腹腔鏡下に肝鎌状間膜を用いて閉鎖した心囊内横隔膜ヘルニアの1例

A case of laparoscopic repair for intrapericardial diaphragmatic hernia using falciform ligament

◆要旨：症例は68歳，男性．2年前に僧帽弁逸脱症・大動脈弁閉鎖不全症に対し開胸下（胸骨正中切開）に僧帽弁形成術・大動脈弁置換術・左心耳縫合術を施行した．今回急激な腹痛と嘔吐で当院搬送となり，造影CT検査で心囊内への小腸脱出を認め，心囊内横隔膜ヘルニア嵌頓の診断で緊急手術を施行した．腹腔鏡下に横隔膜中心部に2cmのヘルニア門と嵌頓する小腸・大網を認め，嵌頓解除した壊死腸管は部分切除・再建した．さらに腹腔鏡下に肝鎌状間膜を一部切離し，パッチ状にヘルニア門を縫合閉鎖した．術後経過は良好で，再燃は認めていない．今回，腹腔鏡下に肝鎌状間膜を用いてヘルニア門閉鎖を行った心囊内横隔膜ヘルニアの1例を経験したので報告する．

　A 68-year-old man who underwent thoracotomy for treatment of mitral valve prolapse and aortic regurgitation 2 years ago, presented to the emergency department with a sudden abdominal pain and vomiting. Computed tomography of the thorco-abdominal region revealed a segment of the small bowel in the pericardium. The diagnosis was intrapericardial diaphragmatic hernia incarceration and emergent laparoscopic surgery was performed. The herniated small bowel was ischemic ; it was easily reduced into the peritoneal cavity, and resected by a small laparotomy. There was a 2cm defect in the diaphragm. Laparoscopic repair of the hernia was performed using falciform ligament of the liver. The postoperative course was uneventful without recurrence.