腹腔鏡補助下に整復しえた子宮広間膜裂孔ヘルニアの1例

A case of hiatal hernia of the broad ligament of the uterus treated by laparoscopy assisted surgery

◆要旨：患者は50歳代の女性で突然の心窩部から臍部痛にて発症した．約1日経過観察をしたが腹痛は変わらず，2回目の腹部CT所見にて内ヘルニアによる小腸イレウスとの診断で緊急腹腔鏡下手術を行った．手術所見は左子宮広間膜の裂孔に小腸が嵌入していたため，ヘルニア門を切開してイレウスを解除した．腸切除は行わず，ヘルニア門は腹腔鏡下に閉鎖した．女性の原因不明のイレウスにおいては本疾患も念頭に置く必要があり，腹腔鏡下手術はその診断・治療において有用な方法である．

　本邦における本疾患に対する腹腔鏡下手術報告例は自験例も加えていまだ12例と少なく，これらについての文献的考察も加えて報告する．

　A 50 year-old woman was admitted to our hospital because of a sudden onset of epigastralgia and periumbilical pain. Her only history of surgery is an appendectomy. There was tenderness in the periumbilical part, but no muscular defence. Elevation of both white blood cells and creatine kinase was noted. Abdominal computed tomography（CT）showed strangulated ileus of the small intestine, because both the dilatated small intestine loop on the left posterior to the uterus and anterior to the rectum and the mesentery converged on the left side of the uterus. We performed laparoscopic surgery. Operative findings revealed that the small intestine, approximately 30 cm in length, incarcerated into a defect of the left broad ligament of the uterus. An attempt to pull out the impacted intestine laparoscopically was unsuccessful. So the hernia orifice was enlarged by cutting the ridge. Since the small intestine was not necrotized, partial resection of small intestine was not performed. Lastly we closed the hernia opening using an EndoloopⓇ. The patient had an uneventful postoperative course and was discharged on the 9 th postoperative day. We should keep in mind this disease, when a woman with no previous abdominal surgery develops an ileus of unknown origin. The laparoscopic procedure appears to be effective for both diagnosis and treatment of this disease. There has been only 11 cases of this disease in reported in Japanese. We experienced this rare case, and report this case with some review of literature.