経腟的標本摘出法による完全腹腔鏡下手術を施行した大腸癌肝転移の1例

Transvaginal specimen extraction after liver resection for metastatic colorectal cancer

◆要旨：患者は73歳，女性．2010年3月に横行結腸癌で腹腔鏡補助下横行結腸切除D3を施行した．2012年6月に腫瘍マーカーが上昇し，画像診断で肝外側区域に単発性肝転移を認め，手術を施行した．腹腔鏡下に肝外側区域切除術を行った後，婦人科用クスコにて腟前壁を腹側へ挙上しながら腟後壁を腹腔内から切開した．腟切開部から回収バックを挿入し，切除標本を収納，経腟的に体外へ摘出した．腟創は腹腔鏡下に縫合閉鎖した．合併症なく術後9日目に退院となった．術後創痛は軽微で，術翌日より積極的に離床が可能であった．経腟的標本摘出法で小開腹を省略した完全腹腔鏡下肝切除術の報告例はなく，貴重な症例と考え若干の文献的考察を加えて報告する．

A 73-year-old woman with a past history of T3N2M0 colon cancer underwent laparoscopic-assisted transverse colectomy followed by adjuvant chemotherapy. Two years and six months later, she was found to have a positron emission tomography-positive lesion of 3cm on the left lateral liver segment. Laparoscopic liver resection was performed by using two 5-mm trocars and two 12-mm trocars. After laparoscopic liver resection, transvaginal route was created to extract the specimen. First, the uterus was elevated and Cusco speculum was inserted into the posterior vagina. Secondly, the posterior vagina was identified and an incision was made on the posterior vagina from the abdominal cavity. Finally, the specimen was placed in an endobag, which was inserted and extracted transvaginally. The posterior vagina was closed from the abdominal cavity. The specimen was 13.5×7.5×5.0cm and the lesion was 4.3×3.4×2.9cm. Operating time was 237minutes and blood loss was minimal. The patient was discharged on postoperative day 9 without any complication. Post-operative pain was particularly mild which made earlier ambulation possible. The patient is well after 90 days. Transvaginal specimen extraction in laparoscopic liver resection is a feasible and safe technique. This technique is an attractive method, which results in quicker recovery, less operative pain, and fewer wound-related complications. We believe it is a potential method of minimally invasive surgery in laparoscopic liver resection.