肝挙上により術後肝梗塞をきたした腹腔鏡補助下幽門側胃切除の1例

A case of liver infarction after laparoscopy-assisted distal gastrectomy due to liver retraction

◆要旨：腹腔鏡補助下胃切除術（以下，LADG）では肝臓圧排鉗子を用いて肝外側区域を挙上し術野を展開することが必須である．これまで圧排操作による術後肝機能障害が指摘されてきたが，肝梗塞にまで至った症例は非常に稀である．今回，肝圧排操作により術後肝梗塞を引き起こした症例を経験したので報告する．患者は75歳，女性．早期胃癌の診断でLADGを行った．術後1日目にAST 2,882IU/lと著明に上昇し，CTではA2，A3根部から血流が途絶し，S2，S3領域が肝梗塞となっていた．肝壊死から膿瘍化には至らず保存的加療で術後15日目に退院した．術後60日目のCTでは同部位の肝萎縮を認めた．不適切な挙上は肝梗塞にまで進展しうる場合があり，注意と工夫が必要である．

　To obtain a good view while performing laparoscopy-assisted distal gastrectomy (LADG), elevating lateral lobe of the liver with a liver retractor is essential. Although postoperative liver dysfunction caused by liver retraction have been reported, a case leading to liver infarction is very rare. We experienced a case of liver infarction after LADG. A 75-year-old female was diagnosed with early gastric cancer. We performed LADG with a fan shaped liver retractor. On postoperative day (POD) 1, serum aspartate aminotransferase (AST) level increased up to 2,882IU/l. Computed tomography (CT) revealed proper hepatic arterial occlusion and liver infarction of the lateral lobe. Fortunately, liver infarction did not progress to liver abscess and the patient was discharged on POD 15. CT on POD 60 revealed severe atrophy of lateral lobe of the liver. Inappropriate retraction may cause liver infarction. Therefore, attention should be paid to avoid liver dysfunction while retracting liver.