Direct Kugel法による閉鎖孔ヘルニア術後再発に対してプラグ法を用いた腹腔鏡下修復術を施行した1例

Laparoscopic repair using plug method for recurrent obturator hernia after the Direct Kugel technique

◆要旨：閉鎖孔ヘルニアの修復法の中で，メッシュシートを用いた腹膜前修復法は広範囲に被覆できる利点があるが，再発例に対する手術が課題となる．症例は93歳，女性．他院にて両側閉鎖孔ヘルニアに対してDirect Kugel法による修復術を受け，KugelパッチSサイズが留置された．術後1年1か月で右側腹部痛を主訴に前医を受診し，右閉鎖孔ヘルニア再発と診断されたが，前医では対応困難とのことで当院紹介となった．造影CTで腸管虚血の所見がなかったため徒手整復を行い待機的手術とした．腹腔鏡下に観察するとKugel patchは閉鎖孔より腹側に位置していた．ヘルニア門の修復はプラグ法にて行った．術後は1年間再発なく経過している．メッシュシートを用いた腹膜前修復後の再発症例に対してプラグ法による腹腔鏡下手術で安全に修復することが可能であった．

　Among the repair methods for obturator hernia, preperitoneal repair using a mesh sheet offers the advantage of wide coverage, but surgery for recurrent cases remains a challenge. A 93-year-old woman was treated for bilateral obturator hernias at another hospital using the Direct Kugel technique with implantation of an S-sized Kugel patch. One year and one month after the operation, her previous physician diagnosed a recurrence of the right obturator hernia. She was referred to our hospital because her previous physician was unable to manage her condition. Contrast-enhanced CT revealed no evidence of intestinal ischemia, manual reduction was performed, followed by repair through laparoscopic surgery. Intraoperatively, it was found that the Kugel patch had deviated ventrally from the obturator foramen. An incision was made in the peritoneum just above the hernia portal, and a plug was inserted into the obturator foramen. Postoperatively, the patient has shown no signs of recurrence for one year. Laparoscopic repair using the plug method was safely performed for recurrent case after preperitoneal repair with a mesh sheet.