腹腔鏡下手術が困難であった成人Bochdalek孔ヘルニアの1例

Laparoscopic surgery for adult Bochdalek's hernia with difficulties : report of a case

◆要旨：患者は37歳，男性．咳嗽，左胸部痛，呼吸困難，発熱を主訴に他院を受診し，CTにて横隔膜ヘルニアを疑われ，精査・加療目的に当科に紹介となった．CTにてヘルニア孔はより明瞭となり，冠状断で腹腔内脂肪組織の左胸腔内への脱出像が確認された．以上の所見より大網が胸腔に脱出したBochdalek孔ヘルニアと診断し，緊急入院のうえ，翌日に手術を施行した．腹腔鏡下に手術を開始し，脱出した大網を腹腔内に還納できたが，視野とワーキングスペースの確保が困難なため開腹手術に移行し縫合閉鎖の後，手術を終了した．術後経過は良好であり，術後8日目に退院となった．術後2年現在，再発を認めていない．

　A 37-year-old man was seen at the hospital because of cough, left chest pain, breathing difficulty, and fever. A chest X-ray film showed an abnormal shadow in the left lower lobe, and multidetector-row computed tomography（MDCT）showed the presence of a left-sided diaphragmatic hernia and incarceration of abdominal fat tissue. He was admitted to our hospital and laparoscopic repair was performed. The greater omentum was herniated into the left thoracic cavity through a dorsolateral defect of the left diaphragm（Foramen Bochdalek）. The omentum was pulled back in to the peritoneal cavitiy. Because it is difficult to suture the hernia orifice by laparoscopic maneuver, laparotomy was performed and the orifice was directly closed using absorbable surgical sutures. He made an uneventful recovery and remains well at 15-month follow-up. MDCT was very useful in diagnosis. Laparoscopic procedure is proving to be more beneficial than laparotomy or thoracotomy, however, several devices are required in order to overcome the difficulties.