ロボット支援下直腸切断術後の会陰ヘルニア修復術後に発症した続発性子宮広間膜裂孔ヘルニアに対し腹腔鏡下にメッシュを用いてヘルニア修復術を行った1例

Broad ligament hernia after perineal hernia repair following robotic abdominoperineal resection : A case report

◆要旨：症例は63歳，女性．直腸癌に対するロボット支援下直腸切断術の術後10か月目に有症状の会陰ヘルニアを認めたため，腹腔鏡下に子宮を仙骨に固定し骨盤底を閉鎖しメッシュで修復を行った．ヘルニア修復術後28か月目に会陰部の膨隆が再燃し，CT検査で会陰部への小腸の脱出を認めたため，会陰ヘルニア再発と診断し再手術を施行した．腹腔鏡下に確認すると子宮の左側にfenestra type，右側にpouch typeの子宮広間膜裂孔ヘルニアを認めた．間隙を縫合閉鎖し，両側の広間膜を覆うようにメッシュを固定して修復術を行った．女性に対する直腸切断術後の子宮固定による会陰ヘルニア修復術後には子宮広間膜の菲薄化，脆弱化による子宮広間膜裂孔ヘルニアをきたすことがあり注意が必要である．

　A 63-year-old woman presented with a symptomatic perineal hernia 10 months after robotic abdominoperineal resection for rectal cancer. Laparoscopic surgery was performed to close the pelvic floor defect by mobilizing the uterus to the front of the sacrum and reinforcing it with a synthetic mesh. At 28 months after the operation, perineal hernia recurred. Computed tomography showed prolapse of the small intestine to the pelvic cavity and perineum, leading to a diagnosis of recurrent perineal hernia and re-operation was planned. The operative findings newly demonstrated bilateral broad ligament hernia（fenestra type on the left side and pouch type on the right side）. The defects were closed by suturing and the mesh was secured to cover both hernia orifices at the broad ligament. It should be noted that perineal hernia repair with uterine mobilization after rectal resection may cause broad ligament hernia due to thinning and weakening of the ligament.