腹腔鏡下胆囊摘出術後早期に発生したポートサイトヘルニア嵌頓の1例

Incarcerated port site hernia after laparoscopic cholecystectomy

細径トロッカー（5mm）刺入部に術後早期に発生したポートサイトヘルニア（port-site hernia：以下，PSH）の1例を経験した．症例は76歳の女性．2005年12月，C型慢性肝炎の経過観察中に指摘された胆石の手術目的で当科へ紹介された．2006年1月に腹腔鏡下胆囊摘出術（laparoscopic cholecystectomy：以下，Lap-C）を施行した．術後1日目に経口摂取を開始し，同日肝床部に留置したペンローズドレーンも抜去したが，その直後から嘔気・嘔吐が続いた．当初は麻痺性イレウスと診断し，絶食にて経過観察していたが，症状改善がまったくないため，術後5日目に腹部CT検査を施行したところ，右側腹部の細径トロッカー刺入部直下の筋組織内に嵌入する腸管を認めたため，緊急開腹術を施行した．小腸の一部が，右前腋窩線上の細径トロッカー刺入部直下の腹膜欠損部から腹直筋内に嵌入し，Richter型ヘルニアを呈していた．稀ではあるが，Lap-C後に細径トロッカー刺入部にもPSHの発生はある．PSHの本邦報告例の検討とともにその概要を報告する．

　A patient with incarcerated port-site hernia（PSH）just after laparoscopic cholecystectomy is reported with a review of the Japanese literature. The patient was a 76-year-old female. Laparoscopic cholecystectomy was performed in January 2006 for cholecystolithiasis. On the following day of the operation, oral nutrition was started and the drain tube which was placed in the liver bed was removed. Immediately, after that, the patient started nauseating and vomiting. She was initially diagnosed as having paralytic ileus, and followed up with fasting. However, her symptoms did not improve. On abdominal CT which was performed 5 days after the operation, we diagnosed a mechanical bowel obstruction due to incarceration of a part of the small intestine. Urgent laparotomy was performed. A peritoneal defect was observed at the port site of the 5 mm trocar which was inserted from the right anterior axillary line, and a part of the jejunum was incarcerated into the rectus abdominis muscle through this defect. These findings presented the feature of Richter's hernia. Incarceration associated with laparoscopic trocar site may occur at a port site as small as 5 mm in length.