腹腔鏡下に修復した食道癌手術歴のある外傷性横隔膜ヘルニアの1例

A case of laparoscopic repair for traumatic diaphragmatic hernia in a patient who had previously undergone surgery for esophageal cancer

◆要旨：患者は80代，男性．自転車走行中に転倒し近医へ搬送された．左下腿の骨折の加療目的に当院へ転院となった．CT検査にて左横隔膜ヘルニアを認め，外傷性横隔膜破裂によるヘルニアの診断で緊急手術となった．また，患者には食道癌の手術の既往があり，右開胸および上腹部正中に胃管作製時の手術創が認められた．胃管は後縦隔経路で再建されており，上腹部には手術による癒着が予想されたが，脱出腸管の色調を確認する目的で腹腔鏡によるアプローチを選択した．手術は，3本のポートを用いて腹腔鏡下に行った．胃管は後縦隔経路で挙上されており，その部分よりやや左側の横隔膜が破裂し小腸が胸腔内へ脱出していた．小腸を腹腔内に還納し，横隔膜は腹腔鏡下に連続縫合修復した．食道癌の手術歴を有する外傷性横隔膜ヘルニア症例においても，腹腔鏡下に修復が可能な症例が存在する．

A man in his 80's was transferred to our hospital due to injuries sustained in a bicycle accident. Although a left leg fracture was suspected, a CT scan revealed the presence of a diaphragmatic hernia. He was finally diagnosed with traumatic diaphragmatic hernia, and emergency surgery was thus performed. As the patient had previously undergone open surgery for esophageal cancer, surgical scars from the previous right posterolateral thoracotomy and laparotomy in the epigastric region were observed. Regarding the method of reconstruction, his stomach had been used as a gastric tube via the posterior mediastinal route. This surgery to treat the hernia was performed laparoscopically using three trocars. The site of rupture was found on the left side of the diaphragm near the stomach route, and the small intestine was found to protrude into the thoracic cavity. The small intestine was pulled back to the abdominal cavity and then the ruptured diaphragm was continuously sutured laparoscopically. The laparoscopic procedures were useful for treating traumatic diaphragmatic hernia despite the patient's history of esophageal cancer surgery.