閉鎖孔ヘルニア嵌頓に対して待機的に両側TEPを施行した1例

Elective surgery of totally extraperitoneal approach after manual reduction of incarcerated obturator hernia

◆要旨：患者は87歳，女性．左閉鎖孔ヘルニア嵌頓によるイレウスの診断で当院に救急搬送された．超音波を併用しヘルニアを還納後に経過観察目的で入院となった．軽快退院後，再発予防のため腹腔鏡下手術を施行した．腹腔内観察で両側の閉鎖孔ヘルニアを認めた．腹膜前腔に入り閉鎖孔まで覆うような形でメッシュを展開し両側TEP法を施行した．当院では修復前後の腹腔内の観察を併用したmodified TEP法を施行している．腹腔内観察にて両側の閉鎖孔ヘルニアが判明し，修復後の腹腔内観察にて両側修復の確認もできた．ヘルニア嵌頓症例は全身状態の悪化の可能性もあり，可能であれば用手的に整復し待機手術が望ましいと考えられた．

An 87-year-old woman was admitted to the hospital because of appetite loss and nausea. Abdominal X-ray and computed tomography（CT） revealed bowel obstruction caused by a left incarcerated obturator hernia. After she was referred to our hospital, hernia content was successfully reduced manually with the guidance of ultrasound. To prevent another incarceration, elective laparoscopy surgery of hernia repair with totally extraperitoneal approach（TEP） was performed. Observation of abdominal cavity using endoscopic laparoscopy identified bilateral obturator hernia. The hernias were reduced and polypropylene mesh was placed bilaterally covering the entire space to fully cover indirect, direct, femoral, and obturator hernias. In our institution, modified TEP procedure which combines conventional TEP with the observation of abdominal cavity is used, enabling us to detect other asymptomatic obturator hernia and allowing us to confirm the position of the mesh. Incarcerated obturator hernia frequently occurrs in elderly women with high incidence of emergency operation. Moreover, emergency hernia repair of elderly people can lead to high mortality rate, and it is difficult to perform implantation of the mesh in such situation. Elective laparoscopic surgery after manual reduction of hernia content is desirable when possible.