直腸癌に対して子宮合併切除を伴う腹腔鏡下Hartmann手術を行い経腟的に標本を摘出した1例

Transvaginal specimen extraction in laparoscopic anterior resection with hysterectomy

◆要旨：患者は84歳，女性．内腔狭窄を伴う巨大直腸癌に対して腹腔鏡下Hartmann手術を施行した．開腹胃切除後の切開創の開大による巨大腹壁瘢痕ヘルニアを合併しており，標本摘出時に腹壁創の開大に伴う術後創トラブルが懸念された．以上より，子宮合併切除後に経腟ルートで標本摘出を行った．術後創トラブルもなく，経過良好であった．女性の場合，腹壁トラブルを回避するために，子宮摘出後に経腟ルートで標本を摘出する腹腔鏡下手術は有効な術式と考えられたので，若干の文献的考察を加えて報告する．

　An 84-year-old woman was found to have advanced rectal cancer with stenosis. She had a high risk of wound-related complications, due to a large ventral hernia. The hernia had formed after a previous open distal gastrectomy. We performed a laparoscopic, low anterior resection（Hartmann's procedure） with 6 trocars. The patient was placed in the lithotomy position, with a bilateral 45 degree tilt. Small, localized nodules which were suspected of dissemination were detected on the surface of the uterus; thus, we decided to include a laparoscopic hysterectomy. After completing the laparoscopic low anterior resection and hysterectomy, the specimen was pulled into the vaginal stump, and extracted transvaginally. The specimen included the rectum, sigmoid colon, and the uterus, with a total length of about 30 cm; the tumor was 11.0×6.0 cm. As a result, no scar remained except the trocar scars and the stoma site on the abdominal wall. We demonstrated that transvaginal specimen extraction is a useful technique, particularly for older women with wound-related complications, like a ventral hernia.