術前に診断し待機的に腹腔鏡下修復術を施行した小網裂孔ヘルニアの1例

A case of lesser omental hernia, diagnosed preoperatively and treated successfully by laparoscopy

◆要旨：小網裂孔ヘルニアは稀な疾患であり，術前診断が難しく，これまで腹腔鏡下手術の報告は少ない．患者は63歳の男性で，上腹部痛を主訴に受診し，腸閉塞の診断で入院となった．2年前にも腸閉塞の既往があり．CT検査の結果，小網内に嵌入する小腸を認め，小網裂孔ヘルニアによる腸閉塞の診断となった．胃管留置による保存加療後，待機的に腹腔鏡下手術を施行した．手術時点で網囊内への小腸迷入は認められなかったが，小網に約4cm大の異常裂孔を認め，これを閉鎖した．自験例を含めた本邦過去報告例19例の検討から，本症の診断にはCT検査が有用であり，手術歴のない内ヘルニア症例で本症が疑われ待機手術を行いうる場合には腹腔鏡下手術の積極的な適応が考えられた．

　Lesser omental hernia is a rare condition and often difficult to diagnosis preoperatively. Only one previous case treated using a laparoscopic approach has been reported in Japan. Here we present a case of lesser omental hernia that was treated successfully by laparoscopic repair after adequate preoperative diagnosis. A 63-year-old man was referred to our hospital due to upper abdominal pain. Two years previously, he had suffered bowel obstruction, which was cured conservatively. Abdominal computed tomography（CT）revealed that the small intestine was incarcerated in the lesser omental bursa. On this basis, we diagnosed bowel obstruction caused by lesser omental hernia. The patient was managed conservatively using a nasogastric tube, and then underwent elective laparoscopic repair. Intraoperative examination revealed that the defect in the lesser omentum was a hernia orifice, although the small intestine was not incarcerated at the time of surgery. The defect in the lesser omentum was closed. Including the present case, a review of 20 cases reported in Japan suggested that abdominal computed tomography was useful for diagnosis of lesser omental hernia. When CT findings are suggestive of lesser omental hernia in patients with internal hernia without a history of previous surgery, a laparoscopic approach is considered a useful option in view of its minimal invasiveness.