Avtor/Urednik		Benedik, Tomaž; Vračko, Jože
Naslov		Vloga laparoskopske operativne metode "okna" pri preprečevanju poškodb žolčevodov med holecistektomijo
Prevedeni naslov		The role of "window" laparoscopic operative technique in the prevention of bile duct injuries associated with cholecystectomy
Tip		članek
Vir		Endoskopska revija
Vol. in št.		Letnik 5, št. 11
Leto izdaje		2000
Obseg		str. 35-41
Jezik		slo
Abstrakt		Laparoscopic cholecystectomy has rapidly become well-established because it prvides ultimate cure of gallstone disease with minimal pain and loss of activity for the patient. However, the incidence of biliary tract injuries, which are potentially life-threatening and associated with major morbidity and prolonged hospitalization, appears to be higher during laparoscopic cholecystectomy than during open surgery. As reported in some studies the rate of bile duct injuries associated with the laparaoscopic technique is 2.5 to 4 times higher than with open cholecystectomy. Several classifications of biliary tract injuries have been proposed. The most frequent direct causes of laparoscopic biliary tract injury include: misidentification of the common bile duct, cautery-related injuries of the bile duct and improper application of clips to the cystic duct. Accurate identification of the cystic duct and cystic artery before their being divided is therefore of utmost imporance in every laparoscopic cystectomy. Calot's triangle should therefore be dissected free of fat and fibrous tissue, and the lower end of the gallbladder should be separated from the liver bed to provide optimal visualization of the only two structures entering the gallbladder - the cystic duct and the cystic artery. Blind use of cautery and clips to control bleeding should be avoided. Low cautery settings should be used in portal dissections to prevent arc. The rate of bile duct injuries associated with laparoscopic cystectomy - which is still intolerably high- can be minimized by meticulous dissection and accurate identification of the cystic duct and cystic artery.
Izvleček		Laparoskopska holecistektomija je postala standardni način zdravljenja simptomatskih žolčnih kamnov, ker povzroča malo bolečin in omogoča hitro okrevanje ter minimalno prekinitev bolnikove aktivnosti. Vendar je z uvedbo nove metode zdravljenja narasla tudi pogostnost poškodb žolčevodov, ki povzročajo podaljšanje hospitalizacije in lahko vodijo v dolgotrajno zdravljenje zgodnjih in poznih zapletov, ki lahko tudi ogrozijo življenje bolnika. Po nekaterih podatkih je incidenca teh poškodb pri laparoskopski holecistektomiji 2,5- do 4-krat višja kot pri klasični holecistektomiji. Najpogostejši vzroki poškodb žolčevodov pri laparoskopski holecistektomiji so: zamenjava cističnega voda s skupnim jetrnim vodom, duktusom holedohusom ali aberantnim desnim jetrnim vodom, termične poškodbe z visokofrekvenčnim električnim tokom in neustrezna namestitev kovinskih sponk. Da bi se izognili napačni prepoznavi žolčnih vodov, moramo pri vsaki laparoskopski holecistektomiji nadvse skrbno in natančno identificirati anatomski strukturi, ki morata biti prekinjeni: to sta cistični vod in cistična arterija. Ti anatomski strukturi lahko najustrezneje prikažemo s tehniko okna. Calotov trikotnik je potrebno odpreparirati od maščobnega tkiva in zarastlin, spodnji del žolčnika pa izluščiti iz jetrnega ležišča. Vidni sta lahko le dve anatomski strukturi, ki vstopata v žolčnik - cistični vod in cistična arterija. Izogibati se moramo slepi uporabi elektrokoagulacije in namestitvi kovinskih sponk za zaustavljanje krvavitve v portalnem predelu. Kutor mora biti nastavljen na nizko moč, da bi preprečili obločni plamen.
Deskriptorji		CHOLECYSTECTOMY, LAPAROSCOPIC BILE DUCTS INTRAOPERATIVE COMPLICATIONS CHOLELITHIASIS RISK FACTORS CHOLANGIOGRAPHY