正中腹壁瘢痕ヘルニアに対するendoscopic component separation法を併施したIPOM-plusの有用性

Usefulness of IPOM-plus combined with endoscopic component separation for median abdominal incisional hernia : Case report

◆要旨：腹壁瘢痕ヘルニア根治術は再発率の低さからメッシュを用いた修復法が選択されることが多く，近年では腹腔鏡下根治術（intraperitoneal onlay mesh，IPOM）が増加している．endoscopic component separation（ECS）法は巨大な正中腹壁瘢痕ヘルニアに対して修復が可能な術式であるが，単独では比較的高率な再発も報告されている．今回，術前に創部感染が否定しきれない巨大例と肥満合併例の2例の正中腹壁瘢痕ヘルニアに対して，ECS後の腹腔鏡下観察にて感染徴候を認めればヘルニア門の縫合閉鎖のみに留め，認めなければヘルニア門閉鎖およびメッシュ留置を行うIPOM-plusの方針とした．結果，ECS後の腹腔鏡下観察では問題となる所見を認めずIPOM-plusを付加しえた．術後2年の時点で無再発経過中である．ECSを併施したIPOM-plusはより再発率が低い術式となりうる.

　Incisional hernia repair with mesh is often chosen because of its low recurrence rate. In recent years, laparoscopic surgery has been selected frequently. Endoscopic component separation （ECS） is a good procedure for large median incisional hernia, but a high-rate of recurrence has been reported when performed alone. We experienced two cases of median incisional hernia repaired with ECS and intraperitoneal onlay mesh-plus （IPOM-plus）. One case was with obese and the other had a large hernia. In these cases, infection could not be denied the before surgery. We decided on the preoperative strategy as follows. Laparoscopic observation is performed after ECS. If there is a sign of infection at the wound site, only suture closure of the hernia gate is performed, and if it does not exist, mesh placement is performed in addition to closure of the hernia gate （IPOM-plus）. As a result, laparoscopic observation after ECS found no problematic findings, and IPOM-plus could be added. IPOM-plus with ECS has the potential to be a surgery with a lower recurrence rate.