脾臓が脱出したⅣ型食道裂孔ヘルニアに対して腹腔鏡下修復術を施行した1例

A case of type Ⅳ hiatal hernia with prolapse of spleen and distal pancreas treated with laparoscopic surgery

◆要旨：症例は74歳，女性．左上腹部痛のため，前医を受診した．胸腹部CTで胃，脾臓，膵尾部が縦隔内へ脱出したⅣ型食道裂孔ヘルニアと診断され，当科紹介となった．手術は腹腔鏡下に行い，脱出した大網，胃，脾臓を愛護的に牽引し，元の位置に戻した．食道裂孔は縫合閉鎖し，メッシュを使用して補強を行った．噴門形成はToupet法で行った．術後経過は良好で，術後12日目に退院した．現在，術後1年半になるが再発を認めていない．Ⅳ型食道裂孔ヘルニアのなかでも脾臓が脱出する症例は稀である．巨大食道裂孔ヘルニア症例に対しても腹腔鏡手術は安全に脱出臓器の還納とヘルニア修復が行える有用な方法であり，文献的考察を加えて報告する．

　A 74-year-old Japanese female was admitted to our hospital with left upper abdominal pain. Her laboratory blood tests were close to normal ranges. Chest and abdominal CT showed that the whole stomach, spleen, and distal pancreas were located in the mediastinum. We diagnosed the patient with a typeⅣhiatal hernia, and elective surgery was performed on the seventh day after admission. Laparoscopically, the omentum, stomach, and spleen were observed prolapsing into the mediastinum through the enlarged esophageal hiatus. The prolapsing organs were carefully retracted and relocated to their usual positions. The esophageal hiatus was closed with a non-absorbable suture followed by mesh reinforcement. Toupet fundoplication was also performed. The patient was discharged on the 12th day after surgery, and there has been no hernia recurrence within 18 months after the operation. TypeⅣhiatal hernias are rare, especially those with splenic prolapse. Laparoscopic repair is a safe and effective treatment, even for giant hiatal hernias, such as in our case.