腹腔鏡補助下横行結腸切除術後の開放腸間膜に内ヘルニアを認めた2症例

Two patients with internal hernia through a mesenteric defect after laparoscopy-assisted transverse colectomy

◆要旨：腹腔鏡補助下結腸切除術後の結腸間膜の閉鎖については，稀に開放結腸間膜内への小腸の嵌入を認めることがあり，閉鎖すべきとする報告もあるが，いまだ統一した見解は得られていない．今回，筆者らは腹腔鏡補助下横行結腸切除術後の内ヘルニアを2症例経験した．頻度は低いものの腹腔鏡下結腸切除後の内ヘルニアの報告は散見され，開放結腸間膜については特に横行結腸切除においては結腸間膜閉鎖を考慮すべきと考えられる．また，腹腔鏡補助下結腸切除術後の開放腸間膜への内ヘルニアに対しての術式として愛護的操作が可能であれば腹腔鏡でのアプローチも可能と考えられた．今回経験した2症例において若干の文献的考察を加えて報告する．

　Mesenteric defect after laparoscopy-assisted colectomy （LAC） is generally not closed. One of the most popular reasons is that the advanced technique for mesenteric closure on laparoscopic procedure is required. Also, as internal hernia through a mesenteric defect on LAC is a rare complication, closure of the mesenteric defect is often omitted. We have experienced two patients with internal hernia through the mesenteric defect after LAC. A 60-year-old woman underwent laparoscopy-assisted transverse colectomy for transverse colon cancer. On the postoperative day 16^th, the patient complained severe abdominal pain. Computed tomography （CT） revealed strangulation of the jejunum, and dilated intestine was observed behind a stomach. Emergency operation revealed an internal hernia protruding through a mesenteric defect opened at the previous operation. After release of the internal hernia, the strangulated jejunum did not show any ischemic change, therefore, the mesenteric defect was closured. A 55-year-old man underwent laparoscopy-assisted transverse colectomy for transverse colon cancer. On the postoperative day 17^th, the patient complained severe abdominal pain and vomiting. CT revealed strangulation of the proximal jejunum, and dilated intestine was observed behind a stomach. Emergency operation was performed laparoscopically. Intraoperative laparoscopic findings revealed an internal hernia protruding through a mesenteric defect at the previous operation. Strangulated jejumum was released by laparoscopic maneuver. As the released jejunum expressed ischemic change, affected intestine was taken through a previous wound and resected extracorporeally. Our experiences suggest the necessity for closure of mesenteric defect on LAC, especially on transverse colectomy.