腹壁ヘルニアに対するeTEPを安全に行うための解剖学的知識と術前エコーガイド下マーキング

Anatomical knowledge and preoperative ultrasound-guided marking for safely performing eTEP for abdominal wall hernias

◆要旨：eTEP法（enhanced view totally extraperitoneal technique）は，術後疼痛の軽減や合併症リスクの低減，腹壁機能の再建といったメリットがあるが，手術手技や時間などの点で手術の難易度が高いとされている．当院ではeTEPを第一選択としているが，術中所見による予定術式の変更を経験した後，腹直筋辺縁に加え，腹横筋筋部の内側縁と肝鎌状間膜の腹膜の外側縁をマーキングすることとした．手術時間の有意な短縮にまではつながっていないが，剝離範囲の想定や血管神経損傷の回避，剝離層の乗り換えの際の腹膜損傷の回避などの点で有用性が高いと考える．当院で行っている，術前エコーガイド下マーキングの手技について報告する．

　Enhanced view totally extraperitoneal（eTEP） technique offers several benefits, including reduced postoperative pain, decreased risk of mesh-related complications, and improved abdominal wall function. However, it is regarded as a technically challenging and time-consuming procedure. At our institution, eTEP is the first-line procedure ; however, following an intraoperative conversion case, we implemented a strategy to mark the medial border of the transversus abdominis muscle and the peritoneum of the falciform ligament of the liver, in addition to the edge of the rectus abdominis muscle. Although this modification has not yet resulted in a significant reduction in operative time, it has proven invaluable for predicting dissection extent, minimizing vascular and nerve injury, and preventing peritoneal tears during dissection. We present our preoperative ultrasound-guided marking technique.