak jej p\u0159eru\u0161ujeme n\u016f\u017ekami. Kle\u0161t\u011b p\u0159em\u00eds\u0165ujeme z infundibula \u017elu\u010dn\u00edku na volnou p\u0159eru\u0161enou \u010d\u00e1st ductus cysticus a stejn\u00fdm zp\u016fsobem pak preparujeme arteria cystica. Centr\u00e1ln\u011b tepnu uzav\u00edr\u00e1me dv\u011bma klipy a p\u0159eru\u0161ujeme ji. Izolace \u017elu\u010dn\u00edku z l\u016f\u017eka se prov\u00e1d\u00ed h\u00e1\u010dkovou elektrodou nebo prepara\u010dn\u00edmi n\u016f\u017ekami za pe\u010dliv\u00e9ho stav\u011bn\u00ed krv\u00e1cen\u00ed (obr. 5 a 6).<\/p>\n<h6>O\u0161et\u0159en\u00ed l\u016f\u017eka \u017elu\u010dn\u00edku<\/h6>\n<p style=\"text-align: justify;\">Po uvoln\u011bn\u00ed cel\u00e9ho \u017elu\u010dn\u00edku z l\u016f\u017eka jej p\u0159em\u00eds\u0165ujeme nad konvexitu jater, kle\u0161t\u011bmi vyzved\u00e1v\u00e1me jatern\u00ed okraj, l\u016f\u017eko \u017elu\u010dn\u00edku oplachujeme a znovu kontrolujeme, zda nedoch\u00e1z\u00ed ke krv\u00e1cen\u00ed. Krv\u00e1cen\u00ed z drobn\u011bj\u0161\u00edch c\u00e9v stav\u00edme h\u00e1\u010dkovou elektrodou, z v\u011bt\u0161\u00edch c\u00e9v pak koagulac\u00ed po p\u0159edchoz\u00edm zachycen\u00ed do bran\u017e\u00ed disektoru. Jestli\u017ee se jedn\u00e1 o plo\u0161n\u00e9 krv\u00e1cen\u00ed, m\u016f\u017eeme p\u0159ilo\u017eit lok\u00e1ln\u00ed hemostyptika \u2013 Spongostan, Gelaspon, Surgicell. P\u0159i kontrole l\u016f\u017eka mus\u00edme po\u010d\u00edtat i s mo\u017en\u00fdm aberantn\u00edm \u017elu\u010dovodem.<\/p>\n<p style=\"text-align: justify;\">Drobn\u00fd aberantn\u00ed \u017elu\u010dovod m\u016f\u017eeme uzav\u0159\u00edt koagulac\u00ed, v\u011bt\u0161\u00ed pak nalo\u017een\u00edm klip\u016f. Koagula odstra\u0148ujeme jednak pomoc\u00ed sac\u00ed kanyly, pevn\u00e1 koagula je mo\u017en\u00e9 odstranit pomoc\u00ed 10mm extrak\u010dn\u00edch kle\u0161t\u00ed.<\/p>\n<h6>Zaveden\u00ed dr\u00e9nu<\/h6>\n<p style=\"text-align: justify;\">Na na\u0161em pracovi\u0161ti se prov\u00e1d\u00ed rutinn\u011b dren\u00e1\u017e, zav\u00e1d\u00edme dr\u00e9n 5mm trokarem um\u00edst\u011bn\u00fdm v p\u0159edn\u00ed axi\u00e1ln\u00ed \u010d\u00e1\u0159e do subhepat\u00e1ln\u00edho prostoru. Samotn\u00fd trokar pak odstra\u0148ujeme a dr\u00e9n fixujeme stehem.<\/p>\n<h6>Extrakce \u017elu\u010dn\u00edku<\/h6>\n<p style=\"text-align: justify;\">V dal\u0161\u00ed f\u00e1zi operace p\u0159em\u00eds\u0165ujeme laparoskop do trokaru pod processus xiphoideus a do trokaru u pupku zav\u00e1d\u00edme extrak\u010dn\u00ed kle\u0161t\u011b. Jimi zachycujeme igelitov\u00fd s\u00e1\u010dek se \u017elu\u010dn\u00edkem. Podle velikosti \u017elu\u010dn\u00edku pak skalpelem roz\u0161i\u0159ujeme incizi pod pupkem a extrahujeme s\u00e1\u010dek se \u017elu\u010dn\u00edkem sou\u010dasn\u011b i s trokarem z dutiny b\u0159i\u0161n\u00ed. Tuto incizi u pupku uzav\u00edr\u00e1me v\u011bt\u0161inou dv\u011bma stehy nalo\u017een\u00fdmi na fascii. Po odstran\u011bn\u00ed zbyl\u00fdch trokar\u016f je pak provedena sutura podko\u017e\u00ed a k\u016f\u017ee.<\/p>\n<h6>Prepar\u00e1t<\/h6>\n<p style=\"text-align: justify;\">Bezprost\u0159edn\u011b po operaci operat\u00e9r prohl\u00e9dne prepar\u00e1t a rozst\u0159ihne \u017elu\u010dn\u00edk v\u010detn\u011b ductus cysticus. M\u016f\u017ee tak posoudit s\u00edlu st\u011bny \u017elu\u010dn\u00edku, obsah \u017elu\u010dn\u00edku a hlavn\u011b p\u0159i ur\u010dit\u00fdch pochybnostech posoudit oblast ductus cysticus, zda neobsahuje i resekovanou \u010d\u00e1st ductus choledochus. Pokud je vy\u0165ata p\u0159ilehl\u00e1 \u010d\u00e1st choledochu, je to na prepar\u00e1tu v\u017edy vid\u011bt. Je zde je\u0161t\u011b posledn\u00ed p\u0159\u00edle\u017eitost prov\u00e9st \u010dasnou revizi, ani\u017e pacient dosud opustil opera\u010dn\u00ed s\u00e1l.<\/p>\n<h5>2.4.2 Peropera\u010dn\u00ed biligrafie<\/h5>\n<p style=\"text-align: justify;\">Cholechodocholiti\u00e1za se dnes v\u011bt\u0161inou \u0159e\u0161\u00ed endoskopickou cestou. Tam, kde je p\u0159edopera\u010dn\u00ed podez\u0159en\u00ed na obstrukci, prov\u00e1d\u00edme ERCP. Tato je mo\u017en\u00e1 i u prok\u00e1zan\u00fdch alergi\u00ed na kontrastn\u00ed l\u00e1tku, nejde o parenter\u00e1ln\u00ed pod\u00e1n\u00ed kontrastu, je pou\u017eiteln\u00e1 i u vy\u0161\u0161\u00edch hodnot bilirubinu a umo\u017e\u0148uje v jednom sezen\u00ed terapii, tzn. endoskopickou papilosfinkterotomii a extrakci kamen\u016f. Pak ji\u017e n\u00e1sleduje jen laparoskopick\u00e1 cholecystektomie. Vzhledem k n\u00edzk\u00e9 incidenci (3,5%) tzv. n\u011bm\u00e9 choledocholiti\u00e1zy se nedoporu\u010duje prov\u00e1d\u011bt ERCP pau\u0161\u00e1ln\u011b.<\/p>\n<p style=\"text-align: justify;\">P\u0159edopera\u010dn\u00ed biligrafie, jak uv\u00e1d\u011bj\u00ed n\u011bkte\u0159\u00ed auto\u0159i, se v\u0161eobecn\u011b neujala a je obsoletn\u00ed metodou. Peropera\u010dn\u00ed biligrafie napom\u00e1h\u00e1 definov\u00e1n\u00ed anatomick\u00fdch pom\u011br\u016f extrahepat\u00e1ln\u00edho \u0159e\u010di\u0161t\u011b, nap\u0159. p\u0159i podez\u0159en\u00ed na poran\u011bn\u00ed nebo na choledocholiti\u00e1zu, kdy sonografick\u00fd p\u0159edopera\u010dn\u00ed n\u00e1lez neodpov\u00edd\u00e1 opera\u010dn\u00edmu n\u00e1lezu.<\/p>\n<h6>Technika proveden\u00ed peropera\u010dn\u00ed biligrafie<\/h6>\n<p>V podstat\u011b jsou dv\u011b mo\u017enosti n\u00e1pln\u011b \u017elu\u010dov\u00fdch cest:<\/p>\n<ul>\n<li>punk\u010dn\u00ed \u2013 nabodnut\u00edm \u017elu\u010dn\u00edku,<\/li>\n<li>transcystick\u00e1 biligrafie.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Nej\u010dast\u011bji je pou\u017e\u00edv\u00e1na metoda transcystick\u00e1. Po vypreparov\u00e1n\u00ed ductus cysticus v dostate\u010dn\u00e9 d\u00e9lce tento uzav\u0159eme vysoko pod infundibulem klipem. Ductus cysticus nast\u0159ihneme, disektorem dilatujeme lumen, do kter\u00e9ho pak zav\u00e1d\u00edme kat\u00e9tr s kovov\u00fdm vodi\u010dem. Centr\u00e1ln\u00ed \u010d\u00e1st ductus cysticus s kat\u00e9trem pak uzav\u00edr\u00e1me ne\u00fapln\u011b dov\u0159en\u00fdm klipem. Odstran\u00edme kovov\u00fd vodi\u010d a aplikujeme kontrastn\u00ed l\u00e1tku. Pro zav\u00e1d\u011bn\u00ed existuj\u00ed rovn\u011b\u017e speci\u00e1ln\u00ed kle\u0161t\u011b, kde st\u0159edem proch\u00e1z\u00ed kat\u00e9tr. Po zaveden\u00ed kat\u00e9tru do ductus cysticus jej pak bran\u017eemi uzav\u0159eme. Tyto kle\u0161t\u011b tak \u010din\u00ed celou techniku zaveden\u00ed jednodu\u0161\u0161\u00ed.<\/p>\n<p style=\"text-align: justify;\">Peropera\u010dn\u00ed biligrafii prov\u00e1d\u00edme selektivn\u011b.<\/p>\n<h5>2.4.3 Laparoskopick\u00e1 sonografie<\/h5>\n<p style=\"text-align: justify;\">Daleko v\u00edce dnes prov\u00e1d\u00edme peropera\u010dn\u00ed sonografii. Laparoskopick\u00e1 sonografie extrahepat\u00e1ln\u00edch \u017elu\u010dov\u00fdch cest pomoc\u00ed flexibiln\u00edch sond v rukou zku\u0161en\u00e9ho sonografisty m\u00e1 stejn\u00e9 procento \u00fasp\u011b\u0161nosti v odhalov\u00e1n\u00ed choledocholiti\u00e1zy jako peropera\u010dn\u00ed biligrafie. U peropera\u010dn\u011b zji\u0161t\u011bn\u00e9 choledocholiti\u00e1zy nast\u00e1v\u00e1 volba laparoskopick\u00e9 explorace choledochu, konverze s choledochotomi\u00ed nebo n\u00e1sledn\u00e1 endoskopick\u00e1 sfinkterotomie a odstran\u011bn\u00ed kamene z choledochu v \u010dasn\u00e9 poopera\u010dn\u00ed dob\u011b. Volba z\u00e1le\u017e\u00ed na mo\u017enostech pracovi\u0161t\u011b, dostupnosti schopn\u00e9ho endoskopisty s pat\u0159i\u010dn\u00fdm vybaven\u00edm, eventu\u00e1ln\u011b na zku\u0161enostech operat\u00e9ra.<\/p>\n<h5>2.4.4 Poopera\u010dn\u00ed sledov\u00e1n\u00ed<\/h5>\n<p style=\"text-align: justify;\">V\u0161eobecn\u011b rizikov\u00e9 pacienty ukl\u00e1d\u00e1me na odd\u011blen\u00ed JIP. K t\u011bmto po\u010d\u00edt\u00e1me rovn\u011b\u017e pacienty ob\u00e9zn\u00ed. Ostatn\u00ed mohou b\u00fdt ulo\u017eeni na standardn\u00ed jednotku. V den operace kontrolujeme TK, pulz, KO, sekreci z dr\u00e9nu, n\u00e1lez na b\u0159i\u0161e. Pokud pacienti nemaj\u00ed bolesti, analgetika neordinujeme. Antibiotika a\u017e na indikovan\u00e9 p\u0159\u00edpady nepod\u00e1v\u00e1me. Prvn\u00ed poopera\u010dn\u00ed den p\u0159i \u017e\u00e1dn\u00e9 nebo mal\u00e9 sekreci do 20ml odstra\u0148ujeme dr\u00e9n. V\u011bt\u0161inou jsou pacienti ji\u017e bez bolest\u00ed s obnovenou peristaltikou st\u0159evn\u00ed. P\u0159i takto norm\u00e1ln\u00edm pr\u016fb\u011bhu propou\u0161t\u00edme pacienta do ambulantn\u00ed p\u00e9\u010de 2. a\u017e 3. poopera\u010dn\u00ed den. Chirurgick\u00e1 kontrola s vyta\u017een\u00edm steh\u016f se d\u011bje ambulantn\u011b. V p\u0159\u00edpad\u011b ur\u010dit\u00e9ho \u201edyskomfortu\u201c v dutin\u011b b\u0159i\u0161n\u00ed bezprost\u0159edn\u011b v poopera\u010dn\u00edm obdob\u00ed \u2013 p\u0159etrv\u00e1vaj\u00edc\u00ed bolesti, st\u0159evn\u00ed par\u00e9za \u2013 je podez\u0159en\u00ed, \u017ee se v b\u0159i\u0161e \u201en\u011bco d\u011bje\u201c. Je to p\u0159\u00edznak zakrv\u00e1cen\u00ed do dutiny b\u0159i\u0161n\u00ed, rozlit\u00ed \u017elu\u010di nebo po\u010d\u00ednaj\u00edc\u00ed peritonitidy. Dnes prov\u00e1d\u00edme laparoskopickou cholecystektomii i v re\u017eimu jednodenn\u00ed chirurgie.<\/p>\n<h5>2.4.5 Komplikace<\/h5>\n<p>Ke v\u0161em komplikac\u00edm doch\u00e1z\u00ed \u010dast\u011bji v obdob\u00ed za\u0161kolov\u00e1n\u00ed do laparoskopick\u00fdch operac\u00ed. Tyto komplikace m\u016f\u017eeme rozd\u011blit na:<\/p>\n<ul>\n<li>obecn\u00e9,<\/li>\n<li>specifick\u00e9.<\/li>\n<\/ul>\n<h6>Komplikace obecn\u00e9<\/h6>\n<p style=\"text-align: justify;\">K \u201eobecn\u00fdm\u201c pat\u0159\u00ed komplikace vznikl\u00e9 nespr\u00e1vn\u011b zavedenou Veressovou jehlou, a to podko\u017en\u00ed emfyz\u00e9m, emfyz\u00e9m st\u011bny b\u0159i\u0161n\u00ed, pneumomediastinum a pneumotorax. Mechanismus je zn\u00e1m\u00fd, difuze plynu p\u0159es otvory pleuroperitone\u00e1ln\u00ed nebo barotrauma s roztr\u017een\u00edm mediastin\u00e1ln\u00ed pleury. Pokud se v\u010das zjist\u00ed rozvoj pneumomediastina a pneumotoraxu, d\u00e1 se stav zvl\u00e1dnout bez n\u00e1sledk\u016f.P\u0159i zav\u00e1d\u011bn\u00ed prvn\u00edho trokaru, tzv. zav\u00e1d\u011bn\u00ed \u201enaslepo\u201c, m\u016f\u017ee doj\u00edt k poran\u011bn\u00ed dut\u00fdch a parenchymatozn\u00edch org\u00e1n\u016f v dutin\u011b b\u0159i\u0161n\u00ed, u astenick\u00fdch pacient\u016f pak i k poran\u011bn\u00ed retroperitone\u00e1ln\u00edch org\u00e1n\u016f, nej\u010dast\u011bji abdomin\u00e1ln\u00ed aorty. Technika, kterou jsme si osvojili pro zav\u00e1d\u011bn\u00ed prvn\u00edho trokaru, jak bylo pops\u00e1no ji\u017e v\u00fd\u0161e, minimalizuje mo\u017enost poran\u011bn\u00ed org\u00e1n\u016f dutiny b\u0159i\u0161n\u00ed i org\u00e1n\u016f retroperitonea. Dojde-li k mal\u00e9mu poran\u011bn\u00ed org\u00e1n\u016f dutiny b\u0159i\u0161n\u00ed, co\u017e zjist\u00edme laparoskopem, m\u016f\u017eeme toto o\u0161et\u0159it laparoskopicky. Pokud dojde k velk\u00e9mu krv\u00e1cen\u00ed, je nutn\u00e1 rychl\u00e1 laparotomie s n\u00e1sledn\u00fdm o\u0161et\u0159en\u00edm podle rozsahu poran\u011bn\u00ed.<\/p>\n<h6>Specifick\u00e9 komplikace<\/h6>\n<p>Specifick\u00e9 komplikace m\u016f\u017eeme d\u00e1le rozd\u011blit na:<\/p>\n<ul>\n<li>komplikace mal\u00e9, sp\u00ed\u0161e probl\u00e9my,<\/li>\n<li>komplikace z\u00e1va\u017en\u00e9, velk\u00e9.<\/li>\n<\/ul>\n<h6>Mal\u00e9 komplikace<\/h6>\n<p style=\"text-align: justify;\">Mal\u00e9 komplikace, sp\u00ed\u0161e probl\u00e9my, b\u011bhem laparoskopick\u00e9 cholecystektomie jsme schopni v\u011bt\u0161inou \u0159e\u0161it laparoskopicky.Krv\u00e1cen\u00ed z l\u016f\u017eka \u017elu\u010dn\u00edku b\u011b\u017en\u011b stav\u00edme koagulac\u00ed h\u00e1\u010dkovou elektrodou, hrotem zav\u0159en\u00fdch n\u016f\u017eek nebo disektorem, do jeho\u017e bran\u017e\u00ed zachyt\u00edme krv\u00e1cej\u00edc\u00ed c\u00e9vu. Krv\u00e1cej\u00edc\u00ed m\u00edsto si m\u016f\u017eeme velmi dob\u0159e oz\u0159ejmit sou\u010dasnou trvalou irigac\u00ed. Stejn\u00fd postup je p\u0159i pou\u017eit\u00ed sonografick\u00fdch n\u00e1stroj\u016f.Krv\u00e1cen\u00ed z arteria cystica. Doch\u00e1z\u00ed k n\u011bmu velmi \u010dasto p\u0159i preparaci ductus cysticus. Vzhledem ke zv\u011bt\u0161en\u00ed, kter\u00e9 laparoskopie poskytuje, vypad\u00e1 toto krv\u00e1cen\u00ed hroziv\u011b, hlavn\u011b tehdy, kdy\u017e si na laparoskopii teprve zvyk\u00e1me. Toto krv\u00e1cen\u00ed m\u016f\u017eeme zm\u00edrnit tlakem infundibula \u017elu\u010dn\u00edku proti hepatoduoden\u00e1ln\u00edmu ligamentu, kdy komprimujeme arteria hepatica. V \u017e\u00e1dn\u00e9m p\u0159\u00edpad\u011b se nesm\u00edme sna\u017eit zastavit krv\u00e1cen\u00ed naslepo nakl\u00e1dan\u00fdmi svorkami. Je zde velk\u00e9 nebezpe\u010d\u00ed zachycen\u00ed \u017elu\u010dovodu, eventu\u00e1ln\u011b arteria hepatica do svorky. Nejl\u00e9pe se osv\u011bd\u010dil postup, kdy sou\u010dasn\u011b irigujeme krv\u00e1cej\u00edc\u00ed m\u00edsto a preparujeme arteria cystica. Krv\u00e1cej\u00edc\u00ed tepnu zachyt\u00edme do bran\u017e\u00ed disektoru a nalo\u017e\u00edme pak dv\u011b svorky. Pokud nejsme schopni vy\u0159e\u0161it krv\u00e1cen\u00ed laparoskopicky, je to d\u016fvod ke konverzi. Zase zde zd\u016fraz\u0148ujeme laparoskopickou operaci ob\u011bma rukama.Perforace \u017elu\u010dn\u00edku. Doch\u00e1z\u00ed k n\u00ed u z\u00e1n\u011btliv\u00fdch zm\u011bn jeho st\u011bny, kter\u00e1 je k\u0159ehk\u00e1, a tahem kle\u0161t\u00ed pak dojde k perforaci. M\u016f\u017ee k n\u00ed doj\u00edt i p\u0159i nezm\u011bn\u011bn\u00e9 st\u011bn\u011b \u017elu\u010dn\u00edku p\u0159i preparaci z l\u016f\u017eka n\u016f\u017ekami nebo h\u00e1\u010dkem. Perforaci se sna\u017e\u00edme uzav\u0159\u00edt klipem nebo kle\u0161t\u011bmi, kter\u00e9 pak uzav\u00edraj\u00ed perforaci a\u017e do dokon\u010den\u00ed izolace \u017elu\u010dn\u00edku. Pokud je perforace v\u011bt\u0161\u00ed, zavedeme iriga\u010dn\u00ed sondu do lumen \u017elu\u010dn\u00edku, kter\u00fd opakovan\u011b vypl\u00e1chneme, a bez uzav\u0159en\u00ed perforace dokon\u010d\u00edme izolaci \u017elu\u010dn\u00edku.Voln\u00e9 kameny v dutin\u011b b\u0159i\u0161n\u00ed souvisej\u00ed samoz\u0159ejm\u011b s perforac\u00ed \u017elu\u010dn\u00edku. Podle literatury se ztr\u00e1ta kamene v b\u0159i\u0161n\u00ed dutin\u011b nepova\u017euje za v\u00e1\u017enou komplikaci. P\u0159esto se sna\u017e\u00edme voln\u00e9 konkrementy z dutiny b\u0159i\u0161n\u00ed odstranit. Vhodn\u00fdm n\u00e1strojem jsou extrak\u010dn\u00ed kle\u0161t\u011b, kter\u00fdmi m\u016f\u017eeme v\u011bt\u0161\u00ed konkrement rozdrtit na men\u0161\u00ed fragmenty a ty pak kle\u0161t\u011bmi odstranit p\u0159es 10mm trokar. Probl\u00e9mem m\u016f\u017ee b\u00fdt mnoho\u010detn\u00e1 drobn\u00e1 liti\u00e1za, kdy se \u017elu\u010dn\u00edk \u201evysype\u201c do podjatern\u00ed krajiny. Zde se osv\u011bd\u010dil s\u00e1\u010dek, kter\u00fd zavedeme 10mm trokarem\u00a0do dutiny b\u0159i\u0161n\u00ed a kameny, mnohdy i se \u017elu\u010dn\u00edkem, vlo\u017e\u00edme do s\u00e1\u010dku a na z\u00e1v\u011br operace exstirpujeme z dutiny b\u0159i\u0161n\u00ed. V\u017edy velmi pe\u010dliv\u011b vypl\u00e1chneme podjatern\u00ed krajinu, zvl\u00e1\u0161t\u011b jednalo-li se o empy\u00e9m \u017elu\u010dn\u00edku.<\/p>\n<h6 style=\"text-align: justify;\">Z\u00e1va\u017en\u00e9 velk\u00e9 komplikace<\/h6>\n<p style=\"text-align: justify;\">Poran\u011bn\u00ed extrahepat\u00e1ln\u00edch \u017elu\u010dov\u00fdch cest. K t\u00e9to komplikaci samoz\u0159ejm\u011b doch\u00e1z\u00ed i u otev\u0159en\u00e9 cholecystektomie. V literatu\u0159e se uv\u00e1d\u00ed incidence poran\u011bn\u00ed \u017elu\u010dov\u00fdch cest u otev\u0159en\u00e9 cholecystektomie 0,2%. Rozvoj laparoskopick\u00e9 cholecystektomie, stejn\u011b jako zaveden\u00ed ka\u017ed\u00e9 nov\u00e9 metody, nese s sebou zpo\u010d\u00e1tku i v\u011bt\u0161\u00ed v\u00fdskyt komplikac\u00ed, v\u010detn\u011b poran\u011bn\u00ed extrahepat\u00e1ln\u00edch \u017elu\u010dov\u00fdch cest. V sou\u010dasn\u00e9 dob\u011b je frekvence poran\u011bn\u00ed \u017elu\u010dov\u00fdch cest u otev\u0159en\u00e9 a laparoskopick\u00e9 operace srovnateln\u00e1.M\u016f\u017ee se jednat o tato poran\u011bn\u00ed:<\/p>\n<ul>\n<li>\u00fapln\u00e9 p\u0159eru\u0161en\u00ed st\u011bny \u017elu\u010dovodu,<\/li>\n<li>tangenci\u00e1ln\u00ed poru\u0161en\u00ed st\u011bny \u017elu\u010dovodu,<\/li>\n<li>striktura \u017elu\u010dovodu.<\/li>\n<\/ul>\n<h6>P\u0159\u00ed\u010dinou vzniku t\u011bchto komplikac\u00ed je v\u011bt\u0161inou technick\u00e1 chyba operat\u00e9ra.<\/h6>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_104.png\"><img loading=\"lazy\" decoding=\"async\" class=\" \" title=\"Obr. 7 \u2013 Chybn\u00e1 identifikace ductus cysticus \u2013 klipy nasazen\u00e9 na ductus choledochus\" alt=\"Obr. 7 \u2013 Chybn\u00e1 identifikace ductus cysticus \u2013 klipy nasazen\u00e9 na ductus choledochus\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_104.png\" width=\"200\" height=\"166\" \/><\/a><p class=\"wp-caption-text\">Obr. 7 \u2013 Chybn\u00e1 identifikace ductus cysticus \u2013 klipy nasazen\u00e9<br \/>na ductus choledochus<\/p><\/div>\n<p>P\u0159i preparaci v oblasti Calotova troj\u00faheln\u00edku m\u016f\u017ee doj\u00edt k z\u00e1m\u011bn\u011b ductus cysticus za ductus choledochus (obr. 7).<\/p>\n<p style=\"text-align: justify;\">Operat\u00e9r se soust\u0159ed\u00ed na preparaci \u201ev\u00fdvodu\u201c, nep\u0159esv\u011bd\u010d\u00ed se o n\u00e1vaznosti infundibula \u017elu\u010dn\u00edku, eventu\u00e1ln\u011b bl\u00edzkosti horn\u00edho okraje duodena. \u00dazk\u00e9 zorn\u00e9 pole laparoskopu, zam\u011b\u0159en\u00e9ho jen na preparovan\u00fd ductus, odv\u00e1d\u00ed pozornost od okoln\u00edch struktur. Rovn\u011b\u017e p\u0159idru\u017een\u00e9 krv\u00e1cen\u00ed znesnad\u0148uje orientaci v t\u00e9to oblasti. Toto je nej\u010dast\u011bj\u0161\u00ed p\u0159\u00ed\u010dina \u00fapln\u00e9ho p\u0159eru\u0161en\u00ed ductus choledochus. Operat\u00e9r si mus\u00ed pamatovat, \u017ee v krajin\u011b Calotova troj\u00faheln\u00edku se velmi \u010dasto vyskytuj\u00ed anom\u00e1lie jak \u017elu\u010dov\u00fdch v\u00fdvod\u016f, tak pr\u016fb\u011bhu c\u00e9v. Pokud operat\u00e9r zaklipuje a p\u0159eru\u0161\u00ed ductus choledochus a pokra\u010duje d\u00e1le v preparaci domn\u011bl\u00e9ho ductus cysticus, klipuje pak ductus hepaticus v domn\u011bn\u00ed, \u017ee se jedn\u00e1 o aberantn\u00ed \u017elu\u010dovod. T\u00edm dojde k vyt\u011bt\u00ed ductus hepatocholedochus a resekovan\u00e1 \u010d\u00e1st pak z\u016fst\u00e1v\u00e1 sou\u010d\u00e1st\u00ed prepar\u00e1tu.<\/p>\n<h6>Tangenci\u00e1ln\u00ed poran\u011bn\u00ed<\/h6>\n<p>K tangenci\u00e1ln\u00edmu poran\u011bn\u00ed doch\u00e1z\u00ed nej\u010dast\u011bji p\u0159i ne\u0161etrn\u00e9 izolaci ductus cysticus h\u00e1\u010dkem nebo n\u016f\u017ekami nebo p\u0159i nakl\u00e1d\u00e1n\u00ed klip\u016f na ductus cysticus.<\/p>\n<h6>Striktura \u017elu\u010dovodu<\/h6>\n<p style=\"text-align: justify;\">Striktura pak m\u016f\u017ee vzniknout \u010dasn\u011b p\u0159i nekontrolovan\u00e9m nalo\u017een\u00ed klip\u016f, nej\u010dast\u011bji p\u0159i stav\u011bn\u00ed krv\u00e1cen\u00ed v oblasti Calotova troj\u00faheln\u00edku. K pozdn\u00ed sten\u00f3ze pak m\u016f\u017ee doj\u00edt na podklad\u011b termick\u00e9ho po\u0161kozen\u00ed spole\u010dn\u00e9ho \u017elu\u010dovodu s n\u00e1slednou strikturou. Jde o n\u00e1sledek ne\u00fam\u011brn\u00e9ho pou\u017e\u00edv\u00e1n\u00ed koagulace v bl\u00edzkosti choledochu.<\/p>\n<p style=\"text-align: justify;\">Jestli\u017ee b\u011bhem laparoskopick\u00e9 cholecystektomie m\u00e1me pochybnosti, zda jsme nep\u0159eru\u0161ili ductus choledochus, provedeme peropera\u010dn\u00ed biligrafii. Kanylu zav\u00e1d\u00edme m\u00edstem poran\u011bn\u00ed. Kdy\u017e biligrafie prok\u00e1\u017ee prot\u011bt\u00ed, tzn. \u017ee se pln\u00ed jen dist\u00e1ln\u00ed \u00fasek ductus choledochus a nenapln\u00ed se intrahepat\u00e1ln\u00ed \u017elu\u010dovody, jsme nuceni operaci konvertovat a \u0159e\u0161it poran\u011bn\u00ed.Pokud v poopera\u010dn\u00edm obdob\u00ed p\u0159etrv\u00e1vaj\u00ed bolesti, objevuje se ikterus, dr\u00e9n odv\u00e1d\u00ed \u017elu\u010d nebo se potvrd\u00ed sonograficky kolekce \u017elu\u010de v podjatern\u00ed krajin\u011b nebo se vyvine bili\u00e1rn\u00ed peritonitida, je pravd\u011bpodobn\u00e9, \u017ee do\u0161lo k poran\u011bn\u00ed extrahepat\u00e1ln\u00edho \u017elu\u010dovodu.<\/p>\n<p style=\"text-align: justify;\">Pro potvrzen\u00ed nebo vylou\u010den\u00ed t\u00e9to diagn\u00f3zy m\u00e1 nejv\u011bt\u0161\u00ed p\u0159\u00ednos vy\u0161et\u0159en\u00ed ERCP. \u00dapln\u00e9 stop kontrastu znamen\u00e1 p\u0159eru\u0161en\u00ed a zaklipov\u00e1n\u00ed ductus choledochus, \u00fanik kontrastu p\u0159i napln\u011bn\u00ed intrahepat\u00e1ln\u00edch \u017elu\u010dov\u00fdch cest pak znamen\u00e1 n\u00e1st\u011bnn\u00e9 poran\u011bn\u00ed, eventu\u00e1ln\u011b \u00fanik z pah\u00fdlu ductus cysticus. Vzhledem k z\u00e1va\u017enosti t\u00e9to problematiky je zcela na m\u00edst\u011b zm\u00ednit se, jak o\u0161et\u0159it peropera\u010dn\u00ed poran\u011bn\u00ed \u017elu\u010dov\u00fdch v\u00fdvod\u016f. Pro osud nemocn\u00e9ho je d\u016fle\u017eit\u00e9, aby bylo poran\u011bn\u00ed rozpozn\u00e1no a dob\u0159e o\u0161et\u0159eno hned p\u0159i operaci. Podm\u00ednky pro reparaci jsou nejlep\u0161\u00ed, daj\u00ed se dob\u0159e rozpoznat p\u0159eru\u0161en\u00e9 konce duktu, tk\u00e1n\u011b se daj\u00ed dob\u0159e mobilizovat.<\/p>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_106.png\"><img decoding=\"async\" title=\"Obr. 8 \u2013 Bismuthova origin\u00e1ln\u00ed klasifikace a kresba (I. a\u017e V. typ) poran\u011bn\u00ed extrahepat\u00e1ln\u00edch \u017elu\u010dov\u00fdch cest\" alt=\"Obr. 8 \u2013 Bismuthova origin\u00e1ln\u00ed klasifikace a kresba (I. a\u017e V. typ) poran\u011bn\u00ed extrahepat\u00e1ln\u00edch \u017elu\u010dov\u00fdch cest\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_106.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 8 \u2013 Bismuthova origin\u00e1ln\u00ed klasifikace a kresba (I. a\u017e V. typ) poran\u011bn\u00ed extrahepat\u00e1ln\u00edch \u017elu\u010dov\u00fdch cest<\/p><\/div>\n<p style=\"text-align: justify;\">Pokud ERCP vy\u0161et\u0159en\u00ed v poopera\u010dn\u00ed dob\u011b prok\u00e1\u017ee jen mal\u00e9 n\u00e1st\u011bnn\u00e9 poran\u011bn\u00ed, m\u016f\u017ee b\u00fdt toto o\u0161et\u0159eno zaveden\u00edm stentu. Stejn\u011b m\u016f\u017eeme o\u0161et\u0159it \u00fanik kontrastu p\u0159i uvoln\u011bn\u00ed klip\u016f z ductus cysticus. P\u0159i v\u011bt\u0161\u00edm n\u00e1st\u011bnn\u00e9m poran\u011bn\u00ed je nutn\u00e1 reoperace s n\u00e1slednou suturou, ji\u017e zajist\u00edme T-dr\u00e9nem, kter\u00fd je zaveden mimo tuto suturu. \u00dapln\u011b p\u0159eru\u0161en\u00fd ductus choledochus lze rovn\u011b\u017e o\u0161et\u0159it suturou na T-dr\u00e9nu. V p\u0159\u00edpad\u011b, \u017ee je ductus choledochus p\u0159eru\u0161en se ztr\u00e1tou sv\u00e9 d\u00e9lky, je l\u00e9pe napojit centr\u00e1ln\u00ed pah\u00fdl na exkludovanou kli\u010dku jejuna podle Rouxe.<\/p>\n<p style=\"text-align: justify;\">Z hlediska l\u00e9\u010debn\u00e9 taktiky je d\u016fle\u017eit\u00e9 rozd\u011blen\u00ed poran\u011bn\u00ed \u017elu\u010dov\u00fdch cest podle lokalizace. Origin\u00e1ln\u00ed, nej\u010dast\u011bji u\u017e\u00edvanou klasifikac\u00ed navrhl Bismuth (obr. 8).<\/p>\n<ol>\n<li>Poran\u011bn\u00ed v oblasti papily Vatersk\u00e9 a retroduoden\u00e1ln\u00edho pr\u016fb\u011bhu choledochu. K t\u011bmto poran\u011bn\u00edm doch\u00e1z\u00ed p\u0159i sfinkteropapilotomii a d\u00e1le p\u0159i resekc\u00edch \u017ealudku. P\u0159i preparaci duodena b\u011bhem resekce doch\u00e1z\u00ed k pro\u0161it\u00ed nebo p\u0159eru\u0161en\u00ed \u017elu\u010dov\u00fdch cest. Tato poran\u011bn\u00ed, nejsou-li v\u010das rozpozn\u00e1na a l\u00e9\u010dena, vedou k rozvoji pankreatitidy a retroperitone\u00e1ln\u00ed flegmony se \u0161patnou progn\u00f3zou. Bli\u017e\u0161\u00ed pou\u010den\u00ed je t\u0159eba hledat v literatu\u0159e o komplikac\u00edch sfinkteropapilotomie a resekc\u00ed \u017ealudku. Zvl\u00e1\u0161tn\u00edm typem poran\u011bn\u00ed je tzv. desinserce papily. P\u0159i izolaci zadn\u00ed st\u011bny duodena od pankreatu dojde k p\u0159eru\u0161en\u00ed \u017elu\u010dov\u00fdch cest t\u011bsn\u011b p\u0159i vstupu do st\u011bny dvan\u00e1ctern\u00edku. O\u0161et\u0159en\u00ed spo\u010d\u00edv\u00e1 v reinzerci \u017elu\u010dovodu do duodena \u010di Rouxovy kli\u010dky.<\/li>\n<li>K poran\u011bn\u00ed hepatocholedochu doch\u00e1z\u00ed nej\u010dast\u011bji p\u0159i cholecystektomii. P\u0159i dostate\u010dn\u00e9m pr\u016fsvitu \u017elu\u010dovodu a dobr\u00e9 kvalit\u011b st\u011bny je mo\u017en\u00e9 prov\u00e9st suturu poran\u011bn\u00ed nebo i kompletn\u00ed end-to-end anastom\u00f3zu na T-dr\u00e9nu. Ten je t\u0159eba v\u017edy zav\u00e9st mimo vlastn\u00ed suturu (obr. 9). Tento zp\u016fsob je nevhodn\u00fd p\u0159i v\u011bt\u0161\u00edm defektu st\u011bny, kdy by byla sutura pod nap\u011bt\u00edm, nebo p\u0159i \u017elu\u010dov\u00fdch cest\u00e1ch velmi mal\u00e9ho pr\u016fsvitu. Pak je l\u00e9pe na\u0161\u00edt anastom\u00f3zu v hilu, jak je uvedeno d\u00e1le. Velmi \u010dasto se setk\u00e1v\u00e1me s t\u00edm, \u017ee chirurg poranil \u017elu\u010dov\u00e9 cesty v\u00fd\u0161e, ne\u017e p\u0159edpokl\u00e1dal. Anatomick\u00e9 pom\u011bry je nutn\u00e9 si pe\u010dliv\u011b ov\u011b\u0159it sond\u00e1\u017e\u00ed a cholangiografi\u00ed.<\/li>\n<li>Nejz\u00e1va\u017en\u011bj\u0161\u00ed je poran\u011bn\u00ed v jatern\u00edm hilu, tj. v oblasti junkce obou hepatik\u016f. Zde je nejvhodn\u011bj\u0161\u00ed zalo\u017eit hepatikojejun\u00e1ln\u00ed anastom\u00f3zu Rouxovou kli\u010dkou.Vedle lokalizace je pro l\u00e9\u010debnou techniku d\u016fle\u017eit\u00fd i rozsah poran\u011bn\u00ed. Bodov\u00e1 poran\u011bn\u00ed se po sutu\u0159e hoj\u00ed mnohem l\u00e9pe ne\u017e prot\u011bt\u00ed v\u011bt\u0161\u00ed \u010d\u00e1sti cirkumference\u00a0\u017elu\u010dovodu. K sekund\u00e1rn\u00edmu jizven\u00ed doch\u00e1z\u00ed po sutu\u0159e po\u0161kozen\u00e9 st\u011bny (nap\u0159. elektrokoagulac\u00ed), nebo byla-li sutura pod nap\u011bt\u00edm po ztr\u00e1tov\u00e9m poran\u011bn\u00ed.Po laparoskopick\u00e9 cholecystektomii jsou \u010dast\u011bj\u0161\u00ed termick\u00e1 poran\u011bn\u00ed, kter\u00e1 se projev\u00ed \u00fanikem \u017elu\u010di a\u017e v poopera\u010dn\u00edm obdob\u00ed. \u010cast\u011bj\u0161\u00ed je i sklouznut\u00ed svorky z pah\u00fdlu ductus cysticus. Nalo\u017een\u00edm svorky na hepatocholedochus m\u016f\u017ee doj\u00edt k jeho z\u00fa\u017een\u00ed.Bohu\u017eel, jen men\u0161\u00ed \u010d\u00e1st poran\u011bn\u00ed \u017elu\u010dov\u00fdch cest je diagnostikov\u00e1na b\u011bhem operace. \u010cast\u011bji jsou cholaskos \u010di zn\u00e1mky obstrukce \u017elu\u010dov\u00fdch cest rozpozn\u00e1ny a\u017e v poopera\u010dn\u00edm obodb\u00ed. Rozhoduj\u00edc\u00ed v\u00fdznam pro stanoven\u00ed diagn\u00f3zy m\u00e1 ERCP.<\/li>\n<\/ol>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" 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\/05\/Image_107.png\"><img decoding=\"async\" title=\"Obr. 9 \u2013 Sutura \u017elu\u010dov\u00fdch cest se zaveden\u00ed T-dr\u00e9nu\" alt=\"Obr. 9 \u2013 Sutura \u017elu\u010dov\u00fdch cest se zaveden\u00ed T-dr\u00e9nu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_107.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 9 \u2013 Sutura \u017elu\u010dov\u00fdch cest se zaveden\u00ed T-dr\u00e9nu<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" 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\/05\/Image_109.png\"><img decoding=\"async\" title=\"Obr. 10 \u2013 Hepatikojejunoanastom\u00f3za v jatern\u00edm hilu s prodlou\u017een\u00edm spojky na lev\u00fd hepatikus (Couinaud-Heppova operace)\" alt=\"Obr. 10 \u2013 Hepatikojejunoanastom\u00f3za v jatern\u00edm hilu s prodlou\u017een\u00edm spojky na lev\u00fd hepatikus (Couinaud-Heppova operace)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_109.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 10 \u2013 Hepatikojejunoanastom\u00f3za v jatern\u00edm hilu s prodlou\u017een\u00edm spojky na lev\u00fd hepatikus (Couinaud-Heppova operace)<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6 style=\"text-align: justify;\">Technika hilov\u00e9 spojky a dren\u00e1\u017ee<\/h6>\n<p style=\"text-align: justify;\">Abychom dos\u00e1hli co nej\u0161ir\u0161\u00edho pr\u016fsvitu hepatojejun\u00e1ln\u00ed anastom\u00f3zy, prodlu\u017eujeme ji sm\u011brem na lev\u00fd ductus hepaticus a zakl\u00e1d\u00e1me tzv. Couinaud-Heppovu anastom\u00f3zu (obr. 10).P\u0159edpokladem \u00fasp\u011bchu je dodr\u017een\u00ed z\u00e1sady mukomuk\u00f3zn\u00ed spojky s p\u0159esnou adaptac\u00ed sliznice \u017elu\u010dovodu na sliznici jejuna. V nep\u0159ehledn\u00e9m ter\u00e9nu m\u016f\u017ee usnadnit adaptaci sliznice \u0161it\u00ed spojky na zaveden\u00e9m dr\u00e9nu. Spojku \u0161ijeme v jedn\u00e9 vrstv\u011b vst\u0159ebateln\u00fdm stehem. Nen\u00ed jednotn\u00fd n\u00e1zor na to, zda m\u00e1 b\u00fdt spojka po operaci dr\u00e9nov\u00e1na. Dostate\u010dn\u011b \u0161irokou spojku s dobrou adaptac\u00ed sliznice na sliznici nen\u00ed t\u0159eba dr\u00e9novat, proto\u017ee dren\u00e1\u017e je v\u017edy pro nemocn\u00e9ho nep\u0159\u00edjemn\u00e1. Spojku je l\u00e9pe dr\u00e9novat u obt\u00ed\u017en\u011bji zakl\u00e1dan\u00fdch anastom\u00f3z, kde \u010dasto nelze dos\u00e1hnout exaktn\u00ed mukomuk\u00f3zn\u00ed adaptace, a p\u0159i \u00fazk\u00fdch \u017elu\u010dov\u00fdch cest\u00e1ch. Dr\u00e9n zde m\u00e1 funkci prot\u00e9zy, na kter\u00e9 se anastom\u00f3za hoj\u00ed. Bo\u010dn\u00ed otvory v dr\u00e9nu zaji\u0161\u0165uj\u00ed u ne zcela t\u011bsn\u00edc\u00ed spojky odtok \u017elu\u010di z jater do st\u0159eva.Absolutn\u00ed nutnost\u00ed je dren\u00e1\u017e tam, kde je junkce hepatik\u016f zni\u010den\u00e1. Vytv\u00e1\u0159\u00edme hluboko v hilu, v jatern\u00edm parenchymu, tzv. bezstehovou anastom\u00f3zu. P\u0159\u00edm\u00fd mukomuk\u00f3zn\u00ed steh zde zalo\u017eit nelze (obr. 11a, b, c, d).Ide\u00e1ln\u00ed je o\u0161et\u0159it poran\u011bn\u00ed ihned po jeho vzniku a rozpozn\u00e1n\u00ed. O\u0161et\u0159en\u00ed by m\u011blo b\u00fdt definitivn\u00ed, proto\u017ee ka\u017ed\u00e1 dal\u0161\u00ed reoperace zhor\u0161uje nad\u011bji na dobr\u00fd v\u00fdsledek rekonstrukce. Jedn\u00e1 se o v\u00fdkon vysoce delik\u00e1tn\u00ed a zodpov\u011bdn\u00fd, kter\u00fd by m\u011bl prov\u00e1d\u011bt chirurg s dostate\u010dn\u00fdmi zku\u0161enostmi. Tyto po\u017eadavky jsou n\u011bkdy obt\u00ed\u017en\u011b splniteln\u00e9. Zvl\u00e1\u0161t\u011b vy\u017eaduje-li o\u0161et\u0159en\u00ed bezprost\u0159edn\u011b rozpoznan\u00e9 v pr\u016fb\u011bhu cholecystektomie zalo\u017een\u00ed hilov\u00e9 anastom\u00f3zy, nemus\u00ed m\u00edt ka\u017ed\u00fd operuj\u00edc\u00ed dostate\u010dn\u00e9 p\u0159edpoklady k dokon\u010den\u00ed t\u00e9to operace. Podle okolnosti je t\u0159eba v\u017edy zajistit nejkvalifikovan\u011bj\u0161\u00ed zp\u016fsob o\u0161et\u0159en\u00ed.Tam, kde je poran\u011bn\u00ed rozpozn\u00e1no a\u017e v poopera\u010dn\u00edm obdob\u00ed, a u opakovan\u00fdch reoperac\u00ed je absolutn\u011b nutn\u00e9, aby operaci prov\u00e1d\u011bl chirurg s dostate\u010dn\u00fdmi zku\u0161enostmi s reoperacemi na \u017elu\u010dov\u00fdch cest\u00e1ch. Iatrogenn\u00ed poran\u011bn\u00ed je l\u00e9pe koncentrovat do specializovan\u00fdch center. Odsunut\u00ed operace o n\u011bkolik dn\u00ed nezhor\u0161uje obvykle vyhl\u00eddky na optim\u00e1ln\u00ed v\u00fdsledek. Nesrovnateln\u011b v\u011bt\u0161\u00edm rizikem pro nemocn\u00e9ho je neadekv\u00e1tn\u00ed o\u0161et\u0159en\u00ed poran\u011bn\u00ed, kter\u00e9 si vy\u017e\u00e1d\u00e1 v budoucnu reoperaci.<\/p>\n<h6>Poran\u011bn\u00ed st\u0159eva<\/h6>\n<p style=\"text-align: justify;\">K tomuto poran\u011bn\u00ed m\u016f\u017ee doj\u00edt jednak p\u0159i zav\u00e1d\u011bn\u00ed trokar\u016f, jak ji\u017e bylo zm\u00edn\u011bno, d\u00e1le p\u0159i preparaci v z\u00e1n\u011btliv\u00e9m infiltr\u00e1tu, do kter\u00e9ho m\u016f\u017ee b\u00fdt zavzato nap\u0159. duodenum. Pokud je poran\u011bn\u00ed zji\u0161t\u011bno b\u011bhem laparoskopick\u00e9 cholecystektomie, je na chirurgovi, zda poran\u011bn\u00ed o\u0161et\u0159\u00ed laparoskopicky stehem, nebo je d\u016fvodem ke konverzi. V poopera\u010dn\u00edm obdob\u00ed m\u016f\u017ee b\u00fdt peritonitida zap\u0159\u00ed\u010din\u011bna pr\u00e1v\u011b poran\u011bn\u00edm st\u0159eva.Krv\u00e1cen\u00ed, kter\u00e9 operat\u00e9r nen\u00ed schopen zvl\u00e1dnout laparoskopicky, je rovn\u011b\u017e d\u016fvodem ke konverzi. Jedn\u00e1 se v\u011bt\u0161inou o krv\u00e1cen\u00ed z arteria cystica, krv\u00e1cen\u00ed z l\u016f\u017eka u z\u00e1n\u011btliv\u011b zm\u011bn\u011bn\u00fdch \u017elu\u010dn\u00edk\u016f. P\u0159\u00ed\u010dinou hemoperitonea v poopera\u010dn\u00ed dob\u011b je \u010dasto uvoln\u011bn\u00fd klip na arteria cystica. Jde-li o krv\u00e1cen\u00ed z l\u016f\u017eka \u017elu\u010dn\u00edku, pak p\u0159i reoperaci ji\u017e zdroj mnohdy nenajdeme.<\/p>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_111.png\"><img decoding=\"async\" title=\"Obr. 11 \u2013 R\u016fzn\u00e9 typy hepatikojejun\u00e1ln\u00ed dren\u00e1\u017ee a) dren\u00e1\u017e podle Voelckerova principu b) transhepatick\u00e1 (diahepatick\u00e1) dren\u00e1\u017e c) diahepatick\u00e1 dren\u00e1\u017e bez konce \u201eU\u201c d) dvojit\u00e1 diahepatick\u00e1 dren\u00e1\u017e\" alt=\"Obr. 11 \u2013 R\u016fzn\u00e9 typy hepatikojejun\u00e1ln\u00ed dren\u00e1\u017ee a) dren\u00e1\u017e podle Voelckerova principu b) transhepatick\u00e1 (diahepatick\u00e1) dren\u00e1\u017e c) diahepatick\u00e1 dren\u00e1\u017e bez konce \u201eU\u201c d) dvojit\u00e1 diahepatick\u00e1 dren\u00e1\u017e\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_111.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 11 \u2013 R\u016fzn\u00e9 typy hepatikojejun\u00e1ln\u00ed dren\u00e1\u017ee<br \/>a) dren\u00e1\u017e podle Voelckerova principu<br \/>b) transhepatick\u00e1 (diahepatick\u00e1) dren\u00e1\u017e<br \/>c) diahepatick\u00e1 dren\u00e1\u017e bez konce \u201eU\u201c<br \/>d) dvojit\u00e1 diahepatick\u00e1 dren\u00e1\u017e<\/p><\/div>\n<p style=\"text-align: justify;\">Bili\u00e1rn\u00ed peritonitida je zp\u016fsobena nej\u010dast\u011bji prosakov\u00e1n\u00edm \u017elu\u010de z l\u016f\u017eka \u017elu\u010dn\u00edku, dal\u0161\u00ed p\u0159\u00ed\u010dinou je aberantn\u00ed \u017elu\u010dovod a nakonec l\u00e9ze \u017elu\u010dovodu. Pokud p\u0159i laparoskopick\u00e9 cholecystektomii p\u0159eru\u0161\u00edme aberantn\u00ed \u017elu\u010dovod, je l\u00e9pe jej uzav\u0159\u00edt klipem ne\u017e koagulac\u00ed. Po koagulaci doch\u00e1z\u00ed \u010dasem k uvoln\u011bn\u00ed koagula\u010dn\u00ed nekr\u00f3zy a op\u011btovn\u00e9mu v\u00fdronu \u017elu\u010de. Pokud dr\u00e9n dostate\u010dn\u011b odv\u00e1d\u00ed, nen\u00ed nutn\u00e1 revize, aberantn\u00ed \u017elu\u010dovod se \u010dasem uzav\u0159e spont\u00e1nn\u011b. O\u0161et\u0159en\u00ed bili\u00e1rn\u00ed peritonitidy p\u0159i l\u00e9zi \u017elu\u010dov\u00fdch v\u00fdvod\u016f bylo ji\u017e uvedeno v\u00fd\u0161e.Hnisav\u00e9 komplikace. P\u0159\u00ed\u010dinou hnisav\u00fdch komplikac\u00ed v dutin\u011b b\u0159i\u0161n\u00ed, tj. abscesu a difuzn\u00ed peritonitidy, m\u016f\u017ee b\u00fdt poran\u011bn\u00ed st\u0159eva, empy\u00e9m \u017elu\u010dn\u00edku nebo rozs\u00e1hl\u00fd hematom v subhepat\u00e1ln\u00edm prostoru. P\u0159i klinick\u00fdch p\u0159\u00edznac\u00edch sv\u011bd\u010d\u00edc\u00edch pro tuto komplikaci prov\u00e1d\u00edme vy\u0161et\u0159en\u00ed sonografick\u00e9, ev. vy\u0161et\u0159en\u00ed CT. Pokud se jedn\u00e1 o absces, je diagnostika pomoc\u00ed t\u011bchto vy\u0161et\u0159en\u00ed jasn\u00e1, hor\u0161\u00ed je to u\u017e u difuzn\u00ed peritonitidy. Stejn\u011b jako u bili\u00e1rn\u00ed peritonitidy n\u00e1m toto vy\u0161et\u0159en\u00ed mnohdy nic neoz\u0159ejm\u00ed, spol\u00e9h\u00e1me se pak jen na klinick\u00e9 vy\u0161et\u0159en\u00ed. O\u0161et\u0159en\u00ed abscesu v subhepat\u00e1ln\u00ed oblasti m\u016f\u017ee b\u00fdt provedeno c\u00edlenou dren\u00e1\u017e\u00ed pod sonografickou nebo CT kontrolou. Velk\u00e9 abscesy a difuzn\u00ed peritonitida vy\u017eaduj\u00ed laparotomii, lav\u00e1\u017e dutiny b\u0159i\u0161n\u00ed, \u010dili o\u0161et\u0159en\u00ed jako peritonitidy z jin\u00e9 p\u0159\u00ed\u010diny.<\/p>\n<h4>2.5 Laparoskopick\u00e1 cholecystektomie u akutn\u00ed cholecystitidy<\/h4>\n<h6>Indikace a p\u0159\u00edprava<\/h6>\n<p style=\"text-align: justify;\">P\u0159ed n\u00e1stupem \u00e9ry laparoskopick\u00fdch cholecystektomi\u00ed spo\u010d\u00edvalo chirurgick\u00e9 l\u00e9\u010den\u00ed akutn\u00ed cholecystitidy v \u010dasn\u00e9 otev\u0159en\u00e9 cholecystektomii.Tento postup se vyvinul na z\u00e1klad\u011b studi\u00ed, kter\u00e9 za\u010daly zavrhovat p\u016fvodn\u00ed terapeutick\u00e9 sch\u00e9ma: zklidn\u011bn\u00ed akutn\u00ed cholecystitidy, propu\u0161t\u011bn\u00ed pacienta a n\u00e1sledn\u00e9 p\u0159ijet\u00ed k pl\u00e1novan\u00e9 operaci, nej\u010dast\u011bji n\u011bkolik t\u00fddn\u016f po prvn\u00ed dimisi. Sou\u010dasnou tendenci operovat pokud mo\u017eno co nejd\u0159\u00edve po p\u0159ijet\u00ed pacienta s akutn\u00ed cholecystitidou zast\u00e1v\u00e1 dnes p\u0159ev\u00e1\u017en\u00e1 \u010d\u00e1st chirurg\u016f.Je\u0161t\u011b ned\u00e1vno byly akutn\u00ed cholecystitida a empy\u00e9m \u017elu\u010dn\u00edku pova\u017eov\u00e1ny za relativn\u00ed kontraindikace laparoskopick\u00e9 cholecystektomie. Rovn\u011b\u017e pr\u00e1ce z \u0159ady dal\u0161\u00edch center referovaly o vysok\u00e9m pod\u00edlu konverz\u00ed, kdy\u017e se l\u00e9ka\u0159i pokou\u0161eli operovat t\u011b\u017ece zan\u00edcen\u00fd \u017elu\u010dn\u00edk, a proto tvrdili, \u017ee takov\u00fd stav je nutno pova\u017eovat za kontraindikaci laparoskopick\u00e9ho v\u00fdkonu. V\u011bt\u0161ina konverz\u00ed byla elektivn\u00edch a hlavn\u00edm faktorem byly z\u00e1n\u011btliv\u00e9 zm\u011bny st\u011bny \u017elu\u010dn\u00edku, a\u0165 u\u017e se sr\u016fsty, nebo bez nich. Dnes nen\u00ed akutn\u00ed cholecystitida kontraindikac\u00ed k laparoskopick\u00e9 cholecystektomii.<\/p>\n<p>Technika a taktika operace se neli\u0161\u00ed v z\u00e1sad\u011b od elektivn\u00ed cholecystektomie.<\/p>\n<h6>Komplikace a jejich \u0159e\u0161en\u00ed<\/h6>\n<p style=\"text-align: justify;\">Laparoskopick\u00e1 cholecystektomie u akutn\u00ed cholecystitidy je bezpe\u010dn\u00e1 a je spojen\u00e1 s prokazateln\u011b krat\u0161\u00ed poopera\u010dn\u00ed hospitalizac\u00ed ve srovn\u00e1n\u00ed s klasickou cholecystektomi\u00ed. Je jen v\u011bc\u00ed operat\u00e9ra, aby v obt\u00ed\u017en\u00e9m ter\u00e9nu Calotova troj\u00faheln\u00edku v\u010das zvolil nevynucenou konverzi, kter\u00e1, je-li provedena v\u010das, zabr\u00e1n\u00ed nej\u010dast\u011bj\u0161\u00edm mo\u017en\u00fdm komplikac\u00edm, vypl\u00fdvaj\u00edc\u00edm z nep\u0159ehledn\u00fdch sr\u016fst\u016f v dan\u00e9 oblasti: poran\u011bn\u00ed \u017elu\u010dovod\u016f, nekontrolovan\u00e9mu krv\u00e1cen\u00ed z a. cystica nebo a. hepatica, poran\u011bn\u00ed st\u011bny duodena \u010di tra\u010dn\u00edku. Pokud jsou tyto komplikace \u0159e\u0161eny b\u011bhem jedn\u00e9 operace, nemus\u00ed b\u00fdt n\u00e1sledky z\u00e1va\u017en\u00e9. P\u0159i peropera\u010dn\u011b nepoznan\u00fdch poran\u011bn\u00edch stoup\u00e1 exponenci\u00e1ln\u011b procento ne\u00fasp\u011bch\u016f.<\/p>\n<h4>2.6 Laparoskopick\u00e9 v\u00fdkony na \u017elu\u010dov\u00fdch cest\u00e1ch<\/h4>\n<p style=\"text-align: justify;\">Od roku 1987, kdy provedl Mouret (Francie) prvn\u00ed laparoskopickou cholecystektomii, se tato metoda postupn\u011b stala metodou volby l\u00e9\u010den\u00ed cholecystoliti\u00e1zy. Aby tento v\u00fdkon spl\u0148oval v naprost\u00e9 v\u011bt\u0161in\u011b po\u017eadavky miniinvazivn\u00ed chirurgie \u2013 poopera\u010dn\u00ed komfort s kr\u00e1tkou rekonvalescenc\u00ed a hospitalizac\u00ed, s \u010dasn\u00fdm n\u00e1vratem do pracovn\u00edho procesu a dobr\u00fdm kosmetick\u00fdm efektem, je nutno um\u011bt \u0161etrn\u011b vy\u0159e\u0161it i choledocholiti\u00e1zu, kter\u00e1 se vyskytuje u 5\u201315% nemocn\u00fdch s cholecystoliti\u00e1zou. Sou\u010dasn\u00e9 mo\u017enosti terapie choledocholiti\u00e1zy jsou:<\/p>\n<ul>\n<li>endoskopick\u00e9 odstran\u011bn\u00ed kamen\u016f ze \u017elu\u010dovodu, a to p\u0159ed \u010di po laparoskopick\u00e9 cholecystektomii,<\/li>\n<li>perkut\u00e1nn\u00ed odstran\u011bn\u00ed kamen\u016f transhepaticky \u010di kan\u00e1lkem po T-dr\u00e9nu,<\/li>\n<li>laparoskopick\u00e9 vyjmut\u00ed kamen\u016f,<\/li>\n<li>klasick\u00e1 chirurgick\u00e1 revize \u017elu\u010dov\u00fdch cest s odstran\u011bn\u00edm konkrement\u016f z hepatocholedochu.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Volba nejvhodn\u011bj\u0161\u00ed metody z\u00e1vis\u00ed nejen na stavu konkr\u00e9tn\u00edho nemocn\u00e9ho, ale i na zku\u0161enostech a zvyklostech pracovi\u0161t\u011b. I p\u0159esto, \u017ee se sna\u017e\u00edme sn\u00ed\u017eit nutnost otev\u0159en\u00e9 chirurgick\u00e9 choledocholitotomie na minimum, n\u011bkdy se j\u00ed nevyhneme.<\/p>\n<h6>Indikace<\/h6>\n<p style=\"text-align: justify;\">V\u011bt\u0161inou lze dnes choleliti\u00e1zu vy\u0159e\u0161it pomoci ERCP. Laparoskopickou revizi \u017elu\u010dov\u00fdch cest indikujeme v p\u0159\u00edpad\u011b ne\u00fasp\u011bchu endoskopick\u00e9 extrakce konkrement\u016f z choledochu nebo v p\u0159\u00edpad\u011b n\u00e1hodn\u00e9ho n\u00e1lezu \u0161irok\u00fdch \u017elu\u010dov\u00fdch cest peropera\u010dn\u011b (nedostate\u010dn\u011b vy\u0161et\u0159en\u00fdch p\u0159ed operac\u00ed). Kontraindikace k laparoskopick\u00e9 revizi \u017elu\u010dov\u00fdch cest je u t\u011bch pacient\u016f, kde je laparoskopie obecn\u011b kontraindikov\u00e1na (respira\u010dn\u00ed, ob\u011bhov\u00e1 insuficience atd.). Z chirurgick\u00e9ho hlediska prakticky nem\u00e1 laparoskopick\u00e1 revize \u017elu\u010dov\u00fdch cest kontraindikace. Laparoskopicky toti\u017e m\u016f\u017eeme v dne\u0161n\u00ed dob\u011b prov\u00e9st v\u0161echny v\u00fdkony jako p\u0159i klasick\u00e9 revizi \u017elu\u010dov\u00fdch cest (peropera\u010dn\u00ed cholangiografie a endosonografie, peropera\u010dn\u00ed choledochotomie, peropera\u010dn\u00ed choledochoskopie). Zku\u0161enost s laparoskopick\u00fdmi operacemi je nejd\u016fle\u017eit\u011bj\u0161\u00edm momentem p\u0159i rozhodov\u00e1n\u00ed chirurga, zda revidovat \u017elu\u010dov\u00e9 cesty klasicky \u010di laparoskopicky.<\/p>\n<h6>Opera\u010dn\u00ed technika<\/h6>\n<p style=\"text-align: justify;\">K laparoskopick\u00e9 revizi \u017elu\u010dov\u00fdch cest p\u0159istupujeme v\u011bt\u0161inou po peropera\u010dn\u00ed cholangiografii nebo peropera\u010dn\u00ed endosonografii. Cholangiografii prov\u00e1d\u00edme vpichem speci\u00e1ln\u00ed jehly p\u0159es st\u011bnu b\u0159i\u0161n\u00ed a zaveden\u00edm kat\u00e9tru jehlou do ductus cysticus (obr. 12a,b).Endosonograf zav\u00e1d\u00edme do dutiny b\u0159i\u0161n\u00ed n\u011bkter\u00fdm z ji\u017e zaveden\u00fdch trokar\u016f. Endosonografie se zd\u00e1 b\u00fdt citliv\u011bj\u0161\u00ed metodou v diagnostice liti\u00e1zy \u017elu\u010dov\u00fdch cest.Stiegmann u pacient\u016f s choledocholiti\u00e1zou zd\u016fraznil senzitivitu endosonografie u 89% a peropera\u010dn\u00ed cholangiografie u 53% pacient\u016f. Bohu\u017eel zat\u00edm nen\u00ed endosonografie na v\u0161ech pracovi\u0161t\u00edch dostupn\u00e1. P\u0159i n\u00e1lezu drobn\u00e9 choledocholiti\u00e1zy se sna\u017e\u00edme konkrementy transcysticky extrahovat nebo protla\u010dit do duodena po eventu\u00e1ln\u00ed papilotomii. Postup\u00a0\u00a0vypad\u00e1 tak, \u017ee inciz\u00ed na ductus cysticus po p\u0159edchoz\u00ed cholangiografii zav\u00e1d\u00edme do choledochu Dormia kli\u010dku a sna\u017e\u00edme se extrahovat konkrementy transcysticky (obr. 13).<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" 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\/05\/Image_114.png\"><img decoding=\"async\" title=\"Obr. 12a \u2013 Klip\u00e1\u017e ductus cysticus\" alt=\"Obr. 12a \u2013 Klip\u00e1\u017e ductus cysticus\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_114.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 12a \u2013 Klip\u00e1\u017e ductus cysticus<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" 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\/05\/Image_115.png\"><img decoding=\"async\" title=\"Obr. 12b \u2013 N\u00e1st\u0159ih ductus cysticus, zaveden\u00ed kat\u00e9tru a peropera\u010dn\u00ed cholangiografie\" alt=\"Obr. 12b \u2013 N\u00e1st\u0159ih ductus cysticus, zaveden\u00ed kat\u00e9tru a peropera\u010dn\u00ed cholangiografie\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_115.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 12b \u2013 N\u00e1st\u0159ih ductus cysticus, zaveden\u00ed kat\u00e9tru a peropera\u010dn\u00ed<br \/>cholangiografie<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" 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\/05\/Image_116.png\"><img decoding=\"async\" title=\"Obr. 13 \u2013 Choledochoskopie a extrakce kamenu\" alt=\"Obr. 13 \u2013 Choledochoskopie a extrakce kamenu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_116.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 13 \u2013 Choledochoskopie a extrakce kamenu<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" 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\/05\/Image_118.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 13px; line-height: 19px; text-align: start;\" title=\"Obr. 14 \u2013 Choledochotomie, sutura choledochu bez T-dr\u00e9nu, zaveden\u00ed T-dr\u00e9nu\" alt=\"Obr. 14 \u2013 Choledochotomie, sutura choledochu bez T-dr\u00e9nu, zaveden\u00ed T-dr\u00e9nu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_118.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 14 \u2013 Choledochotomie, sutura choledochu bez T-dr\u00e9nu, zaveden\u00ed T-dr\u00e9nu<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Neusp\u011bjeme-li, pokus\u00edme se stejnou transcystickou cestou protla\u010dit konkrementy do duodena. V p\u0159\u00edpad\u011b ne\u00fasp\u011bchu m\u016f\u017eeme prov\u00e9st papilotomii. Pak je protla\u010den\u00ed konkrement\u016f do duodena daleko jednodu\u0161\u0161\u00ed. Ne\u00fasp\u011bch nebo velikost konkrement\u016f n\u00e1s nut\u00ed k choledochotomii laparoskopicky. D\u00e9lku choledochotomie vol\u00edme podle velikost konkrement\u016f (p\u0159ev\u00e1\u017en\u011b 1,5\u20132 cm). N\u00e1sleduje extrakce konkrement\u016f Dormia kli\u010dkou nebo za kontroly choledochoskopem. Velk\u00e9 konkrementy je mo\u017eno drtit litotryptory r\u016fzn\u00e9ho druhu. P\u0159ed uz\u00e1v\u011brem choledochotomie d\u016fkladn\u011b cholangioskopicky revidujeme \u017elu\u010dov\u00e9 cesty. Ductus choledochus uzav\u00edr\u00e1me v jedn\u00e9 vrstv\u011b \u2013 pokra\u010duj\u00edc\u00edm nebo jednotliv\u00fdmi stehy. Dren\u00e1\u017e \u017elu\u010dov\u00fdch cest je ot\u00e1zkou zvyklosti jednotliv\u00fdch pracovi\u0161\u0165. M\u016f\u017eeme ji prov\u00e9st transcysticky nebo klasicky T-dr\u00e9nem (obr. 14).Nen\u00ed-li p\u0159etlak ve \u017elu\u010dov\u00fdch cest\u00e1ch, prov\u00e1d\u00edme suturu choledochotomie bez dren\u00e1\u017ee. Tento algoritmus laparoskopick\u00e9 revize \u017elu\u010dov\u00fdch cest se ni\u010d\u00edm neli\u0161\u00ed od algoritmu klasick\u00e9 revize. Rozhoduj\u00edc\u00edm faktorem je zase zku\u0161enost chirurga u laparoskopick\u00fdch operac\u00ed.Nej\u010dast\u011bj\u0161\u00ed komplikac\u00ed p\u0159i laparoskopick\u00e9 revizi \u017elu\u010dov\u00fdch cest jsou rezidu\u00e1ln\u00ed konkrementy a insuficience choledochotomie s \u00fanikem \u017elu\u010de do dutiny b\u0159i\u0161n\u00ed. Jako prevenci rezidu\u00e1ln\u00ed choledocholiti\u00e1zy prov\u00e1d\u00edme v\u017edy p\u0159ed ukon\u010den\u00edm z\u00e1kroku podle mo\u017enost\u00ed kontroln\u00ed cholangiografii nebo cholangioskopii nebo endosonografick\u00e9 vy\u0161et\u0159en\u00ed \u017elu\u010dov\u00fdch cest. V p\u0159\u00edpad\u011b pozitivn\u00edho n\u00e1lezu z\u00e1le\u017e\u00ed na chirurgovi,\u00a0zda se rozhodne k opakovan\u00e9 laparoskopick\u00e9 revizi, endoskopick\u00e9 revizi \u010di revizi klasick\u00e9. Postup je ur\u010dit\u011b z\u00e1visl\u00fd od zku\u0161enost\u00ed chirurga a zvyklost\u00ed pracovi\u0161t\u011b. Dal\u0161\u00ed komplikac\u00ed je insuficience choledochotomie, kterou m\u016f\u017eeme zase podle zku\u0161enost\u00ed chirurga a zvyklost\u00ed pracovi\u0161t\u011b o\u0161et\u0159it endoskopicky (stenty), laparoskopicky (resutura, T-dr\u00e9n, dren\u00e1\u017e okol\u00ed) nebo klasicky (stejn\u00fd postup). M\u00e9n\u011b \u010dast\u00fdmi komplikacemi p\u0159i laparoskopick\u00e9 revizi \u017elu\u010dov\u00fdch cest jsou poran\u011bn\u00ed okoln\u00edch org\u00e1n\u016f (j\u00e1tra, \u017ealudek, duodenum, br\u00e1nice).<\/p>\n<h6>V\u00fdsledky<\/h6>\n<p style=\"text-align: justify;\">Choledocholiti\u00e1za se vyskytuje u 5\u201315% nemocn\u00fdch s cholecystoliti\u00e1zou. V 90% se poda\u0159\u00ed extrahovat konkrementy endoskopicky. Ve zb\u00fdvaj\u00edc\u00edch 10% jsme nuceni revidovat \u017elu\u010dov\u00e9 cesty laparoskopicky nebo klasicky. Nejd\u016fle\u017eit\u011bj\u0161\u00edm faktorem je p\u0159i rozhodov\u00e1n\u00ed zku\u0161enost chirurga-laparoskopisty a zvyklost pracovi\u0161t\u011b. V ka\u017ed\u00e9m p\u0159\u00edpad\u011b mus\u00ed b\u00fdt laparoskopick\u00e1 revize \u017elu\u010dov\u00fdch cest prov\u00e1d\u011bna na pracovi\u0161t\u00edch s v\u00fdborn\u00fdm technick\u00fdm vybaven\u00edm (endosonograf, cholangioskop atd.) a hlavn\u011b odborn\u011b fundovan\u00fdm a zku\u0161en\u00fdm person\u00e1lem. P\u0159i \u0159e\u0161en\u00ed choledocholiti\u00e1zy je d\u016fle\u017eit\u00e1 \u010dasn\u00e1 diagnostika, nejl\u00e9pe p\u0159edopera\u010dn\u00ed, a d\u00e1le pak spolupr\u00e1ce endoskopisty se zku\u0161en\u00fdm chirurgem-laparoskopistou.<\/p>\n<h4>2.7 Konverze a klasick\u00e1 cholecystektomie<\/h4>\n<p style=\"text-align: justify;\">I v dne\u0161n\u00ed dob\u011b, kdy se prov\u00e1d\u00ed v\u00edce ne\u017e 95% cholecystektomi\u00ed laparoskopicky, mus\u00ed zku\u0161en\u00fd chirurg ovl\u00e1dat klasick\u00fd p\u0159\u00edstup \u2013 klasickou cholecystektomii a klasickou revizi \u017elu\u010dov\u00fdch cest.Uvedeme proto z\u00e1kladn\u00ed klasick\u00e9 v\u00fdkony, kter\u00e9 by m\u011bl prov\u00e1d\u011bt zku\u0161en\u00fd chirurg na dan\u00e9m pracovi\u0161ti, nebo by m\u011bl b\u00fdt pacient transportov\u00e1n do centra, kter\u00e9 m\u00e1 s t\u011bmito komplikacemi zku\u0161enosti \u2013 v\u017edy se toti\u017e jedn\u00e1 o pacienta, v\u017edy se toti\u017e m\u016f\u017ee jednat o jeho \u017eivot.Proto zm\u00edn\u00edme z\u00e1sady otev\u0159en\u00fdch klasick\u00fdch v\u00fdkon\u016f, kter\u00e9 plat\u00ed po\u0159\u00e1d.<\/p>\n<ul>\n<li style=\"text-align: justify;\">Anterogr\u00e1dn\u00ed cholecystektomie, p\u0159i kter\u00e9 odstra\u0148ujeme \u017elu\u010dn\u00edk od fundu subperitone\u00e1ln\u011b tak, \u017ee na\u0159\u00edzneme u jater ser\u00f3zu fundu \u017elu\u010dn\u00edku a ten postupn\u011b vyloupneme z jatern\u00edho l\u016f\u017eka, tak\u017ee z\u016fstane viset na cystick\u00e9 arterii a cystiku, kter\u00e9 se po odst\u0159i\u017een\u00ed \u017elu\u010dn\u00edku podv\u00e1\u017eou. Nebezpe\u010d\u00ed t\u00e9to metody, zejm\u00e9na p\u0159i mnoho\u010detn\u00e9 cholecystoliti\u00e1ze, je v mo\u017enosti zatla\u010den\u00ed konkrement\u016f pr\u016fchodn\u00fdm cystikem do choledochu.<\/li>\n<li style=\"text-align: justify;\">Retrogr\u00e1dn\u00ed cholecystektomie spo\u010d\u00edv\u00e1 v p\u0159\u00edstupu opa\u010dn\u00e9m: nalezen\u00ed, vypreparov\u00e1n\u00ed a podvaz arteria cystika a ductus cystikus, po jejich p\u0159eru\u0161en\u00ed se \u017elu\u010dn\u00edk odstra\u0148uje sm\u011brem od kr\u010dku k fundu. Tento zp\u016fsob zaji\u0161\u0165uje p\u0159ehlednost opera\u010dn\u00edho pole a oz\u0159ejm\u011bn\u00ed struktur v ligamentu hepatoduoden\u00e1ln\u00edm p\u0159ed samotnou cholecystektomi\u00ed. Pou\u017eit\u00ed jednoho nebo druh\u00e9ho zp\u016fsobu z\u00e1le\u017e\u00ed p\u0159edev\u0161\u00edm na zvyklostech a zku\u0161enostech toho kter\u00e9ho pracovi\u0161t\u011b a opera\u010dn\u00ed situace u dan\u00e9ho pacienta.<\/li>\n<\/ul>\n<p>Nebezpe\u010d\u00ed cholecystektomie m\u016f\u017ee b\u00fdt v poran\u011bn\u00ed spole\u010dn\u00e9ho hepatiku, junkce hepatik\u016f, choledochu, p\u0159edev\u0161\u00edm v\u0161ak arteria hepatica propria a jej\u00ed prav\u00e9 v\u011btve, n\u011bkdy i vena portae. Tato poran\u011bn\u00ed mohou b\u00fdt podm\u00edn\u011bna i \u010dast\u00fdmi anom\u00e1liemi v pr\u016fb\u011bhu t\u011bchto struktur, zt\u00ed\u017een\u00fdm p\u0159ehledem p\u0159i p\u0159em\u00edst\u011bn\u00ed anatomick\u00fdch \u00fatvar\u016f poz\u00e1n\u011btliv\u00fdmi sr\u016fsty nebo jindy operov\u00e1n\u00edm bez z\u00edsk\u00e1n\u00ed nutn\u00e9ho p\u0159ehledu v opera\u010dn\u00edm poli.<\/p>\n<p>Obecn\u011b plat\u00ed: nem\u00e1me-li jistotu bezpe\u010dn\u00e9ho laparoskopick\u00e9ho v\u00fdkonu, konvertujeme a \u0159e\u0161\u00edme situaci ku prosp\u011bchu pacienta.<\/p>\n<ul>\n<li style=\"text-align: justify;\">Cholecystoanastom\u00f3zy biliodigestivn\u00ed jsou paliativn\u00ed v\u00fdkony, jimi\u017e obch\u00e1z\u00edme p\u0159ek\u00e1\u017eku ve \u017elu\u010dov\u00fdch cest\u00e1ch a dosahujeme odtoku \u017elu\u010de do za\u017e\u00edvac\u00edho traktu a vymizen\u00ed ikteru. \u017dlu\u010dn\u00edk lze spojit se \u017ealudkem (cholecystogastroanastom\u00f3za), s duodenem (cholecystoduodenoanastom\u00f3za) (obr. 15) nebo s jejunem (cholecystojejunoanastom\u00f3za) (obr. 16). P\u0159i v\u0161ech t\u011bchto v\u00fdkonech ukl\u00e1d\u00e1me do podjatern\u00ed krajiny dr\u00e9n, kter\u00fd slou\u017e\u00ed k odv\u00e1d\u011bn\u00ed \u017elu\u010de nebo krve. Dr\u00e9n odstra\u0148ujeme za 48 hodin, jestli\u017ee z n\u011bj nen\u00ed vylu\u010dov\u00e1na patologick\u00e1 sekrece. P\u0159ed t\u011bmito anastom\u00f3zami maj\u00ed dnes jednozna\u010dn\u011b p\u0159ednost endoskopick\u00e9 v\u00fdkony: stenty a dren\u00e1\u017ee \u017elu\u010dov\u00fdch cest.<\/li>\n<\/ul>\n<p>Choledochotomie: otev\u0159en\u00ed \u017elu\u010dovodu, dopln\u011bn\u00e9 exploraci \u017elu\u010dov\u00fdch cest.Indikace k revizi choledochu:<\/p>\n<ul>\n<li style=\"text-align: justify;\">prokazateln\u00e9 konkrementy, kter\u00e9 nem\u016f\u017eeme endoani laparoskopicky extrahovat,<\/li>\n<li style=\"text-align: justify;\">obstruk\u010dn\u00ed ikterus a cholangoitida ne\u0159e\u0161iteln\u00e9\u00a0endo\u010di laparoskopicky,<\/li>\n<li style=\"text-align: justify;\">cholangiograficky p\u0159edopera\u010dn\u011b a peropera\u010dn\u011b\u00a0prok\u00e1zan\u00e9 konkrementy v choledochu nelze endo-ani laparoskopicky extrahovat,<\/li>\n<li style=\"text-align: justify;\">dilatace hepatocholedochu a sten\u00f3zy papily ne\u0159e\u0161iteln\u00e9 endoskopicky.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Choledochotomii pak d\u011bl\u00e1me v supraduoden\u00e1ln\u00edm \u00faseku choledochu v\u011bt\u0161inou pod\u00e9ln\u011b v dlouh\u00e9 ose\u017elu\u010dovodu. Instrument\u00e1ln\u011b pomoc\u00ed Bake\u0161ovy sondy se pak vy\u0161et\u0159\u00ed jak intrahepatick\u00e9, tak extrahepatick\u00e9 \u017elu\u010dov\u00e9 cesty. Konkrementy se odstra\u0148uj\u00ed kle\u0161t\u011bmi, l\u017ei\u010dkami, Fogartyho kat\u00e9trem \u010di Dormiovou kli\u010dkou a tak\u00e9 v\u00fdplachy.V\u00fdkon mus\u00ed b\u00fdt v\u017edy ukon\u010den zji\u0161t\u011bn\u00edm pr\u016fchodnosti papily jej\u00ed sond\u00e1\u017e\u00ed. Je\u0161t\u011b peropera\u010dn\u011b lze prov\u00e9st cholangiografickou kontrolu pomoc\u00ed balonkem zakl\u00edn\u011bn\u00e9 c\u00e9vky, a to sm\u011brem proxim\u00e1ln\u00edm a dist\u00e1ln\u00edm, nebo prohl\u00e9dnout \u017elu\u010dovody pomoc\u00ed choledochoskopu, kter\u00fd nav\u00edc dovoluje c\u00edlen\u00fd odb\u011br materi\u00e1lu k bioptick\u00e9mu vy\u0161et\u0159en\u00ed (nap\u0159. z papily). Choledochotomie se pak uzav\u00edr\u00e1 vodot\u011bsn\u011b atraumatick\u00fdmi stehy bu\u010f prim\u00e1rn\u011b cel\u00e1, nebo se pak do choledochu vkl\u00e1d\u00e1 do\u010dasn\u00e1 dren\u00e1\u017e (nej\u010dast\u011bji se u\u017e\u00edv\u00e1 Kehr\u016fv T-dr\u00e9n) (obr. 17), kter\u00e1 slou\u017e\u00ed:<\/p>\n<ol>\n<li style=\"text-align: justify;\">k dekompresi \u017elu\u010dov\u00fdch cest v poopera\u010dn\u00edm obdob\u00ed, kdy se n\u00e1sledkem instrument\u00e1ln\u00edho vy\u0161et\u0159en\u00ed papily p\u0159edpokl\u00e1d\u00e1 jej\u00ed ed\u00e9m a spazmus sfinkteru a stoup\u00e1 tlak ve \u017elu\u010dovodech,<\/li>\n<li style=\"text-align: justify;\">ke kontroln\u00ed cholangiografii, a to hned po uzav\u0159en\u00ed choledochu (sekund\u00e1rn\u00ed peropera\u010dn\u00ed cholangiografie) a d\u00e1le v sedm\u00e9m a\u017e des\u00e1t\u00e9m dni po operaci jako poopera\u010dn\u00ed cholangiografie,<\/li>\n<li style=\"text-align: justify;\">k instrument\u00e1ln\u00edmu odstran\u011bn\u00ed mo\u017en\u00fdch ponechan\u00fdch kamen\u016f,<\/li>\n<li style=\"text-align: justify;\">k dekompresi u cholangoitid, pankreatitid nebo p\u0159i podez\u0159en\u00ed na ponechanou p\u0159ek\u00e1\u017eku.Jakmile se obnov\u00ed po operaci norm\u00e1ln\u00ed funkce za\u017e\u00edvac\u00edho traktu, za\u010dneme T-dr\u00e9n postupn\u011b zav\u00edrat (asi od 5. poopera\u010dn\u00edho dne) a po cholangiografick\u00e9 kontrole jej odstran\u00edme (kolem 10. dne). \u017dlu\u010dov\u00e1 p\u00ed\u0161t\u011bl,\u00a0kter\u00e1 po jeho odstran\u011bn\u00ed zbude, se uzav\u0159e spont\u00e1nn\u011b, jestli\u017ee je voln\u00fd odtok \u017elu\u010de do duodena.Papilosfinkterotomie je v\u00fdkon na papile a Oddiho sv\u011bra\u010di (obr. 18). P\u0159i papilotomii jde o prot\u011bt\u00ed papil\u00e1rn\u00ed \u010d\u00e1sti a p\u0159i papilosfinkterotomii je\u0161t\u011b nav\u00edc o prot\u011bt\u00ed (v\u011bt\u0161inou \u010d\u00e1ste\u010dn\u00e9) Oddiho sv\u011bra\u010de. Dnes se tyto v\u00fdkony prov\u00e1d\u011bj\u00ed v\u00fdlu\u010dn\u011b endoskopicky, v\u00fdjime\u010dn\u011b chirurgicky.<\/li>\n<\/ol>\n<p style=\"text-align: justify;\">Indikace: kam\u00e9nky zakl\u00edn\u011bn\u00e9 v termin\u00e1ln\u00ed \u010d\u00e1sti \u017elu\u010dovodu, kter\u00e9 nelze odstranit shora z choledochotomie, vypadnou po sfinkterotomii zpravidla rychle do duodena.<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" 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\/05\/Image_120.png\"><img decoding=\"async\" title=\"Obr. 15 \u2013 Cholecystoduodenoanastom\u00f3za; 1 \u2013 \u017ealudek 2 \u2013 duodenum 3 \u2013 blokuj\u00edc\u00ed n\u00e1dor 4 \u2013 \u017elu\u010dn\u00edk\" alt=\"Obr. 15 \u2013 Cholecystoduodenoanastom\u00f3za; 1 \u2013 \u017ealudek 2 \u2013 duodenum 3 \u2013 blokuj\u00edc\u00ed n\u00e1dor 4 \u2013 \u017elu\u010dn\u00edk\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_120.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 15 \u2013 Cholecystoduodenoanastom\u00f3za;<br \/>1 \u2013 \u017ealudek<br \/>2 \u2013 duodenum<br \/>3 \u2013 blokuj\u00edc\u00ed n\u00e1dor<br \/>4 \u2013 \u017elu\u010dn\u00edk<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" 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\/05\/Image_121.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 16 \u2013 Cholecystojejunoanastom\u00f3za s enteroenteroanastom\u00f3zou podle Brauna; 1 \u2013 duodenum 2 \u2013 blokuj\u00edc\u00ed n\u00e1dor 3 \u2013 \u017elu\u010dn\u00edk 4 \u2013 jejunum\" alt=\"Obr. 16 \u2013 Cholecystojejunoanastom\u00f3za s enteroenteroanastom\u00f3zou podle Brauna; 1 \u2013 duodenum 2 \u2013 blokuj\u00edc\u00ed n\u00e1dor 3 \u2013 \u017elu\u010dn\u00edk 4 \u2013 jejunum\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_121.png\" width=\"200\" height=\"220\" \/><\/a><p class=\"wp-caption-text\">Obr. 16 \u2013 Cholecystojejunoanastom\u00f3za<br \/>s enteroenteroanastom\u00f3zou podle Brauna;<br \/>1 \u2013 duodenum<br \/>2 \u2013 blokuj\u00edc\u00ed n\u00e1dor<br \/>3 \u2013 \u017elu\u010dn\u00edk<br \/>4 \u2013 jejunum<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" 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\/05\/Image_122.png\"><img decoding=\"async\" title=\"Obr. 17 \u2013 Dren\u00e1\u017e choledochu T-dr\u00e9nem \u2013 ulo\u017een\u00ed dr\u00e9nu a sutura choledochotomie; 1 \u2013 hepatocholedochus 2 \u2013 st\u011bna b\u0159i\u0161n\u00ed 3 \u2013 T-dr\u00e9n\" alt=\"Obr. 17 \u2013 Dren\u00e1\u017e choledochu T-dr\u00e9nem \u2013 ulo\u017een\u00ed dr\u00e9nu a sutura choledochotomie; 1 \u2013 hepatocholedochus 2 \u2013 st\u011bna b\u0159i\u0161n\u00ed 3 \u2013 T-dr\u00e9n\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_122.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 17 \u2013 Dren\u00e1\u017e choledochu T-dr\u00e9nem \u2013<br \/>ulo\u017een\u00ed dr\u00e9nu a sutura choledochotomie;<br \/>1 \u2013 hepatocholedochus<br \/>2 \u2013 st\u011bna b\u0159i\u0161n\u00ed<br \/>3 \u2013 T-dr\u00e9n<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" 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\/05\/Image_124.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 13px; line-height: 19px; text-align: start;\" title=\"Obr. 18 \u2013 Papilosfinkterotomie po otev\u0159en\u00ed st\u011bny duodena (sch\u00e9ma \u0159ezu papily na zaveden\u00e9 sond\u011b)\" alt=\"Obr. 18 \u2013 Papilosfinkterotomie po otev\u0159en\u00ed st\u011bny duodena (sch\u00e9ma \u0159ezu papily na zaveden\u00e9 sond\u011b)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_124.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 18 \u2013 Papilosfinkterotomie po otev\u0159en\u00ed st\u011bny duodena (sch\u00e9ma<br \/>\u0159ezu papily na zaveden\u00e9 sond\u011b)<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Anastom\u00f3zy hepatocholedochu s n\u011bkterou \u010d\u00e1st\u00ed za\u017e\u00edvac\u00edho traktu (\u017ealudkem, duodenem, jejunem) jsou indikov\u00e1ny (obr. 19a,b, 20a,b):<\/p>\n<ul>\n<li style=\"text-align: justify;\">u kongenit\u00e1ln\u00edch atr\u00e9zi\u00ed operabiln\u00edho typu a u cystick\u00fdch dilatac\u00ed hepatocholedochu,<\/li>\n<li style=\"text-align: justify;\">u striktur dist\u00e1ln\u00edch \u010d\u00e1st\u00ed choledochu po jeho poran\u011bn\u00ed a z\u00e1n\u011btech,<\/li>\n<li style=\"text-align: justify;\">u chronick\u00fdch pankreatitid se sten\u00f3zou pankreatick\u00e9 \u010d\u00e1sti choledochu a s dilatac\u00ed jeho proxim\u00e1ln\u00edho \u00faseku,<\/li>\n<li style=\"text-align: justify;\">u mnoho\u010detn\u00fdch konkrement\u016f v nitrojatern\u00edch v\u00fdvodech, kter\u00e9 nelze peropera\u010dn\u011b odstranit,<\/li>\n<li style=\"text-align: justify;\">u inoperabiln\u00edch n\u00e1dor\u016f hlavy pankreatu, papily nebo termin\u00e1ln\u00edho choledochu, kter\u00e9 p\u016fsob\u00ed obstrukci \u017elu\u010dovodu.<\/li>\n<\/ul>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" 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\/05\/Image_125.png\"><img loading=\"lazy\" decoding=\"async\" class=\" \" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 13px; line-height: 19px; text-align: start;\" title=\"Obr. 19 \u2013 Hepatikojejunoanastom\u00f3za a) s enteroenteroanastom\u00f3zou podle Brauna (1 \u2013 kli\u010dka or\u00e1ln\u00ed), b) s enteroenteroanastom\u00f3zou podle Rouxe (1 \u2013 kli\u010dka or\u00e1ln\u00ed)\" alt=\"Obr. 19 \u2013 Hepatikojejunoanastom\u00f3za a) s enteroenteroanastom\u00f3zou podle Brauna (1 \u2013 kli\u010dka or\u00e1ln\u00ed), b) s enteroenteroanastom\u00f3zou podle Rouxe (1 \u2013 kli\u010dka or\u00e1ln\u00ed)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_125.png\" width=\"200\" height=\"141\" \/><\/a><p class=\"wp-caption-text\">Obr. 19 \u2013 Hepatikojejunoanastom\u00f3za<br \/>a) s enteroenteroanastom\u00f3zou<br \/>podle Brauna<br \/>(1 \u2013 kli\u010dka or\u00e1ln\u00ed),<br \/>b) s enteroenteroanastom\u00f3zou<br \/>podle Rouxe<br \/>(1 \u2013 kli\u010dka or\u00e1ln\u00ed)<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" 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\/05\/Image_126.png\"><img decoding=\"async\" class=\" \" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 13px; line-height: 19px; text-align: start;\" title=\"Obr. 20 \u2013 Choledochoduodenoanastom\u00f3za a) otev\u0159en\u00ed choledochu a duodena, b) zalo\u017een\u00ed anastom\u00f3zy\" alt=\"Obr. 20 \u2013 Choledochoduodenoanastom\u00f3za a) otev\u0159en\u00ed choledochu a duodena, b) zalo\u017een\u00ed anastom\u00f3zy\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_126.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 20 \u2013 Choledochoduodenoanastom\u00f3za<br \/>a) otev\u0159en\u00ed choledochu a duodena,<br \/>b) zalo\u017een\u00ed anastom\u00f3zy<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Proveden\u00ed: nejv\u00fdhodn\u011bj\u0161\u00ed, z hlediska prevence vzestupn\u00e9 cholangoitidy, je choledochojejunoanastom\u00f3za nebo hepatikojejunoanastom\u00f3za s vy\u0159azenou (z pas\u00e1\u017ee) jejun\u00e1ln\u00ed kli\u010dkou podle Rouxe \u2013 tzv. Y anastom\u00f3za, kterou u\u017e\u00edv\u00e1me jako definitivn\u00ed \u0159e\u0161en\u00ed p\u0159i defektu \u017elu\u010dovodu podm\u00edn\u011bn\u00e9m benign\u00ed p\u0159\u00ed\u010dinou, tedy po jeho poran\u011bn\u00ed, vyt\u011bt\u00ed, dlouhodob\u00fdch z\u00e1n\u011btliv\u00fdch striktur\u00e1ch apod. (obr. 19b).V ostatn\u00edch p\u0159\u00edpadech se nej\u010dast\u011bji u\u017e\u00edv\u00e1 choledochoduodenoanastom\u00f3za (obr. 20) a jen v\u00fdjime\u010dn\u011b choledochogastroanastom\u00f3za, ob\u011b zalo\u017een\u00e9 laterolater\u00e1ln\u011b.<\/p>\n<p style=\"text-align: justify;\">Anastom\u00f3zy hilov\u00e9 jsou indikov\u00e1ny prim\u00e1rn\u011b p\u0159i vrozen\u00fdch sten\u00f3z\u00e1ch a atr\u00e9zi\u00edch hepatiku, p\u0159i jeho opera\u010dn\u00edm poran\u011bn\u00ed nebo po resekci n\u00e1doru spole\u010dn\u00e9ho hepatiku nebo cystiku a nej\u010dast\u011bji p\u0159i reoperac\u00edch pro striktury a zevn\u00ed p\u00ed\u0161t\u011ble hepatiku zavin\u011bn\u00e9 p\u0159edchoz\u00edm v\u00fdkonem nebo tak\u00e9 p\u0159i obstrukci d\u0159\u00edve zalo\u017een\u00e9 biliodigestivn\u00ed anastom\u00f3zy s hepatikem.<\/p>\n<p style=\"text-align: justify;\">Jde v\u011bt\u0161inou o anastom\u00f3zu s kli\u010dkou jejuna, do kter\u00e9 se v\u00fast\u00ed soutok obou hepatik\u016f (obr. 19), p\u0159\u00edpadn\u011b ka\u017ed\u00fd hepatikus zvl\u00e1\u0161\u0165, jestli\u017ee je po\u0161kozen\u00ed vysoko. Tyto anastom\u00f3zy se zakl\u00e1daj\u00ed v\u011bt\u0161inou na modeluj\u00edc\u00edm dr\u00e9nu, kter\u00fd se odstran\u00ed po n\u011bkolika m\u011bs\u00edc\u00edch. Bylo o nich ji\u017e tak\u00e9 pojedn\u00e1no v souvislost\u00ed s o\u0161et\u0159en\u00edm poran\u011bn\u00ed \u017elu\u010dov\u00fdch cest (obr. 10).<\/p>\n<p style=\"text-align: justify;\">Anastom\u00f3zy intrahepat\u00e1ln\u00ed se zakl\u00e1daj\u00ed u vrozen\u00fdch atr\u00e9zi\u00ed intrahepat\u00e1ln\u00edch jako nejist\u00fd pokus o z\u00e1chranu d\u00edt\u011bte nebo u jin\u00fdch sten\u00f3z vysoko v jatern\u00edm hilu, kter\u00e9 jsou nedostupn\u00e9 k zalo\u017een\u00ed anastom\u00f3z d\u0159\u00edve uveden\u00fdch. Ve v\u011bt\u0161in\u011b p\u0159\u00edpad\u016f se na\u0161\u00edv\u00e1 exkludovan\u00e1 Rouxova kli\u010dka (obr. 21).<\/p>\n<p style=\"text-align: justify;\">Dal\u0161\u00ed indikac\u00ed jsou zhoubn\u00e9 n\u00e1dory s obstruk\u010dn\u00ed \u017eloutenkou, lokalizovan\u00e9 v hepatocholedochu nebo ve spojen\u00ed hepatik\u016f, jestli\u017ee v j\u00e1trech nen\u00ed rozsev metast\u00e1z. Jde tu o spojen\u00ed intraparechymat\u00f3zn\u011b ulo\u017een\u00fdch jatern\u00edch v\u00fdvod\u016f s kli\u010dkou jejuna. Jeliko\u017e sev\u011bt\u0161inou jedn\u00e1 o velmi nep\u0159\u00edznivou progn\u00f3zu, d\u00e1v\u00e1me p\u0159ednost \u0161etrn\u00e9 endoskopick\u00e9 stent\u00e1\u017ei (8).<\/p>\n<h4>2.8 Laparoskopick\u00e1 cholecystektomie v re\u017eimu jednodenn\u00ed chirurgie<\/h4>\n<p style=\"text-align: justify;\">Prvn\u00ed zpr\u00e1vu o laparoskopicky proveden\u00e9 cholecystektomii v re\u017eimu jednodenn\u00ed chirurgie publikovali v roce 1990 E. J. Reddick a D. O. Olsen.Za\u0159azen\u00ed laparoskopick\u00e9 cholecystektomie do re\u017eimu jednodenn\u00ed chirurgie nen\u00ed zat\u00edm na mnoh\u00fdch chirurgick\u00fdch pracovi\u0161t\u00edch b\u011b\u017en\u011b akceptov\u00e1no. Umo\u017en\u011bn\u00ed t\u00e9to l\u00e9\u010dby nemocn\u00fdm se symptomatickou cholecystoliti\u00e1zou je vhodn\u00e9 na pracovi\u0161t\u00edch s velmi n\u00edzk\u00fdm v\u00fdskytem komplikac\u00ed. Pacienti mohou b\u00fdt spolehliv\u011b a bezpe\u010dn\u011b propu\u0161t\u011bni v den opera\u010dn\u00edho v\u00fdkonu, eventu\u00e1ln\u011b do 24 hodin po jeho ukon\u010den\u00ed.<\/p>\n<h6>Klinick\u00fd soubor<\/h6>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_128.png\"><img decoding=\"async\" title=\"Obr. 21 \u2013 Anastom\u00f3za hilov\u00e1 a) roz\u0161\u00ed\u0159en\u00ed \u017elu\u010dovodu n\u00e1st\u0159ihem lev\u00e9ho hepatiku, b) po zalo\u017een\u00ed anastom\u00f3zy s kli\u010dkou jejuna\" alt=\"Obr. 21 \u2013 Anastom\u00f3za hilov\u00e1 a) roz\u0161\u00ed\u0159en\u00ed \u017elu\u010dovodu n\u00e1st\u0159ihem lev\u00e9ho hepatiku, b) po zalo\u017een\u00ed anastom\u00f3zy s kli\u010dkou jejuna\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_128.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 21 \u2013 Anastom\u00f3za hilov\u00e1<br \/>a) roz\u0161\u00ed\u0159en\u00ed \u017elu\u010dovodu n\u00e1st\u0159ihem lev\u00e9ho hepatiku,<br \/>b) po zalo\u017een\u00ed anastom\u00f3zy s kli\u010dkou jejuna<\/p><\/div>\n<p style=\"text-align: justify;\">V Centru miniinvazivn\u00ed chirurgie Nemocnice Podles\u00ed v T\u0159inci byla prvn\u00ed laparoskopick\u00e1 cholecystektomie provedena 3. prosince 1991. Po nutn\u00e9 stavebn\u00ed \u00faprav\u011b nemocnice a opera\u010dn\u00edch s\u00e1l\u016f bylo vybudov\u00e1no Centrum jednodenn\u00ed chirurgie, kde nedoch\u00e1z\u00ed ke k\u0159\u00ed\u017een\u00ed ambulantn\u00ed a nemocni\u010dn\u00ed \u010d\u00e1sti zdravotnick\u00e9ho za\u0159\u00edzen\u00ed. N\u00e1sledn\u011b od za\u010d\u00e1tku roku 2003 byla zah\u00e1jena i l\u00e9\u010dba pacient\u016f s choleliti\u00e1zou v r\u00e1mci programu jednodenn\u00ed chirurgie.K jednodenn\u00ed chirurgick\u00e9 l\u00e9\u010db\u011b jsou indikov\u00e1ni p\u0159\u00edsn\u011b selektovan\u00ed pacienti spl\u0148uj\u00edc\u00ed anesteziologick\u00e1, chirurgick\u00e1 a soci\u00e1ln\u00ed krit\u00e9ria a samoz\u0159ejm\u011b souhlas\u00edc\u00ed s t\u00edmto l\u00e9\u010debn\u00fdm postupem.Pacienti indikovan\u00ed k jednodenn\u00ed cholecystektomii byli v\u017edy za\u0159azeni na \u00favod opera\u010dn\u00edho programu. Opera\u010dn\u00ed skupinu tvo\u0159\u00ed chirurg s asistentem, instrumentuj\u00edc\u00ed sestra a anesteziolog s anesteziologickou sestrou.<\/p>\n<p style=\"text-align: justify;\">Na tomto pracovi\u0161ti byly operace prov\u00e1d\u011bny ve \u201efrancouzsk\u00e9 pozici\u201c. Operat\u00e9r stoj\u00ed mezi nohama pacienta. Subhepat\u00e1ln\u00ed dren\u00e1\u017e je zakl\u00e1d\u00e1na v\u011bt\u0161inou pro kr\u00e1tkodobou kontrolu d\u016fkladnosti vykonan\u00e9 hemost\u00e1zy p\u0159i nutnosti koagulace v l\u016f\u017eku po cholecystektomii. Antibiotick\u00e1 profylaxe byla indikov\u00e1na individu\u00e1ln\u011b. Poopera\u010dn\u011b byl pacient ulo\u017een ke sledov\u00e1n\u00ed na l\u016f\u017eko Centra jednodenn\u00ed chirurgie. Do dom\u00e1c\u00ed p\u00e9\u010de byl propu\u0161t\u011bn po kontrole anesteziologem a chirurgem a po pohovoru s n\u00edm a s jeho doprov\u00e1zej\u00edc\u00ed osobou. Sou\u010dasn\u011b byla informov\u00e1na agentura dom\u00e1c\u00ed p\u00e9\u010de.<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" 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\/05\/Image_130.png\"><img decoding=\"async\" title=\"Graf 1 \u2013 Rozd\u011blen\u00ed souboru pacient\u016f podle v\u011bku (n = 93)\" alt=\"Graf 1 \u2013 Rozd\u011blen\u00ed souboru pacient\u016f podle v\u011bku (n = 93)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_130.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Graf 1 \u2013 Rozd\u011blen\u00ed souboru pacient\u016f podle v\u011bku (n = 93)<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" 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\/05\/Image_131.png\"><img decoding=\"async\" title=\"Graf 2 \u2013 Rozd\u011blen\u00ed souboru pacient\u016f podle t\u011blesn\u00e9 hmotnosti \u2013 BMI (kg\/m2) (n = 93)\" alt=\"Graf 2 \u2013 Rozd\u011blen\u00ed souboru pacient\u016f podle t\u011blesn\u00e9 hmotnosti \u2013 BMI (kg\/m2) (n = 93)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_131.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Graf 2 \u2013 Rozd\u011blen\u00ed souboru pacient\u016f podle t\u011blesn\u00e9 hmotnosti \u2013 BMI (kg\/m2) (n = 93)<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Prvn\u00ed poopera\u010dn\u00ed den r\u00e1no pacienta nav\u0161t\u00edvila zdravotn\u00ed sestra spolupracuj\u00edc\u00ed agentury dom\u00e1c\u00ed p\u00e9\u010de, kter\u00e1 n\u00e1sledn\u011b informovala l\u00e9ka\u0159e Centra jednodenn\u00ed chirurgie o stavu operovan\u00e9ho. Kontrola v na\u0161em zdravotnick\u00e9m za\u0159\u00edzen\u00ed se v\u011bt\u0161inou uskute\u010dnila 7. a 21. poopera\u010dn\u00ed den.<\/p>\n<p style=\"text-align: justify;\">Prvn\u00ed laparoskopick\u00e1 cholecystektomie byla v programu jednodenn\u00ed chirurgie provedena na na\u0161em pracovi\u0161ti 27. \u00fanora 2003. Od 27. \u00fanora 2003 do 30. \u010dervna 2006 jsme tento opera\u010dn\u00ed postup v l\u00e9\u010db\u011b cholecystoliti\u00e1zy pl\u00e1novali u 93 pacient\u016f, tj. u 15,4%ze v\u0161ech 618 nemocn\u00fdch indikovan\u00fdch v tomto obdob\u00ed k pl\u00e1novan\u00e9 \u010di urgentn\u00ed laparoskopick\u00e9 cholecystektomii. V prezentovan\u00e9m souboru operovan\u00fdch bylo 72 \u017een a 21 mu\u017e\u016f. V den operace ode\u0161lo do dom\u00e1c\u00edho o\u0161et\u0159en\u00ed 84 pacient\u016f, u 9 operovan\u00fdch bylo nutn\u00e9 setrv\u00e1n\u00ed na l\u016f\u017eku zdravotnick\u00e9ho za\u0159\u00edzen\u00ed prvn\u00ed poopera\u010dn\u00ed noc. Tito pacienti byli propu\u0161t\u011bni do dom\u00e1c\u00ed p\u00e9\u010de prvn\u00ed poopera\u010dn\u00ed den r\u00e1no, v\u0161ichni do 24 hodin od ukon\u010den\u00ed opera\u010dn\u00edho v\u00fdkonu.<\/p>\n<p style=\"text-align: justify;\">V prezentovan\u00e9m souboru dominovali pacienti mezi \u010dty\u0159iceti a pades\u00e1ti lety, kte\u0159\u00ed tvo\u0159ili dohromady 61,3% operovan\u00fdch. Bli\u017e\u0161\u00ed rozd\u011blen\u00ed souboru pacient\u016f podle v\u011bku ukazuje graf 1.K jednodenn\u00ed laparoskopick\u00e9 cholecystektomii jsou indikov\u00e1ni zejm\u00e9na pacienti s ni\u017e\u0161\u00edm opera\u010dn\u00edm rizikem za\u0159azen\u00ed do kategorie ASA I a II. V na\u0161em souboru bylo operov\u00e1no 14 pacient\u016f klasifikace ASA I (15,0%), 65 pacient\u016f ASA II (69,9%), 13 pacient\u016f ASA III (14,0%) a 1 pacient s ASA IV (1,1%). Operovan\u00fd pacient s ASA IV byl v\u0161ak po operaci po zhodnocen\u00ed stavu ponech\u00e1n prvn\u00ed poopera\u010dn\u00ed noc v na\u0161em zdravotnick\u00e9m za\u0159\u00edzen\u00ed.Norm\u00e1ln\u00ed t\u011blesnou hmotnost m\u011blo 48,4% operovan\u00fdch, nadv\u00e1hu m\u011blo 36,6% a ob\u00e9zn\u00edch bylo 9,7% pacient\u016f. Rozd\u011blen\u00ed souboru pacient\u016f podle t\u011blesn\u00e9 hmotnosti zn\u00e1zor\u0148uje graf 2.<\/p>\n<h6>V\u00fdsledky<\/h6>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_132.png\"><img decoding=\"async\" title=\"Graf 3 \u2013 Po\u010det operac\u00ed v jednotliv\u00fdch letech\" alt=\"Graf 3 \u2013 Po\u010det operac\u00ed v jednotliv\u00fdch letech\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_132.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Graf 3 \u2013 Po\u010det operac\u00ed v jednotliv\u00fdch letech<\/p><\/div>\n<p style=\"text-align: justify;\">Z 93 pacient\u016f, u kter\u00fdch jsme provedli laparoskopickou cholecystektomii v programu jednodenn\u00ed chirurgie, ode\u0161lo do dom\u00e1c\u00edho o\u0161et\u0159en\u00ed 84 pacient\u016f (90,3%) v den opera\u010dn\u00edho v\u00fdkonu. U 9 operovan\u00fdch (9,7%) jsme se rozhodli pro prodlou\u017een\u00ed pobytu na l\u016f\u017eku Centra jednodenn\u00ed chirurgie o prvn\u00ed poopera\u010dn\u00ed noc. D\u016fvodem k tomuto rozhodnut\u00ed byla u p\u011bti pacient\u016f vy\u0161\u0161\u00ed serosanguinolentn\u00ed produkce do subhepat\u00e1ln\u011b lokalizovan\u00e9ho dr\u00e9nu. Dva operovan\u00ed m\u011bli poopera\u010dn\u011b v\u00fdrazn\u011bj\u0161\u00ed bolestivou reakci. U jednoho pacienta jsme se rozhodli k tomuto postupu vzhledem k z\u00e1va\u017en\u00e9 komorbidit\u011b (ASA IV). Jeden operovan\u00fd z\u016fstal ve zdravotnick\u00e9m za\u0159\u00edzen\u00ed na vlastn\u00ed \u017e\u00e1dost ze strachu p\u0159ed mo\u017en\u00fdmi komplikacemi. V\u0161ech dev\u011bt\u00a0pacient\u016f v\u0161ak bylo propu\u0161t\u011bno do dom\u00e1c\u00ed p\u00e9\u010de prvn\u00ed poopera\u010dn\u00ed den, tzn. do 24 hodin od ukon\u010den\u00ed opera\u010dn\u00edho v\u00fdkonu. Ani u jednoho operovan\u00e9ho jsme nezaznamenali peropera\u010dn\u00ed komplikaci a takt\u00e9\u017e \u017e\u00e1dn\u00fd z pacient\u016f nemusel b\u00fdt rehospitalizov\u00e1n (graf 3).V histopatologick\u00e9m n\u00e1lezu byly ve 45 prepar\u00e1tech p\u0159\u00edtomny zn\u00e1mky chronick\u00e9 cholecystitidy, ve 45 p\u0159\u00edpadech nebyl pops\u00e1n chronick\u00fd ani akutn\u00ed z\u00e1n\u011bt a ve t\u0159ech prepar\u00e1tech byl p\u0159\u00edtomen n\u00e1lez akutn\u00edho flegmon\u00f3zn\u00edho z\u00e1n\u011btu.V\u00fdhoda pro pacienty s choleliti\u00e1zou operovan\u00e9 v programu jednodenn\u00ed chirurgie spo\u010d\u00edv\u00e1 ve v\u00fdrazn\u011bj\u0161\u00edm pohodl\u00ed. U takov\u00e9hoto typu operace je v\u0161ak nutn\u00e9 precizn\u00ed pl\u00e1nov\u00e1n\u00ed ve snaze vyhnout se vzniku komplikac\u00ed. Zku\u0161enosti publikovan\u00e9 r\u016fzn\u00fdmi autory a srovnan\u00e9 s autory na\u0161imi jsou shrnuty v tabulce 1.Potenci\u00e1ln\u00edmi bari\u00e9rami pro uskute\u010dn\u011bn\u00ed jednodenn\u00edho programu jsou medic\u00ednsk\u00e9, subjektivn\u00ed a institucion\u00e1ln\u00ed p\u0159ek\u00e1\u017eky. Medic\u00ednsk\u00fdmi bari\u00e9rami jsou zejm\u00e9na komorbidita pacienta, poopera\u010dn\u00edbolest a zvracen\u00ed v poopera\u010dn\u00edm obdob\u00ed, kter\u00e9 jsou p\u0159ek\u00e1\u017ekami propu\u0161t\u011bn\u00ed nemocn\u00e9ho v den opera\u010dn\u00edho v\u00fdkonu. P\u0159ek\u00e1\u017ekou p\u0159i indikaci k t\u00e9to l\u00e9\u010db\u011b v jednodenn\u00edm re\u017eimu m\u016f\u017ee b\u00fdt rovn\u011b\u017e \u0161patn\u00e1 multidisciplin\u00e1rn\u00ed komunikace a nedostate\u010dn\u00e1 spolupr\u00e1ce ze strany pacienta p\u0159i pl\u00e1nov\u00e1n\u00ed.<\/p>\n<div style=\"width: 480px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_134.jpg\"><img loading=\"lazy\" decoding=\"async\" title=\"Tab. 1 \u2013 Publikovan\u00e9 sestavy laparoskopick\u00fdch cholecystektomi\u00ed v jednodenn\u00edm re\u017eimu (podle Czudek 2009)\" alt=\"Tab. 1 \u2013 Publikovan\u00e9 sestavy laparoskopick\u00fdch cholecystektomi\u00ed v jednodenn\u00edm re\u017eimu (podle Czudek 2009)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_134.jpg\" width=\"470\" height=\"581\" \/><\/a><p class=\"wp-caption-text\">Tab. 1 \u2013 Publikovan\u00e9 sestavy<br \/>laparoskopick\u00fdch cholecystektomi\u00ed<br \/>v jednodenn\u00edm re\u017eimu<br \/>(podle Czudek 2009)<\/p><\/div>\n<p style=\"text-align: justify;\"><span style=\"text-align: justify;\">Oponenti ambulantn\u00ed laparoskopick\u00e9 cholecystektomie argumentuj\u00ed mo\u017en\u00fdm rizikem \u010dasn\u00fdch v\u00e1\u017en\u00fdch poopera\u010dn\u00edch komplikac\u00ed, jak\u00fdmi jsou nap\u0159. krv\u00e1cen\u00ed z arteria cystica nebo z l\u016f\u017eka po odstran\u011bn\u00ed \u017elu\u010dn\u00edku. Pr\u00e1v\u011b p\u0159i obav\u011b z mo\u017en\u00e9ho rizika je v\u0161ak vhodn\u00e9 ponechat pacienta prvn\u00ed poopera\u010dn\u00ed noc ke sledov\u00e1n\u00ed na l\u016f\u017eku zdravotnick\u00e9ho za\u0159\u00edzen\u00ed a propustit ho a\u017e po 24 hodin\u00e1ch od ukon\u010den\u00ed opera\u010dn\u00edho v\u00fdkonu po vylou\u010den\u00ed mo\u017en\u00e9 komplikace. U takto sledovan\u00fdch pacient\u016f nen\u00ed statisticky v\u00fdznamn\u00fd rozd\u00edl ve vzniku komplikac\u00ed v porovn\u00e1n\u00ed se skupinou pacient\u016f hospitalizovan\u00fdch poopera\u010dn\u011b t\u0159i a\u017e \u010dty\u0159i dny.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"text-align: justify;\">Campanelli a kol. ve sv\u00e9 pr\u00e1ci p\u0159edkl\u00e1daj\u00ed n\u00e1vrh na selekci skupiny pacient\u016f indikovan\u00fdch k lapa<\/span>roskopick\u00e9 cholecystektomii s mo\u017en\u00fdm za\u0159azen\u00edm do programu jednodenn\u00ed chirurgie. Krit\u00e9riem pro za\u0159azen\u00ed pacienta do takov\u00e9ho programu m\u00e1 b\u00fdt v\u011bk pod 70 let, ASA I a II, index t\u011blesn\u00e9 hmotnosti (BMI) men\u0161\u00ed ne\u017e 35, nep\u0159\u00edtomn\u00fd anamnestick\u00fd \u00fadaj o obstruk\u010dn\u00edm ikteru, nepravd\u011bpodobn\u00e1 p\u0159\u00edtomnost choledocholiti\u00e1zy a samoz\u0159ejm\u011b souhlas pacienta s takto vedenou l\u00e9\u010dbou. Jako krit\u00e9rium pro vy\u0159azen\u00ed z programu jednodenn\u00ed chirurgie ud\u00e1vaj\u00ed v\u011bk nad 70 let, ASA III a IV<i>, <\/i>index t\u011blesn\u00e9 hmotnosti (BMI) v\u011bt\u0161\u00ed ne\u017e 35, akutn\u00ed cholecystitidu, pozitivn\u00ed anamn\u00e9zu obstruk\u010dn\u00edho ikteru a strach pacienta z takto proveden\u00e9 operace. Nevhodn\u00fd k za\u0159azen\u00ed je i pacient \u017eij\u00edc\u00ed o samot\u011b, pacient, kter\u00fd bydl\u00ed ve velk\u00e9 vzd\u00e1lenosti od nemocnice \u010di nem\u00e1 k dispozici telefon.Podle Voylesa a kol. jsou nej\u010dast\u011bj\u0161\u00edmi p\u0159\u00ed\u010dinami neza\u0159azen\u00ed pacienta do re\u017eimu ambulantn\u00ed operace akutn\u00ed cholecystitida, v\u011bk nad 65 let, pl\u00e1novan\u00fd sdru\u017een\u00fd opera\u010dn\u00ed v\u00fdkon, vysok\u00e9 riziko mo\u017en\u00e9 choledocholiti\u00e1zy, p\u0159idru\u017een\u00e9 onemocn\u011bn\u00ed operovan\u00e9ho, obezita a gravidita. Ale i u pacient\u016f s vy\u0161\u0161\u00edm opera\u010dn\u00edm rizikem dan\u00fdm v\u011bkem pacienta a p\u0159idru\u017een\u00fdmi onemocn\u011bn\u00edmi je laparoskopick\u00e1 cholecystektomie v re\u017eimu ambulantn\u00ed chirurgie ch\u00e1p\u00e1na jako metoda mo\u017en\u00e1 a bezpe\u010dn\u00e1. Tato skupina pacient\u016f je v\u0161ak zat\u00ed\u017eena signifikantn\u011b vy\u0161\u0161\u00edm rizikem nutn\u00e9 zm\u011bny poopera\u010dn\u00ed strategie ve smyslu ponech\u00e1n\u00ed pacienta v nemocni\u010dn\u00ed p\u00e9\u010di.<\/p>\n<p style=\"text-align: justify;\">Voitk ve sv\u00e9 pr\u00e1ci uv\u00e1d\u00ed nutnost takov\u00e9to zm\u011bny a\u017e u 28% operovan\u00fdch vysoce rizikov\u00fdch pacient\u016f. V na\u0161em souboru byl do re\u017eimu ambulantn\u00ed cholecystektomie za\u0159azen jeden pacient s ASA IV, kter\u00fd v\u0161ak byl po operaci na z\u00e1klad\u011b zhodnocen\u00ed stavu ponech\u00e1n prvn\u00ed poopera\u010dn\u00ed noc ve zdravotnick\u00e9m za\u0159\u00edzen\u00ed. U tohoto operovan\u00e9ho u\u017e samotn\u00e1 indikace k ambulantn\u00ed cholecystektomii byla problematick\u00e1.Pr\u016fm\u011brn\u00e1 doba nutn\u00e9ho sledov\u00e1n\u00ed operovan\u00fdch na poopera\u010dn\u00edm pokoji je ud\u00e1v\u00e1na od 180 minut do 7,5 hodiny. Fiorello a kol. ud\u00e1vaj\u00ed jako prediktivn\u00ed faktor \u00fasp\u011b\u0161n\u00e9ho \u010dasn\u00e9ho propu\u0161t\u011bn\u00ed pacienta trv\u00e1n\u00ed opera\u010dn\u00edho v\u00fdkonu. U skupiny ambulantn\u011b operovan\u00fdch pacient\u016f trval opera\u010dn\u00ed v\u00fdkon pr\u016fm\u011brn\u011b 62 minut oproti 82 minut\u00e1m ve skupin\u011b pacient\u016f ponechan\u00fdch na l\u016f\u017eku poopera\u010dn\u00edho pokoje po dobu cel\u00e9 noci. P\u0159ibli\u017en\u011b 20% laparoskopicky operovan\u00fdch pacient\u016f v re\u017eimu jednodenn\u00ed chirurgie preferuje setrv\u00e1n\u00ed na l\u016f\u017eku zdravotnick\u00e9ho za\u0159\u00edzen\u00ed po dobu prvn\u00ed noci po operaci. Robinson a kol. ud\u00e1vaj\u00ed mo\u017enost ambulantn\u00ed laparoskopick\u00e9 cholecystektomie u 70% z neselektovan\u00e9ho souboru pacient\u016f operovan\u00fdch v Denver Health Medical Center.<\/p>\n<p style=\"text-align: justify;\">Skattum a kol. v prospektivn\u00ed studii prezentuj\u00ed soubor 1060 pacient\u016f operovan\u00fdch v obdob\u00ed 10 let v re\u017eimu jednodenn\u00ed chirurgie. U 9,9% operovan\u00fdch byla nutn\u00e1 hospitalizace a u 6,6% po prim\u00e1rn\u00edm propu\u0161t\u011bn\u00ed pak rehospitalizace. Nej\u010dast\u011bj\u0161\u00ed p\u0159\u00ed\u010dinou p\u0159ijet\u00ed pacienta k rehospitalizaci byly v\u0161eobecn\u00e9 symptomy, jako jsou bolest, nauzea \u010di \u00fanava.<\/p>\n<p style=\"text-align: justify;\">Zegarra a kol. ve sv\u00e9 pr\u00e1ci porovn\u00e1vaj\u00ed finan\u010dn\u00ed n\u00e1klady na l\u00e9\u010dbu pacienta v re\u017eimu ambulantn\u00ed chirurgie s pacientem, u kter\u00e9ho je nutn\u00fd pobyt na l\u016f\u017eku po dobu prvn\u00ed noci. U pacienta propu\u0161t\u011bn\u00e9ho bez nutnosti setrv\u00e1n\u00ed na l\u016f\u017eku ud\u00e1v\u00e1 a\u017e 35% redukci ceny (12 000$). Arregui a kol. ud\u00e1vaj\u00ed rozd\u00edl v cen\u011b 501 $ mezi ambulantn\u011b l\u00e9\u010den\u00fdm nemocn\u00fdm a pacientem s 23-hodinovou observac\u00ed na l\u016f\u017eku. Farha a kol. ud\u00e1vaj\u00ed pr\u016fm\u011brnou cenu na pacienta operovan\u00e9ho v centru ambulantn\u00ed chirurgie 2300 $ oproti 6500 $ vynalo\u017een\u00fdch pr\u016fm\u011brn\u011b na laparoskopicky operovan\u00e9ho v sousedn\u00ed v\u0161eobecn\u00e9 nemocnici.<\/p>\n<h6>Z\u00e1v\u011br<\/h6>\n<p style=\"text-align: justify;\">Laparoskopick\u00e1 cholecystektomie m\u016f\u017ee b\u00fdt provedena bezpe\u010dn\u011b u selektovan\u00e9 skupiny pacient\u016f za\u0159azen\u00fdch do syst\u00e9mu ambulantn\u00ed chirurgie. Pacienti indikovan\u00ed k t\u00e9to l\u00e9\u010db\u011b v\u0161ak mus\u00ed b\u00fdt d\u016fkladn\u011b vybr\u00e1ni a pou\u010deni. Takt\u00e9\u017e chirurg prov\u00e1d\u011bj\u00edc\u00ed operaci mus\u00ed m\u00edt dostate\u010dn\u00e9 zku\u0161enosti s laparoskopick\u00fdmi operacemi. Zaji\u0161t\u011bn\u00ed bezpe\u010dnosti opera\u010dn\u00edho v\u00fdkonu a dosa\u017een\u00ed dobr\u00fdch v\u00fdsledk\u016f nez\u00e1vis\u00ed jen na chirurgicko-patologick\u00e9m n\u00e1lezu, ale i na individu\u00e1ln\u00edm p\u0159\u00edstupu, vhodn\u00e9 a precizn\u00ed opera\u010dn\u00ed technice a pl\u00e1novan\u00e9 poopera\u010dn\u00ed analgetick\u00e9 l\u00e9\u010db\u011b a na velmi \u00fazk\u00e9 spolupr\u00e1ci Centra jednodenn\u00ed chirurgie se syst\u00e9mem Home Care p\u00e9\u010de.<\/p>\n<h4>2.9 Literatura<\/h4>\n<ol>\n<li style=\"text-align: justify;\">Arregui ME, Navarrete JL, Davis CJ, Hammond JC, Barkeu J. The Evolving Role of ERCP and Laparoscopic Common Bile Duct. Exploration in the Era of Laparoscopic Cholecystectomy. Int Surg. 1994;79:188\u2013194.<\/li>\n<li style=\"text-align: justify;\">Baigrie RJ, Krahenbuhl L, Dowling BL. Laparoscopic Cholangiography through the gallbladder. J Am Coll Surg. 1994;178:175\u2013176.<\/li>\n<li style=\"text-align: justify;\">Cushieri A, Dubois F, Mouiel J, Mouret P. The European Experience with Laparoscopic Cholecystectomy. Am J Surg. 1991;161:385\u2013387.<\/li>\n<li style=\"text-align: justify;\">Czudek S, Kubiczek J, Brann\u00fd J. Laparoskopick\u00e1 cholecystektomie a choledocholithiasa. Rozhl Chir. 1993;72(3):103\u2013105.<\/li>\n<li style=\"text-align: justify;\">Czudek S. Jednodenn\u00ed chirurgie. Praha: Grada;2009.<\/li>\n<li style=\"text-align: justify;\">Duda M, Czudek S, edito\u0159i. Mininvazivn\u00ed chirurgie. T\u0159inec: Nemocnice Podles\u00ed; 1996.<\/li>\n<li style=\"text-align: justify;\">Duda M, Gryga A, Dlouh\u00fd M, \u0160vach I, Moc\u0148\u00e1kov\u00e1 M. Nov\u00e1 \u00e9ra l\u00e9\u010dby cholelithiasy. \u010cs Slov Gastroent. 1996;50(5):161\u2013165.<\/li>\n<li style=\"text-align: justify;\">Dostal\u00edk J, Kv\u011btensk\u00fd M, Mart\u00ednek L, Mr\u00e1zek T.Prvn\u00ed zku\u0161enosti s laparoskopickou cholecystektomi\u00ed. Rozhl Chir. 1992;71:373\u2013377.<\/li>\n<li style=\"text-align: justify;\">Niederle B. Chirurgie \u017elu\u010dov\u00fdch cest. Praha: Avicenum; 1977, s. 794.<\/li>\n<li style=\"text-align: justify;\">Pa\u0165ha J, Louda V, Krbec J. Na\u0161e prvn\u00ed zku\u0161enosti s laparoskopickou cholecystektomi\u00ed. Rozhl Chir.1992;71:378\u2013381.<\/li>\n<li style=\"text-align: justify;\">Proch\u00e1zka V, Kone\u010dn\u00fd M, Kr\u00e1l, V, Duda M, Fialov\u00e1 J. ERCP v diagnostice a l\u00e9\u010db\u011b bili\u00e1rn\u00edch komplikac\u00ed laparoskopick\u00e9 cholecystektomie. \u010ces SlovGastroent. 1999;53(5):140\u2013144.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>2.1 \u00davod Cholecystektomie pat\u0159\u00ed k nej\u010dast\u011bj\u0161\u00edm operac\u00edm na chirurgick\u00fdch pracovi\u0161t\u00edch. Po\u010d\u00edt\u00e1 se k v\u00fdkon\u016fm st\u0159edn\u011b obt\u00ed\u017en\u00fdm a od roku 1892, kdy ji Langenbuch provedl poprv\u00e9, se na technice prakticky nic nezm\u011bnilo. Po 100 letech v roce 1987 prof. Mouret v Lyonu ve Francii zah\u00e1jil laparoskopickou cholecystektomi\u00ed revoluci v technice operov\u00e1n\u00ed. Pr\u00e1v\u011b cholecystektomie se uk\u00e1zala jako [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":2447,"menu_order":2,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-2516","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2516","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=2516"}],"version-history":[{"count":22,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2516\/revisions"}],"predecessor-version":[{"id":3055,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2516\/revisions\/3055"}],"up":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2447"}],"wp:attachment":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2516"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}