子宮内容除去時の子宮穿孔に伴う絞扼性腸閉塞に対し腹腔鏡下に修復しえた1例

Total laparoscopic repair of small bowel herniation and obstruction from uterine perforation

◆要旨：患者は37歳，女性，1産．経腟分娩後の1か月健診時に胎盤・卵膜遺残に対し子宮内容除去術を施行された．数時間後に下腹部痛と嘔気が出現し，翌日当院へ転院となった．子宮穿孔に伴う絞扼性腸閉塞と診断し，緊急手術の方針とした．CTでは穿孔部は同定可能で腸管損傷は限局していると考え，腹腔鏡下手術を選択した．小腸は子宮内に嵌頓していたが，牽引にて整復可能であった．子宮損傷部は縫合閉鎖した．術後経過良好で，術後6日目に退院とした．子宮内容除去術の重大な合併症として小腸損傷を伴う子宮穿孔があるが，腹腔鏡下で整復しえた症例は検索しうる限り稀であった．腹腔鏡下手術は，子宮・腸管損傷が限局している症例では，有効であると思われた．

　Small bowel obstruction following dilatation and curettage of the uterus is a rare albeit serious complication. Here, we report a case of small bowel herniation and obstruction due to uterine perforation that was managed with total laparoscopic repair. A 37-year-old woman was admitted with acute abdomen one day after undergoing endometrial curettage. The patient was diagnosed with small bowel obstruction with uterine perforation. Emergent laparoscopic surgery was performed because the perforation site was deemed identifiable and damage to the small bowel was limited, as determined by computed tomographic findings. Intraoperatively, a small bowel herniation into the perforated uterus was identified as the cause of the obstruction. The herniation was removed without the need for resection, and the uterine perforation was repaired with full-thickness, interrupted sutures. The postoperative course was uneventful, and the patient was discharged on postoperative day 6. Laparoscopic repair of small bowel obstruction and uterine perforation is rarely performed, but we conclude that this approach is useful when uterine and intestinal damage is identified and localized, as in the present case.