腹腔鏡補助下結腸切除後の腸間膜欠損部に生じた術後内ヘルニアによる腸閉塞の1例

Internal hernia through the mesenteric opening after laparoscopic-assisted colectomy : a case report

◆要旨：腹腔鏡補助下大腸切除後の腸間膜欠損部に小腸が嵌入し，腸閉塞を生じた術後内ヘルニアの1例を経験した．症例は76歳，男性で，横行結腸左側の大腸癌に対し腹腔鏡補助下結腸切除術を施行した．術後38日目より腸閉塞を発症し，保存的治療で改善しないため術後63日目に開腹手術を施行した．トライツ靭帯近傍の空腸が結腸切除後の腸間膜欠損部に嵌入，癒着し狭窄をきたしていた．嵌入腸管に血行障害はなく，癒着を剝離し腸間膜欠損部に大網を充塡した．腹腔鏡補助下大腸手術では腸間膜欠損部は閉鎖しないことが多いが，本症例のように腸間膜欠損部に小腸が嵌入し腸閉塞を発症した報告が散見されており，腸間膜切離部は可能な限り閉鎖するべきと考えられた．

　We report a patient with internal hernia through the mesenteric opening that occurred after the laparoscopic-assisted colectomy. The patient was a-76-year-old man who underwent laparoscopic-assisted colectomy for a transverse colon cancer. On the 38 th postoperative day, he complained of nausea and vomiting and was re-admitted under the diagnosis of small bowel obstruction. Surgical intervention was finally performed on the 25 th day after the re-admission because conservative treatment was unsuccessful to relieve the obstruction. Laparotomy showed that a short segment of the proximal jejunum had herniated through the mesocolonic opening, which was formed after the laparoscopic-assisted colectomy. The obstruction was relieved by adhesiolysis, and the hernia orifice was closed with the part omentum. Suturing the mesenteric gap is not commonly performed in the operative procedure of laparoscopic-assisted colectomy. Some cases, however, have been reported where the mesenteric opening has caused internal hernia resulting in bowel obstruction. Therefore, closing the mesenteric gap should be performed in laparoscopic-assisted colectomy for preventing a postoperative internal hernia.