腹腔鏡下腹会陰式直腸切断術後の会陰ヘルニアの2例

Perineal hernia after laparoscopic abdominoperineal resection : Report of two cases

◆要旨：続発性会陰ヘルニアは稀な病態である．今回，直腸癌に対する腹腔鏡下腹会陰式直腸切断術後に発生した会陰ヘルニアを2例経験したので，文献的考察を加え報告する．2例はそれぞれ術後3か月目と4か月目に会陰部の膨隆が出現し，CTで会陰ヘルニアと診断した．1例は会陰アプローチで手術を行った．ヘルニア門付近に小腸の癒着はまったくなく，Dual Mesh^®を用いた修復術を容易に行うことができた．1例は自覚症状が乏しいため経過観察している．本症の成因には腹腔鏡下手術後の癒着の少なさや，骨盤底腹膜を修復しないことが関与する可能性がある．小腸間膜過長や子宮摘出後といったハイリスク症例では，腹膜修復を考慮すべきである．

Perineal hernias are rare secondary disorders. Here, we report two cases of hernia that developed after laparoscopic abdominoperineal resection（APR） for rectal cancer. Both patients noticed bulges at the perineal region at three and four months after APR respectively. For each patient, the diagnosis of a perineal hernia was made based on the symptoms and CT findings. We performed an operation for one patient to repaire the hernia using Dual Mesh^® via the perineum with no difficulty. Perineal approach was useful for this case because no adhesions were observed around the hernia orifice. Another patient was observed without operation. We speculate that perineal hernia that developed after laparoscopic APR is caused by fewer postoperative adhesions and omission of repairing the pelvic peritoneum. So, we must take pelvic peritoneal repair into consideration in patients with extra long mesenterium or post-total hysterectomy cases.