食道裂孔ヘルニア嵌頓に伴う胃穿孔に対し腹腔鏡下手術を施行した1例

A case of incarcerated hiatal hernia with gastric perforation successfully treated by laparoscopic surgery

◆要旨：患者は94歳，女性．腰痛に対して非ステロイド性抗炎症薬を常用していた．突然の左側腹部痛を自覚し，当院へ救急搬送された．造影CTで食道裂孔ヘルニア嵌頓，胃穿孔と診断した．全身状態は安定しており腹膜炎も軽度であったことから，腹腔鏡下手術を選択した．術中所見では，臓器軸性の胃軸捻転を呈し，全胃が縦隔へ嵌頓していた．また穿孔部は胃体下部後壁に認めた．腹腔鏡下に胃を腹腔内へ還納し，穿孔部の大網被覆と，食道裂孔の縫縮を行った．術後経過は良好で29日目に転院となった．食道裂孔ヘルニアに胃穿孔を合併すると致死率は決して低くないが，全身状態が安定している症例では腹腔鏡下手術の施行も考慮される．

　A 94-year-old woman with daily oral administration of non-steroidal anti-inflammatory agent presented to the emergency department with acute onset of left upper quadrant pain. Computed tomography revealed large esophageal hiatal hernia with gastric perforation. Because her clinical condition was stable and peritonitis was mild, we performed emergency laparoscopic surgery. At surgery, we observed typeⅣ hiatal hernia and gastric perforation, so omentopexy, esophageal hiatal hernia repair, and enterostomy were carried out. Esophageal hiatal hernia with gastric perforation can be life threatening, but it would be possible to perform laparoscopic surgery if patient's clinical condition is stable.