腹腔鏡下腹会陰式直腸切断術後に後腹膜経路にて挙上した腸管に穿孔をきたし汎発性腹膜炎を呈した1例

A case of panperitonitis caused by perforated extraperitoneal colostomy after laparoscopic abdomino-perineal resection for rectal cancer

◆要旨：患者は77歳，男性．糖尿病・高血圧・陳旧性心筋梗塞の既往歴があった．3か月前に下部直腸癌に対し腹腔鏡下腹会陰式直腸切断術を施行し，傍ストーマヘルニアの予防のため後腹膜経路にてS状結腸人工肛門を造設した．今回突然の腹痛を主訴に当院を受診し，腸管穿孔に伴う汎発性腹膜炎の診断にて緊急手術を施行した．S状結腸人工肛門の腹膜トンネルの入口部に穿孔部を認め，同部位を切除後，横行結腸人工肛門を造設した．標本肉眼所見では人工肛門の腹壁固定部と後腹膜経路への入口部の粘膜に潰瘍を認め，病理所見は虚血性腸炎に矛盾しない所見であった．人工肛門の造設経路について若干の文献的考察を加え報告する．

The patient was a 77-year-old man with diabetes, hypertension, and old myocardial infarction. He came to our hospital with acute abdomen and a diagnosis of panperitonitis caused by perforated bowel was made. Past medical history revealed that the patient had undergone laparoscopic abdomino-perineal resection for lower rectal cancer three months ago; sigmoid colostomy was created through the extraperitoneal route in order to prevent parastomal hernia. Emergency surgery was performed. During surgery, perforation at the edge of the extraperitoneal space was confirmed. We resected the perforated bowel and constructed transverse colostomy. The resected specimen revealed ulcer formation at the segment of abdominal wall and edge of the peritoneum. Pathological findings were compatible with ischemic colitis. The route for stoma creation is discussed with review of the literature.