Richter型小腸嵌頓を伴うⅣ型食道裂孔ヘルニアに対して腹腔鏡下腸閉塞解除およびヘルニア修復術を施行した1例

A case of type Ⅳ Richter's hiatal hernia with small bowel obstruction treated by laparoscopic hernia repair

◆要旨：症例は82歳，女性．腸閉塞疑いで当院救急外来紹介となった．腹部造影CT検査で食道裂孔を介して小腸が縦隔内に脱出したⅣ型食道裂孔ヘルニアによる腸閉塞であり，腹痛や脱出小腸の虚血所見を認めず，全身状態も安定していたため，経鼻胃管およびイレウス管による腸管減圧後に腹腔鏡下腸閉塞解除およびヘルニア修復術を施行した．術中所見で小腸壁が小網の腹側から食道裂孔に嵌頓したRichter型ヘルニアであった．小腸壁の圧迫痕はあったが，虚血所見はなく腸切除は行わなかった．術後3日目から経口摂取を再開し，術後8日目に自宅退院した. Richter型のⅣ型食道裂孔ヘルニアの報告はなく，文献的考察を加えて報告する．

　The patient was an 82-year-old woman. She was referred to our hospital because of suspected bowel obstruction. She was diagnosed with typeⅣhiatal hernia with small intestine prolapsed into the mediastinum via the esophageal hiatus on contrast-enhanced CT scan of the abdomen. She had no abdominal pain, no evidence of ischemia of the prolapsed small intestine, and was in stable general condition. After intestinal decompression with nasogastric tube and ileus tube, laparoscopic release of the obstructed bowel and hernia repair procedure were performed. Intraoperative findings revealed a Richter's hernia with inserted small intestinal wall into the esophageal hiatus from the ventral side of the small mesentery. The patient resumed oral intake on the third postoperative day and was discharged on the eighth postoperative day. There have been no reports of Richter's typeⅣhiatal hernia, and we report this case with a review of the literature.