腹腔鏡下に整復しえた大網裂孔ヘルニア嵌頓の1例―開腹歴のないイレウスにおける診断治療アルゴリズムの提案

A case of transomental hernia treated by laparoscopic surgery : The proposal of a new diagnostic-therapeutic algorithm for internal hernia including transomental hernia

◆要旨：患者は開腹歴のない73歳，男性．上腹部痛を主訴に救急外来を受診した．受診時上腹部に軽度の圧痛を認め，腹部CTでは横行結腸頭側に拡張した小腸を認め，大網裂孔ヘルニアによるイレウスの診断にて緊急腹腔鏡下手術を行った．術中所見にて大網裂隙から網囊内へと陥入した一部色調不良の小腸を認めたが，裂隙開放にて血流は改善し，腸管切除は不要であった．患者は第8病日に軽快退院した．術前に大網裂孔ヘルニアを含めた内ヘルニアを疑った場合，腹腔内を直接観察することで正確な診断が得られ治療的腹腔鏡へも移行可能な審査腹腔鏡は，有効な手段であると思われる．また今回筆者らは，自験例のような大網裂孔ヘルニアを含む開腹歴のないイレウスにおける診断治療アルゴリズムを考案したので報告する．

A 73-year-old man who had no surgical history presented with upper abdominal pain. Abdominal CT scan showed small bowel dilatation which formed a ‘closed loop', anterior to the transverse colon. The diagnosis was ileus due to transomental hernia. Emergent laparoscopic surgery was performed on the same day. Operative findings revealed that strangulated small intestine had herniated through an abnormal hiatus of the greater omentum. After the greater omentum was opened and the strangulation was released laparoscopically, strangulated small intestine was found to be viable and hence no resection was needed. The postoperative course was uneventful and the patient was discharged 8 days after the surgery. We present a new diagnostic-therapeutic algorithm for internal hernia including transomental hernia. Laparoscopic surgery, which is useful for the observation and clarification of cause and which can be shifted from diagnosis to treatment, is useful for internal hernia including transomental hernia.