{"id":312,"date":"2013-03-14T09:37:18","date_gmt":"2013-03-14T09:37:18","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=312"},"modified":"2013-06-09T14:09:16","modified_gmt":"2013-06-09T14:09:16","slug":"8-2","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=312","title":{"rendered":"8 Hi\u00e1tov\u00e1 hernie"},"content":{"rendered":"

8.1 Definice a klasifikace<\/h3>\n

Hi\u00e1tovou herni\u00ed (HH) rozum\u00edme p\u0159esunut\u00ed gastroezofage\u00e1ln\u00edho spojen\u00ed anebo v\u011bt\u0161\u00ed \u010di men\u0161\u00ed \u010d\u00e1sti \u017ealudku ezofage\u00e1ln\u00edm hi\u00e1tem do mediastina. V roce 1926 uve\u0159ejnil \u0161v\u00e9dsk\u00fd rentgenolog Ake Akerlund [1] klasifikaci HH na z\u00e1klad\u011b 60 liter\u00e1rn\u00edch a 30 vlastn\u00edch pozorov\u00e1n\u00ed. Toto rozd\u011blen\u00ed bylo modifikov\u00e1no \u0159adou autor\u016f, ale v podstat\u011b plat\u00ed dodnes. Rozli\u0161oval t\u0159i z\u00e1kladn\u00ed typy:<\/p>\n

    \n
  1. Hi\u00e1tov\u00e1 hernie s (kongenit\u00e1ln\u011b) zkr\u00e1cen\u00fdm j\u00edcnem, kde nen\u00ed mo\u017en\u00e1 repozice.<\/li>\n
  2. Paraezofage\u00e1ln\u00ed hi\u00e1tov\u00e1 hernie.<\/li>\n
  3. Ostatn\u00ed hi\u00e1tov\u00e9 hernie, kde j\u00edcen nen\u00ed zkr\u00e1cen, ale dist\u00e1ln\u00ed konec ezofagu tvo\u0159\u00ed \u010d\u00e1st obsahu k\u00fdln\u00edho vaku.<\/li>\n<\/ol>\n

    Skluzn\u00e1 hi\u00e1tov\u00e1 hernie je obdobn\u011b, jako to m\u016f\u017eeme vid\u011bt u t\u0159\u00edseln\u00fdch k\u00fdl, herni\u00ed par glissement. Peritone\u00e1ln\u00ed vak je vytvo\u0159en jen na ventr\u00e1ln\u00ed stran\u011b ezofagogastrick\u00e9ho spojen\u00ed a dorz\u00e1ln\u00ed retroperitone\u00e1ln\u00ed \u010d\u00e1st \u017ealudku vak nem\u00e1 (obr. 1).<\/p>\n

    Ezofagogastrick\u00e1 junkce, kter\u00e1 \u010dasto ztr\u00e1c\u00ed svou kompetenci, je i s p\u0159ilehlou \u010d\u00e1st\u00ed \u017ealudku dislokov\u00e1na do hrudn\u00edku. Pro III. typ popsan\u00fd Akerlundem se dnes b\u011b\u017en\u011b u\u017e\u00edv\u00e1 term\u00ednu skluzn\u00e1 hi\u00e1tov\u00e1 hernie (\u201esliding\u201c, \u201egleiten\u201c). Toto ozna\u010den\u00ed bylo zavedeno a\u017e Olsenem a Harringtonem [2] v roce 1947.<\/p>\n

    Paraezofage\u00e1ln\u00ed hernie m\u00e1 naopak vytvo\u0159en\u00fd typick\u00fd peritone\u00e1ln\u00ed vak. Charakteristick\u00e9 je, \u017ee kardie z\u016fst\u00e1v\u00e1 pod br\u00e1nic\u00ed a zachov\u00e1v\u00e1 si svou kompetenci. Do mediastina se dislokuje r\u016fzn\u011b velk\u00e1 \u010d\u00e1st \u017ealudku \u2013 vlevo, vpravo nebo ventr\u00e1ln\u011b od j\u00edcnu. Pro m\u00e9n\u011b obvyklou formu paraezofage\u00e1ln\u00ed hernie, kdy se do hrudn\u00edku p\u0159esunuje jen \u010d\u00e1st \u017ealudku krani\u00e1ln\u011b od bursa infracardiaca, u\u017e\u00edvaj\u00ed Gahagan a Lam [3] v\u00fdrazu \u201einfracardiac bursa hernia\u201c. V extr\u00e9mn\u00edm p\u0159\u00edpad\u011b, kdy v dutin\u011b b\u0159i\u0161n\u00ed z\u016fst\u00e1v\u00e1 pouze kardie a pylorus, pou\u017e\u00edv\u00e1me term\u00ednu \u201eup-side-down stomach\u201c. Sweet [4] hovo\u0159\u00ed o parahi\u00e1tov\u00e9 hernii m\u00edsto paraezofage\u00e1ln\u00ed. Podle n\u011bho z\u016fst\u00e1v\u00e1 \u010d\u00e1st svaloviny hi\u00e1tu mezi j\u00edcnem a k\u00fdln\u00edm vakem, kter\u00fd pronik\u00e1 samostatn\u00fdm otvorem vedle hi\u00e1tu. Zku\u0161enosti Nissenovy a Rossettiho [5], Ellisovy [6] i na\u0161e v\u0161ak existenci tohoto typu nepotvrzuj\u00ed.<\/p>\n

    Ji\u017e Akerlund upozornil na existenci p\u0159echodn\u00fdch forem mezi paraezofage\u00e1ln\u00ed a skluznou herni\u00ed. Pr\u00e1ce Barreta [7], Sweeta [4], Nissena, Rossettiho [5] a dal\u0161\u00edch rozli\u0161uj\u00ed jako dal\u0161\u00ed druh hernie formu sm\u00ed\u0161enou. Sou\u010dasn\u011b s vysunut\u00edm fundu \u017ealude\u010dn\u00edho do hi\u00e1tu doch\u00e1z\u00ed i ke skluzu kardie nad br\u00e1nici a zpravidla i k jej\u00ed inkompetenci. Podle vytvo\u0159en\u00e9ho peritone\u00e1ln\u00edho vaku lze rozli\u0161ovat dva typy [7, 8]. Schlegal\u016fv typ A je vlastn\u011b velkou skluznou herni\u00ed, kde prolaps \u017ealudku do mediastina je tak velk\u00fd, \u017ee za sebou vyt\u00e1hne peritone\u00e1ln\u00ed duplikaturu i na dorz\u00e1ln\u00ed stran\u011b \u017ealudku a k\u00fdln\u00ed vak je vytvo\u0159en po cel\u00e9 cirkumferenci. Rentgenologicky nen\u00ed mo\u017en\u00e1 diferenciace od velk\u00e9 skluzn\u00e9 hernie [9]. Typ B je obvykl\u00fdm obrazem sm\u00ed\u0161en\u00e9 hernie. P\u0159edstavuje paraezofage\u00e1ln\u00ed v\u00fdh\u0159ez \u017ealudku a z\u00e1rove\u0148 doch\u00e1z\u00ed ke skluzu kardie do mediastina (obr. 2).<\/p>\n\n\n\n
    \n

    \"Obr.<\/a>

    Obr. 1 \u2013 R\u016fzn\u00e9 typy hi\u00e1tov\u00fdch herni\u00ed se zn\u00e1zorn\u011bn\u00edm jejich k\u00fdln\u00edch vak\u016f<\/p><\/div><\/td>\n

    		\n

    \"Obr.<\/a>

    Obr. 2 \u2013 Rozsah herniovan\u00e9 \u010d\u00e1sti \u017ealudku do mediastina u r\u016fzn\u00fdch typ\u016f hi\u00e1tov\u00e9 hernie<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

    .<\/span><\/p>\n

    Na z\u00e1klad\u011b kinematografick\u00fdch studi\u00ed zjistil Imdahl se spolupracovn\u00edky, \u017ee u \u0159ady paraezofage\u00e1ln\u00edch herni\u00ed doch\u00e1z\u00ed p\u0159i inspiriu k dislokaci kardie nad br\u00e1nici a z\u00e1rove\u0148 k jej\u00ed funk\u010dn\u00ed poru\u0161e spojen\u00e9 s gastroezofage\u00e1ln\u00edm refluxem. Doporu\u010doval ozna\u010den\u00ed intermitentn\u00ed sm\u00ed\u0161en\u00e1 hernie, a t\u00edm vysv\u011btloval p\u0159\u00edtomnost refluxn\u00edch obt\u00ed\u017e\u00ed u cel\u00e9 \u0159ady paraezofage\u00e1ln\u00edch k\u00fdl [9].<\/p>\n

    P\u0159edstupn\u011bm HH b\u00fdv\u00e1 ozna\u010dov\u00e1na kardiotuber\u00f3zn\u00ed malpozice, popsan\u00e1 v roce 1953 Lortat-Jacobem a Robertem [10]. Tento stav, kter\u00fd b\u00fdv\u00e1 p\u0159\u00ed\u010dinou refluxu, je charakterizov\u00e1n \u0161irok\u00fdm hi\u00e1tem, kr\u00e1tk\u00fdm abdomin\u00e1ln\u00edm j\u00edcnem, m\u011blk\u00fdm Hisov\u00fdm \u00fahlem a relaxac\u00ed Laimerovy membr\u00e1ny.<\/p>\n

    Hi\u00e1tov\u00e1 hernie m\u016f\u017ee b\u00fdt bu\u010f reponibiln\u00ed do podbr\u00e1ni\u010dn\u00edho prostoru, nebo trvale fixov\u00e1na v mediastinu. \u010casto je to pak ve spojen\u00ed s kr\u00e1tk\u00fdm j\u00edcnem neboli brachyezofagem (viz kapitola 9. Refluxn\u00ed nemoc j\u00edcnu).<\/p>\n

    V klinick\u00e9 praxi vysta\u010d\u00edme obvykle se \u010dlen\u011bn\u00edm herni\u00ed na \u010dty\u0159i z\u00e1kladn\u00ed typy:<\/p>\n

      \n
    1. skluzn\u00e1,<\/li>\n
    2. paraezofage\u00e1ln\u00ed,<\/li>\n
    3. sm\u00ed\u0161en\u00e1,<\/li>\n
    4. kr\u00e1tk\u00fd j\u00edcen a ostatn\u00ed komplikovan\u00e9 stavy.<\/li>\n<\/ol>\n

      N\u011bkdy je t\u0159eba se p\u0159ipojit ji\u017e k d\u00e1vno Allisonem [11] vysloven\u00fdm slov\u016fm, kter\u00fdmi shrnul sv\u00e9 celo\u017eivotn\u00ed zku\u0161enosti, \u017ee \u010dasto je p\u0159esn\u00e1 klasifikace mo\u017en\u00e1 jen teoreticky.\u00a0Podle n\u011bj je spr\u00e1vn\u00e9 hovo\u0159it o predominantn\u011b skluzn\u00fdch a predominantn\u011b paraezofage\u00e1ln\u00edch herni\u00edch.<\/p>\n

      \"Obr.<\/a>

      Obr. 3 \u2013 Pr\u00e1ce J. T. Klinkosche z roku 1764, v n\u00ed\u017e najdeme prvn\u00ed zm\u00ednku o hi\u00e1tov\u00fdch herni\u00edch<\/p><\/div>\n

      8.2 Historie<\/h3>\n

      Ran\u00e1 historie hi\u00e1tov\u00fdch k\u00fdl je spojena s k\u00fdlami br\u00e1ni\u010dn\u00edmi.<\/p>\n

      V roce 1853 uv\u00e1d\u00ed Bowditch v monografii o br\u00e1ni\u010dn\u00edch herni\u00edch 27 liter\u00e1rn\u00edch citac\u00ed do roku 1847 s popisem 88 br\u00e1ni\u010dn\u00edch k\u00fdl. Jejich v\u00fd\u010det za\u010d\u00edn\u00e1 dv\u011bma br\u00e1ni\u010dn\u00edmi traumatick\u00fdmi herniemi, kter\u00e9 popsal v roce 1575 Ambroise Par\u00e9. Vedle nejstar\u0161\u00edch prac\u00ed o br\u00e1ni\u010dn\u00edch herni\u00edch (Par\u00e9 1575, Riverius 1698, Kirschbaum 1755, Morgani 1769) poch\u00e1z\u00ed jedna z prvn\u00edch zm\u00ednek o hi\u00e1tov\u00fdch herni\u00edch z \u010desk\u00e9 literatury a je citov\u00e1na i v klasick\u00e9 Akerlundov\u011b pr\u00e1ci.V roce 1764 vy\u0161la v Praze pr\u00e1ce zn\u00e1m\u00e9ho pra\u017esk\u00e9ho anatoma J. T. Klinkosche \u201eDe Herniarum Divisione\u201c [1, 12, 13] (obr. 3).<\/p>\n

      Klinick\u00e1 diagnostika br\u00e1ni\u010dn\u00edch herni\u00ed p\u0159ed rokem 1900 pat\u0159ila k v\u00fdjimk\u00e1m. V roce 1912 Giffin referuje o 690 br\u00e1ni\u010dn\u00edch herni\u00edch, z nich\u017e jen 15 bylo diagnostikov\u00e1no klinicky. Botha [14] ve sv\u00e9 monografii p\u00ed\u0161e, \u017ee p\u0159ed rokem 1900 nebyl klinicky diagnostikov\u00e1n ani jeden p\u0159\u00edpad HH. Eppinger do roku 1911 nalezl v literatu\u0159e popis 635 br\u00e1ni\u010dn\u00edch herni\u00ed, z toho 11 hi\u00e1tov\u00fdch. Kienb\u00f6ck v roce 1913 uve\u0159ejnil p\u0159ehled n\u011bmeck\u00e9 literatury. Z 37 br\u00e1ni\u010dn\u00edch herni\u00ed byla stanovena diagn\u00f3za jen t\u0159ikr\u00e1t za\u017eiva. Ani jednou se to nepoda\u0159ilo u t\u0159ech pozorovan\u00fdch hi\u00e1tov\u00fdch herni\u00ed (Gadechens 1838, Banga 1874, Knaggs 1904). Maydl v monografii \u201eNauka o k\u00fdl\u00e1ch \u010dili herni\u00edch\u201c z roku 1897 m\u00e1 v souvislosti s brani\u010dn\u00edmi herniemi jen kr\u00e1tkou zm\u00ednku o k\u00fdl\u00e1ch prostupuj\u00edc\u00edch \u0161t\u011brbinou pa\u017eer\u00e1ku [12].<\/p>\n

      V roce 1928 publikuje rentgenologicky zam\u011b\u0159en\u00e9 kazuistick\u00e9 sd\u011blen\u00ed Sigmund [15] z Prahy. Ve stejnou dobu rentgenolog Simon [16] z kliniky Pet\u0159ivalsk\u00e9ho v Brn\u011b p\u0159i popisu sv\u00fdch dvou pozorov\u00e1n\u00ed upozor\u0148uje pravd\u011bpodobn\u011b jako prvn\u00ed ve sv\u011btov\u00e9 literatu\u0159e na gastroezofage\u00e1ln\u00ed reflux v souvislosti se skluznou hi\u00e1tovou herni\u00ed.<\/p>\n

      8.3 Etiologie<\/h3>\n

      Za hlavn\u00ed p\u0159\u00ed\u010dinu vzniku HH se pova\u017euje insuficience pojivov\u00fdch tk\u00e1n\u00ed fixa\u010dn\u00edho apar\u00e1tu GES a \u017ealudku. Podp\u016frn\u00fdmi faktory jsou obezita a zv\u00fd\u0161en\u00fd intraabdomin\u00e1ln\u00ed tlak. Tuto hypot\u00e9zu podporuje i zv\u00fd\u0161en\u00fd v\u00fdskyt hi\u00e1tov\u00fdch herni\u00ed ve vy\u0161\u0161\u00edm v\u011bku [17]. Jedna z nov\u011bj\u0161\u00edch prac\u00ed uv\u00e1d\u00ed u pacient\u016f s hi\u00e1tovou herni\u00ed v\u00edce jak dvojn\u00e1sobn\u011b \u010dast\u011bj\u0161\u00ed sou\u010dasn\u00fd v\u00fdskyt inguin\u00e1ln\u00ed hernie ve srovn\u00e1n\u00ed s pacienty bez p\u0159\u00edtomnosti hi\u00e1tov\u00e9 hernie [18]. Traumatick\u00e9 vlivy se a\u017e na v\u00fdjimky uplatn\u00ed zpravidla jen p\u0159i p\u0159\u00edm\u00e9m po\u0161kozen\u00ed fixa\u010dn\u00edho apar\u00e1tu peropera\u010dn\u011b. Vz\u00e1cn\u011b se m\u016f\u017ee HH vytvo\u0159it jako n\u00e1sledek funk\u010dn\u00edho nebo organick\u00e9ho zkr\u00e1cen\u00ed j\u00edcnu. P\u0159\u00edkladem je difuzn\u00ed spazmus j\u00edcnu, polept\u00e1n\u00ed nebo refluxn\u00ed ezofagitida. V t\u011bchto p\u0159\u00edpadech hovo\u0159\u00edme o sekund\u00e1rn\u00edch HH [19].<\/p>\n

      8.4 Epidemiologie<\/h3>\n

      Skute\u010dn\u00fd v\u00fdskyt HH v populaci nen\u00ed p\u0159esn\u011b zn\u00e1m. Jejich zji\u0161t\u011bn\u00ed z\u00e1vis\u00ed na zp\u016fsobu vy\u0161et\u0159en\u00ed a pozornosti, kter\u00e1 se tomuto stavu v\u011bnuje. Na skute\u010dnou incidenci m\u016f\u017eeme usuzovat z v\u00fdskytu HH p\u0159i rentgenov\u00e9m vy\u0161et\u0159en\u00ed horn\u00ed \u010d\u00e1sti za\u017e\u00edvac\u00edho traktu. Hafter zjistil mezi 5557 vy\u0161et\u0159en\u00edmi HH ve 24,3 %. Incidence stoupala s v\u011bkem [20]. V\u011bt\u0161ina ostatn\u00edch autor\u016f [21] ud\u00e1v\u00e1 obdobn\u00fd v\u00fdskyt mezi 18\u201333 %. Sp\u00ed\u0161e v\u00fdjimkou [22, 23] je frekvence ni\u017e\u0161\u00ed mezi 2\u20133 % [24, 25]. Jin\u00fdm zdrojem informac\u00ed je vy\u0161et\u0159en\u00ed zdrav\u00fdch dobrovoln\u00edk\u016f. V t\u011bchto skupin\u00e1ch [26, 27] je ud\u00e1v\u00e1n v\u00fdskyt dokonce mezi 33\u201350 %. Zaj\u00edmav\u00fd je odhad Weisera, Siewerta a spol. [28] (1978). Podle nich lze v NSR p\u0159edpokl\u00e1dat skluznou HH u 15 milion\u016f ob\u010dan\u016f. Z 245 diagnostikovan\u00fdch herni\u00ed zjistili gastroezofage\u00e1ln\u00ed reflux v 65 % a chirurgickou l\u00e9\u010dbu bylo nutn\u00e9 indikovat v 39 %.<\/p>\n

      Rovn\u011b\u017e \u00fadaje v nov\u011bj\u0161\u00ed odborn\u00e9 literatu\u0159e ud\u00e1vaj\u00ed v\u00fdskyt herni\u00ed ve zna\u010dn\u00e9m rozmez\u00ed. V jedn\u00e9 pr\u00e1ci byla skluzn\u00e1 hi\u00e1tov\u00e1 hernie zji\u0161t\u011bna u nekardi\u00e1ln\u00edch bolest\u00ed na hrudn\u00edku u 29 % vy\u0161et\u0159en\u00fdch a v souvislosti s refluxn\u00edmi pot\u00ed\u017eemi u 45 % [29]. Sm\u00ed\u0161en\u00e9 a paraezofage\u00e1ln\u00ed hernie p\u0159edstavuj\u00ed jen kolem 5 % ze v\u0161ech hi\u00e1tov\u00fdch herni\u00ed [30], jejich v\u00fdznam je v\u0161ak d\u00e1n mo\u017en\u00fdm v\u00fdskytem z\u00e1va\u017en\u00fdch komplikac\u00ed. V \u00e9\u0159e laparoskopick\u00e9 chirurgie byl zaznamen\u00e1n zv\u00fd\u0161en\u00fd v\u00fdskyt t\u011bchto typ\u016f herni\u00edjako komplikace po laparoskopick\u00fdch v\u00fdkonech v oblasti j\u00edcnov\u00e9ho hi\u00e1tu, nej\u010dast\u011bji po zalo\u017een\u00ed fundoplikace, a to v 1\u20136 % po t\u011bchto operac\u00edch [31, 32, 33]. V\u011bt\u0161ina nov\u011bj\u0161\u00edch epidemiologick\u00fdch prac\u00ed je zam\u011b\u0159ena sp\u00ed\u0161e na v\u00fdskyt refluxn\u00ed nemoci j\u00edcnu a teprve sekund\u00e1rn\u011b na koincidenci s hi\u00e1tov\u00fdmi herniemi, jak o tom bude je\u0161t\u011b v\u00edce pojedn\u00e1no v kapitole o refluxn\u00ed nemoci j\u00edcnu.<\/p>\n

      8.5 Klinick\u00fd obraz, komplikace a diagnostika<\/h3>\n

      Skluzn\u00e1 hi\u00e1tov\u00e1 hernie je \u010dast\u00fdm vedlej\u0161\u00edm n\u00e1lezem p\u0159i rentgenov\u00e9m vy\u0161et\u0159en\u00ed horn\u00ed \u010d\u00e1sti za\u017e\u00edvac\u00ed trubice a ne\u010din\u00ed sv\u00e9mu nositeli zpravidla \u017e\u00e1dn\u00e9 obt\u00ed\u017ee. V\u00fdznam nab\u00fdv\u00e1 jen spolu se zji\u0161t\u011bnou inkompetenc\u00ed gastroezofage\u00e1ln\u00edho spojen\u00ed vedouc\u00ed ke gastroezofage\u00e1ln\u00edmu refluxu a k rozvoji refluxn\u00ed choroby j\u00edcnu se v\u0161emi jej\u00edmi p\u0159\u00edznaky [34], jak o tom bude podrobn\u011b pojedn\u00e1no v dal\u0161\u00ed kapitole.<\/p>\n

      Rozd\u00edln\u00e1 je situace u nemocn\u00fdch se sm\u00ed\u0161enou a s paraezofage\u00e1ln\u00ed herni\u00ed a up-side-down stomachem. P\u0159i vyhodnocen\u00ed na\u0161eho souboru v\u00edce ne\u017e 100 operovan\u00fdch z obdob\u00ed od roku 1948 do po\u010d\u00e1tku devades\u00e1t\u00fdch let minul\u00e9ho stolet\u00ed [35, 36] jsme zjistili n\u00e1sleduj\u00edc\u00ed symptomatologii, charakteristickou p\u0159edev\u0161\u00edm pro paraezofage\u00e1ln\u00ed typ herni\u00ed:<\/p>\n

      Vedouc\u00edm p\u0159\u00edznakem byla nej\u010dast\u011bji bolest lokalizovan\u00e1 v epigastriu (62 %) a za sternem (38 %). V 6 % mezi vedouc\u00ed p\u0159\u00edznaky pat\u0159ilo zvracen\u00ed, kter\u00e9 celkov\u011b bylo p\u0159\u00edtomno u 38 % nemocn\u00fdch. Jen 12 % pacient\u016f bylo asymptomatick\u00fdch. Pr\u016fm\u011brn\u00e1 d\u00e9lka obt\u00ed\u017e\u00ed byla 2 roky, nepo\u010d\u00edtaje v to inkarcera\u010dn\u00ed p\u0159\u00edhody.<\/p>\n

      Z na\u0161eho souboru m\u011blo tak\u0159ka 20 % operovan\u00fdch z\u00e1va\u017enou komplikaci ohro\u017euj\u00edc\u00ed \u017eivot.<\/p>\n

      U sm\u00ed\u0161en\u00fdch HH byly obt\u00ed\u017ee z\u00e1visl\u00e9 na tom, zda byl p\u0159\u00edtomen gastroezofage\u00e1ln\u00ed reflux. Zaznamenali jsme jej v 75 % p\u0159\u00edpadech s odpov\u00eddaj\u00edc\u00ed klinickou symptomatologi\u00ed, zat\u00edmco u typick\u00fdch parazeofage\u00e1ln\u00edch forem jsme nev\u00fdrazn\u00fd reflux p\u0159edopera\u010dn\u011b prok\u00e1zali p\u0159i rentgenov\u00e9m vy\u0161et\u0159en\u00ed jen v\u00fdjime\u010dn\u011b (7 %). Subjektivn\u00ed obt\u00ed\u017ee t\u011bchto nemocn\u00fdch se bl\u00ed\u017eily refluxn\u00ed nemoci j\u00edcnu. U ostatn\u00edch p\u0159eva\u017eovala symptomatologie charakteristick\u00e1 pro hernie paraezofage\u00e1ln\u00ed. V\u011bt\u0161ina nemocn\u00fdch (43 %) byla star\u0161\u00ed \u0161edes\u00e1ti let, operov\u00e1no v\u0161ak bylo tak\u00e9 10 d\u011bt\u00ed v prvn\u00ed dek\u00e1d\u011b \u017eivota. Pokud jde o pohlav\u00ed, nepatrn\u011b p\u0159eva\u017eovali mu\u017ei. Z v\u011bkov\u00e9ho rozvrstven\u00ed se zd\u00e1, \u017ee u tohoto typu herni\u00ed se na jejich vzniku pod\u00edl\u00ed insuficience pojivov\u00fdch tk\u00e1n\u00ed ve vy\u0161\u0161\u00edm v\u011bku nebo kongenit\u00e1ln\u00ed tk\u00e1\u0148ov\u00fd defekt u operovan\u00fdch d\u011bt\u00ed.<\/p>\n

      \"Obr.<\/a>

      Obr. 4 \u2013 Mechanizmus vzniku obstrukce a\u017e strangulace u up-side-down stomach podle Larsona a Hilla [38]b\u0159i\u0161n\u00ed \u0161irok\u00fdm ezofage\u00e1ln\u00edm hi\u00e1tem. Dojde k angulaci a\u017e obstrukci v oblasti antra \u010di kardie a na kompresi se m\u016f\u017ee pod\u00edlet i okraj j\u00edcnov\u00e9ho hi\u00e1tu (obr. 4). V na\u0161em souboru m\u011blo sedm nemocn\u00fdch zn\u00e1mky obstruk\u010dn\u00edho syndromu. Obstruk\u010dn\u00ed syndrom u paraezofage\u00e1ln\u00ed hernie vy\u017eaduj\u00edc\u00ed urgentn\u00ed operaci jsme pozorovali \u010dty\u0159ikr\u00e1t. U dal\u0161\u00edch t\u0159\u00ed nemocn\u00fdch byla tato p\u0159\u00edhoda v anamn\u00e9ze.<\/p><\/div>\n

      Nositel\u00e9 paraezofage\u00e1ln\u00edch a sm\u00ed\u0161en\u00fdch hi\u00e1tov\u00fdch herni\u00ed jsou ohro\u017eeni vznikem z\u00e1va\u017en\u00fdch komplikac\u00ed:<\/p>\n

        \n
      1. Obstruk\u010dn\u00ed syndrom<\/i>. M\u016f\u017ee j\u00edt o obstrukci, inkarceraci a\u017e strangulaci herniovan\u00e9 \u010d\u00e1sti \u017ealudku, se kterou se nej\u010dast\u011bji setk\u00e1v\u00e1me u up-side-down stomach [37]. Podle Larsona a Hilla [38, 39] doch\u00e1z\u00ed u \u017ealudku dislokovan\u00e9ho do hrudn\u00edku k rozepnut\u00ed fundu, kter\u00fd prolabuje svoj\u00ed hmotnost\u00ed z mediastina zp\u011bt do dutiny<\/li>\n
      2. Krv\u00e1cen\u00ed <\/i>vyvolan\u00e9 ven\u00f3zn\u00ed st\u00e1zou v prolabovan\u00e9 \u010d\u00e1sti \u017ealudku, vznikem slizni\u010dn\u00edch eroz\u00ed nebo v\u0159edem v m\u00edst\u011b k\u00fdln\u00ed branky, ozna\u010dovan\u00fdm jako v\u0159ed kr\u010dku [40,41] (\u201eriding ulcer\u201c, \u201eulcer du Colle\u201c). \u010cast\u011bj\u0161\u00ed ne\u017e prudk\u00e9 akutn\u00ed krv\u00e1cen\u00ed je vznik sideropenick\u00e9 an\u00e9mie, jej\u00ed\u017e p\u0159\u00ed\u010dinou jsou eroze a venost\u00e1za [42, 43].
        \nZ na\u0161eho v\u00fd\u0161e hodnocen\u00e9ho souboru byla u 12 nemocn\u00fdch operace indikov\u00e1na pro krv\u00e1cen\u00ed, zpravidla po konzervativn\u00edm zvl\u00e1dnut\u00ed akutn\u00ed ataky. U 5 nemocn\u00fdch byl zdrojem krv\u00e1cen\u00ed v\u0159ed kr\u010dku a u 7 slizni\u010dn\u00ed eroze v prolabovan\u00e9 \u010d\u00e1sti \u017ealudku [40]. V\u0159ed kr\u010dku je typickou komplikac\u00ed paraezofage\u00e1ln\u00edch a sm\u00ed\u0161en\u00fdch hi\u00e1tov\u00fdch herni\u00ed [44]. Je lokalizov\u00e1n zpravidla na mal\u00e9m zak\u0159iven\u00ed \u017ealudku ve v\u00fd\u0161i k\u00fdln\u00ed branky, tj. hi\u00e1tu ezofage\u00e1ln\u00edho. Pravd\u011bpodobn\u011b nejde o \u010dist\u011b peptick\u00fd v\u0159ed, ale v\u00fdzna\u010dn\u00fd je i pod\u00edl traumatizace st\u011bny \u017ealudku v m\u00edst\u011b k\u00fdln\u00ed branky. Sv\u011bd\u010d\u00ed pro to mo\u017enost \u00fasp\u011b\u0161n\u00e9ho l\u00e9\u010den\u00ed nejen resekc\u00ed, ale i pouhou \u00fapravou hi\u00e1tov\u00e9 hernie [41]. Z p\u011bti na\u0161ich pozorov\u00e1n\u00ed byl resek\u010dn\u00ed v\u00fdkon nutn\u00fd jen jednou.<\/li>\n
      3. Kardiopulmon\u00e1ln\u00ed poruchy <\/i>z tlaku herniov\u00e9 \u010d\u00e1sti \u017ealudku na okoln\u00ed org\u00e1ny.
        \nU n\u011bkolika na\u0161ich pacient\u016f s paraezofage\u00e1ln\u00ed a sm\u00ed\u0161enou HH pot\u00ed\u017ee r\u016fzn\u011b dlouho imitovaly kardi\u00e1ln\u00ed onemocn\u011bn\u00ed, ne\u017e byla stanovena spr\u00e1vn\u00e1 diagn\u00f3za (obr. 9).<\/li>\n<\/ol>\n

        Na rentgenogramech na obr. 5, 6, 7, 8, 9 jsou uvedeny p\u0159\u00edklady z\u00e1va\u017en\u00fdch komplikac\u00ed z na\u0161eho klinick\u00e9ho materi\u00e1lu.<\/p>\n\n\n\n\n\n\n\n
        \n

        		\n

        \n

        		\n

        \n

        		\n

        \n

        		\n

        \n

        		\n

        \"Obr.<\/a>

        Obr. 9a
        Sm\u00ed\u0161en\u00e1 hi\u00e1tov\u00e1 hernie s gastroezofage\u00e1ln\u00edm refluxem imituj\u00edc\u00ed kardi\u00e1ln\u00ed p\u0159\u00edhodu<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

        Paraezofage\u00e1ln\u00ed hernie jsou typick\u00fdm onemocn\u011bn\u00edm vy\u0161\u0161\u00edho v\u011bku, a tito nemocn\u00ed trp\u00ed \u010dasto i \u0159adou dal\u0161\u00edch onemocn\u011bn\u00ed. S t\u00edm je spojeno zv\u00fd\u0161en\u00e9 opera\u010dn\u00ed riziko. S rozvojem laparoskopick\u00e9 chirurgie se zna\u010dn\u011b zv\u011bt\u0161il po\u010det nemocn\u00fdch s hi\u00e1tov\u00fdmi herniemi, kte\u0159\u00ed jsou indikov\u00e1ni k operaci [45]. Tato skute\u010dnost spolu s \u010dasto i \u201epreventivn\u00edmi\u201c operacemi hi\u00e1tov\u00fdch herni\u00ed se patrn\u011b v\u00fdznamn\u011b pod\u00edl\u00ed na skute\u010dnosti, \u017ee se v sou\u010dasnosti s komplikacemi paraezofage\u00e1ln\u00edch herni\u00ed setk\u00e1v\u00e1me m\u00e9n\u011b \u010dasto. P\u0159esto je v\u0161ak t\u0159eba u star\u0161\u00edch pacient\u016f s komorbiditami a diagnostikovanou paraezofage\u00e1ln\u00ed herni\u00ed v\u017edy zva\u017eovat opr\u00e1vn\u011bnost opera\u010dn\u00ed indikace. Velmi pravd\u011bpodobn\u011b se ve srovn\u00e1n\u00ed s minulost\u00ed zmen\u0161uje z uveden\u00fdch d\u016fvod\u016f riziko \u017eivot ohro\u017euj\u00edc\u00edch komplikac\u00ed u nemocn\u00fdch s paraezofage\u00e1ln\u00edmi herniemi. Podle ned\u00e1vn\u00e9 studie [46] se riziko strangulace pro nositele paraezofage\u00e1ln\u00edch herni\u00ed pohybuje pouze kolem 1% za rok. Z t\u011bchto d\u016fvod\u016f doporu\u010duj\u00ed auto\u0159i t\u00e9to pr\u00e1ce chirurgickou intervenci jen u pacient\u016f mlad\u0161\u00edch 60 let a t\u011bch, kte\u0159\u00ed maj\u00ed obt\u00ed\u017ee.<\/p>\n

        Nejd\u016fle\u017eit\u011bj\u0161\u00edm diagnostick\u00fdm postupem <\/b>k ur\u010den\u00ed typu a velikosti HH z\u016fst\u00e1v\u00e1 st\u00e1le kontrastn\u00ed rentgenov\u00e1 pas\u00e1\u017e j\u00edcnem a \u017ealudkem. Endoskopie m\u00e1 v\u00fdznam p\u0159edev\u0161\u00edm pro posouzen\u00ed slizni\u010dn\u00edch zm\u011bn, ale lze dle zp\u011btn\u00e9ho pohledu ze \u017ealudku a polohy kardie ur\u010dit, o jak\u00fd typ hernie se jedn\u00e1 (obr. 10a,b). P\u0159i sou\u010dasn\u00fdch zn\u00e1mk\u00e1ch refluxn\u00ed nemoci j\u00edcnu jsou na m\u00edst\u011b i dal\u0161\u00ed p\u0159i t\u00e9to diagn\u00f3ze u\u017e\u00edvan\u00e1 vy\u0161et\u0159en\u00ed. P\u0159i velk\u00e9 paraezofage\u00e1ln\u00e9\u00ed hernii v\u0161ak m\u016f\u017ee b\u00fdt zaveden\u00ed sondy p\u0159i manometrii a pH-metrii obt\u00ed\u017en\u00e9 a je pak nutn\u00e9 se bez t\u011bchto vy\u0161et\u0159en\u00ed obej\u00edt.<\/p>\n

        8.6 Chirurgick\u00e1 l\u00e9\u010dba<\/h3>\n

        8.6.1 Historie<\/h4>\n
        \"Obr.<\/a>

        Obr. 10b
        Paraezofage\u00e1ln\u00ed hernie, k\u00fdln\u00ed vak je later\u00e1ln\u011b od kardie, kter\u00e1 je v norm\u00e1ln\u00ed poloze<\/p><\/div>\n

        Spole\u010dn\u011b s rozvojem chirurgie br\u00e1nice se od po\u010d\u00e1tku minul\u00e9ho stolet\u00ed mno\u017eily zpr\u00e1vy o operativn\u00ed \u00faprav\u011b hi\u00e1tov\u00fdch herni\u00ed. Nep\u0159ekvapuje, \u017ee u\u017eit\u00e9 postupy se \u0159\u00eddily ji\u017e v t\u00e9to dob\u011b podrobn\u011b rozpracovan\u00fdmi z\u00e1sadami v\u0161eobecn\u00e9 herniologie. \u00dasil\u00ed bylo zam\u011b\u0159eno na \u00fapravu anatomick\u00e9 odchylky a funk\u010dn\u00ed v\u00fdznam gastroezofage\u00e1ln\u00edho spojen\u00ed a refluxu byl docen\u011bn teprve pozd\u011bji (obr. 11). Pracovn\u00edci Mayo kliniky v Rochesteru do roku 1924 shrom\u00e1\u017edili liter\u00e1rn\u00ed zpr\u00e1vy o 395 operovan\u00fdch br\u00e1ni\u010dn\u00edch herni\u00ed. Z toho bylo jen 24 hi\u00e1tov\u00fdch [12]. Mezi prvn\u00ed zm\u00ednky o operativn\u00edm \u0159e\u0161en\u00ed traumatick\u00fdch br\u00e1ni\u010dn\u00edch herni\u00ed pat\u0159\u00ed sd\u011blen\u00ed Ricolfiho z roku 1886. Naumann v roce 1888 jako prvn\u00ed operoval br\u00e1ni\u010dn\u00ed hernii, u n\u00ed\u017e org\u00e1ny neprolabovaly p\u0159es st\u011bnu b\u0159i\u0161n\u00ed. Prvn\u00ed operaci hi\u00e1tov\u00e9 hernie provedl patrn\u011b v roce 1911 Mayo. O zku\u0161enostech t\u00e9to kliniky, kter\u00e9 se op\u00edraly o 26 diafragmatick\u00fdch a 7 HH, referoval v roce 1928 Harrington. Pat\u0159il mezi pr\u016fkopn\u00edky tohoto \u00faseku chirurgie. Byl zast\u00e1ncem abdomin\u00e1ln\u00edho p\u0159\u00edstupu, ze kter\u00e9ho prov\u00e1d\u011bl resekci k\u00fdln\u00edho vaku a z\u00fa\u017een\u00ed ezofage\u00e1ln\u00edho hi\u00e1tu matracov\u00fdmi stehy. T\u00edmto zp\u016fsobem do roku 1948 operoval 343 nemocn\u00fdch [47] (obr. 11). V t\u00e9to dob\u011b byl Sauerbruch pro lep\u0161\u00ed p\u0159\u00edstup ke kardii zast\u00e1ncem cesty torak\u00e1ln\u00ed [48]. Modern\u00ed \u00e9ra chirurgick\u00e9 l\u00e9\u010dby HH a gastroezofage\u00e1ln\u00edho refluxu byla zah\u00e1jena pr\u016fkopnickou prac\u00ed Allisonovou v roce 1951 [11].<\/p>\n

        O prvn\u00edch zm\u00ednk\u00e1ch o HH z pera Klinkosche a Maydla v \u010desk\u00e9m p\u00edsemnictv\u00ed jsme se ji\u017e zm\u00ednili. Do roku 1950 bylo v na\u0161\u00ed literatu\u0159e uve\u0159ejn\u011bno je\u0161t\u011b n\u011bkolik kazuistick\u00fdch sd\u011blen\u00ed s popisem celkem 13 nemocn\u00fdch [12]. Poprv\u00e9 \u00fasp\u011b\u0161n\u011b operoval inkarcerovanou paraezofage\u00e1ln\u00ed hernii v roce 1931 Leischner v Brn\u011b [49].<\/p>\n

        8.6.2 Indikace<\/h5>\n

        Skluzn\u00e1 HH je indikov\u00e1na k chirurgick\u00e9 terapii jen tehdy, je-li prov\u00e1zena refluxn\u00ed nemoc\u00ed j\u00edcnu, ji\u017e nelze zvl\u00e1dnout konzervativn\u00ed l\u00e9\u010dbou (viz kapitola Refluxn\u00ed nemoc j\u00edcnu).<\/p>\n

        Sm\u00ed\u0161en\u00e1 a paraezofage\u00e1ln\u00ed hi\u00e1tov\u00e1 hernie p\u0159edstavovala v minulosti bez ohledu na v\u011bk a moment\u00e1ln\u00ed symptomatologii absolutn\u00ed indikaci k operaci. D\u016fvodem bylo velk\u00e9 nebezpe\u010d\u00ed komplikac\u00ed ohro\u017euj\u00edc\u00edch \u017eivot. V\u011bt\u0161ina chirurg\u016f zast\u00e1vala n\u00e1zor, \u017ee i star\u0161\u00ed nemocn\u00e9, kte\u0159\u00ed pro sv\u016fj vysok\u00fd v\u011bk nejsou v nejlep\u0161\u00ed biologick\u00e9 kondici, je l\u00e9pe operovat v\u010das, ne\u017eli vy\u010dk\u00e1vat bezprost\u0159edn\u00edho ohro\u017een\u00ed \u017eivota. Rossetti ze 17 nemocn\u00fdch star\u0161\u00edch 80 let 14 operoval z vit\u00e1ln\u00ed indikace [50]. Tato z\u00e1sada plat\u00ed i dnes u mlad\u0161\u00edch a symptomatick\u00fdch pacient\u016f. Paraezofage\u00e1ln\u00ed hernie jsou typick\u00fdm onemocn\u011bn\u00edm vy\u0161\u0161\u00edho v\u011bku, kdy n\u011bkte\u0159\u00ed nemocn\u00ed maj\u00ed v\u00fdznamn\u011b zv\u00fd\u0161en\u00e9 opera\u010dn\u00ed riziko a je v\u017edy t\u0159eba pe\u010dliv\u011b zva\u017eovat opr\u00e1vn\u011bnost opera\u010dn\u00ed indikace. S p\u0159ihl\u00e9dnut\u00edm ke skute\u010dnosti, \u017ee riziko komplikac\u00ed paraezofage\u00e1ln\u00edch herni\u00ed je dnes ni\u017e\u0161\u00ed [46], je mo\u017eno z t\u011bchto d\u016fvod\u016f \u010dast\u011bji zva\u017eovat observaci.<\/p>\n\n\n\n
        \n

        \"Obr.<\/a>

        Obr. 11
        Chirurgick\u00e9 metody u\u017e\u00edvan\u00e9 v l\u00e9\u010db\u011b hi\u00e1tov\u00fdch herni\u00ed a refl uxn\u00ed nemoci j\u00edcnu<\/p><\/div><\/td>\n

        \"Obr.<\/a>

        Obr. 12
        Modifi kovan\u00fd Rochard\u016fv rozv\u011bra\u010d usnad\u0148uj\u00edc\u00ed z horn\u00ed st\u0159edn\u00ed laparotomie p\u0159\u00edstup ke kardiihorn\u00ed st\u0159edn\u00ed laparotomie. Umo\u017e\u0148ovala v\u00fdkon i u star\u00fdch rizikov\u00fdch nemocn\u00fdch a \u0159e\u0161en\u00ed \u010dast\u00fdch sou\u010dasn\u00fdch intraabdomin\u00e1ln\u00edch onemocn\u011bn\u00ed, jako choleliti\u00e1zy a v\u0159edov\u00e9 choroby gastroduodena. P\u0159\u00edstup ke kardii a ezofage\u00e1ln\u00edmu hi\u00e1tu usnad\u0148uje u\u017eit\u00ed r\u016fzn\u00fdch typ\u016f rozv\u011bra\u010d\u016f. K p\u0159\u00edstupu do subfrenia u\u017e\u00edv\u00e1me vlastn\u00ed modifikace Rochardova rozv\u011bra\u010de [51] (obr. 12).<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

        .<\/span><\/p>\n

        8.6.3 Opera\u010dn\u00ed taktika a technika otev\u0159en\u00fdch operac\u00ed a olomouck\u00e9 zku\u0161enosti<\/h5>\n

        O taktice a technice chirurgick\u00e9 l\u00e9\u010dby u refluxn\u00ed nemoci j\u00edcnu a s n\u00ed zpravidla spojenou skluznou HH je pojedn\u00e1no v n\u00e1sleduj\u00edc\u00ed kapitole Refluxn\u00ed nemoc j\u00edcnu. V \u00e9\u0159e klasick\u00e9 chirurgie byla p\u0159i operaci paraezofage\u00e1ln\u00ed HH nejvhodn\u011bj\u0161\u00edm p\u0159\u00edstupem horn\u00ed st\u0159edn\u00ed laparotomie. Umo\u017e\u0148ovala v\u00fdkon i u star\u00fdch rizikov\u00fdch nemocn\u00fdch a \u0159e\u0161en\u00ed \u010dast\u00fdch sou\u010dasn\u00fdch intraabdomin\u00e1ln\u00edch onemocn\u011bn\u00ed, jako choleliti\u00e1zy a v\u0159edov\u00e9 choroby gastroduodena. P\u0159\u00edstup ke kardii a ezofage\u00e1ln\u00edmu hi\u00e1tu usnad\u0148uje u\u017eit\u00ed r\u016fzn\u00fdch typ\u016f rozv\u011bra\u010d\u016f. K p\u0159\u00edstupu do subfrenia u\u017e\u00edv\u00e1me vlastn\u00ed modifi kace Rochardova rozv\u011bra\u010de [51] (obr. 12).<\/p>\n

        \"Obr.<\/a>

        Obr. 13
        R\u016fzn\u00e9 varianty p\u0159edn\u00ed gastropexe: 1 \u2013 dv\u011b \u0159ady steh\u016f k p\u0159edn\u00ed st\u011bn\u011b b\u0159i\u0161n\u00ed (Nissen), 2 \u2013 \u0159ada steh\u016f v prodlou\u017een\u00ed osy j\u00edcnu a fundofrenopexe (Rossetti), 3 \u2013 varianta p\u0159ede\u0161l\u00e9ho s fixac\u00ed fundu k okraji nez\u00fa\u017een\u00e9ho hi\u00e1tu (Rossetti), 4 \u2013 Rossettiho postup u sm\u00ed\u0161en\u00fdch hi\u00e1tov\u00fdch herni\u00ed, 5 \u2013 n\u00e1\u0161 postup s fi xac\u00ed fundoplikace k okol\u00ed ezofage\u00e1ln\u00edho hi\u00e1tu u paraezofage\u00e1ln\u00edch a sm\u00ed\u0161en\u00fdch hi\u00e1tov\u00fdch herni\u00ed u\u017e\u00edvan\u00fd v \u00e9\u0159e otev\u0159en\u00fdch operac\u00ed, 6 \u2013 p\u0159edn\u00ed gastropexe jednou \u0159adou steh\u016f p\u0159i mal\u00e9m zak\u0159iven\u00ed, jak jsme ji u\u017eili u n\u011bkter\u00fdch nemocn\u00fdch s paraezofage\u00e1ln\u00edmi hitov\u00fdmi herniemi<\/p><\/div>\n

        Velikost nutn\u00e9ho tahu rozv\u011bra\u010de za \u017eebern\u00ed oblouky je rozd\u00edln\u00e1 podle habitu nemocn\u00e9ho a p\u0159i na\u0161ich m\u011b\u0159en\u00edch kol\u00edsala od 12 do 22 kg. D\u016fle\u017eit\u00fd je spr\u00e1vn\u00fd sm\u011br tahu, kter\u00fd mus\u00ed co nejv\u00edce sledovat tangenci\u00e1ln\u00ed klenut\u00ed hrudn\u00edku, proto\u017ee p\u0159i tahu p\u0159\u00edli\u0161 nahoru se kardie vzdaluje od opera\u010dn\u00ed r\u00e1ny. Dal\u0161\u00edho zlep\u0161en\u00ed p\u0159\u00edstupu k j\u00edcnov\u00e9mu hi\u00e1tu dos\u00e1hneme prot\u011bt\u00edm lig. falciforme l. sin. a odsunut\u00edm lev\u00e9ho jatern\u00edho laloku medi\u00e1ln\u011b. Torak\u00e1ln\u00edho p\u0159\u00edstupu jsme u tohoto typu hernie nebyli nikdy nuceni pou\u017e\u00edt. V\u00fdhody, kter\u00e9 p\u0159in\u00e1\u0161\u00ed u\u017eit\u00ed rozv\u011bra\u010de pro zp\u0159\u00edstupn\u011bn\u00ed opera\u010dn\u00edho pole, jsou nesporn\u00e9 a ocen\u00ed je jak operat\u00e9r, tak asistence, kter\u00e1 je zbavena nam\u00e1hav\u00e9ho tahu za \u017eebern\u00ed oblouk a m\u016f\u017ee se tak aktivn\u011b pod\u00edlet na pr\u016fb\u011bhu operace. Sna\u017eili jsme se o kritick\u00e9 posouzen\u00ed, zda n\u011bkdy dosti zna\u010dn\u00fd tah za okraje opera\u010dn\u00ed r\u00e1ny a \u017eebern\u00ed oblouky nem\u00e1 pro nemocn\u00e9ho i negativn\u00ed odezvu. Na\u0161e zku\u0161enosti uk\u00e1zaly, \u017ee po nasazen\u00ed l\u017e\u00edce rozv\u011bra\u010de doch\u00e1zelo n\u011bkdy u nemocn\u00e9ho ke zm\u011bn\u011b pulzov\u00e9 frekvence a poklesu krevn\u00edho tlaku. Tyto v\u00fdkyvy, kter\u00e9 si vysv\u011btlujeme jako d\u016fsledek p\u0159enesen\u00e9 komprese na srdce nebo zt\u00ed\u017een\u00ed \u017eiln\u00edho n\u00e1vratu z doln\u00ed dut\u00e9 \u017e\u00edly, se po chv\u00edli samy uprav\u00ed a jen zcela v\u00fdjime\u010dn\u011b jsme museli tah na ur\u010ditou dobu zru\u0161it nebo sn\u00ed\u017eit. V poopera\u010dn\u00edm obdob\u00ed si n\u011bkte\u0159\u00ed nemocn\u00ed st\u011b\u017eovali na zv\u00fd\u0161enou bolestivost pod\u00e9l obou \u017eebern\u00edch oblouk\u016f, co\u017e je jist\u011b d\u016fsledek distenze svalov\u00e9ho a vazivov\u00e9ho apar\u00e1tu. Obt\u00ed\u017ee ustupovaly soub\u011b\u017en\u011b s odezn\u00edv\u00e1n\u00edm bolestivosti opera\u010dn\u00ed r\u00e1ny. Sna\u017eili jsme se zodpov\u011bd\u011bt ot\u00e1zku, zda u\u017eit\u00ed rozv\u011bra\u010de nevede ke zv\u00fd\u0161en\u00ed \u010dasn\u00fdch a pozdn\u00edch ran\u00fdch komplikac\u00ed, kde by mohla hr\u00e1t roli traumatizace opera\u010dn\u00ed r\u00e1ny. Objektivn\u00edm rozborem na\u0161ich v\u00fdsledk\u016f jsme zjistili, \u017ee s u\u017eit\u00edm rozv\u011bra\u010de nedo\u0161lo ke zv\u00fd\u0161en\u00ed frekvence komplikac\u00ed v r\u00e1n\u011b ve srovn\u00e1n\u00ed s operacemi z horn\u00ed st\u0159edn\u00ed laparotomie bez u\u017eit\u00ed Rochardova rozv\u011bra\u010de [51]. Dnes je k dispozici cel\u00e1 \u0159ada b\u0159i\u0161n\u00edch rozv\u011bra\u010d\u016f na obdobn\u00e9m principu.<\/p>\n

        Vlastn\u00ed operace spo\u010d\u00edv\u00e1 v repozici hernie \u0161etrn\u00fdm tahem za \u017ealudek, pop\u0159\u00edpad\u011b s nat\u011bt\u00edm hi\u00e1tu k usnadn\u011bn\u00ed vta\u017een\u00ed dislokovan\u00e9ho \u017ealudku do dutiny b\u0159i\u0161n\u00ed. Repozice ne\u010din\u00ed zpravidla v\u011bt\u0161\u00edch obt\u00ed\u017e\u00ed, ale m\u016f\u017ee b\u00fdt zt\u00ed\u017eena sr\u016fsty \u017ealudku k okraji hi\u00e1tu nebo k\u00fdln\u00edmu vaku intratorak\u00e1ln\u011b. Zaveden\u00ed siln\u00e9 sondy do j\u00edcnu usnadn\u00ed jeho identifikaci a je bezpodm\u00edne\u010dn\u011b nutn\u00e9, chceme-li p\u0159ipojit fundoplikaci. K\u00fdln\u00ed vak je mo\u017eno ponechat in situ, proto\u017ee vlivem negativn\u00edho intratorak\u00e1ln\u00edho tlaku kolabuje a podlehne obliteraci [49]. Sami jsme v\u011bt\u0161inou k\u00fdln\u00ed vak pomoc\u00ed Kocherov\u00fdch kle\u0161t\u00ed zachytili v jeho vrcholu, evertovali do dutiny b\u0159i\u0161n\u00ed a resekovali p\u0159i okraji k\u00fdln\u00ed branky. Prevenc\u00ed vzniku recidivy hernie je z\u00fa\u017een\u00ed hi\u00e1tu n\u011bkolika stehy za j\u00edcnem nebo jednodu\u0161eji p\u0159ed j\u00edcnem a proveden\u00ed p\u0159edn\u00ed gastropexe, jak byla v klasick\u00e9 podob\u011b zavedena Nissenem [5]. Jej\u00edm c\u00edlem je fixace \u017ealudku pod br\u00e1nic\u00ed i p\u0159i povolen\u00ed sutury hi\u00e1tu. Nissen zpo\u010d\u00e1tku k fixaci \u017ealudku vyu\u017e\u00edval fasci\u00e1ln\u00edho pruhu z p\u0159edn\u00ed st\u011bny b\u0159i\u0161n\u00ed (1954), pozd\u011bji pak p\u0159\u00edm\u00e9 na\u0161it\u00ed st\u011bny \u017ealudku k peritoneu (1956) dv\u011bma \u0159adami steh\u016f. Lev\u00e1 byla zakl\u00e1d\u00e1na \u0161ikmo na p\u0159edn\u00ed st\u011bn\u011b fundu pod\u00e9l velk\u00e9 kurvatury a prav\u00e1 pod\u00e9l mal\u00e9 k\u0159iviny subkardi\u00e1ln\u011b. Z tohoto principu vych\u00e1zej\u00ed r\u016fzn\u00e9 modifikace, jak jsou zn\u00e1zorn\u011bny na obr. 13.<\/p>\n

        Chirurgick\u00e1 l\u00e9\u010dba hi\u00e1tov\u00fdch herni\u00ed a refluxn\u00ed nemoci j\u00edcnu prod\u011blala i v Olomouci od roku 1945 v\u00fdvoj od operac\u00ed odvozen\u00fdch od Allisonova principu k fundoplikac\u00edm [52, 53]. U sm\u00ed\u0161en\u00fdch a paraezofage\u00e1ln\u00edch herni\u00ed prov\u00e1d\u011bl profesor Rapant do po\u010d\u00e1tku 70. let minul\u00e9ho stolet\u00ed hiatorafii a gastropexi. P\u0159i sledov\u00e1n\u00ed dlouhodob\u00fdchv\u00fdsledk\u016f se pak uk\u00e1zal vysok\u00fd v\u00fdskyt poopera\u010dn\u00edch recidiv, subjektivn\u00edch obt\u00ed\u017e\u00ed a refluxu, jak to ukazuje tab. 1.<\/p>\n\n\n\n\n\n\n\n\n\n\n\n
        Tab. 1<\/span>
        \n Srovn\u00e1n\u00ed v\u00fdsledk\u016f Rossettiho a olomouck\u00e9 sestavy operovan\u00fdch pro paraezofage\u00e1ln\u00ed a sm\u00ed\u0161en\u00e9 hernie z let 1948\u20131982 [54, 55]<\/span><\/td>\n<\/tr>\n
        <\/td>\nRossetti<\/strong><\/td>\nOlomouc<\/strong><\/td>\n<\/tr>\n
        Opera\u010dn\u00ed v\u00fdkon<\/td>\nGastropexe<\/td>\nGastropexe<\/td>\nFundoplikace<\/td>\n<\/tr>\n
        Po\u010det kontrolovan\u00fdch<\/td>\n96<\/td>\n23<\/td>\n33<\/td>\n<\/tr>\n
        D\u00e9lka poopera\u010dn\u00edho sledov\u00e1n\u00ed<\/td>\n2\u201310 let<\/td>\n1\u201316 let<\/td>\n1\u201310 let<\/td>\n<\/tr>\n
        Subj. obt\u00ed\u017ee<\/td>\n19 %<\/td>\n20 %<\/td>\n6 %<\/td>\n<\/tr>\n
        Recidiva hernie<\/td>\n22 %<\/td>\n47 %<\/td>\n27 %<\/td>\n<\/tr>\n
        Reflux<\/td>\n10 %<\/td>\n43 %<\/td>\n9 %<\/td>\n<\/tr>\n
        Mortalita<\/td>\n1,2 %<\/td>\n4 %<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

        .<\/span><\/p>\n

        Toto dlouhodob\u00e9 sledov\u00e1n\u00ed pacient\u016f jsme pak uzav\u0159eli v roce 1990, kdy jsme hodnotili sestavu v\u00edce ne\u017e 100 nemocn\u00fdch s paraezofage\u00e1ln\u00edmi herniemi. P\u0159edopera\u010dn\u011b se u t\u011bchto pacient\u016f vyskytoval reflux v 52 %, krv\u00e1cen\u00ed v 18 %, v\u0159ed kr\u010dku v 7 % a inkarcerace a obstrukce v 9 %. P\u0159i dlouhodob\u00fdch kontrol\u00e1ch byl v\u00fdskyt recidivy hernie v\u00edce ne\u017e ve 40 %, stejn\u011b jako p\u0159\u00edtomnost refluxu a subjektivn\u00ed pot\u00ed\u017ee m\u011bla asi \u010dtvrtina kontrolovan\u00fdch [54, 55]. Rentgenologicky zji\u0161t\u011bn\u00e1 recidiva hernie m\u00e1 v\u011bt\u0161inou jen charakter mal\u00e9 skluzn\u00e9 HH. P\u0159\u00ed\u010dinou je m\u00e9n\u011bcennost pojivov\u00e9 tk\u00e1n\u011b v oblasti hi\u00e1tu. Sou\u010dasn\u00e1 gastropexe br\u00e1n\u00ed v\u011bt\u0161\u00edmu proniknut\u00ed \u017ealudku do hrudn\u00edku a jeho rotaci, a pokud nen\u00ed p\u0159\u00edtomen gastroezofage\u00e1ln\u00ed reflux, nemus\u00ed m\u00edt nemocn\u00fd v\u011bt\u0161\u00ed obt\u00ed\u017ee. \u010casto byly p\u0159i recidiv\u011b hi\u00e1tov\u00e9 hernie zji\u0161t\u011bny pot\u00ed\u017ee z refluxu, kter\u00fd nebyl p\u0159ed operac\u00ed p\u0159\u00edtomen. Zde si jeho vznik m\u016f\u017eeme vysv\u011btlit mechanicky. P\u0159i \u010d\u00e1ste\u010dn\u00e9m prolapsu \u017ealudku insuficientn\u00edm hi\u00e1tem do mediastina a sou\u010dasn\u00e9 fixaci jeho zbyl\u00e9 \u010d\u00e1sti pod br\u00e1nic\u00ed gastropex\u00ed dojde k trycht\u00fd\u0159ovit\u00e9mu rozev\u0159en\u00ed kardie a jej\u00ed insuficienci, jak je to zn\u00e1zorn\u011bno na obr. 14.<\/p>\n

        To n\u00e1s na z\u00e1klad\u011b na\u0161ich dlouhodob\u00fdch zku\u0161enost\u00ed vedlo k tomu, \u017ee jsme pak za\u010dali prov\u00e1d\u011bt jak u sm\u00ed\u0161en\u00fdch, tak u paraezofage\u00e1ln\u00edch herni\u00ed od po\u010d\u00e1tku 70. let minul\u00e9ho stolet\u00ed [12] fundoplikaci a man\u017eetu jsme fixovali 3\u20134 stehy k br\u00e1nici v okol\u00ed z\u00fa\u017een\u00e9ho hi\u00e1tu. Hiatorafii jsme prov\u00e1d\u011bli n\u011bkolika stehy n\u011bkdy p\u0159ed j\u00edcnem pro lep\u0161\u00ed p\u0159\u00edstupnost a kvalitu zab\u00edran\u00e9ho materi\u00e1lu, ale pozd\u011bji v\u00fdhradn\u011b retroezofage\u00e1ln\u011b. Je nutno respektovat z\u00e1sadu, aby mezi j\u00edcnem se zavedenou silnou sondou a okrajem hi\u00e1tu bylo mo\u017eno je\u0161t\u011b voln\u011b zav\u00e9st prst. N\u011bkdy jsme se u \u010dist\u011b paraezofage\u00e1ln\u00edho typu hernie, za okolnost\u00ed podm\u00edn\u011bn\u00fdch v\u011bkem, lok\u00e1ln\u00edm n\u00e1lezem a stavem operovan\u00e9ho, spokojili s jednodu\u0161\u0161\u00ed p\u0159edn\u00ed gastropex\u00ed jednou \u0159adou steh\u016f v d\u00e9lce 5\u20136 cm mezi malou kurvaturou \u017ealudku subkardi\u00e1ln\u011b a p\u0159edn\u00ed st\u011bnou b\u0159i\u0161n\u00ed spolu s hiatorafi\u00ed. P\u0159i kontrol\u00e1ch po\u010d\u00e1tkem 90. let minul\u00e9ho stolet\u00ed poklesl v\u00fdskyt recidivy u takto operovan\u00fdch na 21 %, gastroezofage\u00e1ln\u00edho refluxu na 9 % a subjektivn\u00ed pot\u00ed\u017ee ud\u00e1valo jen asi 10 % kontrolovan\u00fdch. Doba sledov\u00e1n\u00ed kol\u00edsala od 1 roku do 19 let [54, 55].<\/p>\n

        \"Obr.<\/a>

        Obr. 14
        Hiatorafie a p\u0159edn\u00ed gastropexe u sm\u00ed\u0161en\u00e9 \u010di paraezofage\u00e1ln\u00ed hi\u00e1tov\u00e9 hernie (vlevo); p\u0159i vzniku recidivy doch\u00e1z\u00ed k trycht\u00fd\u0159ovit\u00e9mu roz\u0161\u00ed\u0159en\u00ed kardie (uprost\u0159ed); je-li sou\u010dasn\u011b zalo\u017eena fundoplikace, pak i p\u0159i recidiv\u011b z\u016fst\u00e1v\u00e1 kardie kompetentn\u00ed (vpravo)<\/p><\/div>\n

        U komplikac\u00ed paraezofage\u00e1ln\u00edch a sm\u00ed\u0161en\u00fdch hi\u00e1tov\u00fdch herni\u00ed je opera\u010dn\u00ed postup stejn\u00fd. P\u0159i inkarceraci a strangulaci \u017ealudku je nutno posoudit stav \u017ealude\u010dn\u00ed st\u011bny a podle pot\u0159eby p\u0159e\u0161\u00edt po\u0161kozen\u00e1 m\u00edsta a jen zcela v\u00fdjime\u010dn\u011b p\u0159i t\u011b\u017ek\u00fdch infarza\u010dn\u00edch zm\u011bn\u00e1ch prov\u00e9st resekci posti\u017een\u00e9 \u010d\u00e1sti \u017ealudku. Krv\u00e1cen\u00ed, kter\u00e9 m\u00e1 p\u0159\u00ed\u010dinu ve slizni\u010dn\u00edch zm\u011bn\u00e1ch v prolabovan\u00e9 \u010d\u00e1sti \u017ealudku do hrudn\u00edku, se zastav\u00ed po \u00faprav\u011b anatomick\u00fdch pom\u011br\u016f v kombinaci s konzervativn\u00ed l\u00e9\u010dbou. V\u0159ed kr\u010dku se z hlediska sv\u00e9 etiopatogeneze vymyk\u00e1 b\u011b\u017en\u00e9mu peptick\u00e9mu \u017ealude\u010dn\u00edmu v\u0159edu.<\/p>\n

        V\u011bt\u0161inou se nen\u00ed t\u0159eba \u0159\u00eddit z\u00e1sadami platn\u00fdmi pro chirurgick\u00e9 l\u00e9\u010den\u00ed \u017ealude\u010dn\u00edho v\u0159edu. K jeho zhojen\u00ed zpravidla sta\u010d\u00ed pouh\u00e1 \u00faprava hi\u00e1tov\u00e9 hernie. Vysok\u00fd po\u010det recidiv po operaci sm\u00ed\u0161en\u00fdch a paraezofage\u00e1ln\u00edch herni\u00ed kol\u00eds\u00e1 v odborn\u00e9 literatu\u0159e u klasick\u00fdch operac\u00ed mezi 15 a\u017e 20 % a u laparoskopick\u00fdch jsou tato \u010d\u00edsla ud\u00e1v\u00e1na je\u0161t\u011b vy\u0161\u0161\u00ed [56, 57]. \u010c\u00e1st t\u011bchto recidiv je v\u0161ak zji\u0161\u0165ov\u00e1na pouze p\u0159i rentgenov\u00e9m vy\u0161et\u0159en\u00ed a jsou asymptomatick\u00e9. To vedlo ke snaze o zlep\u0161en\u00ed v\u00fdsledk\u016f pou\u017eit\u00edm zpevn\u011bn\u00ed hi\u00e1tu implantac\u00ed s\u00ed\u0165ky. Opakovan\u011b byly vyzkou\u0161eny aplikace s\u00edt\u011bk <\/i>z r\u016fzn\u00e9ho materi\u00e1lu na uz\u00e1v\u011br roz\u0161\u00ed\u0159en\u00e9ho hi\u00e1tu u rozs\u00e1hl\u00fdch paraezofage\u00e1ln\u00edch herni\u00ed na principu beznapje\u0165ov\u00e9 plastiky [58]. N\u011bkter\u00e9 randomizovan\u00e9 studie u\u017e\u00edvaj\u00edc\u00ed s\u00ed\u0165ky ze syntetick\u00e9ho materi\u00e1lu prok\u00e1zaly signifikantn\u00ed sn\u00ed\u017een\u00ed v\u00fdskytu recidiv [59, 59]. Probl\u00e9mem syntetick\u00fdch s\u00edt\u011bk implantovan\u00fdch do dynamicky funguj\u00edc\u00edho hi\u00e1tu jsou v\u0161ak komplikace v podob\u011b slizni\u010dn\u00edch eroz\u00ed, v\u0159edu, \u010di dokonce p\u00ed\u0161t\u011bl\u00ed, striktur a vzniku dysfagie [60, 61]. Podobn\u00e9 komplikace jsme vid\u011bli po implantaci s\u00edt\u011bk na jin\u00fdch pracovi\u0161t\u00edch, a sami jsme je proto neaplikovali. Z toho d\u016fvodu za\u010daly b\u00fdt u\u017e\u00edv\u00e1ny s\u00ed\u0165ky z biologick\u00e9ho materi\u00e1lu [62, 63]. Nakolik to bude p\u0159\u00ednosem v dlouhodob\u011bj\u0161\u00edm horizontu, nen\u00ed zat\u00edm jednozna\u010dn\u011b vyhodnoceno (viz tak\u00e9 kap. 18).<\/p>\n

        Jednozna\u010dn\u00fd nen\u00ed ani n\u00e1zor na nutnost p\u0159ipojen\u00ed fundoplikace p\u0159i operaci velk\u00fdch paraezofage\u00e1ln\u00edch herni\u00ed. Na jedn\u00e9 stran\u011b pro u\u017eit\u00ed fundoplikace sv\u011bd\u010d\u00ed mnoha autory zji\u0161t\u011bn\u00fd vysok\u00fd v\u00fdskyt gastroezofage\u00e1ln\u00edho refluxu i u tohoto typu hernie, na druh\u00e9 stran\u011b tak v\u00fdznamn\u00ed j\u00edcnov\u00ed chirurgov\u00e9, jako jsou Siewert a Stein, maj\u00ed n\u00e1zor odli\u0161n\u00fd [64, 65]. Podle jejich n\u00e1zor\u016f je dostate\u010dn\u00fdm v\u00fdkonem hiatoplastika a gastropexe. P\u0159ednost d\u00e1vaj\u00ed fundofrenopexi a zadn\u00ed gastropexi fixuj\u00edc\u00ed or\u00e1ln\u00ed \u010d\u00e1st mal\u00e9ho zak\u0159iven\u00ed \u017ealudku k preaort\u00e1ln\u00ed fascii nebo k zadn\u00ed komisu\u0159e hi\u00e1tu. P\u0159edn\u00ed gastropexi pova\u017euj\u00ed za p\u0159ekonanou a vyu\u017eit\u00ed aloplastick\u00e9ho materi\u00e1lu na zpevn\u011bn\u00ed hi\u00e1tu jen za zcela v\u00fdjime\u010dn\u011b nutn\u00e9. P\u0159ipojen\u00ed fundoplikace nepova\u017euj\u00ed u t\u011bchto nemocn\u00fdch za nezbytn\u00e9 a vid\u00ed v tom zbyte\u010dn\u00e9 prodlou\u017een\u00ed v\u00fdkonu. P\u0159\u00edpadn\u00fd perzistuj\u00edc\u00ed \u010di nov\u011b po operaci vznikl\u00fd gastroezofage\u00e1ln\u00ed reflux doporu\u010duj\u00ed \u0159e\u0161it modern\u00ed medikament\u00f3zn\u00ed l\u00e9\u010dbou.<\/p>\n

        8.6.4 Laparoskopick\u00fd p\u0159\u00edstup<\/h5>\n
        \"Video<\/a>

        VIDEO 1<\/p><\/div>\n

        V sou\u010dasnosti se chirurgick\u00e1 l\u00e9\u010dba sm\u00ed\u0161en\u00fdch a paraezofage\u00e1ln\u00edch herni\u00ed prov\u00e1d\u00ed tak\u0159ka v\u00fdhradn\u011b laparoskopicky a pot\u0159eba konverze nedosahuje v rukou zku\u0161en\u00fdch laparoskopick\u00fdch chirurg\u016f ani 10 % [45, 66, 67, 68, 69, 45, 70, 57, 72]. Laparoskopicky jsme za\u010dali tyto stavy \u0159e\u0161it v Olomouci od poloviny 90. let minul\u00e9ho stolet\u00ed [73, 55, 74, 75]. Opera\u010dn\u00ed postup se v z\u00e1sad\u011b neli\u0161\u00ed od operace p\u0159i RNJ a je bl\u00ed\u017ee pops\u00e1n v kapitole 9. Hlavn\u00ed rozd\u00edl je v \u0161\u00ed\u0159i j\u00edcnov\u00e9ho hi\u00e1tu a rozsahu dislokace \u017ealudku do mediastina.<\/p>\n

        Dob\u0159e je to patrn\u00e9 na videoz\u00e1znamu operace (video \u2013 laparoskopick\u00e1 operace paraezofage\u00e1ln\u00ed hernie \u2013 je dostupn\u00e9 v elektronick\u00e9 verzi, viz tir\u00e1\u017e knihy). V posledn\u00ed souborn\u00e9 pr\u00e1ci publikovan\u00e9 v roce 2011 z Olomouce [45] hodnot\u00ed auto\u0159i soubor 27 pacient\u016f s extr\u00e9mn\u00ed formou paraezofage\u00e1ln\u00ed hernie (tzv. upside-down stomach), kte\u0159\u00ed byli laparoskopicky operov\u00e1ni v letech 1997 a\u017e 2008. Jednalo se o 16 mu\u017e\u016f a 11 \u017een ve v\u011bku od 43 do 77 let. Principem operace byla ve v\u0161ech p\u0159\u00edpadech repozice \u017ealudku do b\u0159i\u0161n\u00ed dutiny, resekce k\u00fdln\u00edho vaku, hiatorafie a u 15 nemocn\u00fdch (56 %), kte\u0159\u00ed m\u011bli refluxn\u00ed symptomatologii nebo byla prok\u00e1z\u00e1na ezofagitida, byla p\u0159ipojena fundoplikace, kter\u00e1 u 12 (ve 44 %) byla dopln\u011bna fundopex\u00ed. U \u017e\u00e1dn\u00e9ho operovan\u00e9ho nebylo nutno prov\u00e9st konverzi, poopera\u010dn\u00ed mortalita byla nulov\u00e1. Morbidita je uv\u00e1d\u011bna v 11 %. V pr\u016fm\u011bru byli nemocn\u00ed propu\u0161t\u011bni mezi 5. a\u017e 6. poopera\u010dn\u00edm dnem. Kontrola po 1 roce byla provedena u 77 % souboru. Dle endoskopick\u00e9ho a rentgenov\u00e9ho vy\u0161et\u0159en\u00ed nebyla zji\u0161t\u011bna recidiva a 76 % nemocn\u00fdch hodnotilo sv\u016fj stav jako uspokojiv\u00fd. Dva pacienti m\u011bli lehkou dys\ue01fagii bez \u00fabytku na v\u00e1ze a t\u0159i ud\u00e1vali dyspeptick\u00e9 pot\u00ed\u017ee p\u0159\u00edzniv\u011b reaguj\u00edc\u00ed na prokinetika. U jednoho nemocn\u00e9ho do\u0161lo k dislokaci fundoplikace do mediastina 17 m\u011bs\u00edc\u016f po prim\u00e1rn\u00ed operaci a byla provedena \u00faprava polohy man\u017eety op\u011bt laparoskopicky. Se svolen\u00edm autor\u016f jsou na obr. 15, 16, 17 a 18 uvedeny sn\u00edmky z jejich klinick\u00e9ho materi\u00e1lu.<\/em><\/p>\n\n\n\n\n
        \n

        \"Obr.<\/a>

        Obr. 15
        Kontrastn\u00ed rtg pas\u00e1\u017e u upside-down stomachu<\/p><\/div><\/td>\n

        		\n

        \"Obr.<\/a>

        Obr. 16
        CT obraz upside-down stomachu v transverz\u00e1ln\u00edm \u0159ezu<\/p><\/div><\/td>\n<\/tr>\n

        \n

        \"Obr.<\/a>

        Obr. 17
        Laparoskopick\u00fd pohled do dutiny b\u0159i\u0161n\u00ed u pacienta s upside-down stomachem, kde je \u017ealudek dislokov\u00e1n hi\u00e1tem do mediastina<\/p><\/div><\/td>\n

        		\n

        \"Obr.<\/a>

        Obr. 18
        Vypreparovan\u00fd j\u00edcnov\u00fd hi\u00e1tus po repozici \u017ealudku a resekci k\u00fdln\u00edho vaku, p\u0159ed hiatorafi\u00ed a zalo\u017een\u00edm fundoplikace<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

        .<\/span><\/p>\n

        8.6.5 Existuje optim\u00e1ln\u00ed opera\u010dn\u00ed postup pro \u0159e\u0161en\u00ed sm\u00ed\u0161en\u00fdch a paraezofage\u00e1ln\u00edch herni\u00ed?<\/h5>\n

        Existuje shoda, \u017ee operace paraezofage\u00e1ln\u00edch a sm\u00ed\u0161en\u00fdch herni\u00ed by dnes m\u011bla b\u00fdt prov\u00e1d\u011bna laparoskopicky zku\u0161en\u00fdmi laparoskopick\u00fdmi chirurgy. Sou\u010d\u00e1st\u00ed operace je repozice hernie, resekce vaku a hiatorafie. \u010c\u00e1st chirurg\u016f doporu\u010duje zpevn\u011bn\u00ed hi\u00e1tu s\u00ed\u0165kou z biologick\u00e9ho vst\u0159ebateln\u00e9ho materi\u00e1lu. Syntetick\u00e9 s\u00ed\u0165ky jsou spojeny s vy\u0161\u0161\u00edm v\u00fdskytem komplikac\u00ed a jejich u\u017eit\u00ed se nedoporu\u010duje. K zaji\u0161t\u011bn\u00ed podbr\u00e1ni\u010dn\u00ed polohy \u017ealudku je pak nutn\u00e1 n\u011bkter\u00e1 forma gastropexe. Jej\u00ed p\u0159esn\u00fd typ z\u00e1vis\u00ed na individu\u00e1ln\u00ed zku\u0161enosti chirurga. Pokud jde o p\u0159ipojen\u00ed fundoplikace, pak je zcela jist\u011b indikov\u00e1na, kdy\u017e je u nemocn\u00e9ho p\u0159edopera\u010dn\u011b p\u0159\u00edtomen gastroezofage\u00e1ln\u00ed reflux, v ostatn\u00edch p\u0159\u00edpadech nen\u00ed n\u00e1zor jednotn\u00fd. Z na\u0161ich zku\u0161enost\u00ed vypl\u00fdv\u00e1, \u017ee p\u0159ipojen\u00ed fundoplikace, pokud je to pro nemocn\u00e9ho \u00fanosn\u00e9, je v\u011bt\u0161inou p\u0159\u00ednosem.<\/p>\n

        Literatura<\/h3>\n
          \n
        1. Akerlund A. I. Hernia diaphragmatica Hiatus oesophagei vom anatomischen und r\u00f6ntgenologischen Gesichtspunkt. Acta Radiol. 1926;6:3\u201322.<\/li>\n
        2. Olsen AM, Harrington SW. Esophageal hiatal hernias of the short esophagus type: Etiologic and therapeutic considerations. J Thorac Cardiovasc Surg. 1947;17:189.<\/li>\n
        3. Gahagam T, Lam CR. Esophageal Hiatus Hernia. Springfield: Thomas; 1976.<\/li>\n
        4. Sweet RH. Analysis of one hundred-thirty cases of hiatus hernia treated surgically. JAMA. 1953;151(5):376\u2013378.<\/li>\n
        5. Nissen R, Rossetti M. Die Behandlung der Hiatushernien und Reflux-Oesophagitis mit Gastropexie und Fundoplicatio. Stuttgart: G. Thieme; 1959.<\/li>\n
        6. Ellis FH Jr. Esophageal Hiatal Hernia. N Engl J Med. 1972;287(13):646\u2013649.<\/li>\n
        7. Barrett NR. Hiatus Hernia. Br J Surg. 1954;42(173):231\u2013234.<\/li>\n
        8. Schlegal JJ. Hiatus oesophageus, Hiatus-Hernie und ihre chirurgische Bahandlung. Ergeb Chi. Orthop, 1958;41:350.<\/li>\n
        9. Imdahl H. Der terminale \u00d6sophagus. Stuttgart: F. K. Schattauer-Verlag; 1963.<\/li>\n
        10. Lortat-Jacob JL, Robert F. Les malpositions cardio-tuberositaires. Arch Fr Mal App Dig. 1953;42(6):750\u2013774.<\/li>\n
        11. Allison PR. Reflux oesophagitis, sliding hiatal hernia and the anatomy of repair. Surg Gyn Obst. 1951;92(4):419\u2013431.<\/li>\n
        12. Duda M, \u0160er\u00fd Z. Geschichte und Stand der Chirurgie der Hiatushernien und Refluxkrankheit des \u00d6sophagus. Dt Z Verdau \u2013 Stoffwechselkr. 1980;40(6):177\u2013183.<\/li>\n
        13. Klinkosch JT. Programma quo Divisionem Herniarum, Novamque Herniae ventralis speciem proponit. Praha: 1764.<\/li>\n
        14. Botha GSM. The Gastro-Oesophageal Junction. London: J. & L. Churchill Ltd.; 1962.<\/li>\n
        15. Sigmund A. Demonstrace p\u0159\u00edpadu. \u010cas L\u00e9k \u010ces. 1928;67(11):413\u2013414.<\/li>\n
        16. \u0160imon J. Hi\u00e1tov\u00e1 br\u00e1ni\u010dn\u00ed k\u00fdla. \u010cas L\u00e9k \u010ces. 1928;67(12):423\u2013427,462\u2013466.<\/li>\n
        17. Hafter E. R\u00f6ntgendiagnostik der Hiatushernie. Leber Magen Darm. 1972;2(1):5\u201310.<\/li>\n
        18. DeLuca L, DiGiorgio P, Signoriello G, et al. Relationship between hiatal hernia and inguinal hernia. Dig Dis Sci. 2004;49:243.<\/li>\n
        19. Weiser HF, Lepsien G, Schattenmann G, Siewert R. Klinische Bedeutung der Hiatushernie. Zbl Chir. 1978;103(1):20\u201329.<\/li>\n
        20. Baker JR, Alexander-Wiliams J. The effect of cholecystectomy on esophageal symptoms. Br J Surg. 1974;61(5):346\u2013348.<\/li>\n
        21. Wolf BS, et al. The incidence of hiatal hernia in barium meal examination. J Mount Sinai Hosp N. Y. 1959;26:598.<\/li>\n
        22. Burgess JN, Fayne WS, Andersen HA, Weiland LH, Carlson HC. Barrett Esophagus. The Columnar \u2013 Epithelial Lined Lower Esophagus. Mayo Clin Proc. 1971;46(11):728\u2013734.<\/li>\n
        23. Proke\u0161 B, Koci\u00e1nov\u00e1 A. Gastroezofage\u00e1ln\u00ed reflux. \u010ceskoslov Radiol. 1975;29(4):249\u2013252.<\/li>\n
        24. Casasa JM, Boix-Ochoa J. Surgical or conservative treatment in hiatal hernia in children: A new decisive parameter. Surgery. 1977;82(5):573\u2013575.<\/li>\n
        25. Tesa\u0159 O. Prudk\u00e9 krv\u00e1cen\u00ed do tr\u00e1vic\u00ed trubice. Praha: Albertova sb\u00edrka 55, St\u00e1tn\u00ed zdravotnick\u00e9 nakladatelstv\u00ed; 1967.<\/li>\n
        26. Siegrist PW, Krejs GJ, Blum AL. Symptomatik der gastroesophagealen Reflux-krankenheit. Dtsch Med Wschr. 1974;99(42):2088\u20132094.<\/li>\n
        27. Venkatachalm B, Da Costa LR, Beck IT. What is a normal esophageal-gastric junction? Gas- troenterology. 1972;62(4):521\u2013528.<\/li>\n
        28. Weiser HF, Lepsien G, Schattenmann G, Siewert R. Klinische Bedeutung der Hiatushernie. Zbl Chir. 1978;103(1):20\u201329.<\/li>\n
        29. Dickman R, Matteck N, Holub J, et al. Prevalence of upper gastrointestinal tract findings in patient with noncardiac chest pain versus those with gastroesophageal reflux disease-related symptoms. Am J Gastroenterol. 2007;102:1173.<\/li>\n
        30. Kahrilas PJ, Wu S, Lim S, Ponderoux P. Attenuation of esophageal shortening during peristalsis with hiatal hernia. Gastroenterology. 1995;109:1818.<\/li>\n
        31. Seeling MH, Hinder RA, Klingler PJ, et al. Paraesophagel herniation as a complication following laparoscopic antireflux surgery. J Gastroentest Surg. 1999;3:95.<\/li>\n
        32. Idani H, Narusue M, Kin H, et al. Acute intrathoracic incarceration of the stomach after laparoscopic Nissen fundoplication. Surg Lap Endo Percut Tech. 2000;10:99.<\/li>\n
        33. Yaw P, Watson DI, Devitt PG, et al. Early reoperation following laparoscopic antireflux surgery. Am J Surg. 2000;179:172.<\/li>\n
        34. Holloway RH. The anti-reflux barrier and mechanisms of gastrooesophageal reflux. Bailliers Best Pract Res Clin Gastroenterol. 2000;14:681.<\/li>\n
        35. Duda M, Dlouh\u00fd M, Gryga A, Ro\u010dek V, Herman J. Langzeitige Beobachtung der wegen para\u00f6sophagealen und gemischten Hiatushernien operierten Kranken. Erfahrungen mit mehr als 100 Operierten. Zentralbl Chir. 1991;116(12):729\u2013736.<\/li>\n
        36. Duda M, Dlouh\u00fd M, Gryga A, Ro\u010dek V, K\u00f6cher M, Herman J. Chirurgische Behandlung der Kranken mit para\u00f6sophagealen und gemischten Hiatushernien. Biomed Pap Med Fac Palacky Univ Olomouc. 1991;130:353\u2013363.<\/li>\n
        37. Rapant V, Doubravsk\u00fd J, Kr\u010d C. Zum Mechanismus der Incarcerationen bei Parahiatushernien. Gastroenterologia. 1966;106(2):105\u2013110.<\/li>\n
        38. Hill LD. Incarcerated Paraesophageal Hernia. Am J Surg. 1973;126(2):286\u2013291.<\/li>\n
        39. Larson NE, Larson RH, Doresey JM. Mechanism of obstructional strangulation in hernias of the esophageal hiatus. Surg Gynecol Obstet. 1964;119(4):835\u2013841.<\/li>\n
        40. Brasil A. Aperistalsis of the oesophagus. Rev Brasil Gastroent. 1955;7:21\u201344.<\/li>\n
        41. Kr\u00e1l\u00edk J, \u0160er\u00fd Z, Kr\u010d C. Krv\u00e1cen\u00ed jako komplikace paraezofage\u00e1ln\u00ed hernie. \u010cs Gastroent V\u00fd\u017e. 1972;26(1):40\u201342.<\/li>\n
        42. Allen MS, Trastek VF, Deschamps C, Pairolero PC. Intrathoracic stomach: presentation and results of operation. J Thor Cardiovasc Surg. 1993;105:253.<\/li>\n
        43. Landreneau RJ, Johnson JA, Marshall JB, et al. Clinical spektrum of paraesophageal herniation. Dig Dis Sci. 1992;37:537.<\/li>\n
        44. Ch\u00e9rigie A, Goulon M, Terquem J. Hernie hiatal et ulcere du collet. Arch Fr Appar Dig. 1963;52(10):1017\u20131020.<\/li>\n
        45. Vrba R, Aujesk\u00fd R, Vom\u00e1\u010dkov\u00e1 K, Zbrozkov\u00e1 L, Neoral L. Upside-down stomach results of mini-invasive surgical therapy. Videosurgery and other miniinvasive techniques. 2011;6(4):231\u2013235.<\/li>\n
        46. Stylopoulos N, Gazelle GS, Rattner DW. Paraesophageal hernias: Operation or observation? Ann Surg. 2002;236:492\u2013501.<\/li>\n
        47. Harrington SW. Various Types of Diaphragmatic Hernia Treated Surgically. Report of 430 Cases. Surg Gynecol Obst. 1948;86(6):735\u2013755.<\/li>\n
        48. Sauerbruch F, Chaoul H, Adam A. Anatomisch-klinisch und r\u00f6ntgenologischer Beitrag zur \u201eHiatushernie\u201c. Dtsch. Med. Wschr. 1931;58:1390.<\/li>\n
        49. Leischner H. P\u0159\u00edsp\u011bvek k chirurgii usk\u0159inut\u00fdch diafragmatick\u00fdch paraoesofage\u00e1ln\u00edch k\u00fdl. \u010cas L\u00e9k \u010ces. 1933;72(46\u201347):1468\u20131469.<\/li>\n
        50. Rossetti M. Hiatushernien und andere Erkrankungen des Zwerchfells. Chirurgische Gastroenterologie. Berlin, Heidelberg, New York: Springer-Verlag; 1981.<\/li>\n
        51. Duda M, \u0160er\u00fd Z, Matu\u0161\u016f I. Erfahrungen bei Anwendung des modifizierten Rippenbogenhakens nach Rochard. Chirurg. 1981;52(9):605\u2013607.<\/li>\n
        52. Rapant V. K strategii chirurgick\u00e9ho v\u00fdkonu po druhotn\u00fdch komplikac\u00edch hi\u00e1tov\u00fdch k\u00fdl. Acta Univ Palacki Olomuc. 1961;23:253\u2013264.<\/li>\n
        53. Rapant V. Behandlung von Hiatushernien. Zur Technik und Taktik der chirurgischen Behandlung. Zentralbl Chir. 1966;91(19):698\u2013707.<\/li>\n
        54. Duda M. Chirurgische Behandlung der Funktionsst\u00f6rungen der Speiser\u00f6hre. Olomouc: Univerzita Palack\u00e9ho v Olomouci; 1984.<\/li>\n
        55. Duda M. Koment\u00e1\u0159 k problematice refluxn\u00ed nemoci j\u00edcnu a hi\u00e1tov\u00fdm herni\u00edm. In: Duda M, Czudek S, editors. Mininvazivn\u00ed chirurgie. T\u0159inec: Nemocnice Podles\u00ed; 1996. s. 78\u201384.<\/li>\n
        56. Hashemi M, Peters JH, De Meester TR, et al. Laparoscopic repair of large typ III hiatal hernia: Objective follow-up revers high recurrence rate. J Am Coll Surg. 2000;190:554\u2013561.<\/li>\n
        57. Mattar SG, Bowers SP, Galloway KD, et al. Long-term outcome of laparoscopic repair of paraesophageal hernia. Surg Endosc. 2002;16:745\u2013749.<\/li>\n
        58. Frantzides CT, Madan AK, Carlson MA, et al. A prospective randomized trial ot laparoscopic polytetrafluoroethylene (PTFE) patch repair vs simple cruroplasty for large hiatal hernia. Arch Surg. 2002;137:649\u2013652.<\/li>\n
        59. Granderath FA, Schweiger UM, Kamolz T, et al. Laparoscopic Nissen fundoplication with prosthetic hiatal closure reduce postoperative intrathoracic wrap herniation: Preliminary results of a prospective randomized functional and clinical study. Arch Surg. 2005;140:40\u201348.<\/li>\n
        60. Trus TL, Bax T, Richardson WS, et al. Complications of laparoscopic paraesophageal hernia repair. J Gastrointest Surg. 1997;1:221\u2013228.<\/li>\n
        61. Paul MG, DeRosa RP, Petrucci PE, et al. Laparoscopic tension-free repair of large paraesophageal hernias. Surg Endosc. 1997;11:303\u2013307.<\/li>\n
        62. Oelschlager BK, Barreca M, Chang L, et al. The use of small intestine submucosa in the repair of paraesophagel hernias: Initial observation of new technique. Am J Surg. 2003;186:4\u20138.<\/li>\n
        63. Zehetner J, Lipham JC, Ayazi S, Oezcelik A, Abate E, et al. A simplifield technique for intrathoracic stomach repair: Laparoscopic fundoplication with Vicryl mesh and BioGlue crural reinforcement. Surg Endosc. 2010;24:675\u2013679.<\/li>\n
        64. Siewert JR, Stein HJ. Zwerchfell. In: Siewert JR, et al, Hrsg. Chirurgie. 7. Aufl. Berlin Heidelberg New York Tokyo: Springer; 2001. p. 579\u2013582. 116 8 Hi\u00e1tov\u00e1 hernie<\/li>\n
        65. Stein HJ, Siewert JR. Hiatushernie. Refluxkrankheit und Barret-\u00d6sephagus (Endobrachy\u00f6sophagus). In: Bruch H-P, Trentz O, Berchtholt R, Hrsg. Chirurgie. M\u00fcnchen Jena: Urban & Fischer; 2001. p. 511\u2013520.<\/li>\n
        66. Oddsdottir M. Paraesophageal hernia. Surg Clin North Am. 2000;80:1243\u20131252.<\/li>\n
        67. Andujar JJ, Papasavas PK, Birdas T, Robke J, Raftopoulos Y, Gagne DJ, Caushaj PF, Landreneau RJ, Keenan RJ. Laparoscopic repair of large paraesophageal hernia is associated with a low incidence of recurrence and reoperation. Surg Endosc. 2004;18:444\u2013447.<\/li>\n
        68. Diaz S, Brunt LM, Klingensmith ME, Frisella PM, Soper NJ. Laparoscopic paraesophageal hernia repair, a challenging operation: medium-term outcome of 116 patients. J Gastrointest Surg. 2003;7:59\u201366.<\/li>\n
        69. Draha\u0148ovsk\u00fd V. Refluxn\u00ed nemoc j\u00edcnu a hi\u00e1tov\u00e9 hernie. In: Duda M, Czudek S. Mininvazivn\u00ed chirurgie. T\u0159inec: Nemocnice Podles\u00ed; 1996. s. 73\u201378.<\/li>\n
        70. Draha\u0148ovsk\u00fd V, Vrbensk\u00fd L, Hnuta J, Pec\u00e1k P. Pozitivn\u00ed vliv laparoskopick\u00e9 antirefluxn\u00ed operace na v\u00fdvoj slizni\u010dn\u00edch zm\u011bn Barrettova j\u00edcnu p\u011bt a v\u00edce let od proveden\u00e9 operace. \u010ces Slov Gastroent Hepatol. 2008;62(4):190\u2013202.<\/li>\n
        71. Oelschlager BK, Pellegrini CA. Paraesophageal hernias: open, laparoscopic, or thoracic repair? Chest Surg Clin North Am. 2001;11:589\u2013603.<\/li>\n
        72. Yano F, Stadlhuber RJ, Tsuboi K, Gerhardt J, Filipi CJ, Mittal SK. Outcomes of surgical treatment of intrathoracic stomach. Disease of the Esophagus. 2009;22:284\u2013288.<\/li>\n
        73. Duda M, Dlouh\u00fd M, Gryga A, K\u00f6cher M. Mo\u017enosti laparoskopick\u00fdch a torakoskopick\u00fdch operac\u00ed v chirurgii j\u00edcnu a \u017ealudku. In: \u0158\u00edha V, et al., editor. Endoskopick\u00e1 chirurgie. Sborn\u00edk prac\u00ed III. celost\u00e1tn\u00ed konference o laparoskopick\u00e9 chirurgii; 22.\u201323. 4. 1994; Bene\u0161ov u Prahy.s. 74\u201379.<\/li>\n
        74. Neoral \u010c, Kr\u00e1l V. Laparoskopick\u00e1 fundoplikace. Rozhl Chir. 1996; 75(7):345\u2013348.<\/li>\n
        75. Neoral \u010c, Aujesk\u00fd R, Kr\u00e1l V. M\u00edsto antirefluxn\u00edho v\u00fdkonu v terapii refluxn\u00ed nemoci j\u00edcnu – probl\u00e9m diagnostick\u00fd, terapeutick\u00fd a indika\u010dn\u00ed. \u010ces a slov Gastroent. 1997;51(6):207\u2013209.<\/li>\n<\/ol>\n

           <\/p>\n","protected":false},"excerpt":{"rendered":"

          8.1 Definice a klasifikace Hi\u00e1tovou herni\u00ed (HH) rozum\u00edme p\u0159esunut\u00ed gastroezofage\u00e1ln\u00edho spojen\u00ed anebo v\u011bt\u0161\u00ed \u010di men\u0161\u00ed \u010d\u00e1sti \u017ealudku ezofage\u00e1ln\u00edm hi\u00e1tem do mediastina. V roce 1926 uve\u0159ejnil \u0161v\u00e9dsk\u00fd rentgenolog Ake Akerlund [1] klasifikaci HH na z\u00e1klad\u011b 60 liter\u00e1rn\u00edch a 30 vlastn\u00edch pozorov\u00e1n\u00ed. Toto rozd\u011blen\u00ed bylo modifikov\u00e1no \u0159adou autor\u016f, ale v podstat\u011b plat\u00ed dodnes. Rozli\u0161oval t\u0159i z\u00e1kladn\u00ed typy: […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":65,"menu_order":40,"comment_status":"closed","ping_status":"open","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-312","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/312","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=312"}],"version-history":[{"count":65,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/312\/revisions"}],"predecessor-version":[{"id":1033,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/312\/revisions\/1033"}],"up":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/65"}],"wp:attachment":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=312"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}