下大静脈背側に密接した巨大な後腹膜神経節神経腫に対するHALSの有用性

Retroperitoneal ganglioneuroma attached to inferior vena cava removed by HALS : A case report

◆要旨：患者は30歳代女性．近医にて下大静脈背面の巨大後腹膜腫瘍を指摘され紹介となった．神経原性腫瘍の術前診断となり，腹腔鏡補助下に摘出の方針となった．横隔膜直下で腫瘤と下大静脈の癒着が強く，鉗子のみでの操作が困難となり，約9cmの開腹創を加えGelPort^Ⓡを挿入し，用手的牽引によって剝離を完遂し，同創部より腫瘍を摘出した．最大径15.5cm，総重量730gの神経節神経腫と病理組織診断された．大血管に密接した大きな後腹膜腫瘍こそ，腹腔鏡下手術ならではの視野展開・拡大視効果とHALS（hand-assisted laparoscopic surgery）を併用することで安全な手術が可能であることが示された．

　A 30 years old woman complaining of right abdominal pain was referred to our institute for further examination of a large retroperitonaeal tumor. Imaging studies revealed a 15cm-sized tumor in the proximity of the dorsal aspect of the inferior vena cava. The tumor expanded from the diaphragm to the upper pole of the right kidney. Laparoscopic assisted removal was planned because the endocrine examination was normal and a ganglioneuroma was highly suspected. After the mobilization of the right side colon to expose the inferior vena cava and the left and right renal veins, these veins were encircled and taped. Strong adhesion of this tumor and the inferior vena cava was noted at the right diaphragm. Because the tumor was too large to handle by laparoscopic forceps, we inserted a GelPort^Ⓡ from the right oblique subcostal incision of 9 cm in length. Dissection of this tumor was completed by the hand-assisted maneuver, and the specimen was extracted from the same wound. The tumor measured 155 mm in maximum diameter. It was a well-defined solid lesion, weighed 730g and the pathological diagnosis was ganglioneuroma. The postoperative course was uneventful and she was discharged on the postoperative day 7. In cases of large retroperitoneal tumor closely attached to the large vessels, laparoscopic surgery is less common as yet. For such cases, however, HALS（Hand-Assisted Laparoscopic Surgery） is potentially valuable because the fingers can comfortably be used while maintaining the close-up view with laparoscopy.