安全性を重視し二期的に施行した仰臥位胸腔鏡腹腔鏡併用横隔膜ヘルニア根治術の1例

A case of diaphragmatic hernia treated with definitive two-stage surgery using thoracoscopy and laparoscopy in the supine position, emphasizing safety

◆要旨：症例は68歳，男性．早期胃癌に対する腹腔鏡下幽門側胃切除後4年で非還納性の左横隔膜ヘルニアと診断された．待機的に腹腔鏡手術の方針としたが，大網と横行結腸がヘルニア門に強固に癒着し安全な剝離が困難であったため，二期的に仰臥位で胸腔鏡腹腔鏡併用横隔膜ヘルニア根治術を施行した．胸腔鏡下の観察を併用して胸腔内臓器損傷を回避し，仰臥位腹腔鏡下にヘルニア門の癒着剝離と還納，単純閉鎖，メッシュ固定を行った．横隔膜ヘルニアに対する術式は統一されていないが，ヘルニア門に癒着を伴う症例も多く安全な手術操作が肝要である．自験例のような仰臥位胸腔鏡腹腔鏡併用手術は横隔膜ヘルニアに対して汎用性に富む安全な術式と考えられた．

　A 68-year-old man was diagnosed with left diaphragmatic hernia four years after laparoscopic distal gastrectomy for early stage gastric cancer. Laparoscopic surgical hernia repair was planned, but the transverse colon and omentum were adhered strongly to the hernia orifice. Therefore, we performed supine thoracoscopic laparoscopic combined surgery in two stages. Using laparoscopy, adhesiolysis of the hernial orifice, reduction of the herniated contents into the abdominal cavity, primary closure of the hernial orifice, and mesh fixation were performed with the patient in the supine position. Thoracoscopic observation facilitated avoidance of internal thoracic organ injury. No standardized surgical approach to diaphragmatic hernia exists, but safe surgical approaches are of paramount importance in all cases because many cases show adhesion to the hernia orifice. The supine thoracoscopic laparoscopic combined approach that we applied successfully, is safe and useful.