骨盤臓器脱に対する腹腔鏡下仙骨腟固定術術後に内ヘルニアを発症した1例

A case of internal hernia after laparoscopic sacrocolpopexy for pelvic prolapse

◆要旨：骨盤臓器脱に対する腹腔鏡下仙骨腟固定術（LSC）術後に内ヘルニアを発症した症例を経験した．症例は70歳，女性．LSCの術後3か月で腸閉塞を発症した．緊急手術を施行したところ，Douglas窩左側に腹膜の陥凹を認め，ここに小腸が嵌頓していた．用手的に嵌頓を解除し，ヘルニア門となっていた腹膜を縫合閉鎖した．本症例は仙骨子宮靭帯とメッシュ，骨盤壁でヘルニア門を形成し，死腔となった小骨盤腔に小腸が脱出することで内ヘルニアを呈したと推測された．LSCは骨盤臓器脱に対して有効な術式とされているが，術後に内ヘルニアによる腸閉塞は合併症として過去に報告はない．解剖学的に起こりえる合併症の一つであり，改めて認識することが必要である．

　Laparoscopic sacrocolpopexy （LSC） is asurgical procedure that has recently gained prominence for the treatment of pelvic organ prolapse. We present the case of a 70-year-old woman who developed bowel obstruction three months after having undergone LSC for bladder prolapse. The patient was diagnosed with an internal hernia in the pelvis, and emergency surgery was performed. A peritoneal depression was detected on the left side of the Douglas pouch in the pelvic floor, with incarceration of the small intestine. The incarceration was manually released, and the peritoneal cavity was closed. Subsequently, the patient has had no recurrence of pelvic organ prolapse or bowel obstruction. In the present case, we presume that the hernia had developed due to LSC procedure when the mesh lifted the vagina and the sacral uterine ligament; the small intestine consequently penetrated into the small pelvic cavity, which had become a dead space. Intestinal obstruction due to internal hernia has never been reported as a postoperative complication of LSC in the past; however it is one of the possible anatomical complications.