腹腔鏡下幽門側胃切除Roux-en-Y再建後に内ヘルニアを繰り返した1例

A case of repeated internal hernia after Roux-en-Y reconstruction following laparoscopic distal gastrectomy

◆要旨：患者は71歳，男性．早期胃癌に対して腹腔鏡下幽門側胃切除術（以下，LDG），結腸前Roux-en-Y（以下，RY）再建を行った．術後1年3か月で腹痛が出現し救急外来を受診した．CTにて上腸間膜動静脈の渦巻様構造を認め，腸間膜捻転症あるいは内ヘルニアと診断し，緊急手術を施行した．ほぼ全小腸がPetersen裂孔に右側から左側に嵌頓しており，小腸を整復し，裂孔を縫縮した．4か月後に再度内ヘルニアを起こし手術となり，裂孔縫縮部が裂けていたため小腸整復，裂孔縫縮を行った．それ以後，内ヘルニアの再発はなく外来通院中である．胃癌に対するLDG，RY再建後に発生した内ヘルニアの報告例は少ないが重篤化しうる重要な合併症として念頭に置く必要がある．確実な縫合閉鎖が内ヘルニアの発生を予防するために重要と考えられた．

　The patient was a 71 year-old man with abdominal pain with a past history of laparoscopic distal gastrectomy (LDG) with an ante-colic Roux-en-Y (RY) reconstruction for gastric cancer. Abdominal computed tomography of the small intestine showed a whirling appearance, and the patient was diagnosed as having internal hernia or torsion of the small intestine. Emergency laparotomy under general anesthesia revealed the entire small intestine was strangulated in the right side of the Petersen hiatus. We released the strangulated small intestine, and sutured to close the hiatus. Four months later, the operation was repeated as the hiatus re-opened, and an inner hernia recurred. There are few reports of internal hernia after LDG for gastric cancer. We should recognize that internal hernia is a serious complication after LDG with RY reconstruction. In addition, it is important that the hiatus is correctly sutured to prevent the internal hernia from recurring.