腹腔鏡下手術で根治したS状結腸間膜内ヘルニアの1例

A case of intramesosigmoid hernia treated with laparoscopy

◆要旨：患者は開腹歴のない48歳男性．突然の腹痛，嘔吐で救急外来を受診した．間歇的に激しい腹痛が継続したため入院となり，入院翌日の腹部単純X線，腹部CT検査でイレウスと診断されたが，腸管虚血所見を認めなかったため，イレウス管による保存的加療を行った．その2日後のイレウス管造影検査で，骨盤内小腸に完全閉塞所見を認め，CT所見と併せてS状結腸間膜内ヘルニアを疑い，入院5日目に腹腔鏡下に手術を施行した．S状結腸間膜左葉に径3cm大の欠損孔を認め，そこへ回腸が約10cm嵌入していた．ヘルニア門を切開して嵌入回腸を整復し,間膜欠損部を縫合閉鎖して手術を終了した．腸管切除は不要であった．S状結腸間膜内ヘルニアは稀な疾患で，術前診断は困難と言われているが，あらゆる画像検査を駆使して内ヘルニアを疑い，低侵襲である腹腔鏡下手術を検討すべきである．

Intramesosigmoid hernia is uncommon and very difficult to be diagnosed preoperatively. A 48-year-old man, who had no past medical history of laparotomy, was admitted to our hospital due to severe abdominal pain. On admission, X-ray showed no fluid levels and contrast-enhanced CT scan suggested enteritis. On the following day, contrast-enhanced CT scan showed small intestinal obstruction without bowel ischemia and a long tube was placed to decompress the bowel. Enterography via long tube with gastrographin showed complete obstruction of the small intestine in the pelvis. Colonoscopy showed no abnormal findings. These findings suggested intramesosigmoid hernia. After 5 days of admission, laparoscopic surgery was performed. Oval defect 3cm in diameter was observed in the sigmoid mesocolon and a segment of small intestine, approximately 10cm in length, was entrapped in the defect. The defect was repaired without resection of the involved intestine. The patient was discharged on the 6th postoperative day without complications. When the diagnosis of internal hernia is suspected, laparoscopic surgery is recommended.