腹腔鏡下に切除した小児特発性大網捻転症の1例

Laparoscopic surgery for pediatric idiopathic omental torsion

◆要旨：患者は5歳，女児．2日前から腹痛を認め前医で便秘症と診断された．疼痛が右下腹部に移動し悪化したため急性虫垂炎疑いで当院を紹介された．微熱と右下腹部に著明な圧痛と腹膜刺激症状を認めた．血液検査で白血球とCRPの著明な上昇を認めた．単純CTで腫大した虫垂は描出できなかったが，周囲には渦巻き状構造を伴う脂肪構造を認め，臨床所見より急性虫垂炎・限局性腹膜炎を疑い，同日腹腔鏡下で緊急手術を施行した．手術所見では，正常虫垂と捻転し壊死した大網を認め，大網捻転症と診断し切除を施行した．経過は良好で，術後4日目に退院となった．小児特発性大網捻転症は腹腔鏡下手術が診断の確定・治療において低侵襲で有用であった．

　A 5-year-old girl presented to our emergency department for evaluation of right lower abdominal pain concomitant with low-grade fever that lasted for two days. The physical examination showed clear tenderness and muscle guarding in the right lower quadrant of the abdomen. Laboratory tests demonstrated leukocytosis（20.7×1000/μl） and elevation of C-reactive protein（17.4mg/dl）. A computed tomography scan revealed a slightly swollen appendix and a large fatty density mass with lineal strands inside the ascending colon. The initial diagnosis was acute appendicitis and she underwent an emergent laparoscopic exploration via the umblilicus. The laparoscopy revealed mild hemorrhagic ascites in the pelvis and a thick uneven mass in the right lower abdominal cavity. The mass was found to be a necrotic omentum that was twisted around its vascular axis several times. The appendix was normal in appearance. We performed partial omentectomy including all the necrotic areas of the omentum without appendectomy. The clinical course was uneventful and the patient was discharged at postoperative day 4. Laparoscopic approach was effective in the diagnosis and treatment for pediatric patient with omental torsion.