{"id":2566,"date":"2013-05-21T09:47:52","date_gmt":"2013-05-21T09:47:52","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=2566"},"modified":"2013-06-11T16:18:04","modified_gmt":"2013-06-11T16:18:04","slug":"3-onemocneni-apendixu-a-meckelova-divertiklu","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=2566","title":{"rendered":"3 Onemocn\u011bn\u00ed apendixu a Meckelova divertiklu"},"content":{"rendered":"<h4>3.1 Onemocn\u011bn\u00ed apendixu<\/h4>\n<h5>3.1.1 Anatomick\u00e9 pozn\u00e1mky<\/h5>\n<p style=\"text-align: justify;\">Apendix (<i>\u010dervovit\u00fd p\u0159\u00edv\u011bsek, processus vermicularis, <\/i>laicky <i>\u201eslep\u00e9 st\u0159evo\u201c<\/i>) odstupuje z b\u00e1ze c\u00e9ka v m\u00edst\u011b, kde se spojuj\u00ed jednotliv\u00e9 t\u00e9nie. To je d\u016fle\u017eit\u00e1 orienta\u010dn\u00ed pom\u016fcka p\u0159i hled\u00e1n\u00ed \u010derva, kter\u00fd je ulo\u017een atypicky, nebo v ter\u00e9nu zm\u011bn\u011bn\u00e9m pokro\u010dil\u00fdm z\u00e1n\u011btem, kter\u00fd ji\u017e p\u0159estoupil na okol\u00ed. D\u00e9lka a ulo\u017een\u00ed apendixu jsou velmi variabiln\u00ed. Nej\u010dast\u011bj\u0161\u00ed jeho ulo\u017een\u00ed jsou: <i>subcek\u00e1ln\u00ed, pelvick\u00e9, ileocek\u00e1ln\u00ed<\/i>. Celkem \u010dasto je ulo\u017een <i>subserozn\u011b, sub-, retronebo laterocek\u00e1ln\u011b<\/i>. Jeho \u0161pi\u010dka \u2013 apex \u2013 m\u016f\u017ee dosahovat a\u017e ke spodin\u011b jater, v retroperitoneu se m\u016f\u017ee dot\u00fdkat mo\u010dovodu, v mal\u00e9 p\u00e1nvi m\u016f\u017ee m\u00edt intimn\u00ed vztah k mo\u010dov\u00e9mu m\u011bch\u00fd\u0159i, u \u017een k adnex\u016fm. P\u0159i nadm\u011brn\u00e9 pohyblivosti c\u00e9ka, tzv. <i>c\u00e9kum mobile, <\/i>se pak m\u016f\u017ee nach\u00e1zet v kter\u00e9mkoliv m\u00edst\u011b v dutin\u011b b\u0159i\u0161n\u00ed. Tato skute\u010dnost je jednou z p\u0159\u00ed\u010din \u010dasto netypick\u00fdch p\u0159\u00edznak\u016f a velmi obt\u00ed\u017en\u00e9 diagnostiky. Vz\u00e1cn\u00e1 je ageneze apendixu, \u010dasto spojen\u00e1 s jin\u00fdmi anom\u00e1liemi za\u017e\u00edvac\u00edho traktu. V\u00fdjime\u010dn\u00e1 je i duplicita \u010dervovit\u00e9ho v\u00fdb\u011b\u017eku. Po narozen\u00ed obsahuje st\u011bna apendixu velk\u00e9 mno\u017estv\u00ed lymfatick\u00e9 tk\u00e1n\u011b. Postupnou vazivovou p\u0159estavbou se jej\u00ed mno\u017estv\u00ed b\u011bhem adolescence redukuje.<\/p>\n<h5>3.1.2 Apendicitida a dal\u0161\u00ed onemocn\u011bn\u00ed \u010dervovit\u00e9ho p\u0159\u00edv\u011bsku<\/h5>\n<p style=\"text-align: justify;\">Nej\u010dast\u011bj\u0161\u00edm onemocn\u011bn\u00edm apendixu je jeho z\u00e1n\u011bt \u2013 appendicitis. M\u016f\u017ee b\u00fdt tak\u00e9 posti\u017een \u0159adou dal\u0161\u00edch patologi\u00ed, jako Crohnovou chorobou, z dal\u0161\u00edch benign\u00edch zm\u011bn je to mukok\u00e9la a pot\u00ed\u017ee vyvolan\u00e9 cizopasn\u00edkem \u2013 \u0161krkavkou. Vz\u00e1cn\u011bj\u0161\u00ed je n\u00e1lez karcinoidu v jeho benign\u00ed nebo malign\u00ed podob\u011b. Sporadick\u00fd je v t\u00e9to lokalizaci v\u00fdskyt adenokarcinomu.<\/p>\n<h6>Appendicitis acuta<\/h6>\n<p style=\"text-align: justify;\">Z\u00e1n\u011bt \u010dervovit\u00e9ho v\u00fdb\u011b\u017eku je \u010dast\u00fdm onemocn\u011bn\u00edm a jednou z nej\u010dast\u011bj\u0161\u00edch diagn\u00f3z na chirurgick\u00fdch odd\u011blen\u00edch. <i>\u201ePr\u016fb\u011bh z\u00e1n\u011btu \u010derva je nevypo\u010ditateln\u00fd a potm\u011b\u0161il\u00fd, proto mus\u00ed b\u00fdt do jasn\u00e9ho rozhodnut\u00ed o l\u00e9\u010db\u011b hodinu od hodiny kontrolov\u00e1n\u201c <\/i>(prof. Arnold Jir\u00e1sek: N\u00e1hl\u00e9 p\u0159\u00edhody b\u0159i\u0161n\u00ed).Je nej\u010dast\u011bj\u0161\u00ed z\u00e1n\u011btlivou p\u0159\u00edhodou b\u0159i\u0161n\u00ed, kter\u00e1 postihne b\u011bhem \u017eivota v\u00edce jak 10% populace se st\u00e1le vysokou letalitou a\u017e 3%. Diagnostika je nejobt\u00ed\u017en\u011bj\u0161\u00ed u d\u011bt\u00ed do 5 let a u senior\u016f. U obou v\u011bkov\u00fdch skupin prob\u00edh\u00e1 v\u011bt\u0161inou netypicky.Faktory, kter\u00e9 se pod\u00edlej\u00ed na vzniku apendicitidy, jsou: lok\u00e1ln\u00ed zmno\u017een\u00ed lymfatick\u00e9 tk\u00e1n\u011b (hlavn\u011b u d\u011bt\u00ed a adolescent\u016f), porucha evakuace apendixu do c\u00e9ka (fibr\u00f3zn\u00ed zm\u011bny, d\u00e9lka a ulo\u017een\u00ed, koprolit, cizopasn\u00edci). V dne\u0161n\u00ed dob\u011b je st\u00e1le \u010dast\u011bji uzn\u00e1v\u00e1n vliv dysmikrobie navozen\u00e9 nadu\u017e\u00edv\u00e1n\u00edm antibiotik.<\/p>\n<ul>\n<li style=\"text-align: justify;\"><strong>Patologick\u00fd n\u00e1lez<br \/>\n<\/strong>Nejjednodu\u0161\u0161\u00ed formou z\u00e1n\u011btu je katar\u00e1ln\u00ed apendicitis: appendicitis catarrhalis. Dal\u0161\u00edm stupn\u011bm je flegm\u00f3na. O pokro\u010dilosti flegm\u00f3ny sv\u011bd\u010d\u00ed fibrinov\u00e9 n\u00e1lety na st\u011bn\u011b \u010derva a v jeho bl\u00edzk\u00e9m okol\u00ed. Gangren\u00f3zn\u00edzm\u011bny mohou postihnout apendix cel\u00fd nebo jen n\u011bkterou jeho \u010d\u00e1st. Dal\u0161\u00edm stupn\u011bm je potom perforace \u2013 appendicitis perforans. Z\u00e1n\u011btem zm\u011bn\u011bn\u00e1 st\u011bnaapendixu vede k pros\u00e1knut\u00ed seropurulentn\u00edho v\u00fdpotku do okol\u00ed, kde je p\u0159\u00ed\u010dinou ohrani\u010den\u00e9 nebo difuzn\u00ed peritonitidy. Infekt a z\u00e1n\u011bt, kter\u00e9 nejsou tak agresivn\u00ed, vedou k vytvo\u0159en\u00ed periapendikul\u00e1rn\u00edho infiltr\u00e1tu. V tomto p\u0159\u00edpad\u011b je nemocn\u00fd apendix zaobalen fibrinem, omentem a kli\u010dkami tenk\u00e9ho st\u0159eva a mluv\u00edme o z\u00e1n\u011btliv\u00e9m tumoru. U mal\u00fdch d\u011bt\u00ed vzhledem ke kr\u00e1tk\u00e9mu a graciln\u00edmu omentu je tato mo\u017enost ohrani\u010den\u00ed z\u00e1n\u011btu \u010derva prakticky vylou\u010dena. Pokud \u010derv do infiltr\u00e1tu perforuje, vyvine se periapendikul\u00e1rn\u00ed absces. Perforace apendixu m\u016f\u017ee b\u00fdt zp\u016fsobena za ur\u010dit\u00fdch anatomick\u00fdch p\u0159edpoklad\u016f ciz\u00edm t\u011blesem.<\/li>\n<li style=\"text-align: justify;\"><strong style=\"text-align: justify;\">Klinick\u00e9 projevy<br \/>\n<\/strong>Apendicitida vznik\u00e1 v\u011bt\u0161inou n\u00e1hle. Obecn\u00fdmi p\u0159\u00edznaky jsou nevolnost a zvracen\u00ed, kter\u00e9 nep\u0159in\u00e1\u0161\u00ed \u00falevu. Neur\u010dit\u00fd tlak ve st\u0159edn\u00edm mezogastriu se postupn\u011b p\u0159esouv\u00e1 do prav\u00e9ho podb\u0159i\u0161ku a p\u0159itom se m\u011bn\u00ed na st\u00e1lou bolest. Tato se zhor\u0161uje p\u0159i pohybu, zv\u00fd\u0161en\u00ed intraabdomin\u00e1ln\u00edho tlaku a p\u0159i nap\u011bt\u00ed st\u011bny b\u0159i\u0161n\u00ed p\u0159i ka\u0161li. S rozvojem onemocn\u011bn\u00ed se objevuje bolest v Mac-Burneyov\u011b nebo Lanzov\u011b bodu (Mac-Burney\u016fv bod je na hranici zevn\u00edch t\u0159etin spojnice mezi pupkem a spina iliaca vpravo, Lanz\u016fv bod na rozhran\u00ed dvou t\u0159etin vpravo na bispin\u00e1ln\u00ed linii). P\u0159i vy\u0161et\u0159en\u00ed lze vyvolat bolestivou reakci a sta\u017een\u00ed svalstva na pohmat a poklep (znamen\u00ed Pleniesovo). Bolest p\u0159i dekompresi st\u011bny b\u0159i\u0161n\u00ed (Blumbergovo znamen\u00ed \u2013 dekomprese v prav\u00e9m pod\u017eeb\u0159\u00ed a Rovsingovo znamen\u00ed \u2013 dekomprese v lev\u00e9m podb\u0159i\u0161ku), nebo dokonce svalov\u00e9 sta\u017een\u00ed (d\u00e9fense musculaire) ji\u017e sv\u011bd\u010d\u00ed pro \u0161\u00ed\u0159en\u00ed z\u00e1n\u011btu do okol\u00ed, z\u00e1n\u011bt pob\u0159i\u0161nice (peritonitis).<br \/>\nTachykardie neodpov\u00edd\u00e1 v\u011bt\u0161inou jen lehce zv\u00fd\u0161en\u00e9 teplot\u011b. D\u0159\u00edve byl d\u00e1v\u00e1n v\u00fdznam Lennanderovu znamen\u00ed (teplotn\u00ed rozd\u00edl v podpa\u017e\u00ed a v rektu ve prosp\u011bch teploty nam\u011b\u0159en\u00e9 v kone\u010dn\u00edku + 1,6\u20132 \u00b0C) Toto jsou typick\u00e9 projevy onemocn\u011bn\u00ed.<\/li>\n<li><strong style=\"text-align: justify;\">Z\u00e1n\u011bt u atypicky ulo\u017een\u00e9ho apendixu m\u00e1 n\u011bkter\u00e9 specifick\u00e9 projevy:<\/strong>\n<ul>\n<li><span style=\"text-align: justify;\">pelvick\u00e1 apendicitis se \u010dasto projevuje stranguri\u00ed (bolest p\u0159i mo\u010den\u00ed, \u010dast\u00e9 nep\u0159\u00edjemn\u00e9 nucen\u00ed na mo\u010den\u00ed), n\u00e1lezem erytrocyt\u016f v mo\u010dov\u00e9m sedimentu, pr\u016fjmy. P\u0159i vy\u0161et\u0159en\u00ed per rektum nemocn\u00fd ud\u00e1v\u00e1 bolest p\u0159i tlaku \u0161pi\u010dky ukazov\u00e1ku na st\u011bnu rekt\u00e1ln\u00ed ampuly;<\/span><\/li>\n<li>\u00a0ileocek\u00e1ln\u00ed nebo mez oceliak\u00e1ln\u00ed apendicitis b\u00fdv\u00e1 diagnosticky obt\u00ed\u017en\u00e1. V pop\u0159ed\u00ed b\u00fdv\u00e1 poslechov\u00fd a RTG n\u00e1lez par\u00e9zy a zn\u00e1mek lehk\u00e9ho subileu, netypick\u00e1 bolest bez vyj\u00e1d\u0159en\u00e9ho peritone\u00e1ln\u00edho dr\u00e1\u017ed\u011bn\u00ed. Postupn\u011b nar\u016fstaj\u00ed z\u00e1n\u011btliv\u00e9 laboratorn\u00ed markery. Nen\u00ed v\u00fdjimkou, \u017ee takov\u00e1 apendicitis se manifestuje a\u017e ve chv\u00edli komplikace: mezikli\u010dkov\u00fdmi abscesy;<\/li>\n<li>retrocek\u00e1ln\u00ed ulo\u017een\u00ed zan\u00edcen\u00e9ho \u010derva vyvol\u00e1v\u00e1 nauzeu, bolest sp\u00ed\u0161e v mezogastriu. Pokud nemocn\u00e9ho ulo\u017e\u00edme na lev\u00fd bok s napjatou lehce zano\u017eenou pravou doln\u00ed kon\u010detinou, later\u00e1ln\u011b od Mac-Burneyova bodu vyvol\u00e1me tlakem bolest.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p style=\"padding-left: 30px; text-align: justify;\"><strong><em>Apendicitida d\u011btsk\u00e9ho v\u011bku<\/em><\/strong> je p\u0159\u00ed\u010dinou NPB u d\u011bt\u00ed v 90%. Prob\u00edh\u00e1 velmi rychle a dramaticky. Dominantn\u00edm p\u0159\u00edznakem m\u016f\u017ee b\u00fdt zvracen\u00ed.<\/p>\n<p style=\"padding-left: 30px; text-align: justify;\">Pokud dojde k perfora\u010dn\u00ed peritonitid\u011b, jde o komplikaci, kter\u00e1 kon\u010d\u00ed fat\u00e1ln\u011b a\u017e ve 30% (v literatu\u0159e n\u011bkdy uv\u00e1d\u011bno a\u017e 50%).<\/p>\n<p style=\"padding-left: 30px; text-align: justify;\">Mal\u00e9 neklidn\u00e9 d\u00edt\u011b lze vy\u0161et\u0159it v n\u00e1ru\u010d\u00ed matky. Sledujeme zorni\u010dky. D\u011bti z obavy z nemocnice pot\u00ed\u017ee dissimuluj\u00ed. Na bolest zp\u016fsobenou man\u00e9vry p\u0159i vy\u0161et\u0159en\u00ed b\u0159\u00ed\u0161ka reaguj\u00ed miozou (Torrek\u016fv p\u0159\u00edznak). U mal\u00fdch chlapc\u016f palpace b\u0159icha p\u0159i NPB vyvol\u00e1 povyta\u017een\u00ed varlete (Rychl\u00edkovo znamen\u00ed).<\/p>\n<p style=\"padding-left: 30px; text-align: justify;\"><strong>Sta\u0159eck\u00e1 apendicitis<\/strong> naopak neprob\u00edh\u00e1 v\u011bt\u0161inou tak dramaticky. V\u011bt\u0161inou se opouzd\u0159\u00ed jako infiltr\u00e1t nebo periapendikul\u00e1rn\u00ed absces.<\/p>\n<ul>\n<li><strong>Klinick\u00fd n\u00e1lez (\u201e5 P\u201c)<\/strong>\n<ul>\n<li>Pohled: bledost, skleslost, antalgick\u00e9 dr\u017een\u00ed t\u011bla\u00a0a antalgick\u00e1 ch\u016fze (pozorn\u00fd l\u00e9ka\u0159 si pov\u0161imne opatrn\u00e9 ch\u016fze, nemocn\u00fd jde zvolna, aby se vyvaroval zbyte\u010dn\u00fdch ot\u0159es\u016f, \u0161et\u0159\u00ed bolestivou stranu, je v lehk\u00e9m p\u0159edklonu vpravo a \u010dasto si podv\u011bdom\u011b rukou p\u0159idr\u017euje prav\u00fd podb\u0159i\u0161ek),zkr\u00e1cen\u00fd dech a nepostupuj\u00edc\u00ed dechov\u00e1 vlna na st\u011bn\u011b b\u0159i\u0161n\u00ed (zn\u00e1mky ohrani\u010den\u00e9 peritoniidy). K tomu p\u0159istupuje tachykardie 100\/mina v\u00edce, lehce zv\u00fd\u0161en\u00e1 teplota 37,2 <i>\u00b0<\/i>C (lze zjistit vy\u0161\u0161\u00ed teplotu v kone\u010dn\u00edku proti hodnot\u011b v podpa\u017e\u00ed o 1,6\u20132 <i>\u00b0<\/i>C, tzv. Lennanderovo znamen\u00ed).<\/li>\n<li>Poslech: \u201eklid\u201c v dutin\u011b b\u0159i\u0161n\u00ed, sv\u011bd\u010d\u00edc\u00ed pro st\u0159evn\u00ed par\u00e9zu.<\/li>\n<li style=\"text-align: justify;\">Pohmat a Poklep: posouzen\u00ed prohmatnosti st\u011bny b\u0159i\u0161n\u00ed, lokalizace bolestiv\u00e9 oblasti a dekompresn\u00ed p\u0159\u00edznaky. Blumbergovo znamen\u00ed. V m\u00edst\u011b, kde je ud\u00e1v\u00e1na pohmatov\u00e1 bolestivost, zvolna zatla\u010d\u00edme prsty vy\u0161et\u0159uj\u00edc\u00ed ruky do hloubky a potom n\u00e1hle ruku odd\u00e1l\u00edme. P\u0159\u00edznak je pozitivn\u00ed, pokud vy\u0161et\u0159ovan\u00fd reaguje bolestiv\u011b a ud\u00e1v\u00e1 bolest v\u00fdrazn\u011bj\u0161\u00ed v druh\u00e9 f\u00e1zi tohoto man\u00e9vru ne\u017eli p\u0159i pozvoln\u00e9m tlaku na st\u011bnu b\u0159i\u0161n\u00ed. Rovsingovo znamen\u00ed: Na stran\u011b opa\u010dn\u00e9, ne\u017eli ud\u00e1v\u00e1 nemocn\u00fd bolest, zatla\u010d\u00edme prsty vy\u0161et\u0159uj\u00edc\u00ed ruky do hloubi a pak ruku rychle odd\u00e1l\u00edme, nemocn\u00fd ud\u00e1v\u00e1 bolest v m\u00edst\u011b, kde je aktivn\u00ed z\u00e1n\u011bt. Pleniesovo znamen\u00ed: Prov\u00e1d\u00edme zvolna poklep po cel\u00e9 st\u011bn\u011b b\u0159i\u0161n\u00ed \u2013 nemocn\u00fd ud\u00e1v\u00e1 bolest v m\u00edst\u011b z\u00e1n\u011btu.<\/li>\n<li style=\"text-align: justify;\">Per rektum: Nemocn\u00fd le\u017e\u00ed na z\u00e1dech s lehce pokr\u010den\u00fdmi doln\u00edmi kon\u010detinami, kolena m\u00edrn\u011b od sebe. Vy\u0161et\u0159ujeme z\u00e1sadn\u011b z prav\u00e9 strany.Na ukazov\u00e1\u010dek prav\u00e9 ruky, kter\u00e1 je chr\u00e1n\u011bna chirurgickou rukavic\u00ed, naneseme mal\u00e9 mno\u017estv\u00ed vazel\u00edny nebo gelu. V r\u00e1mci komplexnosti tohoto vy\u0161et\u0159en\u00ed, a tak\u00e9 abychom vylou\u010dili bolestivou reakci zp\u016fsobenou jin\u00fdmi patologick\u00fdmi zm\u011bnami, si v\u0161\u00edm\u00e1me okol\u00ed (fissura \u2013 prasklinka na hranici k\u016f\u017ee a sliznice rekta, p\u00ed\u0161t\u011bl nebo velk\u00e9 hemoroidy). Indagace \u2013 zaveden\u00ed ukazov\u00e1ku \u2013 mus\u00ed b\u00fdt \u0161etrn\u00e1 a pozvoln\u00e1. K usnadn\u011bn\u00ed indagace vyzveme nemocn\u00e9ho, aby lehce zatla\u010dil jako p\u0159i defekaci. V\u0161\u00edm\u00e1me si, jak\u00fd je tonus sv\u011bra\u010d\u016f. Sn\u00ed\u017een\u00fd b\u00fdv\u00e1 zn\u00e1mkou z\u00e1n\u011btliv\u00fdch zm\u011bn v Douglasov\u011b prostoru. V\u011bt\u0161inou je to zn\u00e1mka pokro\u010dil\u00e9 peritonitidy. Bolestivost p\u0159i vy\u0161et\u0159en\u00ed a vyklenut\u00ed pros\u00e1knut\u00e9 st\u011bny do lumen kone\u010dn\u00edku sv\u011bd\u010d\u00ed pro tvo\u0159\u00edc\u00ed se absces Douglasova prostoru. Bolest na dohmat \u0161pi\u010dky ukazov\u00e1ku potvrzuje pelvickou formu apendicitidy. P\u0159i vy\u0161et\u0159en\u00ed u mu\u017ee hmat\u00e1me vp\u0159edu prostatu. Je-li bolestiv\u00e1, je to zn\u00e1mka z\u00e1n\u011btu prostaty, a nemocn\u00fd by m\u011bl b\u00fdt d\u00e1le vy\u0161et\u0159en rovn\u011b\u017e urologem. U \u017eeny v tomto m\u00edst\u011b nahmat\u00e1me d\u011blo\u017en\u00ed \u010d\u00edpek. Pokud s n\u00edm p\u0159i zatla\u010den\u00ed prstem lehce pohneme a p\u0159itom vyvol\u00e1me bolest, mus\u00edme pom\u00fd\u0161let na gynekologick\u00e9 onemocn\u011bn\u00ed, nejsp\u00ed\u0161e z\u00e1n\u011bt adnex (vaje\u010dn\u00edk\u016f a podobn\u011b).Dnes se t\u011bchto klasick\u00fdch 5-P dopl\u0148uje standardn\u011b ultrazvukov\u00fdm vy\u0161et\u0159en\u00edm (UZ). Podez\u0159en\u00ed na apendicitidu bud\u00ed n\u00e1lez pros\u00e1knut\u00ed b\u00e1ze c\u00e9ka a okoln\u00edch tk\u00e1n\u00ed, zv\u011bt\u0161en\u00ed lymfatick\u00fdch uzlin v t\u00e9to oblasti, pros\u00e1knut\u00ed a zdu\u0159en\u00ed apendixu. P\u0159i pokro\u010dilej\u0161\u00edm z\u00e1n\u011btu vede pros\u00e1knut\u00ed st\u011bny apendixu k jej\u00ed \u201estratifikaci\u201c, k projekci jednotliv\u00fdch vrstev v ultrazvukov\u00e9m obraze.\u017deny, p\u0159edev\u0161\u00edm ve v\u011bku, kdy maj\u00ed cyklus, by m\u011bl standardn\u011b vy\u0161et\u0159it gynekolog k vylou\u010den\u00ed gynekologick\u00e9ho onemocn\u011bn\u00ed.<\/li>\n<\/ul>\n<\/li>\n<li><strong>Paraklinick\u00e9 n\u00e1lezy<\/strong>\n<ul>\n<li>KO: lehce zv\u00fd\u0161en\u00e1 leukocyt\u00f3za (Le), eosinofilie.<\/li>\n<\/ul>\n<ul>\n<li>CRP: vy\u0161et\u0159en\u00ed \u201ecreaktivn\u00edho proteinu\u201c a p\u0159edev\u0161\u00edm v\u00fdvoj a dynamika jeho hodnot je velmi citliv\u00fdm ukazatelem z\u00e1n\u011btu. Vy\u0161et\u0159en\u00ed leukocyt\u00f3zy a CRP by m\u011blo b\u00fdt provedeno v\u017edy, opakovan\u011b p\u0159i kontrol\u00e1ch.<\/li>\n<li>Mo\u010d: zji\u0161t\u011bn\u00ed v\u011bt\u0161\u00edho po\u010dtu erytrocyt\u016f v mo\u010dov\u00e9m sedimentu m\u016f\u017ee sv\u011bd\u010dit pro nal\u00e9h\u00e1n\u00ed zan\u00edcen\u00e9ho \u010derva na ureter. M\u016f\u017ee b\u00fdt zn\u00e1mkou sv\u011bd\u010d\u00edc\u00ed pro ren\u00e1ln\u00ed koliku.Tato laboratorn\u00ed vy\u0161et\u0159en\u00ed se prov\u00e1d\u011bj\u00ed rutinn\u011b,n\u00e1sleduj\u00edc\u00ed vy\u0161et\u0159en\u00ed jen p\u0159i obt\u00ed\u017en\u00e9 diferenci\u00e1ln\u00ed diagnostice. UZ se pro dnes snadnou dostupnost st\u00e1v\u00e1 \u010dasto sou\u010d\u00e1st\u00ed tak\u0159ka ka\u017ed\u00e9ho vy\u0161et\u0159en\u00ed b\u0159icha:<\/li>\n<li>RTG prost\u00fd sn\u00edmek b\u0159icha: dle lokalizace lehk\u00e1 distenze c\u00e9ka, ojedin\u011bl\u00e9 hladinky v kli\u010dk\u00e1ch tenk\u00e9ho st\u0159eva.<\/li>\n<li>UZ: s touto diagnostikou mus\u00ed m\u00edt vy\u0161et\u0159uj\u00edc\u00ed\u00a0zku\u0161enost, potom je tato metoda p\u0159\u00ednosn\u00e1.<\/li>\n<li>CT: jen p\u0159i velmi obt\u00ed\u017en\u00e9m rozhodov\u00e1n\u00ed\n<ul>\n<li>NPB, p\u0159i komplikac\u00edch.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\"><strong>Diferenci\u00e1ln\u00ed diagnostika<br \/>\n<\/strong>Apendicitida je onemocn\u011bn\u00ed velmi <i>\u201epotm\u011b\u0161i<\/i>l\u00e9\u201c a m\u016f\u017ee b\u00fdt napodobov\u00e1no nebo napodobuje\u00a0i jin\u00e9 NPB a onemocn\u011bn\u00ed jin\u00fdch org\u00e1n\u016f nejen dutiny b\u0159i\u0161n\u00ed:<\/p>\n<ul>\n<li>perforovan\u00fd v\u0159ed gastroduodena,<\/li>\n<li>akutn\u00ed gastroenteritida,<\/li>\n<li>cholecystitis,<\/li>\n<li>ren\u00e1ln\u00ed kolika,<\/li>\n<li>akutn\u00ed pyelonefritida,<\/li>\n<li>mezenteri\u00e1ln\u00ed lymfadenitida,<\/li>\n<li>Crohnova nemoc,<\/li>\n<li>pneumonie u d\u011bt\u00ed,<\/li>\n<\/ul>\n<ul>\n<li>mimod\u011blo\u017en\u00ed t\u011bhotenstv\u00ed,<\/li>\n<\/ul>\n<ul>\n<li>ruptura cysty ovaria, intermenstru\u00e1ln\u00ed pot\u00ed\u017ee \u2013\u00a0ovula\u010dn\u00ed krize,<\/li>\n<\/ul>\n<ul>\n<li>torze ovari\u00e1ln\u00ed cysty.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<h6>Appendicitis chronica<\/h6>\n<p style=\"text-align: justify;\">Jedn\u00e1 se o \u010dasto pou\u017e\u00edvan\u00e9 ozna\u010den\u00ed recidivuj\u00edc\u00edch bolest\u00ed v prav\u00e9m podb\u0159i\u0161ku. Zda se opravdu jedn\u00e1 o samostatnou nosologickou jednotku, je sporn\u00e9. Rad\u011bji mluv\u00edme o bolestiv\u00e9m syndromu prav\u00e9ho podb\u0159i\u0161ku. D\u00edky miniinvazivn\u00edm p\u0159\u00edstup\u016fm p\u0159edev\u0161\u00edm d\u00edvk\u00e1m a mlad\u00fdm \u017een\u00e1m doporu\u010dujeme laparoskopickou exploraci a apendektomii, pokud jin\u00e1 vy\u0161et\u0159en\u00ed nevedla k vysv\u011btlen\u00ed jejich pot\u00ed\u017e\u00ed. \u010casto nalezneme dlouh\u00fd sto\u010den\u00fd apendix, n\u011bkdy s p\u0159\u00edtomnost\u00ed koprolit\u016f nebo s parazity.L\u00e9\u010debn\u00fd postup se tedy neli\u0161\u00ed od akutn\u00edho z\u00e1n\u011btu p\u0159\u00edv\u011bsku a spo\u010d\u00edv\u00e1 v jeho odstran\u011bn\u00ed.<\/p>\n<h6>Dal\u0161\u00ed onemocn\u011bn\u00ed apendixu<\/h6>\n<p style=\"text-align: justify;\">Jak ji\u017e bylo uvedeno na po\u010d\u00e1tku kapitoly, dal\u0161\u00ed patologie, jako Crohnova choroba, mukok\u00e9la, pot\u00ed\u017ee vyvolan\u00e9 cizopasn\u00edkem \u2013 \u0161krkavkou a vz\u00e1cn\u011bj\u0161\u00ed n\u00e1lez karcinoidu v jeho benign\u00ed nebo malign\u00ed podob\u011b a posti\u017een\u00ed \u010dervu adenokarcinomem, jsou pom\u011brn\u011b vz\u00e1cn\u00e9. Obvykle je diagnostikujeme jako akutn\u00ed \u010di chronick\u00fd z\u00e1n\u011bt \u010dervu a spr\u00e1vn\u00e1 diagn\u00f3za se stanov\u00ed a\u017e p\u0159i operaci \u010di a\u017e na z\u00e1klad\u011b histologick\u00e9ho vy\u0161et\u0159en\u00ed. Dostate\u010dn\u00fdm v\u00fdkonem je v\u011bt\u0161inou apendektomie a jen v\u00fdjime\u010dn\u011b u zhoubn\u00e9ho onemocn\u011bn\u00ed se v\u00fdkon roz\u0161i\u0159uje na pravostrannou hemikolektomii, zpravidla v druh\u00e9 dob\u011b.<\/p>\n<h5>3.1.3 L\u00e9\u010dba<\/h5>\n<p style=\"text-align: justify;\">L\u00e9\u010dba apendicitity a v\u011bt\u0161iny ostatn\u00edch patologi\u00ed spo\u010d\u00edv\u00e1 v odstran\u011bn\u00ed \u010dervu \u2013 apendektomii. Ohrani\u010den\u00fd periapendikul\u00e1rn\u00ed infiltr\u00e1t (zji\u0161t\u011bn\u00fd palpa\u010dn\u011b, sonografi\u00ed a eventu\u00e1ln\u011b CT) bez zn\u00e1mek peritonitidy v dosp\u011bl\u00e9m v\u011bku se l\u00e9\u010d\u00ed obvykle konzervativn\u011b antibiotiky, klidem na l\u016f\u017eku a lehkou bezezbytkovou dietou. Operace v t\u00e9to f\u00e1zi by byla v\u011bt\u0161inou velmi obt\u00ed\u017en\u00e1, ne-li nemo\u017en\u00e1, a proto je l\u00e9pe prov\u00e9st apendektomii a\u017e po zklidn\u011bn\u00ed v odstupu 4\u20136 t\u00fddn\u016f (tzv.: \u00e1 froid \u2013\u201eza studena\u201c). U d\u011bt\u00ed je ohrani\u010den\u00ed z\u00e1n\u011btu jemn\u00fdm omentem velmi nejist\u00e9, a proto u nich i p\u0159i podez\u0159en\u00ed na infiltr\u00e1t je indikov\u00e1na operace. P\u0159i periapendikul\u00e1rn\u00edm abscesu se zpravidla provede jen dren\u00e1\u017e, proto\u017ee vlastn\u00ed apendix je z\u00e1n\u011btem zpravidla zcela destruov\u00e1n. V\u00fdkon se prov\u00e1d\u00ed v celkov\u00e9 anestezii. \u0158ez je veden \u0161ikmo dle \u0161t\u011bpnosti k\u016f\u017ee medi\u00e1ln\u011b od okraje lopaty kosti ky\u010deln\u00ed. K abscesu pronik\u00e1me extraperitone\u00e1ln\u011b (bez otev\u0159en\u00ed dutiny peritone\u00e1ln\u00ed), aby nedo\u0161lo ke kontaminaci dutiny b\u0159i\u0161n\u00ed hnisem. Pod\u00e9l zaveden\u00e9 siln\u00e9 punk\u010dn\u00ed jehly, kterou za\u010dn\u011b vyt\u00e9kat obsah periapendik\u00e1ln\u00ed hl\u00edzy, provedeme jej\u00ed malou incizi. Otvor roz\u0161\u00ed\u0159\u00edme pe\u00e1nem a do dutiny vlo\u017e\u00edme perforovan\u00fd dr\u00e9n, kter\u00fd je vyveden mimo opera\u010dn\u00ed r\u00e1nu. V\u017edy provedeme odb\u011br na mikrobiologick\u00e9 vy\u0161et\u0159en\u00ed k c\u00edlen\u00e9 antibiotick\u00e9 terapii.<\/p>\n<p style=\"text-align: justify;\">Nejen akutn\u00ed apendicitis s projevy floridn\u00edho z\u00e1n\u011btu, ale i diagnostick\u00e1 nejistota a obt\u00ed\u017ee, zejm\u00e9na u d\u011bt\u00ed a senior\u016f, jsou d\u016fvodem k operaci.<\/p>\n<h6>3.1.3.1 Klasick\u00e1 operace<\/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_141.png\"><img decoding=\"async\" style=\"text-align: justify;\" title=\"Obr. 1 \u2013 St\u0159\u00eddav\u00fd \u0159ez v prav\u00e9m podb\u0159i\u0161ku, nej\u010dast\u011bj\u0161\u00ed p\u0159\u00edstup k otev\u0159en\u00e9 apendektomii\" alt=\"Obr. 1 \u2013 St\u0159\u00eddav\u00fd \u0159ez v prav\u00e9m podb\u0159i\u0161ku, nej\u010dast\u011bj\u0161\u00ed p\u0159\u00edstup k otev\u0159en\u00e9 apendektomii\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_141.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 1 \u2013 St\u0159\u00eddav\u00fd \u0159ez v prav\u00e9m podb\u0159i\u0161ku, nej\u010dast\u011bj\u0161\u00ed p\u0159\u00edstup k otev\u0159en\u00e9 apendektomii<\/p><\/div>\n<p style=\"text-align: justify;\">Pokud je diagnostika akutn\u00ed apendicitidy\u00a0jednozna\u010dn\u00e1,\u00a0pokud z r\u016fzn\u00fdch d\u016fvod\u016f nechceme nebo nem\u016f\u017eeme\u00a0operovat laparoskopicky, je optim\u00e1ln\u00edm p\u0159\u00edstupem\u00a0do dutiny b\u0159i\u0161n\u00ed \u201est\u0159\u00eddav\u00fd \u0159ez\u201c v prav\u00e9m podb\u0159i\u0161ku\u00a0(obr. 1).<\/p>\n<p style=\"text-align: justify;\">Ko\u017en\u00ed \u0159ez vedeme dle \u0161t\u011bpnosti k\u016f\u017ee od m\u00edsta Lanzova\u00a0nebo Mac-Burneyova bodu (viz v\u00fd\u0161e) \u0161ikmo\u00a0sm\u011brem medi\u00e1ln\u00edm. Jeho d\u00e9lka je z\u00e1visl\u00e1 na habitu\u00a0nemocn\u00e9ho. Po prot\u011bt\u00ed k\u016f\u017ee a podko\u017e\u00ed ve stejn\u00e9m\u00a0sm\u011bru prot\u00edn\u00e1me aponeur\u00f3zu zevn\u00edho \u0161ikm\u00e9ho b\u0159i\u0161n\u00edho\u00a0svalu a pod n\u00edm rozhrnujeme pod\u00e9ln\u011b vl\u00e1kna\u00a0vnit\u0159n\u00edho \u0161ikm\u00e9ho svalu. Opatrn\u011b otev\u00edr\u00e1me peritoneum\u00a0tak, abychom neporanili nal\u00e9haj\u00edc\u00ed kli\u010dky\u00a0st\u0159evn\u00ed. Zalo\u017e\u00edme jemn\u00e9 ekartery (h\u00e1\u010dky) do laparotomie.\u00a0Pokud je v dutin\u011b b\u0159i\u0161n\u00ed v\u00fdpotek, odebereme\u00a0p\u0159ed jeho ods\u00e1t\u00edm vzorek pro mikrobiologick\u00e9 vy\u0161et\u0159en\u00ed.\u00a0Opatrn\u011b do r\u00e1ny luxujeme (vt\u00e1hneme) b\u00e1zi\u00a0c\u00e9ka a za n\u00edm apendix. Nikdy nemanipulujeme tahem\u00a0za apendix, kter\u00fd je zvl\u00e1\u0161t\u011b p\u0159i z\u00e1n\u011btliv\u00fdch zm\u011bn\u00e1ch\u00a0k\u0159ehk\u00fd, stejn\u011b jako mezenteriolum a arterie apendikul\u00e1rn\u00ed.\u00a0Mohlo by doj\u00edt k jejich natr\u017een\u00ed. Jejich o\u0161et\u0159en\u00ed\u00a0by pak bylo problematick\u00e9 a \u010dasto si takov\u00e1 situace\u00a0vynut\u00ed roz\u0161\u00ed\u0159en\u00ed laparotomie. Po vysunut\u00ed apendixu\u00a0do r\u00e1ny odpreparujeme mezenteriolum v rozsahu\u00a015\u201320 mm od b\u00e1ze a odstupuj\u00edc\u00ed \u010d\u00e1sti processus vermicularis. Mezi peany\u00a0mezenteriolum a v n\u011bm a. appendicularis\u00a0protneme a oba konce o\u0161et\u0159\u00edme ligaturou\u00a0\u2013 podvazem. Nyn\u00ed nalo\u017e\u00edme dva peany na odstup\u00a0\u010dervu z c\u00e9ka tak, abychom jej mezi nimi mohli odd\u011blit\u00a0(obr. 2). Okol\u00ed chr\u00e1n\u00edme longetami napu\u0161t\u011bn\u00fdmi \u0159ed\u011bnou\u00a0Betadinou. Skalpel p\u0159ed\u00e1me instrument\u00e1\u0159ce\u00a0spole\u010dn\u011b s peanem a apendixem. Tyto n\u00e1stroje v dal\u0161\u00edm\u00a0pr\u016fb\u011bhu operace ji\u017e nepou\u017e\u00edv\u00e1me. Pova\u017eujeme\u00a0je za kontaminovan\u00e9. Sliznici pah\u00fdlu m\u016f\u017eeme lehce\u00a0po\u017eehat elektrokauterem a o\u0161et\u0159\u00edme jej tamponem\u00a0smo\u010den\u00fdm v Betadin\u011b nebo jin\u00e9m dezinfek\u010dn\u00edm prost\u0159edku (pozor na alergickou anamn\u00e9zu nemocn\u00e9ho).\u00a0Pah\u00fdl pod peanem podv\u00e1\u017eeme. Kolem pah\u00fdlu apendixu\u00a0se zakl\u00e1d\u00e1 \u201etab\u00e1\u010dkov\u00fd steh\u201c (jehla je vedena ser\u00f3zou\u00a0a svalovinou c\u00e9ka, nem\u011bla by proniknut do jeho\u00a0lumen). Asistence zachyt\u00ed pinzetou pah\u00fdl a opatrn\u011b\u00a0jej vchlipuje do lumen c\u00e9ka. Operat\u00e9r sou\u010dasn\u011b nad\u00a0zano\u0159en\u00fdm pah\u00fdlem dot\u00e1hne a zauzl\u00ed tab\u00e1\u010dkov\u00fd steh\u00a0(obr. 3). Takto o\u0161et\u0159en\u00e9 c\u00e9kum vr\u00e1t\u00edme zp\u011bt do dutiny\u00a0b\u0159i\u0161n\u00ed. Pokud na apendixu nebyl zjevn\u011b pokro\u010dil\u00fd n\u00e1lez\u00a0(zkalen\u00fd v\u00fdpotek v okol\u00ed, pokro\u010dil\u00e1 flegmona s fibrinov\u00fdmi\u00a0n\u00e1lety nebo po\u010d\u00ednaj\u00edc\u00ed gangren\u00f3zn\u00ed zm\u011bny),\u00a0po\u010d\u00ednaje od ileocek\u00e1ln\u00edho spojen\u00ed opatrn\u011b p\u0159ed ranou\u00a0revidujeme asi 100 cm ilea a p\u00e1tr\u00e1me po anom\u00e1li\u00edch,\u00a0p\u0159edev\u0161\u00edm Meckelov\u011b divertiklu. Jeho o\u0161et\u0159en\u00ed je pops\u00e1no\u00a0v dal\u0161\u00ed kapitole. U \u017een se sna\u017e\u00edme p\u0159ehl\u00e9dnout\u00a0uterus a adnexa. Na z\u00e1v\u011br pe\u010dliv\u011b odsajeme v\u00fdpotek\u00a0v dutin\u011b b\u0159i\u0161n\u00ed, m\u016f\u017eeme prov\u00e9st v\u00fdplach \u0159ed\u011bnou Betadinou.\u00a0Po odsouhlasen\u00ed rou\u0161ek a n\u00e1stroj\u016f po jednotliv\u00fdch\u00a0vrstv\u00e1ch uzav\u0159eme laparotomii.<\/p>\n<p style=\"text-align: justify;\">P\u0159i pokro\u010dil\u00e9m n\u00e1lezu m\u016f\u017eeme dutinu b\u0159i\u0161n\u00ed zajistit\u00a0dr\u00e9nem, kter\u00fd nejl\u00e9pe zav\u00e1d\u00edme kolem c\u00e9ka\u00a0a\u017e do nejni\u017e\u0161\u00edho m\u00edsta dutiny b\u0159i\u0161n\u00ed do Douglasova\u00a0prostoru. Dr\u00e9n z\u00e1sadn\u011b vyv\u00e1d\u00edme mimo vlastn\u00ed r\u00e1nu\u00a0a ke k\u016f\u017ei jej fixujeme stehem. Je v\u00fdhodn\u00e9 pou\u017e\u00edt tzv.\u00a0Redon\u016fv dr\u00e9n, tedy uzav\u0159en\u00fd syst\u00e9m kdy dr\u00e9n napoj\u00edme\u00a0po uzav\u0159en\u00ed dutiny b\u0159i\u0161n\u00ed na podtlakov\u00fd sb\u011brn\u00fd\u00a0syst\u00e9m, kter\u00fd je kalibrov\u00e1n a dovoluje n\u00e1m sledovat\u00a0charakter v\u00fdpotku a jeho mno\u017estv\u00ed. Pokud byly u pokro\u010dil\u00e9\u00a0apendicitidy pot\u0159\u00edsn\u011bny i okraje laparotomie\u00a0nebo kde p\u0159edpokl\u00e1d\u00e1me komplikovan\u00e9 hojen\u00ed nap\u0159\u00edklad\u00a0pro vysokou vrstvu podko\u017en\u00edho tuku, m\u016f\u017eeme\u00a0i tuto oblast zajistit dr\u00e9nem.<\/p>\n<p>Antibiotika pod\u00e1v\u00e1me jen p\u0159i pokro\u010dil\u00e9 flegmon\u011b\u00a0a pokro\u010dilej\u0161\u00edch form\u00e1ch apendicitidy. Pokud maj\u00ed b\u00fdt\u00a0pod\u00e1na nejen profylakticky ale i kurativn\u011b sna\u017e\u00edme se\u00a0co nejd\u0159\u00edve konzultovat mikrobiologa.<\/p>\n<p>U nemocn\u00fdch ob\u00e9zn\u00edch a p\u0159i klinicky pokro\u010dil\u00fdch\u00a0zn\u00e1mk\u00e1ch z\u00e1n\u011btu (zn\u00e1mky peritonitidy) vol\u00edme rad\u011bji\u00a0doln\u00ed st\u0159edn\u00ed laparotomii. \u0158ez na k\u016f\u017ei vedeme\u00a0ve st\u0159edn\u00ed \u010d\u00e1\u0159e pod pupkem, sna\u017e\u00edme se rozhrnout<br \/>\nokraje mm. recti abdominis. D\u00e1le prot\u00edn\u00e1me v jedn\u00e9\u00a0vrstv\u011b pov\u00e1zky a peritoneum ve st\u0159edn\u00ed \u010d\u00e1\u0159e. V\u00fdhoda\u00a0tohoto p\u0159\u00edstupu je v mo\u017enosti jeho roz\u0161\u00ed\u0159en\u00ed kolem\u00a0pupku do pot\u0159ebn\u00e9 v\u00fd\u0161e.<\/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_142.png\"><img decoding=\"async\" title=\"Obr. 2 \u2013 Odstran\u011bn\u00ed apendixu po podvazu mezenteriola\" alt=\"Obr. 2 \u2013 Odstran\u011bn\u00ed apendixu po podvazu mezenteriola\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_142.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 2 \u2013 Odstran\u011bn\u00ed apendixu po podvazu mezenteriola<\/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_144.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. 3 \u2013 Zano\u0159en\u00ed pah\u00fdlu apendixu cirkul\u00e1rn\u00edm zdrhovac\u00edm (tab\u00e1\u010dkov\u00fdm) stehem\" alt=\"Obr. 3 \u2013 Zano\u0159en\u00ed pah\u00fdlu apendixu cirkul\u00e1rn\u00edm zdrhovac\u00edm (tab\u00e1\u010dkov\u00fdm) stehem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_144.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 3 \u2013 Zano\u0159en\u00ed pah\u00fdlu apendixu cirkul\u00e1rn\u00edm zdrhovac\u00edm (tab\u00e1\u010dkov\u00fdm) stehem<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h4>3.2 Laparoskopick\u00e1 apendektomie<\/h4>\n<ul>\n<li style=\"text-align: justify;\"><strong>\u00davod<br \/>\n<\/strong><span style=\"text-align: justify;\">Prvn\u00ed laparoskopickou apendektomii provedl v N\u011bmecku v roce 1983 Semm. Dal\u0161\u00ed zpr\u00e1va je z Ji\u017en\u00edho Walesu z roku 1985 od Fleminga a o rok pozd\u011bji referuje z australsk\u00e9ho Sydney Wilson o laparoskopicky asistovan\u00e9 apendektomii. Rozbor souboru takto operovan\u00fdch nemocn\u00fdch publikuje v N\u011bmecku v roce 1987 Schreiber.<br \/>\nPo zvl\u00e1dnut\u00ed laparoskopick\u00e9 cholecystektomie,kter\u00e1 se stala baz\u00e1ln\u00ed operac\u00ed na poli miniinazivn\u00ed chirurgie, jsou dal\u0161\u00ed opera\u010dn\u00ed v\u00fdkony odvozov\u00e1ny ze zku\u0161enost\u00ed s touto technikou a jsou nemalou m\u011brou z\u00e1visl\u00e9 na technick\u00e9m v\u00fdvoji nov\u00fdch n\u00e1stroj\u016f. Nejinak tomu bylo u apendektomie.<\/span><\/li>\n<li style=\"text-align: justify;\"><strong>Indikace<br \/>\n<\/strong>Pokud nebyly koment\u00e1\u0159e k prvn\u00edm laparoskopick\u00fdm apendektomi\u00edm zdr\u017eenliv\u00e9, pak sp\u00ed\u0161e vyzn\u00edvaly negativn\u011b. Za mnoh\u00e9 uve\u010fme n\u00e1zor, kter\u00fd vyslovil britsk\u00fd chirurg Wiliam Thompson: \u201e\u2026otev\u0159en\u00e1 apendektomie je tak jednoduch\u00e1 \u2013 na\u010d je\u0161t\u011b laparoskopickou\u00a0techniku?\u201c<\/li>\n<li>P\u0159ipome\u0148me v\u00fdhody miniinvazivn\u00edho postupu:\n<ul>\n<li>minim\u00e1ln\u00ed traumatizace b\u0159i\u0161n\u00ed st\u011bny,<\/li>\n<li>v\u00fdrazn\u011b ni\u017e\u0161\u00ed procento ran\u00fdch komplikac\u00ed, \u015c krat\u0161\u00ed doba poopera\u010dn\u00ed rekonvalescence,<\/li>\n<li>sn\u00ed\u017een\u00ed poopera\u010dn\u00edch bolest\u00ed,<\/li>\n<li>mo\u017enost explorace nejen oblasti mal\u00e9 p\u00e1nve\u00a0a p\u00e1tr\u00e1n\u00ed po p\u0159\u00ed\u010din\u011b pot\u00ed\u017e\u00ed, pokud nebyly spr\u00e1vn\u011b rozpozn\u00e1ny p\u0159edem.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">V\u00fdhody laparoskopie jsou tedy jednozna\u010dn\u00e9. Nicm\u00e9n\u011b zejm\u00e9na v\u00fdhodn\u00fd je laparoskopick\u00fd p\u0159\u00edstupu d\u00e1le uveden\u00e9 skupiny nemocn\u00fdch:<\/p>\n<ul>\n<li style=\"text-align: justify;\"><em>\u017eeny a dosp\u00edvaj\u00edc\u00ed d\u00edvky s nemocemi v oblasti mal\u00e9\u00a0p\u00e1nve.<\/em><br \/>\nSymptomatologie prav\u00e9ho podb\u0159i\u0161ku je v t\u00e9to skupin\u011b populace velmi \u010dast\u00e1. P\u0159\u00ed\u010dinou b\u00fdvaj\u00ed ovari\u00e1ln\u00ed cysty, endometri\u00f3za, salpingitida. Vy\u0161et\u0159en\u00ed ultrazvukem neb\u00fdv\u00e1 p\u0159esn\u00e9 a tak chybn\u00e1 diagn\u00f3za je uv\u00e1d\u011bna a\u017e 46%. Nav\u00edc zde b\u00fdvaj\u00ed \u010dasto patologick\u00e9 zm\u011bny na apendixu indukovan\u00e9 z\u00e1kladn\u00edm onemocn\u011bn\u00edm. Laparoskopie a explorace dutiny b\u0159i\u0161n\u00ed, p\u0159edev\u0161\u00edm mal\u00e9 p\u00e1nve, je zde pln\u011b indikov\u00e1na. V\u011bt\u0161inou b\u00fdv\u00e1 vy\u0159e\u0161ena gynekologick\u00e1 p\u0159\u00ed\u010dina pot\u00ed\u017e\u00ed. Sou\u010dasn\u00e1 apendektomie je pln\u011b indikov\u00e1na.<\/li>\n<li style=\"text-align: justify;\"><em>Nemocn\u00ed s atypickou lokalizac\u00ed abdomin\u00e1ln\u00edch bolest\u00ed a pot\u00ed\u017e\u00ed<\/em><br \/>\nKompletn\u00ed vy\u0161et\u0159en\u00ed za\u017e\u00edvac\u00edho traktu, v\u010detn\u011b n\u00e1kladn\u00fdch metodik, jako je CT, MRI, mnohdy nep\u0159in\u00e1\u0161\u00ed jednozna\u010dn\u00e9 vysv\u011btlen\u00ed pot\u00ed\u017e\u00ed nemocn\u00e9ho. Laparoskopie m\u016f\u017ee objevit retroc\u00e9k\u00e1ln\u00ed \u201echronickou\u201c apendicitidu, resp. subhepatickou apendicitidu. Sou\u010dasn\u00fd laparoskopick\u00fd v\u00fdkon p\u0159edpokl\u00e1d\u00e1 zku\u0161enost s mobilizac\u00ed c\u00e9ka a \u010d\u00e1sti ascendens. Pokud s touto mo\u017enost\u00ed po\u010d\u00edt\u00e1me, usnadn\u00ed n\u00e1m bezpe\u010dnost preparace uretr\u00e1ln\u00ed c\u00e9vka zaveden\u00e1 p\u0159ed operac\u00ed vpravo.<\/li>\n<li style=\"text-align: justify;\"><em>Sta\u0159\u00ed nemocn\u00ed<\/em><br \/>\nJe zn\u00e1m\u00e9, \u017ee apendicitida m\u016f\u017ee u star\u00fdch lid\u00ed prob\u00edhat zcela atypicky. Mnoh\u00e9 symptomy neb\u00fdvaj\u00ed vyj\u00e1d\u0159eny. Proto p\u0159i diagnostick\u00fdch pochybnostech je laparoskopie a dle n\u00e1lezu apendektomie pln\u011b indikov\u00e1na. Jsou pops\u00e1ny kazuistiky, kdy tak byla nalezena perforovan\u00e1 divertikulitida, tumor c\u00e9ka \u2013 jinak nediagnostikovan\u00e9. D\u00edky laparoskopii pak byl zvolen optim\u00e1ln\u00ed l\u00e9\u010debn\u00fd postup a p\u0159edev\u0161\u00edm opera\u010dn\u00ed p\u0159\u00edstup.<\/li>\n<li style=\"text-align: justify;\"><em>Ob\u00e9zn\u00ed nemocn\u00ed<\/em><br \/>\nLaparoskopie jednak usnad\u0148uje a zp\u0159es\u0148uje diagnostiku, jednak zaji\u0161\u0165uje u t\u00e9to skupiny nemocn\u00fdch,n\u00e1chyln\u00fdch k ran\u00e9 infekci a komplikac\u00edm v\u011bt\u0161inou prim\u00e1rn\u00ed zhojen\u00ed. Samotn\u00e1 apendektomie v\u0161ak b\u00fdv\u00e1 technicky n\u00e1ro\u010dn\u011bj\u0161\u00ed.<\/li>\n<li style=\"text-align: justify;\"><em>Nemocn\u00ed preferuj\u00edc\u00ed zkr\u00e1cen\u00ed doby l\u00e9\u010den\u00ed<\/em><br \/>\nV n\u011bkter\u00fdch kategori\u00edch nemocn\u00fdch, soci\u00e1ln\u00edch skupin\u00e1ch, profesn\u00edch skupin\u00e1ch je snaha co nejm\u00e9n\u011b stonat. Jedn\u00e1 se o v\u00fdkonn\u00e9 sportovce, mana\u017eery a podobn\u011b. Zde pova\u017eujeme laparoskopickou techniku za ide\u00e1ln\u00ed.<\/li>\n<li style=\"text-align: justify;\"><em>P\u0159\u00edprava nemocn\u00e9ho<\/em><br \/>\nNemocn\u00fd mus\u00ed b\u00fdt p\u0159ed operac\u00ed srozumiteln\u011b sezn\u00e1men s d\u016fvodem operace a s alternativou jak otev\u0159en\u00e9ho, tak endoskopick\u00e9ho postupu, resp. kombinac\u00ed obou. Obvykl\u00e1 p\u0159edopera\u010dn\u00ed p\u0159\u00edprava spo\u010d\u00edv\u00e1 ve vypr\u00e1zdn\u011bn\u00ed mo\u010dov\u00e9ho m\u011bch\u00fd\u0159e t\u011bsn\u011b p\u0159ed operac\u00ed. U star\u0161\u00edch mu\u017e\u016f a \u017een rad\u011bji zavedeme permanentn\u00ed mo\u010dov\u00fd kat\u00e9tr. Pr\u00e1zdn\u00fd mo\u010dov\u00fd m\u011bch\u00fd\u0159 je d\u016fle\u017eit\u00fd pr\u00e1v\u011b p\u0159i laparoskopick\u00e9 operaci.<\/li>\n<li style=\"text-align: justify;\"><em>Opera\u010dn\u00ed technika<\/em><br \/>\nP\u0159i facilitovan\u00e9 operaci m\u016f\u017ee doj\u00edt k propojen\u00ed jak operace klasick\u00e9, tak endoskopick\u00e9 \u2013 laparoskopick\u00e9.<\/li>\n<li>Mluv\u00edme o v\u00fdkonu \u201ekombinovan\u00e9m\u201c. Rovn\u011b\u017e m\u016f\u017ee doj\u00edt k p\u0159echodu z metody laparoskopick\u00e9 na otev\u0159enou po ur\u010dit\u00e9 f\u00e1zi, kter\u00e1 n\u00e1m operaci usnadn\u00ed. V jin\u00e9m p\u0159\u00edpad\u011b m\u016f\u017eeme laparoskopicky prov\u00e9st \u010d\u00e1st preparace, pod kontrolou laparoskopu prov\u00e9st c\u00edlen\u011b laparotomii a dokon\u010dit v\u00fdkon otev\u0159enou cestou \u2013 \u201elaparoskopicky asistovan\u00e1 operace\u201c.\n<ul>\n<li style=\"text-align: justify;\">\u00a0<em>Technika \u201eOUT\u201c<br \/>\n<\/em>Pokud je podstatn\u00e1 \u010d\u00e1st apendektomie provedena mimo dutinu peritone\u00e1ln\u00ed, potom hovo\u0159\u00edme o technice \u201eOUT\u201c. Jedn\u00e1 se o laparoskopicky asistovan\u00fd v\u00fdkon. Pokud jsou p\u0159\u00edzniv\u00e9 anatomick\u00e9 pom\u011bry, potom pomoc\u00ed laparoskopie povyt\u00e1hneme apendix i s mezenteriolem p\u0159ed st\u011bnu b\u0159i\u0161n\u00ed. Klasick\u00fdm zp\u016fsobem podv\u00e1\u017eeme mezenteriolum a c\u00e9vn\u00ed z\u00e1soben\u00ed \u010derva pomoc\u00ed laparoskopie. V posledn\u00ed dob\u011b je k takov\u00e9 technice apendektomie pou\u017e\u00edv\u00e1n jen jeden speci\u00e1ln\u00ed opera\u010dn\u00ed laparoskop zaveden\u00fd inciz\u00ed na horn\u00edm valu pupku (nen\u00ed podm\u00ednkou). Laparoskop d\u00edky optick\u00e9mu hranolu dovoluje i zaveden\u00ed n\u00e1stroje. Jsou-li topograficko-anatomick\u00e9 podm\u00ednky p\u0159\u00edzniv\u00e9, apendix opatrn\u011b vt\u00e1hneme do portu a dr\u017e\u00edme jej kl\u00ed\u0161\u0165kami.<br \/>\nZru\u0161\u00edme kapnoperitoneum a potom opatrn\u011b tubus povytahujeme ven z r\u00e1ny. Z\u016fst\u00e1v\u00e1 navle\u010den na n\u00e1stroji, kter\u00fdm dr\u017e\u00edme apendix. Apendix p\u0159echyt\u00edmedo peanu a dle pot\u0159eby p\u016fvodn\u00ed incizi je\u0161t\u011b roz\u0161\u00ed\u0159\u00edme o n\u011bkolik milimetr\u016f (z\u00e1le\u017e\u00ed na objemu mezenteriola a apendixu), abychom dostali m\u00edrn\u011b nad \u00farove\u0148 k\u016f\u017ee i b\u00e1zi \u010derva s p\u0159ilehlou st\u011bnou c\u00e9ka. Obvykl\u00fdm zp\u016fsobem o\u0161et\u0159\u00edme a. appendicularis a b\u00e1zi \u010derva.<\/li>\n<li style=\"text-align: justify;\">O\u0161et\u0159enou b\u00e1zi c\u00e9ka nech\u00e1me sklouznout do p\u016fvodn\u00ed polohy a na z\u00e1v\u011br je\u0161t\u011b jednou na vodi\u010di zavedeme laparoskop a zkontrolujeme cel\u00e9 opera\u010dn\u00ed pole,zda nedo\u0161lo n\u00e1sledn\u011b ke sklouznut\u00ed ligatury, natr\u017een\u00ed mezenteriola a krv\u00e1cen\u00ed. Tato technika p\u0159edpokl\u00e1d\u00e1 speci\u00e1ln\u00ed laparoskop s pracovn\u00edm kan\u00e1lem. V\u011bt\u0161ina pracovi\u0161\u0165 takov\u00e9 vybaven\u00ed postr\u00e1d\u00e1. B\u011b\u017en\u00fd je postup n\u00e1sleduj\u00edc\u00ed. Po zalo\u017een\u00ed kapnoperitonea zavedeme zvykle na horn\u00edm valu pupku 11 mm port (dle konkr\u00e9tn\u00ed situace lze pou\u017e\u00edt \u201evisiport\u201c, tedy trokar, jeho\u017e hrot je z pr\u016fhledn\u00e9ho plastu. Zav\u00e1d\u00edme jej sou\u010dasn\u011b s vlo\u017eenou optikou, tak\u017ee b\u011bhem jeho pr\u016fniku st\u011bnoub\u0159i\u0161n\u00ed m\u00e1me kontrolu a zaveden\u00ed prvn\u00edho portu je tak podstatn\u011b bezpe\u010dn\u011bj\u0161\u00ed). Po zaveden\u00ed prvn\u00edho portu opera\u010dn\u00ed st\u016fl sklop\u00edme do Trendelenburgovy polohy(asi 20 stup\u0148\u016f hlavou dol\u016f). Nyn\u00ed ji\u017e za vizu\u00e1ln\u00ed kontroly zav\u00e1d\u00edme dal\u0161\u00ed 11 mm port nad symf\u00fdzou (pozor\u00a0na epigastrick\u00e9 c\u00e9vy, mo\u010dov\u00fd m\u011bch\u00fd\u0159 nebo dokonce ilick\u00fd c\u00e9vn\u00ed svazek). Jemn\u00fdm grasperem revidujeme oblast b\u00e1ze c\u00e9ka, mezenteriolum a p\u0159edev\u0161\u00edm apendix. Pokud jsou patologicko anatomick\u00e9 zm\u011bny minim\u00e1ln\u00ed a apendix je dostate\u010dn\u011b voln\u00fd, v\u010detn\u011b b\u00e1ze c\u00e9ka, pokus\u00edme se jej pozvolna vtahovat do tohoto portu. Zru\u0161\u00edme kapnoperitoneum a port i s n\u00e1strojem opatrn\u011b kroutiv\u00fdm pohybem vytahujeme. Op\u011bt z\u016fst\u00e1v\u00e1 navle\u010den na n\u00e1stroj, kter\u00fd dr\u017e\u00ed apendix. Tento p\u0159echyt\u00edme peanem, jemn\u00fdmi h\u00e1\u010dky rozt\u00e1hneme m\u011bkk\u00e9 tk\u00e1n\u011b v m\u00edst\u011b incize tak, abychom voln\u011b povyt\u00e1hli nejm\u00e9n\u011b do \u00farovn\u011b k\u016f\u017ee odstupuj\u00edc\u00ed b\u00e1zi \u010derva a p\u0159edev\u0161\u00edm mezenteriolum. Arterii a apendix o\u0161et\u0159\u00edme obvykle, ligaturami, a apendix sneseme. Nech\u00e1me jej vklouznout <i>in situ<\/i>, na vodi\u010di zavedeme znovu 11 mm port inciz\u00ed nad symf\u00fdzou pod kontrolou optiky a revidujeme cel\u00e9 opera\u010dn\u00ed pole, oblast mal\u00e9 p\u00e1nve, kli\u010dky tenk\u00e9ho st\u0159eva do vzd\u00e1lenosti asi 80 a\u017e 100 cm od c\u00e9ka, tedy oblasti, kde se m\u016f\u017ee nach\u00e1zet Meckel\u016fv divertikl.<br \/>\nPokud zjist\u00edme pokro\u010dilej\u0161\u00ed n\u00e1lez, kdy by mohlo doj\u00edt k otev\u0159en\u00ed, nebo dokonce roztr\u017een\u00ed zan\u00edcen\u00e9ho apendixu, nebo se n\u00e1m tato technika nejev\u00ed bezpe\u010dn\u00e1, pak ji nepou\u017eijeme. Stejn\u011b tak v p\u0159\u00edpadech, kdy n\u00e1lez v oblasti \u010derva nevysv\u011btluje pot\u00ed\u017ee nemocn\u00e9ho, zav\u00e1d\u00edme dal\u0161\u00ed port paraumbilik\u00e1ln\u011b na stran\u011b operuj\u00edc\u00edho a pe\u010dliv\u011b revidujeme celou dutinu b\u0159i\u0161n\u00ed.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\"><strong>Opera\u010dn\u00ed postup p\u0159i laparoskopick\u00e9 apendek\u00adtomii<br \/>\n<\/strong>Nemocn\u00fd je v poloze na z\u00e1dech. V celkov\u00e9 intuba\u010dn\u00ed anestezii mu zavedeme permanentn\u00ed kat\u00e9tr.<br \/>\nVypr\u00e1zdn\u011bn\u00fd mo\u010dov\u00fd m\u011bch\u00fd\u0159 je podm\u00ednkou dobr\u00e9 orientaci v mal\u00e9 p\u00e1nvi a prevenc\u00ed jeho poran\u011bn\u00ed. To je d\u016fle\u017eit\u00e9 zvl\u00e1\u0161t\u011b p\u0159i zav\u00e1d\u011bn\u00ed suprapubick\u00e9ho trokaru. Sledov\u00e1n\u00ed diur\u00e9zy b\u011bhem operace, zvl\u00e1\u0161t\u011b p\u0159i prvn\u00edch v\u00fdkonech, kter\u00e9 trvaj\u00ed v\u011bt\u0161inou d\u00e9le, pat\u0159\u00ed ke standardn\u00edmu monitorov\u00e1n\u00ed nemocn\u00fdch. U d\u011bt\u00ed a mlad\u0161\u00edch operujeme bez kat\u00e9tru. Pokud je nezbytn\u00fd, pak jej hned po ukon\u010den\u00ed v\u00fdkonu odstran\u00edme.Vedeme asi 10\u201312 mm dlouh\u00fd poloobloukovit\u00fd \u0159ez na doln\u00edm nebo horn\u00edm valu pupku, kter\u00fdm zavedeme Veressovu jehlu. Po dosa\u017een\u00ed kapnoperitonea 10\u201312 mm Hg jehlu odstran\u00edme a zavedeme 10mm port. Trokar zav\u00e1d\u00edme sm\u011brem dol\u016f v \u00fahlu asi 30<sup>o<\/sup>, abychom se vyhnuli kolizi bodce s velk\u00fdmi c\u00e9vami. Pro b\u011b\u017enou apendektomii tudy zav\u00e1d\u00edme progr\u00e1dn\u00ed optiku, kter\u00e1 je zcela dosta\u010duj\u00edc\u00ed. Optika se sklonem 30\u201345\u00b0 umo\u017e\u0148uje bezpe\u010dn\u00e9 zaveden\u00ed opera\u010dn\u00edch port\u016f a p\u0159edev\u0161\u00edm optim\u00e1ln\u00ed vizualizaci opera\u010dn\u00edho pole. Po revizi peritone\u00e1ln\u00ed dutiny operovan\u00e9ho sklop\u00edme do Trendelenburgovy polohy a m\u00edrn\u011b nato\u010d\u00edme na lev\u00fd bok. Operat\u00e9r je na lev\u00e9 stran\u011b nemocn\u00e9ho. Proti n\u011bmu stoj\u00ed asistent, kter\u00fd m\u00e1 po prav\u00e9 ruce instrument\u00e1\u0159ku. Alternativou je,\u017ee operat\u00e9r i asistent jsou na lev\u00e9 stran\u011b a instrument\u00e1\u0159ka je proti nim.<\/li>\n<li style=\"text-align: justify;\">Vysta\u010d\u00edme s jedn\u00edm monitorem, kter\u00fd je um\u00edst\u011bn \u0161ikmo od hlavy operovan\u00e9ho. Dnes ale ta pracovi\u0161t\u011b, kter\u00e1 maj\u00ed velk\u00fd pod\u00edl laparoskopick\u00fdch operac\u00ed, preferuj\u00ed monitory dva tak, aby v\u0161ichni \u010dlenov\u00e9 t\u00fdmu m\u011bli pohodln\u00fd p\u0159ehled o opera\u010dn\u00edm poli a v\u00fdkonu.<br \/>\nDal\u0161\u00ed trokar o pr\u016fm\u011bru 12 mm zav\u00e1d\u00edme pod optickou kontrolou ve st\u0159edn\u00ed \u010d\u00e1\u0159e asi 2 cm nad \u00farovn\u00ed symf\u00fdzy. Mus\u00edme d\u00e1vat pozor, aby pronikaj\u00edc\u00ed bodec trokaru neporanil mo\u010dov\u00fd m\u011bch\u00fd\u0159. Pomoc\u00ed disektoru nebo jemn\u00e9ho grasperu se p\u0159esv\u011bd\u010d\u00edme o ulo\u017een\u00ed c\u00e9ka a apendixu. To je d\u016fle\u017eit\u00e9 pro um\u00edst\u011bn\u00ed t\u0159et\u00edho pracovn\u00edho kan\u00e1lu. Ten b\u00fdv\u00e1 um\u00edst\u011bn later\u00e1ln\u011b vlevo paraumbilik\u00e1ln\u011b. Dosta\u010duj\u00edc\u00ed je 5mm port (obr. 4). Zav\u00e1d\u00edme j\u00edm grasper nebo jin\u00e9 kl\u00ed\u0161\u0165ky, kter\u00e9 nezran\u00ed ser\u00f3zu c\u00e9ka nebo vzestupn\u00fd tra\u010dn\u00edk.<\/p>\n<p><div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_147.png\"><img decoding=\"async\" title=\"Obr. 4 \u2013 Um\u00edst\u011bn\u00ed jednoliv\u00fdch trokar\u016f\" alt=\"Obr. 4 \u2013 Um\u00edst\u011bn\u00ed jednoliv\u00fdch trokar\u016f\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_147.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 4 \u2013 Um\u00edst\u011bn\u00ed jednoliv\u00fdch trokar\u016f<\/p><\/div><\/li>\n<\/ul>\n<p><span style=\"text-align: justify;\">Tahem c\u00e9ka sm\u011brem k hlav\u011b nemocn\u00e9ho, vyluxujeme apendix k p\u0159edn\u00ed st\u011bn\u011b b\u0159i\u0161n\u00ed (obr. 5). Pokud nejsou zjevn\u00e9 pokro\u010dil\u00e9 z\u00e1n\u011btliv\u00e9 zm\u011bny, p\u0159esuneme atraumatick\u00e9 kl\u00ed\u0161\u0165ky asi 1 cm nad b\u00e1zi \u010derva. Nyn\u00ed uvoln\u00edme mezenteriolum v dostate\u010dn\u00e9m rozsahu od apendixu (obr. 6). Dv\u011bma klipy o\u0161et\u0159\u00edme v tomto m\u00edst\u011b mezenteriolum a v n\u011bm prob\u00edhaj\u00edc\u00ed arterii apendikul\u00e1rn\u00ed. Na hranici horn\u00edho okraje \u201eokna\u201c mezenteriolum p\u0159eru\u0161\u00edme n\u016f\u017ekami s koagulac\u00ed.Nyn\u00ed zavedeme suprapubick\u00fdm trokarem postupn\u011b t\u0159i kli\u010dky \u201e<\/span><i style=\"text-align: justify;\">endoloop<\/i><span style=\"text-align: justify;\">\u201c. Prvn\u00ed dv\u011b postupn\u011b nalo\u017e\u00edme t\u011bsn\u011b nad sebou nad b\u00e1z\u00ed \u010derva, mezi druhou a t\u0159et\u00ed ponech\u00e1me dostate\u010dn\u00fd prostor, abychom apendix mohli n\u016f\u017ekami protnout, tato t\u0159et\u00ed kli\u010dka m\u016f\u017ee b\u00fdt nahrazena klipem (obr. 7).Apendix vt\u00e1hneme do tubusu a odstran\u00edme. Stejn\u00fdm portem zavedeme irig\u00e1tor, odsajeme p\u0159\u00edpadn\u00fd v\u00fdpotek, opl\u00e1chneme vlastn\u00ed opera\u010dn\u00ed pole a p\u0159itom se p\u0159esv\u011bd\u010d\u00edme, zda nen\u00ed n\u011bkde krv\u00e1cen\u00ed a zda je uzav\u0159en\u00ed pah\u00fdlu apendixu dokonal\u00e9. Pokud n\u00e1lez nebyl v\u00fdznamn\u011b pokro\u010dil\u00fd, revidujeme celou dutinu b\u0159i\u0161n\u00ed, p\u0159edev\u0161\u00edm ileum, kde p\u00e1tr\u00e1me po Meckelov\u011b divertiklu. Pokud to pova\u017eujeme za vhodn\u00e9, m\u016f\u017eeme\u00a0opera\u010dn\u00ed pole nebo Douglas\u016fv prostor zajistit Redonov\u00fdm dr\u00e9nem.<\/span><\/p>\n<p style=\"text-align: justify;\">Pod kontrolou odstran\u00edme oba porty, vyjmeme z posledn\u00edho optiku a po desuflaci dutiny b\u0159i\u0161n\u00ed i tento trokar. V m\u00edst\u011b po zaveden\u00ed 12mm trokaru je vhodn\u00e9 se\u0161\u00edt i aponeur\u00f3zu.<\/p>\n<p style=\"text-align: justify;\">Konkr\u00e9tn\u00ed opera\u010dn\u00ed n\u00e1lez a morfologick\u00e9 zm\u011bny mezenteriola a apendixu jsou d\u016fvodem k volb\u011b jin\u00e9 techniky. Popsan\u00fdm oknem u b\u00e1ze \u010derva m\u016f\u017eeme zav\u00e9st stapler \u201e<i>Endo GIA<\/i>\u201c. Jeho bran\u017eemi obejmeme apendix v m\u00edst\u011b jeho b\u00e1ze. Mus\u00edme db\u00e1t na to, aby tk\u00e1\u0148 st\u0159eva nep\u0159esahovala zna\u010dku na bran\u017ei. Tato vymezuje aktivn\u00ed linii p\u0159\u00edstroje \u2013 tedy oblast, kter\u00e1 bude svorkami uzav\u0159ena (obr. 8). P\u0159\u00edstroj odjist\u00edme a po jeho plynul\u00e9m stisku a pak uvoln\u011bn\u00ed bran\u017e\u00ed je apendix slep\u011b uzav\u0159en a odd\u011blen od b\u00e1ze c\u00e9ka. Tato je rovn\u011b\u017e uzav\u0159ena dv\u011bma \u0159adami svorek (obr. 9). Jak ji\u017e bylo uvedeno, n\u011bkdy jsme nuceni stapler pou\u017e\u00edt opakovan\u011b jak na apendix, tak i na mezenteriolum (obr. 10). Nicm\u00e9n\u011b bude z\u00e1viset na zvyklostech ka\u017ed\u00e9ho pracovi\u0161t\u011b.<\/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_149.png\"><img decoding=\"async\" title=\"Obr. 5 \u2013 Zachycen\u00ed apendixu a c\u00e9ka\" alt=\"Obr. 5 \u2013 Zachycen\u00ed apendixu a c\u00e9ka\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_149.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 5 \u2013 Zachycen\u00ed apendixu a c\u00e9ka<\/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_150.png\"><img decoding=\"async\" title=\"Obr. 6 \u2013 Vytvo\u0159en\u00ed \u201eokna\u201c v mezenteriolu\" alt=\"Obr. 6 \u2013 Vytvo\u0159en\u00ed \u201eokna\u201c v mezenteriolu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_150.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 6 \u2013 Vytvo\u0159en\u00ed \u201eokna\u201c v mezenteriolu<\/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_151.png\"><img decoding=\"async\" title=\"Obr. 7 \u2013 Odd\u011blen\u00ed apendixu po nalo\u017een\u00ed t\u0159\u00ed kli\u010dek \u201eendo-loop\u201c\" alt=\"Obr. 7 \u2013 Odd\u011blen\u00ed apendixu po nalo\u017een\u00ed t\u0159\u00ed kli\u010dek \u201eendo-loop\u201c\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_151.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 7 \u2013 Odd\u011blen\u00ed apendixu po nalo\u017een\u00ed t\u0159\u00ed kli\u010dek \u201eendo-loop\u201c<\/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_152.png\"><img decoding=\"async\" title=\"Obr. 8 \u2013 Stapler \u201eEndo GIA 30 mm\u201c k odd\u011blen\u00ed apendixu\" alt=\"Obr. 8 \u2013 Stapler \u201eEndo GIA 30 mm\u201c k odd\u011blen\u00ed apendixu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_152.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 8 \u2013 Stapler \u201eEndo GIA 30 mm\u201c k odd\u011blen\u00ed apendixu<\/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_153.png\"><img decoding=\"async\" title=\"Obr. 9 \u2013 B\u00e1ze c\u00e9ka o\u0161et\u0159ena staplerem, mezenteriolum klipy\" alt=\"Obr. 9 \u2013 B\u00e1ze c\u00e9ka o\u0161et\u0159ena staplerem, mezenteriolum klipy\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_153.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 9 \u2013 B\u00e1ze c\u00e9ka o\u0161et\u0159ena staplerem, mezenteriolum klipy<\/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_155.png\"><img decoding=\"async\" title=\"Obr. 10 \u2013 B\u00e1ze c\u00e9ka i mezenteriolum o\u0161et\u0159eny staplerem\" alt=\"Obr. 10 \u2013 B\u00e1ze c\u00e9ka i mezenteriolum o\u0161et\u0159eny staplerem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_155.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 10 \u2013 B\u00e1ze c\u00e9ka i mezenteriolum o\u0161et\u0159eny staplerem<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Pokud k t\u00e9to komplikaci dojde, je pro osud nemocn\u00e9ho d\u016fle\u017eit\u00e1 v\u010dasn\u00e1 diagn\u00f3za. Op\u011bt n\u00e1m m\u016f\u017ee pomoci zaveden\u00fd dr\u00e9n. M\u016f\u017eeme se pokusit o exploraci laparoskopem. Ale zaveden\u00ed port\u016f nen\u00ed bez rizika, orientace b\u00fdv\u00e1 zt\u00ed\u017een\u00e1. Laparoskopii sp\u00ed\u0161e provedeme jako \u201e<i>asistovanou<\/i>\u201c. Toaleta dutiny peritone\u00e1ln\u00ed a jej\u00ed lav\u00e1\u017e a dren\u00e1\u017e dle rozsahu peritonitidy jsou nezbytnou sou\u010d\u00e1st\u00ed o\u0161et\u0159en\u00ed pah\u00fdlu. V\u011bt\u0161inou se nevyhneme resekci b\u00e1ze c\u00e9ka. Pod\u00e1n\u00ed antibiotik, nejl\u00e9pe c\u00edlen\u011b, je sou\u010d\u00e1st\u00ed l\u00e9\u010dby.<\/p>\n<ul>\n<li style=\"text-align: justify;\"><strong>\u00daskal\u00ed a komplikace laparoskopick\u00e9 apendek\u00adtomie<\/strong>\n<ul>\n<li style=\"text-align: justify;\"><em>Krv\u00e1cen\u00ed<\/em><br \/>\nP\u0159\u00ed\u010din a zdroj\u016f m\u016f\u017ee b\u00fdt hned n\u011bkolik: a. apendikul\u00e1rn\u00ed, poran\u011bn\u00e1 vena mezenteria, krv\u00e1cen\u00ed z m\u00edsta po zaveden\u00ed trokaru. Nejdramati\u010dt\u011bj\u0161\u00ed je jist\u011b krv\u00e1cen\u00ed p\u0159i poran\u011bn\u00ed velk\u00fdch c\u00e9v zp\u016fsoben\u00e9 bodcem trokaru. Tomu se sna\u017e\u00edme p\u0159edej\u00edt opatrn\u00fdm zav\u00e1d\u011bn\u00edm port\u016f. Na n\u011bkter\u00fdch pracovi\u0161t\u00edch rad\u011bji prvn\u00ed trokar zav\u00e1d\u011bj\u00ed bez bodce minilaparotomi\u00ed, jej\u00ed\u017e okraje nadzved\u00e1vaj\u00ed <em>vhodn\u00fdmi<\/em> n\u00e1stroji nebo siln\u00fdmi stehy, kter\u00fdmi pak incizi kolem portu ut\u011bsn\u00ed.<br \/>\nArterii apendikul\u00e1rn\u00ed v\u017edy pe\u010dliv\u011b o\u0161et\u0159\u00edme dv\u011bma klipy, a pokud nen\u00ed v infiltrovan\u00e9m mezenteriolu dob\u0159e patrn\u00e1, potom rad\u011bji pou\u017e\u00edv\u00e1me stapler. Preparujeme a revidujeme oblast kolem c\u00e9ka \u0161etrn\u011b a traumatick\u00fdmi n\u00e1stroji. Tak sn\u00ed\u017e\u00edme mo\u017enost poran\u011bn\u00ed c\u00e9v mezenteria na minimum. Porty odstra\u0148ujeme v\u017edy pod kontrolou kamery. P\u0159\u00edpadn\u00e9 krv\u00e1cen\u00ed v m\u00edst\u011b vpichu vy\u0159e\u0161\u00edme koagulac\u00ed, klipem nebo propichovou ligaturou. Pokud byla operace obt\u00ed\u017en\u00e1, zajist\u00edme opera\u010dn\u00ed pole Redonov\u00fdm dr\u00e9nem, i kdy\u017e opakovan\u00fd proplach a ods\u00e1t\u00ed poplachov\u00e9 tekutiny nesv\u011bd\u010d\u00ed v dan\u00e9 chv\u00edli pro krv\u00e1cen\u00ed.<\/li>\n<li style=\"text-align: justify;\"><em>Dehiscence pah\u00fdlu<\/em><br \/>\nJedn\u00e1 se o jednu z nejob\u00e1van\u011bj\u0161\u00edch komplikac\u00ed. Nej\u010dast\u011bj\u0161\u00ed p\u0159\u00ed\u010dinou je \u0161patn\u00e1 volba zp\u016fsobu uzav\u0159en\u00ed pah\u00fdlu apendixu p\u0159edev\u0161\u00edm s ohledem na lok\u00e1ln\u00ed n\u00e1lez a anatomick\u00e9 podm\u00ednky. Pou\u017eit\u00ed koagulace p\u0159i prot\u011bt\u00ed apendixu, manipulace s pah\u00fdlem apendixu a nalo\u017eenou kli\u010dkou m\u016f\u017ee v\u00e9st k povolen\u00ed a n\u00e1sledn\u00e9mu sklouznut\u00ed se v\u0161emi d\u016fsledky. V p\u0159\u00edpad\u011b pokro\u010dil\u00e9 apendicitidy, kter\u00e1 postihuje i b\u00e1zi \u010derva, je nejbezpe\u010dn\u011bj\u0161\u00ed pou\u017e\u00edt stapleru a apendektomii prov\u00e9st sp\u00ed\u0161e jako parci\u00e1ln\u00ed resekci b\u00e1ze c\u00e9kave zdrav\u00e9 tk\u00e1ni.<\/li>\n<li style=\"text-align: justify;\"><em>Infekt r\u00e1ny<\/em><br \/>\nVznik\u00e1 kontaktem st\u011bny b\u0159i\u0161n\u00ed se zan\u00edcen\u00fdm apendixem p\u0159i jeho obt\u00ed\u017en\u00e9 extrakci. Ta m\u016f\u017ee b\u00fdt komplikov\u00e1na velikost\u00ed \u010derva nebo tlou\u0161\u0165kou b\u0159i\u0161n\u00ed st\u011bny operovan\u00e9ho. Jako prevence se proto doporu\u010duje n\u011bkdy periopera\u010dn\u00ed pod\u00e1n\u00ed vhodn\u00e9ho antibiotika, proplach r\u00e1ny 3% peroxidem vod\u00edku, u\u017eit\u00ed prepar\u00e1tu typu Betadine, zaji\u0161t\u011bn\u00ed podko\u017e\u00ed r\u00e1ny rukavicov\u00fdm dr\u00e9nem. Zan\u00edcen\u00fd apendix je nutn\u00e9 vlo\u017eit do speci\u00e1ln\u00edho s\u00e1\u010dku (endo bag, prst chirurgick\u00e9 rukavice, improvizovan\u00fd igelitov\u00fd s\u00e1\u010dek, kondom\u2026) a teprve takto jej extrahovat.<\/li>\n<li style=\"text-align: justify;\"><em>Ostatn\u00ed komplikace<\/em><br \/>\nSami jsme v jednom p\u0159\u00edpad\u011b zaznamenali v poopera\u010dn\u00edm obdob\u00ed vznik adnexitidy u d\u00edvky, kde byl p\u0159i operaci n\u00e1lez na adnexech z\u0159eteln\u011b negativn\u00ed.<br \/>\nZhojila se po pod\u00e1n\u00ed antibiotik. P\u0159\u00ed\u010dinou teplota neprosp\u00edv\u00e1n\u00ed po v\u00fdkonu, kter\u00fd byl jinak sn\u00e1\u0161en velmi dob\u0159e, m\u016f\u017ee b\u00fdt absces kolem \u010d\u00e1sti apendixu, kter\u00e1 se p\u0159i manipulaci odd\u011blila a z\u016fstala v dutin\u011b peritone\u00e1ln\u00ed.<br \/>\nJe pot\u0159eba pom\u00fd\u0161let i na dehiscenci o\u0161et\u0159en\u00e9ho pah\u00fdlu. Mus\u00edme si b\u00fdt v\u011bdomi, \u017ee miniinvazivn\u00ed v\u00fdkon nevylu\u010duje vznik \u017e\u00e1dn\u00e9 z komplikac\u00ed, jak je zn\u00e1me z konven\u010dn\u00ed chirurgie.<br \/>\nLaparoskopick\u00e1 apendektomie se dnes prov\u00e1d\u00ed zcela rutinn\u011b v zahrani\u010d\u00ed a na \u0159ad\u011b na\u0161ich pracovi\u0161\u0165. Sou\u010dasn\u00e9 pr\u00e1ce potvrzuj\u00ed jej\u00ed pozitivn\u00ed p\u0159\u00ednos i u pokro\u010dil\u00e9 formy apendicitidy spojen\u00e9 s peritonitidou, a to i u mal\u00fdch d\u011bt\u00ed.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<h4>3.3 Onemocn\u011bn\u00ed<\/h4>\n<h6>Meckelova divertiklu<\/h6>\n<ul>\n<li style=\"text-align: justify;\"><strong>Anatomick\u00e9 pozn\u00e1mky<br \/>\n<\/strong>Meckel\u016fv divertikl je pravou v\u00fdchlipkou st\u011bny ilea. Nal\u00e9z\u00e1me jej v\u011bt\u0161inou ve vzd\u00e1lenosti 60\u201390 cmod Bauhinsk\u00e9 chlopn\u011b. Je poz\u016fstatkem duktus omphaloentericus. V\u00fdjime\u010dn\u011b m\u016f\u017ee b\u00fdt jeho vrchol spojen obliterovan\u00fdm, ale zachovan\u00fdm duktem s oblast\u00ed pupe\u010dn\u00ed jizvy. Takov\u00fdto n\u00e1lez m\u016f\u017ee jeho nositeli \u010dinit\u00a0zna\u010dn\u00e9 pot\u00ed\u017ee, neobjasniteln\u00e9 k\u0159e\u010dovit\u00e9 bolesti b\u0159icha a opakuj\u00edc\u00ed se subile\u00f3zn\u00ed stavy.<\/li>\n<li style=\"text-align: justify;\"><strong>Onemocn\u011bn\u00ed divertiklu<br \/>\n<\/strong>Meckel\u016fv divertikl b\u00fdv\u00e1 nej\u010dast\u011bj\u0161\u00edm n\u00e1hodn\u00fdm n\u00e1lezem. Pokud jde o jeho vlastn\u00ed onemocn\u011bn\u00ed,diagnostika je velmi obt\u00ed\u017en\u00e1. P\u0159ed operac\u00ed se da\u0159\u00ed sp\u00ed\u0161e per exclusionem a je d\u00e1na zku\u0161enost\u00ed diagnostikuj\u00edc\u00edho l\u00e9ka\u0159e, kter\u00fd na takovou mo\u017enost mysl\u00ed.<\/li>\n<li style=\"text-align: justify;\"><strong>Posti\u017een\u00ed z\u00e1n\u011btem<\/strong><br \/>\nCiz\u00ed t\u011bleso, \u0161patn\u00e1 evakuace obsahu divertiklu nebo indukce z okol\u00ed m\u016f\u017ee b\u00fdt p\u0159\u00ed\u010dinou z\u00e1n\u011btu v\u00fdchlipky.<\/li>\n<li style=\"text-align: justify;\"><strong>Atopick\u00e1 p\u0159\u00edtomnost \u017ealude\u010dn\u00ed sliznice<\/strong><br \/>\nV takto atopicky lokalizovan\u00e9 sliznici \u010dasto vznikaj\u00ed krv\u00e1cej\u00edc\u00ed ulcerace. Na tuto mo\u017enost mus\u00edme myslet p\u0159i opakovan\u00fdch projevech krv\u00e1cen\u00ed do za\u017e\u00edvac\u00ed trubice s projevy meleny nebo \u201erychl\u00e9 pas\u00e1\u017ee\u201c. V diagnostice m\u016f\u017ee b\u00fdt \u00fasp\u011b\u0161n\u00e1 selektivn\u00ed angiografie, pokud se jedn\u00e1 o krv\u00e1cen\u00ed intenzivn\u00ed, nebo scintigrafie pod\u00e1n\u00edm zna\u010den\u00fdch erytrocyt\u016f. Ojedin\u011blou p\u0159\u00ed\u010dinou perfora\u010dn\u00ed peritonitidy je perforace takov\u00e9ho v\u0159edu.<\/li>\n<li style=\"text-align: justify;\"><strong>Karcinoid<\/strong><br \/>\nP\u0159i p\u00e1tr\u00e1n\u00ed po karcinoidu, pokud m\u00e1 klinick\u00e9 a laboratorn\u00ed projevy, je tato jeho lokalizace jednou z mo\u017en\u00fdch.<\/li>\n<li style=\"text-align: justify;\"><strong>Patologick\u00fd n\u00e1lez<\/strong><br \/>\nMeckel\u016fv divertikl, jak bylo uvedeno, m\u016f\u017ee b\u00fdt r\u016fzn\u011b velik\u00fd: od pouh\u00e9ho n\u00e1znaku vyklenut\u00ed a\u017e po n\u011bkolik centimetr\u016f velkou v\u00fdchlipku. M\u016f\u017ee b\u00fdt\u00a0bez jak\u00e9hokoli patologick\u00e9ho n\u00e1lezu a\u017e po nekrotizuj\u00edc\u00ed v\u00fdchlipku, kterou nalezneme v\u011bt\u0161inou ohrani\u010denou v mezikli\u010dkov\u00e9m abscesu.<\/li>\n<li style=\"text-align: justify;\"><strong>Klinick\u00e9 vy\u0161et\u0159en\u00ed<\/strong><br \/>\nNa onemocn\u011bn\u00ed Meckelova divertiklu je t\u0159eba myslet v r\u00e1mci diferenci\u00e1ln\u00ed diagnostiky nejr\u016fzn\u011bj\u0161\u00edch obt\u00ed\u017e\u00ed. M\u016f\u017ee j\u00edt o projevy spojen\u00e9 s krv\u00e1cen\u00edm, obrazem perfora\u010dn\u00ed peritonitidy, specifick\u00e9 projevy karcinoidu, bolesti b\u0159icha, teploty, leukocyt\u00f3zu, par\u00e9zu st\u0159evn\u00ed nebo naopak dr\u00e1\u017ediv\u00e9 pr\u016fjmy a an\u00e9mii.<br \/>\nNej\u010dast\u011bji se v\u0161ak s Meckelov\u00fdm divertiklem setk\u00e1me v pr\u016fb\u011bhu apendektomie \u2013 patologick\u00e9 zm\u011bny nemus\u00ed b\u00fdt na apendixu z\u0159eteln\u00e9 a nevysv\u011btluj\u00ed pot\u00ed\u017ee nemocn\u00e9ho. Potom v\u017edy revidujeme dist\u00e1ln\u00edch 100 cm ilea, kde m\u016f\u017eeme nal\u00e9zt zm\u011bny na Meckelov\u011b divertiklu.<\/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_157.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 11 \u2013 Snesen\u00ed Meckelova divertiklu se \u0161irokou b\u00e1z\u00ed p\u0159i klasick\u00e9 apendektomii\" alt=\"Obr. 11 \u2013 Snesen\u00ed Meckelova divertiklu se \u0161irokou b\u00e1z\u00ed p\u0159i klasick\u00e9 apendektomii\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_157.png\" width=\"200\" height=\"192\" \/><\/a><p class=\"wp-caption-text\">Obr. 11 \u2013 Snesen\u00ed Meckelova divertiklu se \u0161irokou b\u00e1z\u00ed p\u0159i klasick\u00e9 apendektomii<\/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_158.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 12 \u2013 P\u0159\u00ed\u010dn\u00e9 se\u0161it\u00ed vznikl\u00e9ho otvoru ve st\u0159ev\u011b\" alt=\"Obr. 12 \u2013 P\u0159\u00ed\u010dn\u00e9 se\u0161it\u00ed vznikl\u00e9ho otvoru ve st\u0159ev\u011b\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_158.png\" width=\"200\" height=\"139\" \/><\/a><p class=\"wp-caption-text\">Obr. 12 \u2013 P\u0159\u00ed\u010dn\u00e9 se\u0161it\u00ed vznikl\u00e9ho otvoru ve st\u0159ev\u011b<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<ul>\n<li style=\"text-align: justify;\"><strong>L\u00e9\u010den\u00ed<br \/>\n<\/strong>P\u0159i n\u00e1hodn\u00e9m n\u00e1lezu, nap\u0159\u00edklad p\u0159i apendektomii, m\u016f\u017eeme mal\u00fd divertikl vchl\u00edpit do lumen st\u0159eva.<br \/>\nV\u011bt\u0161ina chirurg\u016f vzhledem k popsan\u00e9 mo\u017en\u00e9 atopiitk\u00e1n\u011b a jin\u00fdm zm\u011bn\u00e1m preferuje snesen\u00ed divertiklup\u0159i b\u00e1zi klasick\u00fdm zp\u016fsobem nebo pomoc\u00ed staplerov\u00e9techniky. V n\u011bkter\u00fdch p\u0159\u00edpadech, kdy b\u00e1ze divertikluzauj\u00edm\u00e1 v\u00edce jak polovinu obvodu st\u0159evn\u00ed kli\u010dky, jetechnicky nejsch\u016fdn\u011bj\u0161\u00ed kl\u00ednovit\u00e1 \u00fasporn\u00e1 resekces anastom\u00f3zou \u201eend-to-end\u201c. Jeho odstran\u011bn\u00ed m\u016f\u017eeme prov\u00e9st analogicky laparoskopicky stejnou technikou jako apendektomii. Pokud je b\u00e1ze divertiklu \u00fazk\u00e1, pak op\u011bt vytvo\u0159\u00edme v\u00fd\u0161e popsan\u00e9 <i>\u201eokno\u201c <\/i>mezi n\u00eda mezenteriolem, kter\u00e9 zaklipujeme a divertikl o\u0161et\u0159\u00edme technikou kli\u010dek <i>\u201eendo-loop\u201c<\/i>, kombinac\u00ed kli\u010dek a svorek. Pokud je b\u00e1ze divertiklu \u0161irok\u00e1, pak resekci provedeme pomoc\u00ed stapleru <i>\u201eEndo GIA\u201c <\/i>(obr. 11 a 12).<\/li>\n<\/ul>\n<h6>Pozn\u00e1mka na z\u00e1v\u011br<\/h6>\n<p style=\"text-align: justify;\">Flexibiln\u00ed endoskopie se postupem \u010dasu a v\u00fdvojem techniky stala nejen metodou diagnostickou, ale i kurativn\u00ed s velk\u00fdmi mo\u017enostmi do budoucna. Novodob\u00e1 laparoskopie (rigidn\u00ed endoskopie) prim\u00e1rn\u011b coby kurativn\u00ed metoda se zase naopak suver\u00e9nn\u011b stala i metodou diagnostickou. Metodou, kter\u00e1 p\u0159i diagnostick\u00fdch rozpac\u00edch po vy\u010derp\u00e1n\u00ed mo\u017enost\u00ed komplementu m\u016f\u017ee v\u00e9st ke spr\u00e1vn\u00e9 diagn\u00f3ze. Pr\u00e1v\u011b ve v\u010dasn\u00e9m \u0159e\u0161en\u00ed z\u00e1n\u011btliv\u00fdch n\u00e1hl\u00fdch p\u0159\u00edhod b\u0159i\u0161n\u00edch m\u016f\u017ee v\u00fdznamn\u011b ovlivnit mortalitu, ale i st\u00e1le je\u0161t\u011b vysokou morbiditu. St\u00e1le v\u00edce pronik\u00e1 i do komplikovan\u00fdch stav\u016f v d\u011btsk\u00e9 chirurgii z\u00e1n\u011btliv\u00fdch NPB, ukazuje se perspektivn\u00ed a u\u017eite\u010dnou pro nemocn\u00e9 s komorbiditami. Objevuj\u00ed se nov\u00e9 technologie, pou\u017eit\u00ed p\u0159\u00edstupu \u201esingle port\u201c, je k dispozici miniinstrumentarium.<\/p>\n<h4>3.4 Pou\u017eit\u00e1 a doporu\u010den\u00e1 literatura<\/h4>\n<ol>\n<li style=\"text-align: justify;\">Duda M, Dlouh\u00fd M, Gryga A, \u0160vach I. Laparoskopick\u00e1 appendektomie. V: \u0158\u00edha V, editor. Endoskopick\u00e1 chirurgie \u017elu\u010dov\u00fdch cest. Laparoskopick\u00e1 cholecystektomie. Sborn\u00edk prac\u00ed II. celost\u00e1tn\u00ed konference o laparoskopick\u00e9 chirurgii; 1993,24\u201326.<\/li>\n<li style=\"text-align: justify;\">Bene\u0161ov u Prahy; 2, 1993, s. 152\u2013155.2. Engstr\u00f6m L. Appendectomy : assessment ofstump invagination: a prospective, randomizedtrial. Br J Surg. 1985;27:971.<\/li>\n<li style=\"text-align: justify;\">Engstr\u00f6m L, Fenyo G. Appendicectomy: assessment of stump invagination versus simple ligation: a prospective, randomized trial. Br J Surg.1985;27:971\u20132.<\/li>\n<li style=\"text-align: justify;\">Fleming JS. Laparoscopically directe appendectomy. Aust N Z, Obstet Gynaecol. 1982;25:283\u2013240.<\/li>\n<li style=\"text-align: justify;\">Gangal HT, Gangal MH. Laparoscopic appendectomy. Endoskopy. 1987;19:127\u2013129.<\/li>\n<li style=\"text-align: justify;\">Gotz F, Pier A, Bachor C. Modified laparoscopicappendectomy in surgery: A report on 388 operations. J Surg Endosc. 1990;4:6\u20139.<\/li>\n<li style=\"text-align: justify;\">Gryga A. Laparoskopick\u00e1 apendektomie a resekce Meckelova divertiklu. In Duda M, Czudek S.,edito\u0159i. Miniinvazivn\u00ed chirurgie. T\u0159inec: Nemocnice Podles\u00ed T\u0159inec; 1996. s. 60\u201365.<\/li>\n<li style=\"text-align: justify;\">Chow A, Aziz O. Single incision laparoscopic surgery for acute appendicitis: feasibility in pediatricpatient. Dian Ther Endosc. 2010: 294958. Epub2010 Feb 4.<\/li>\n<li style=\"text-align: justify;\">Kala Z, Hanke, I, Neumann, \u010c. Modifikovan\u00e1technika laparoskopicky asistentovan\u00e9 apedektomie \u2013 transumbilik\u00e1ln\u00ed p\u0159\u00edstup jedn\u00edm portem.Rozhl Chir. 1996;75:15.<\/li>\n<li style=\"text-align: justify;\">Koleh A, Delibegovic S, et al. Laparoscopic appendectomy in the treatment of acute appendicitis. Med Arch. 2010;64(3):147\u2013150.<\/li>\n<li style=\"text-align: justify;\">Leahy PF. Techniquo of laparoscopic appendectomy. Br J Surg. 1989;76:616.<\/li>\n<li style=\"text-align: justify;\">Lori L, Fritts MD, Rocco Orgando III MD. Laparoscopic Appendectomy. A Safety and Cost Analysis. Arch Surg. 1993;128:521\u2013525.<\/li>\n<li style=\"text-align: justify;\">McAnen, OJ. Laparoscopic Versus Open Appendectomy. Lancet. 1991;338:693.<\/li>\n<li style=\"text-align: justify;\">Meador JH, Nowzaradan Y, Matzelle W. Laparoscopic cholecystectomy: New indications. Surg Laparosc Endosc. 1991;84:186\u2013189.<\/li>\n<li style=\"text-align: justify;\">Minutolo V, Gaglian G. Laparoscopic appendectomy for acute appendicitis. Chir Ital. 2009;61(5\u20136):591\u2013596.Nowzaradan Y, Westrnoreland JC. Laparoscopiccholecystectomy: New indications. Surg LaparoscEndosc. 1991;1:71\u2013176.<\/li>\n<li style=\"text-align: justify;\">Pelosi Marco A. Laparoscopic Appendectomyusing a Single Umbilical Puncture (Minilaparoscopy). J Repro Med. 1992;37:588\u2013594.<\/li>\n<li style=\"text-align: justify;\">Pier A, Gotz F, Bachor C. Laparoscopic appendectomy in 625 cases: From inovation to routine.Surg Laparosc Endosc. 1991;1:8\u201313.<\/li>\n<li style=\"text-align: justify;\">Planta L, Star\u00fd D. Laparoscopic versus laparotomic appendectomy for generalisatiom peritonitisin children. Skripta Med. Fac. Med. Univ. Brunensis 2010(2).Reddick EJ, Saye WB. Laparoscopicappendectomy. In: Zucker KA, Bailey RW, Reddick EJ. Surgical Laparoscopy. St. Louis: DualityMedical Publishing, Inc. 1991;227\u201339.<\/li>\n<li style=\"text-align: justify;\">Semm K. Endoscopic appendectomy. Endoskopy.1983;15:59\u201364.<\/li>\n<li style=\"text-align: justify;\">Schreiber JH. Early experience with laparoscopicappendectomy in women. Surg Endosc. 1987;1:211\u2013216.<\/li>\n<li style=\"text-align: justify;\">Schreiber JH. Laparoscopic appendectomy inpregnancy. Surg Endosc. 1990;4:100\u2013102.<\/li>\n<li style=\"text-align: justify;\">Schultz LS, Pietrafitta JJ, Graber JN, Hickok DF.Retrograde laparoscopic appendectomy: Reportof a case. J Laparosc Surg. 1991;1:111\u2013114.<\/li>\n<li style=\"text-align: justify;\">Tuggle KR, Ortega G. Laparoscopic versus openappendectomy in complicated apendicitis. J SurgRes. 2010; 63(2): pp. 225\u2013228.<\/li>\n<li style=\"text-align: justify;\">Verner T, Vran\u00fd M. Laparoskopick\u00e1 apendektomie. Chir Rozhl. 1994;73(4):171\u2013172.<\/li>\n<li style=\"text-align: justify;\">Wilson T. Laparoscopicaly \u2013 asistent appendectomies. Med J Aust. 1986;145:551.<\/li>\n<li style=\"text-align: justify;\">Yeh CC, Wu SC. Laparoscopic appendectomy foracute appendicitis is more favorable for patientwith comorbidities. Nationwide populationbased study. Surg Endosc. 2011;25(9):2932\u20132942.Epub 2011 Mar 18.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>3.1 Onemocn\u011bn\u00ed apendixu 3.1.1 Anatomick\u00e9 pozn\u00e1mky Apendix (\u010dervovit\u00fd p\u0159\u00edv\u011bsek, processus vermicularis, laicky \u201eslep\u00e9 st\u0159evo\u201c) odstupuje z b\u00e1ze c\u00e9ka v m\u00edst\u011b, kde se spojuj\u00ed jednotliv\u00e9 t\u00e9nie. To je d\u016fle\u017eit\u00e1 orienta\u010dn\u00ed pom\u016fcka p\u0159i hled\u00e1n\u00ed \u010derva, kter\u00fd je ulo\u017een atypicky, nebo v ter\u00e9nu zm\u011bn\u011bn\u00e9m pokro\u010dil\u00fdm z\u00e1n\u011btem, kter\u00fd ji\u017e p\u0159estoupil na okol\u00ed. D\u00e9lka a ulo\u017een\u00ed apendixu jsou velmi variabiln\u00ed. [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":2447,"menu_order":3,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-2566","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2566","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=2566"}],"version-history":[{"count":23,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2566\/revisions"}],"predecessor-version":[{"id":3883,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2566\/revisions\/3883"}],"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=2566"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}