腹腔鏡下膵頭十二指腸切除術後の内ヘルニアに起因する胆汁性腹膜炎の1例

Laparoscopic treatment of internal hernia which caused biliary peritonitis after laparoscopic pancreatoduodenectomy

◆要旨：57歳男性の分枝型膵管内乳頭粘液性腫瘍に対し腹腔鏡下幽門輪温存膵頭十二指腸切除術，Child変法再建を行った．術後13日目に退院したが，術後16日目に突然の腹痛をきたして当科を再受診した．CTで再建挙上空腸の内ヘルニアと診断し，緊急手術を行った．腹腔内には多量の胆汁性腹水を認め，挙上空腸は結腸間膜頭側に引き込まれ，胆管空腸吻合部前壁が破綻していた．腹腔鏡下に内ヘルニアを解除し，胆管空腸吻合部を修復，挙上空腸を結腸間膜に縫合固定した．術後経過は良好であった．本症例は初回手術時に挙上空腸を結腸間膜に固定しなかったために内ヘルニアと胆汁性腹膜炎を生じたが，それに対しても腹腔鏡下手術で対処しえた．

A 57-year-old male patient underwent laparoscopic pylorus-preserving pancreatoduodenectomy followed by modified Child-type reconstruction for branch duct intraductal papillary mucinous neoplasm of the pancreas. He was discharged on postoperative day 13; however, sudden onset of abdominal pain brought him back to the hospital on postoperative day 16. Computed tomography revealed dilatation of the afferent jejunal loop and ascites, and a decision was made to undertake emergency laparoscopic surgery under the diagnosis of internal hernia. A large amount of bilious ascites was observed in the abdominal cavity. The jejunal loop migrated up through the transverse mesocolon and dilated, and the ventral side of hepaticojejunostomy was disrupted. The jejunal loop was pulled down and fixed to the mesocolon, and the disrupted hepaticojejunostomy was re-closed over a stent tube laparoscopically. This internal hernia was caused by the lack of fixation of the jejunal loop to the mesocolon at the time of the initial operation and can be treated laparoscopically.