腹腔鏡補助下括約筋間直腸切除術後の直腸脱再発に対して腹腔鏡下直腸固定術を施行した1例

Laparoscopic rectopexy for recurrent rectal prolapse after laparoscopic intersphincteric resection : A case report

◆要旨：患者は83歳，女性．前医で下部直腸癌に対し，術前補助放射線化学療法後に腹腔鏡補助下括約筋間直腸切除術（Lap-ISR）・左側方リンパ節郭清が施行された．術後1年で直腸脱を認めたため，Gant-三輪法-Thiersch法による治療が行われた．しかし，その術後3年で直腸脱が再発したため当院に紹介となった．経会陰手術後の再発であり，腹腔鏡手術を行う方針とした．術中所見からsuture rectopexyを選択し，癒着剝離のうえでintersphincteric spaceに滑脱した腸管を引き抜き，挙肛筋上間隙より頭側で仙骨前筋膜と縫合固定した．術後8日で退院し，術後約5か月間再発なく，便失禁も改善している．Lap-ISR後の直腸脱再発に対して確立した治療法はないが，本症例では腹腔鏡手術で安全に治療を遂行できた．

　［Aims］ We report an elderly woman who underwent laparoscopic rectopexy for recurrent rectal prolapse after laparoscopic intersphincteric resection （Lap-ISR） for lower rectal cancer. ［Patient］ An 83-year-old woman presented to our hospital with recurrent rectal prolapse after lap-ISR. She had received neoadjuvant chemoradiotherapy prior to lap-ISR with left pelvic side-wall lymph node resection for lower rectal cancer. One year after lap-ISR, she developed rectal prolapse and underwent a Gant-Miwa/Thiersch procedure at another hospital. However, despite using a perineal approach, her rectal prolapse recurred. ［Results］ We decided to perform a laparoscopic rectopexy. Postoperative intraperitoneal adhesions around the rectum were not severe, except at the posterior rectal wall and pelvic surface of the sacrum. We therefore chose a laparoscopic suture rectopexy rather than our usual method with a mesh. After peeling off the adhesions around the rectum as much as possible, we pulled out the rectum in the intersphincteric space and then fixed the mesorectum to the presacral fascia using monofilament string. The operating time was 123 minutes and there were no intraoperative complications. The patient was discharged on the 8th postoperative day. She has no recurrence 5 months after surgery and no symptoms such as incontinence. ［Conclusions］ Laparoscopic rectopexy is a challenging technique in such cases, but it should be considered because of its minimally invasive nature.