胃・十二指腸穿孔に対する腹腔鏡下手術

Laparoscopic omental patch repair of perforated peptic ulcers

　要旨：胃・十二指腸潰瘍穿孔に対する治療法には，開腹潰瘍症手術，開腹穿孔部閉鎖術，腹腔鏡下穿孔部閉鎖術，保存的治療がある．筆者らは1992年以降，腹腔鏡下穿孔部閉鎖術を基本術式とし，現在まで93例に施行してきた．本法の適応はリスクの少ない十二指腸潰瘍穿孔と胃前壁の小潰瘍穿孔である．術前に内視鏡検査を行い，確実な術前診断を行った後，手術を施行する．穿孔部閉鎖は開腹と同様に大網被覆で行う．3-0吸収糸で全層縫合を2針かけ，大網とともにRoeder knotあるいは結紮鉗子を用いた体外式結紮で縫合閉鎖する．重篤な合併症は3例（3.2％）に認めた．最近の平均在院日数は9.5日であり，適応を考慮したうえで積極的に施行すべき術式と考える．

　Laparoscopic closure of perforated peptic ulcer was performed in ninety three patients between 1992 and 2006. The indications for laparoscopic surgery of perforated duodenal ulcer were relatively good general condition, no severe underlying disease, no duodenal and within 24 hours of perforation. The indication for perforated gastric ulcer was small perforation of the anterior wall of the stomach. Before laparoscopic treatment, endoscopy was performed to diagnose the peptic ulcer and confirm the absence of stenosis. Simple closure with an omental patch was performed by laparoscopic interrupted suture. An extracorporeal Roeder knot was tied in the suture and pushed down to fix the patch of omentum over the perforation. Peritoneal irrigation was carried out with 3-5 liters of saline. The mean operating time was 89.5 minutes. A nasogastric tube was maintained for 1 day after operation, and proton pump inhibiter was administered. The patients could resume oral ingestion of food 3 days after surgery. Postoperative course was uneventful in 90 cases（96.8％）. The mean hospital stay was 9.5 days. We concluded that laparoscopic omental patch repair should be considered as standard therapy for perforated peptic ulcers.