腹腔鏡下に診断し修復しえた子宮全摘術後の腟断端離開による腹腔内遊離ガス像を呈した急性腹症の1例

Successful laparoscopic diagnosis and repair for vaginal stump dehiscence : a case of acute abdomen with intra-abdominal free air

◆要旨：子宮全摘術後の腟断端離開による腹腔内遊離ガス像を伴った急性腹症に対して腹腔鏡下に診断，穿孔部を修復した1例を経験した．患者は43歳，女性．4か月前，子宮筋腫に対して腹式子宮全摘術を施行されていた．心窩部痛，右下腹部痛，腹部膨満感を主訴に近医を受診した．腹部単純X線検査で腹腔内遊離ガス像を認め，当院を紹介され受診した．上部消化管内視鏡検査で異常所見は認められなかったが，消化管穿孔を疑い腹腔鏡下手術を行った．子宮全摘術後の腟断端に離開部を認め，腹腔鏡下に縫合閉鎖した．子宮全摘術後腟断端離開による気腹症はきわめて稀で，術前診断は困難であった．腹腔鏡下手術により容易に診断可能であり，急性腹症に対する腹腔鏡下手術の有用性が示唆された．

　We experienced a patient with acute abdomen with intra-abdominal free air caused by the vaginal stump dehiscence. The patient was a 43-year-old woman and had underwent hysterectomy for myoma uteri 4 months before this episode. She was admitted due to sudden onset epigastralgia, right lower quadrant pain, and abdominal fullness. Plain X-p and computed tomography revealed intra-abdominal free air without ascites. Although upper gastro-intestinal fiberscope showed no abnormal findings of the stomach and the duodenum, bowel perforation could not be entirely excluded. Thus, laparoscopic surgery was performed. Laparoscopically, only vaginal dehiscence without purulent peritonitis was observed so it was closed with intra-abdominal suturing technique. Pneumoperitoneum caused by vaginal perforation after hysterectomy is extremely rare. Preoperative diagnosis is difficult. Laparoscopic surgery appears to be absolutely feasible for both the diagnosis and the treatment of acute abdomen, especially in such spontaneous pneumoperitoneum.