腹腔鏡下修復術を行った成人Bochdalek孔ヘルニアの2例

Two cases of laparoscopic repair of Bochdalek hernia in adults

◆要旨：学童期以降に発見されるBochdalek孔ヘルニアは成人Bochdalek孔ヘルニアと呼ばれ，成人発症は全例の10％前後で比較的稀とされている．今回，筆者らは術前に成人Bochdalek孔ヘルニアと診断し，腹腔鏡下に修復しえた2症例を経験したので報告する．症例1は16歳，女性．運動中の左側腹部痛で発症した．CTで横隔膜左背側をヘルニア門とする胸腔内への胃と結腸の脱出を認め，成人Bochdalek孔ヘルニアと診断した．症例2は特発性血小板減少性紫斑病の診断で脾摘の既往がある71歳，女性．左季肋部痛で発症し，CTで左胸腔内に左腎臓上極や膵体尾部や横行結腸を認めた．ヘルニア門は左腰肋三角にあり，成人Bochdalek孔ヘルニアと診断した．手術はともに腹腔鏡下で行い，左横隔膜後方の腰肋三角部にスリット状のヘルニア門を認め，Bochdalek孔ヘルニアに合致する所見であった．また成書にも記載があるようにヘルニア囊を認めなかった．ヘルニア内容を腹腔内に引き戻し，ヘルニア門を縫合閉鎖し，手術を終了した．2症例とも術後経過は良好であった．

Adult Bochdalek hernia occurs infrequently. Although the defect in the left-posterior diaphragm is congenital, only 10％ of Bochdalek hernias reportedly become evident after childhood. Here, we present two cases of adult Bochdalek hernia repaired laparoscopically. Case 1: A 16-year-old woman presented with left lateral abdominal pain during exercise. CT scan showed her stomach and colon herniating into the thoracic cavity via a hernia orifice located in the dorsal side of the left diaphragm, and she was diagnosed as having adult Bochdalek hernia. The hernia orifice was successfully closed via a laparoscopic suturing technique. Case 2: A 71-year-old woman with a history of splenectomy due to immune thrombocytopenia presented with left hypochondriac pain. CT scan showed massive herniation of several abdominal visceral organs, including the left superior pole of the left kidney, pancreatic body and tail, and transverse colon, into the thoracic cavity. Laparoscopic surgery was conducted, and a slit-shaped hernia orifice was identified in the left vertebrocostal trigone of the diaphragm, which is compatible with a diagnosis of Bochdalek hernia. The hernia orifice was probably missed during the previous splenectomy. The viscera was successfully reduced to the abdominal cavity, and the hernia orifice was sutured closed. Both patients experienced an uneventful postoperative course, and recurrence of hernia has not been noted to date.