開腹幽門側胃切除 Roux-en Y 再建後の内ヘルニアを腹腔鏡下に整復した1例

A case of laparoscopic internal hernia reposition after open distal gastrectomy with Roux-en Y reconstruction

◆要旨：患者は62歳，男性．胃癌に対し開腹幽門側胃切除 Roux-en Y 再建を行った．術後1年1か月で腹痛が出現し当院を受診した．CTで whirl sign を認めたが，虚血所見がなく腹痛症状も弱かったため，保存的に治療したが，短期間に症状が寛解・増悪した．再度CT検査を行い，内ヘルニアが疑われ手術の方針となった．小腸の可動性が高いために起こるという内ヘルニアの性質上，癒着が軽微であることが予想され，腹腔鏡下手術とした．Petersen's defect に空腸空腸吻合部以下の大部分の小腸が陥入していたが，血流障害はなく，整復した後に腹腔鏡下にヘルニア門を縫合閉鎖した．開腹胃切除後に内ヘルニアが起こった場合でも，腹腔鏡下に整復できる可能性が示唆された．

The patient was a 62-year-old man who underwent open distal gastrectomy followed by Roux-en-Y reconstruction for gastric cancer. Approximately a year after surgery, the patient was admitted to our hospital with lower abdominal pain. Abdominal computed tomography images revealed mesenteric vessel twisting（whirl sign）, but no ischemic changes of the small intestine were observed. Moreover, there was only a slight tenderness. Since conservative treatment was ineffective, the patient was again evaluated with computed tomography. We suspected internal hernia and performed surgery accordingly. Because of the property that the internal hernia is caused by high mobility of the small intestine, it was expected that the adhesion was slight. Therefore, we opted for laparoscopic repair of the internal hernia. Based on the intraoperative findings, we diagnosed the patient with internal hernia caused by the defect between the small bowel limb and the transverse mesocolon（Petersen's defect）. Almost the entire small intestine was impacted in the space. Because there were no signs of ischemic changes, we replaced the intestine and closed the hernia orifice. Laparoscopic internal hernia repair is a possible treatment option for internal hernia that occurs after open gastrectomy.