―囊胞性婦人科疾患―囊胞性子宮腺筋症に対する腹腔鏡下手術

The rare cystic uterine disease : the pathogenesis and laparoscopic surgery for the cystic adenomyoma

　要旨：囊胞性子宮腺筋症はきわめて稀な子宮の囊胞性疾患の代表であり，発症年齢は20.7±4.6歳と若年女性に好発する．特徴的な症状は激烈な月経困難症であり，通常NSAIDsはあまり有効ではない．経腟超音波断層像やMRIにおいて，囊胞性腺筋症は肥厚した筋層の中に血腫を有する腫瘤像として描出される．囊胞性腺筋症は子宮内腔と連続性がなく，ほとんどが左右の子宮円靱帯起始部に認められる．囊胞性腺筋症を腹腔鏡下に摘出することは比較的容易であり，漿膜切開を加え，腫瘤を糸で牽引しつつ摘出する．摘出後の筋層は吸収糸で2～3層に連続縫合し，漿膜も吸収糸でインターロック縫合する．病理検索を行うため，摘出した腫瘤はダグラス窩から回収する．囊胞性腺筋症の組織所見は，内腔面に内膜腺と間質構造を有し，周囲筋層には子宮腺筋症組織を認める．症状や組織所見から，本症の発生機序は先天的なものと推定される．腹腔鏡下腫瘤摘出術により月経困難などの症状は劇的に改善し，術後の妊娠も可能である．

　Cystic adenomyoma, an extremely rare disease, is the most typical cystic disease of the uterus. The onset of the disease is reported to be 20.7±4.6 years. The characteristic symptom of this disease is severe dysmenorrhea that nonsteroidal anti-inflammatory drugs are generally not so effective. Transvaginal ultrasonography and MRI show cystic adenomyosis to be a tumor that is located within the thickened muscular layer and contains blood within the cystic lesion. The cystic tumor has no continuity to uterine cavity and in most cases the lesion is detected at the uterine side of either right or left round ligament. Resection of cystic adnomyoma is comparatively easy and an incision is made above the serosa. The whole cyst is enucleated by pulling the strings tied firmly to the muscular layer. After enucleation, 2 to 3 layer running suture is used to close the myometrium and interlock suture is employed to close the serous layer, using the absorbent surgical thread. The enucleated tumor is removed from Douglas pouch for pathological examination. The pathological findings of cystic adenomyoma show the endometrial glands and stroma in the inner surface of the cystic lesion and adenomyosis in the surrounding muscular tissue. Considering the symptoms and the pathological findings, cystic adenomyoma may considered to be congenital. Symptoms including severe dysmenorrhea are dramatically improved after laparoscopic surgery and postoperative pregnancy is also possible.