心不全と肥満を合併した成人Bochdalek孔ヘルニアに対しhand-assisted laparoscopic surgeryで修復しえた1例

Hand-assisted laparoscopic surgery for adult Bochdalek hernia with heart failure and obesity : a case report

◆要旨：心不全・肥満を伴った成人Bochdalek孔ヘルニアを経験したので報告する．患者は47歳，女性．2010年2月から急性心不全にて当院循環器内科で加療中であった．咳嗽と心窩部痛にてCT検査を施行し，Bochdalek孔ヘルニアと診断され当科を紹介された．腹腔鏡下に手術を開始したがヘルニア内容の癒着や内臓脂肪による視野不良のために施行困難となり，hand-assisted laparoscopic surgery（HALS）に変更した．その後脱出した横行結腸，大網を還納し，ヘルニア門を縫合閉鎖，さらにpolypropylene meshで補完して手術を完遂した．24か月経った現在，再発は認めていない．自験例のような肥満・癒着症例，心合併症症例で完全腹腔鏡下での修復術が困難な場合に，HALSは良好な視野で安全かつ低侵襲に施行でき，有用な手技と考える．

　A 47-year-old obese woman who had been treated for heart failure in our institution, suffered from persistent cough and epigastralgia. The CT revealed Bochdalek hernia and total laparoscopic repair was performed. Because of poor operative field view due to severe obesity, the surgery was converted to hand-assisted laparoscopic approach. The fatty tissue that obstructed the view was pushed aside and the hands were free for blunt dissection. The operation was performed successfully and the patient is in good health without recurrence, 24 months after the surgery. Hand-assisted laparoscopic surgery is useful in difficult cases, such as obese patient, and should be tried before converting to open surgery.