腹腔鏡下手術が有用であった胆囊Rokitansky-Aschoff sinus穿孔の1例

Effectiveness of laparoscopic surgery for perforation of Rokitansky-Aschoff sinus of the gallbladder：A case report

◆要旨：症例は92歳，女性．脳梗塞後で長期臥床状態．他医の画像所見で肝周囲の腹水貯留を指摘され，腹腔穿刺で胆汁性腹水が確認されたため当院へ紹介された．胆囊穿孔による胆汁性腹膜炎の診断で緊急の腹腔鏡下手術を行った．右横隔膜下に胆汁が多量に貯留していたが，胆囊底部以外の炎症はなく操作は容易であり，胆囊摘出および腹腔ドレナージを行った．摘出胆囊内に胆石を認めず，病理所見では，筋層を欠き粘膜が漿膜下層に嵌入した陥凹部の穿孔部に限局した慢性炎症のみで壊死や血栓を認めず，Rokitansky-Aschoff sinus穿孔と診断した．本疾患に対する腹腔鏡下手術は，穿孔部以外の炎症が軽度であるため難度は高くなく，高齢者であっても低侵襲で有用な手段と考えた．

　A 92-year-old woman was bedridden due to cerebral infarction for a year and was admitted with pneumonia to another hospital for a month. Abdominal ultrasonographic examination revealed cholecystic wall thickening and ascites around the liver. Abdominal paracentesis revealed biliary ascites. The patient was then referred to our hospital for further medical work-up and was diagnosed with biliary peritonitis due to perforation of the gallbladder. An emergent laparoscopic operation was performed. About 500ml of leaked bile had accumulated below the right diaphragm. Cholecystectomy and abdominal drainage were performed. There were no stones or perforation at the fundus of the gallbladder. Pathologic examination revealed that only the perforated site had chronic inflammation, and no sign of necrosis or thrombus was shown. Moreover, body and neck of the gallbladder was almost normal. Perforation of Rokitansky-Aschoff sinus of the gallbladder was considered from features of pathological findings. Similar cases in the literature were reported as idiopathic perforation of the gallbladder. The management of cystic duct and artery was not difficult in this case as the gallbladder was healthy except for mild inflammation at the perforated site. Laparoscopic surgery for idiopathic perforation of the gallbladder is minimally invasive and may be feasible and effective even for the elderly patients.