Leriche症候群を併存した肝細胞癌に対し腹腔鏡下肝左葉切除術を施行した1例

Laparoscopic left hepatic lobectomy for hepatocellular carcinoma with Leriche syndrome

◆要旨：症例は71歳，男性．Leriche症候群に対して保存的に加療されていた．間欠性跛行の増悪にて施行した造影CTで肝S3/4のグリソンに接した腫瘤を認めた．血管は腹部大動脈から両側総腸骨動脈まで閉塞しており，下肢の血流は下腹壁動脈をはじめとする側副血行路で保たれていた．Leriche症候群を伴う肝細胞癌と診断し，側副血行路の損傷時に備え，血管外科のバックアップのもと手術の方針とした．アプローチ方法は側副血行路の損傷を避けるべく腹腔鏡手術を選択し，肝予備能は許容されることから，術式は切離面がシンプルな肝左葉切除とした．術前の体表超音波でマーキングした腹壁の側副血行路を避けて計7ポートで手術を施行した．手術は腹腔鏡で完遂し，合併症なく第7病日に退院した．適切な術式選択と血管外科との連携による十分な準備のもとで安全に腹腔鏡下肝切除術を施行しえた．

　A case of laparoscopic left hepatic lobectomy for hepatocellular carcinoma associated with Leriche syndrome is described along with a review of the literature. The patient was a 71-year-old man. He had undergone femoral artery bypass surgery 18 years ago for Leriche syndrome. A contrast CT scan performed due to worsening intermittent claudication revealed a mass adjacent to Glisson's sheath in the liver S3/4. Both common iliac arteries and bypass vascular grafts were occluded, and blood flow to the lower limbs was maintained by collateral circulation, including the inferior epigastric artery. He was diagnosed with hepatocellular carcinoma and surgery was performed with the support of a vascular surgeon. Laparoscopic surgery was selected to avoid damage to the collateral circulation. A left hepatic lobectomy was performed using a total of seven ports, avoiding the collateral circulation marked by preoperative ultrasound. The patient was discharged on the seventh postoperative day without any complications. Appropriate treatment strategy and adequate preoperative preparation enabled safe hepatectomy.