直腸癌腹腔鏡下側方リンパ節郭清後の露出血管による腸閉塞の1例

Small bowel obstruction secondary to exposed umbilical artery following laparoscopic lateral lymph node dissection for rectal cancer : A case report

◆要旨：症例は60歳，女性．腹痛，嘔吐にて前医を受診し腸閉塞の診断でイレウス管留置されるも改善なく，手術目的に当院へ紹介となった．直腸癌に対し腹腔鏡補助下直腸切断術，両側側方リンパ節郭清術の既往があり，CTで骨盤左側への内ヘルニア嵌頓を疑って腹腔鏡下腸閉塞解除術を施行した．腹腔内を観察すると，左側方リンパ節郭清後に形成された臍動脈-内腸骨動脈の間隙に小腸が嵌入しており，嵌入を解除してヘルニア門を縫合閉鎖し手術を終了した．以後腸閉塞の再燃は認めない．稀な合併症ではあるが，腹腔鏡下側方リンパ節郭清手技の普及とともに増加が予測され，文献的考察を加えて報告する．

　A 60-year-old woman, who had already been admitted to another hospital because of abdominal pain and nausea, was referred to our hospital with intractable ileus. She had undergone laparoscopic-assisted abdominoperineal resection with lateral lymph node dissection 33 months ago. Exploratory laparoscopy revealed incarcerated small bowel segments beneath the left umbilical artery. After reduction of the herniated small bowel, the reduced segments appeared viable, eliminating the need for subsequent bowel resection. Finally, the hernia orifice was closed using sutures, and no bowel obstruction recurrence was observed within 16 months after the operation. There are few reports of bowel obstruction due to exposed structures after laparoscopic lateral lymphadenectomy for rectal cancer, which is a less invasive procedure than open surgery and therefore, reduces postoperative adhesion formation between the exposed structures, such as the urinary tract, superior vesical artery, and umbilical artery. To avoid cutting these structures during the operation, we must be aware that the popularization of laparoscopic lateral lymph node dissection can lead to an increased risk of intestinal obstruction.