癒着性腸閉塞に鼠径ヘルニア囊からアプローチし腹腔鏡下癒着剝離術を施行した1例

A case of laparoscopic adhesiolysis approached via inguinal hernia sac

◆要旨：症例は72歳，男性．絞扼性腸閉塞の手術から6か月後に腹痛，右鼠径部の膨隆を主訴に来院した．CT検査で癒着性腸閉塞・右鼠径ヘルニアと診断された．保存療法で改善するも1か月に癒着性腸閉塞で3回入院し，鼠径部の膨隆は増大傾向で，鼠径ヘルニア囊からアプローチし腹腔鏡下癒着剝離術を予定した．右鼠径部を切開し，ヘルニア囊から12mmトロッカーを挿入した．5mmトロッカーを右側腹部に2本追加し，腹壁と小腸を癒着剝離した．鼠径ヘルニアはLichtenstein法で修復した．術後3か月，問題なく経過している．手術を必要とする鼠径ヘルニア併存癒着性腸閉塞にヘルニア囊から腹腔内にアプローチする手技は，安全な術式の1つと考える．

　A 72-year-old man, who had received open adhesiolysis for strangulated small bowel obstruction 6 months earlier, presented to our hospital complaining of abdominal pain and a bulge on the right inguinal region. A computed tomography scan showed an adhesive small bowel obstruction and a right inguinal hernia. The non-operative management of the adhesive small bowel obstruction was successful, but recurrence occurred immediately. Consequently, the patient experienced adhesive small bowel obstruction 3times a month, and the right inguinal hernia grew gradually. We planned a laparoscopic adhesiolysis approach through the right inguinal hernia sac. We opened the hernia sac, and inserted a 12mm trocar into the intraperitoneal space through the hernia sac. We added two 5mm trocars on the right side of the abdomen, performed laparoscopic surgery to release the adhesion of the abdominal wall and small bowel, and repaired the right inguinal hernia using the Lichtenstein method. The patient had no abdominal symptoms and no recurrence of the inguinal hernia 3months after the surgery. Because it makes it possible to avoid damage to the small bowel when inserting the first trocar, this laparoscopic adhesiolysis approach via a right inguinal hernia sac is useful for a patient who underwent laparotomy and suffered from an adhesive small bowel obstruction and inguinal hernia.