解剖学的変異を伴う完全内臓逆位の胆石性胆囊炎に対して腹腔鏡下胆囊摘出術を行った1例

A case of laparoscopic cholecystectomy for cholecystitis with situs inversus totalis

◆要旨：【緒言】完全内臓逆位は1/5,000〜1/10,000の頻度とされる稀な先天性奇形で，解剖学的変異を伴うことがあり，手術時には脈管走向に注意を要する．【症例】68歳，女性．上腹部痛を主訴に，当院救急を受診し，精査で内臓逆位と総胆管結石を伴う胆石性胆囊炎と診断された．内科的加療後，待機的な腹腔鏡下胆囊摘出術を施行した．従来式を正反対の鏡面配置した4ポートで行った．術前CTで門脈が総胆管腹側を走向する変異を認めた．またCalot三角部の剝離は左手操作を多用した．術後合併症なく，術後4病日に軽快退院した．【結語】このような症例は左手操作の習熟だけでなく，解剖学的変異にも注意して手術に臨むべきである．

　Situs inversus totalis is a rare congenital malformation characterized by anatomical anomalies with a frequency of 1/5,000 to 1/10,000. Surgical dissection of the gallbladder requires careful attention to vascular and bile ducts. ［Case］ A 68-year-old woman came to our hospital with complaints of upper abdominal pain. Enhanced CT revealed situs inversus totalis and cholecystitis with common bile duct stones. After diagnosis, she was given conservative treatment. Two months later, elective laparoscopic cholecystectomy was performed. The operation was performed using 4 ports in an opposite arrangement as conventional settings. Preoperative CT showed that the portal vein was positioned in front of common bile duct. In addition, the Calot triangle was positioned such that dissection had to be performed left-handed. The patient was discharged 4 days after surgery without any complications. ［Conclusion］ In cases of situs inversus totalis and cholecystitis, surgery should be performed with a left-handed technique while paying special attention to anatomical anomalies.