HCCに対するTACE・RFA後に発症した遅発性横隔膜ヘルニア嵌頓に対し腹腔鏡下修復術を施行した1例

Case report : Laparoscopic repair for a diaphragmatic hernia after transcatheter arterial chemoembolization and percutaneous radiofrequency ablation for hepatocellular carcinoma

◆要旨：患者は81歳，女性．C型慢性肝炎に伴う肝細胞癌に対して繰り返しTACEおよびRFAを施行されていた．2009年には左下横隔動脈の塞栓術が施行され，術後に咳嗽および左胸水の貯留を認めたが保存的に改善した．その4年後に上腹部痛と食思不振を主訴に当院を受診した．左横隔膜ヘルニア嵌頓の診断で腹腔鏡下に手術を開始した．術中所見では左横隔膜に欠損を認め，同部位より胃の穹窿部が胸腔内に脱出していた．腹腔内に還納したところ壊死の所見はなく，腹腔鏡下に連続縫合でヘルニア門を修復した．経過やヘルニア門の位置からTACEが関与した可能性が考えられた．症例を選択すれば腹腔鏡下手術は有効な治療方法であると考えられた．

　The patient was an 81-year-old female. TACE and RFA for hepatocellular carcinoma related to chronic hepatitis C had been repeatedly conducted. In 2009, embolization of the left inferior phrenic artery was performed. After surgery, cough and retention of pleural effusion on the left side were observed, but conservative therapy led to an improvement. Four years later, she consulted our hospital with upper abdominal pain and anorexia. Under a diagnosis of left incarcerated diaphragmatic hernia, laparoscopic surgery was started. Intraoperative findings included a defect of the left diaphragm and prolapse of the gastric fornix into the thoracic cavity. Intraperitoneal reduction was performed. There was no necrosis. Under laparoscopy, the hernia orifice was repaired by continuous suture. The course and orifice's position suggested the involvement of TACE. If patients are appropriately selected, laparoscopic surgery may be effective for hernia of the diaphragm.