腹腔鏡下に整復した傍下行結腸窩ヘルニアの1例

A case of internal hernia in the paracolic gutter of the descending colon treated with laparoscopic surgery

◆要旨：患者は82歳，男性．脳梗塞治療のため入院中に心窩部痛と嘔気・嘔吐が出現し，保存的治療で改善せず外科転科となった．左下腹部に圧痛があり腹部CTで下行結腸背側に小腸の係蹄を認め，傍下行結腸窩ヘルニアと診断し腹腔鏡で緊急手術を施行した．傍下行結腸溝の2cmの裂孔に小腸が陥入していたが，容易に整復され裂孔を縫合閉鎖して手術を終了した．経過良好で術後7日で転科となった．傍下行結腸窩ヘルニアは報告例の少ない希少な内ヘルニアで，CTで特徴的な下行結腸背側の小腸係蹄を認め，その発生機序として傍下行結腸溝の裂開や過伸展が考えられる．

The patient was an 82-year-old man who developed epigastric pain, nausea and vomiting while admitted to the Department of Neurosurgery for a cerebral infarction. No improvement was noted after conservative therapy, so he was referred to our department. An abdominal computed tomography （CT） scan showed that the small bowel posterior to the descending colon was obstructed, and the patient was quickly diagnosed with impaction of a paracolic fossa hernia. We performed emergency laparoscopic surgery, and noted a 2 cm tear in the lateral peritoneal attachment of the descending colon, and noted intussusception of the small bowel, though there was no necrosis when this was repaired. The tear was closed and the surgery was concluded. Surgery lasted 54 minutes and a small volume of blood was lost. The clinical course was favorable and the patient was transferred back to the referring department on postoperative day 7. A characteristic CT finding of paracolic fossa hernia is a small bowel loop posterior to the descending colon and the mechanism of onset is thought to involve both dehiscence and hyperextension of the paracolic gutter.