腸回転異常を伴う上行結腸癌に対し完全腹腔鏡下手術を施行した1例

Complete laparoscopic colectomy with intracorporeal anastomosis for colon cancer with intestinal malrotation

◆要旨：症例は60代の男性．大動脈弁閉鎖不全症の精査目的に入院中，便潜血陽性を指摘され，下部消化管内視鏡検査にて上行結腸癌の診断となった．造影CT検査にて小腸が体の右側に偏在し，上腸間膜動脈の左側に上腸間膜静脈が並走するSMV rotation signを認め，腸回転異常が疑われた．手術は腹腔鏡下に施行した．血管の走行異常に注意しながら回結腸動静脈を処理してリンパ節郭清を行った．結腸は広範囲で後腹膜に固定されていたため，結腸の脱転操作を最小限にすべく腸管切除と吻合は体腔内で行った．術後は経過良好であった．腸回転異常を合併した大腸癌に対する腹腔鏡下手術は，解剖の理解と手技の工夫により安全に施行可能である．

　We report a rare case of a male in his sixties presenting with aortic regurgitation, and showing positive fecal blood reaction. Colonoscopy showed a suspected small tumor in the ascending colon. Contrast CT showed that most of the small intestine was located on the right side in the abdomen, and the superior mesenteric vein was located on the left side of the superior mesenteric artery - the SMV rotation sign - indicating intestinal malrotation. We performed laparoscopic surgery to cut the ileocolic vein and artery in order to dissect the lymph nodes. The ascending colon and transverse colon were adhered strongly to the retroperitoneum, making extracorporeal anastomosis difficult. Therefore, we performed intracorporeal anastomosis after intestinal resection. The postoperative course was uneventful, and the patient was discharged at 14 days after surgery. In cases of colon cancer with intestinal malrotation, it is important to understand the anatomy especially the direction of flow in the mesenteric vasculature, prior to surgery. In the present case, intracorporeal anastomosis could be performed successfully and did not require wide remobilization of the intestine which was adhered to the peritoneum.