“対側アプローチ”によるTAPP法を施行した再発鼠径ヘルニアの1例

A case of recurrent inguinal hernia repaired using the “contralateral approach” during the trans-abdominal pre-peritoneal approach （TAPP）

◆要旨：腹膜前修復法後の再発鼠径ヘルニアを，反対側鼠径部よりアプローチするTAPP法で修復した．患者は47歳，男性．2年前に左内鼠径ヘルニアをDirect Kugel法で修復されていた．今回，左鼠径ヘルニア再発と右鼠径ヘルニア初発に対しTAPP法を行った．左鼠径部に前回の人工補強材が透見され，その恥骨頭側に2cmのヘルニア門を認めた．右鼠径部にはⅡ-2型ヘルニアを認め，通常のTAPP法に準じて右鼠径部の腹膜を切開し右ヘルニア門を露出した．そのまま膀胱上腔を越えて腹膜前腔の剝離を左方へと進め，左のヘルニア門を露出した．両ヘルニア門をメッシュで一括に被覆し修復した．癒着のない反対側から行う“対側アプローチ”は，再発側のヘルニア門露出が容易で再発側の腹膜閉鎖も要らず，有効な術式となりうる．

We used the “contralateral approach” during the trans-abdominal pre-peritoneal approach （TAPP） to repair a recurrent inguinal hernia. A 47-year-old man developed left recurrent inguinal hernia 2 years after direct Kugel repair for a left direct inguinal hernia. He also had a right primary inguinal hernia and underwent TAPP repair. Laparoscopy revealed a 2-cm hernial orifice on the ventral and pubic side of the old direct Kugel patch, which was illuminated through the peritoneum at the left inguinal region （Ⅱ-1-Rec）. At the right inguinal region, a direct inguinal hernia was observed （Ⅱ-2）. We cut the right inguinal peritoneum, expanded the pre-peritoneal space, and identified the right hernial orifice according to the standard TAPP method. We proceeded to the left side through the supravesical preperitoneal space from the right side and exposed the left inguinal hernial orifice. We used Bard 3D Max^® mesh to cover the bilateral hernial orifices and tacked it at the transversus abdominis aponeurosis, rectus abdominis muscle, and direct Kugel patch. The opening of the peritoneum was closed with running 3-0 absorbable sutures. The “contralateral approach, which utilizes the non-adhesive area for access to the adhesive hernial orifice in cases of recurrent hernia, is a novel and useful technique.