腹腔鏡下に治療した尿管皮膚瘻に起因する医原性内ヘルニアの1例

Laparoscopic treatment of iatrogenic internal hernia caused by cutaneous ureterostomy : A case report

◆要旨：症例は63歳，男性．膀胱癌に対してロボット支援腹腔鏡下膀胱全摘除術，尿管皮膚瘻造設術の手術歴あり．腹痛を主訴に当院へ搬送となった．腹部造影CT検査で尿管皮膚瘻周囲にclosed loop型の腸閉塞の所見を認めた．医原性内ヘルニアによる絞扼性腸閉塞を疑い，腹腔鏡下で緊急手術を施行した．手術所見では尿管皮膚瘻と腹壁によって形成された間隙に小腸が嵌入しており，絞扼の解除により腸管の血流は改善した．合併症なく第5病日に退院となった．尿管皮膚瘻に起因する医原性内ヘルニアは極めて稀ではあるが術前診断が可能であり，重度の腸管拡張や複雑な癒着が予測される症例でなければ，腹腔鏡手術は有用な治療選択肢となりうる．

　A 63-year-old man who had a history of undergoing robot-assisted radical cystectomy and cutaneous ureterostomy for bladder cancer was admitted to our hospital with a chief complaint of abdominal pain. Abdominal CT revealed caliber changes in the small bowel around the cutaneous ureterostomy and a closed loop obstruction. Emergency laparoscopic surgery was performed on suspicion of strangulated bowel obstruction caused by an iatrogenic internal hernia. Intraoperative findings showed the small bowel incarcerated into the space between the ureterocutaneous fistula and the abdominal wall. After releasing from the strangulation laparoscopically, the bowel viability was confirmed. The postoperative course was uneventful, and the patient was discharged on postoperative day 5. Since the most of iatrogenic internal hernia caused by cutaneous ureterostomy can be preoperatively diagnosed, laparoscopic surgery is an effective treatment option unless severe intestinal dilatation or complex adhesions are expected.