胃癌合併Bochdalek孔ヘルニアに対する用手補助腹腔鏡下手術による一期的根治手術の1例

A case of adult Bochdalek hernia coexisting with gastric cancer treated simultaneously by hand-assisted laparoscopic surgery

◆要旨：患者は65歳，男性．腹痛・嘔吐を主訴に前医を受診し，上部消化管内視鏡検査で早期胃癌を，CTで左横隔膜にBochdalek孔ヘルニアを指摘された．胃癌に対する内視鏡的切除が非治癒切除となり，追加切除目的に当院紹介となった．胃癌のリンパ節郭清と今後のヘルニア嵌頓のリスクを考慮し，同時手術にて腹腔鏡補助下に胃切除およびヘルニア修復術を行った．気腹による胸腔内圧上昇に胸腔トロッカーを要し，ヘルニア門修復での視野確保には用手補助を追加したが，腹腔鏡下に幽門側胃切除とヘルニア根治術を完遂した．これまでに横隔膜ヘルニアと悪性腫瘍とを同時に手術した報告はなく，若干の文献的考察を加えて報告する．

A 65-year-old man complaining of abdominal pain and vomiting was diagnosed with both an early gastric cancer and a left-sided diaphragmatic hernia, a so-called Bochdalek hernia. Firstly, endoscopic dissection was performed for gastric cancer, however the resection was noncurative. He was referred to our hospital for additional gastrectomy. Then, laparoscope-assisted distal gastrectomy and hernia repair were performed simultaneously. Pneumoperitoneum caused tension pneumothorax though the defect, which required placing a trocar through the left chest wall to relieve it. The herniated spleen which was adhesive to the left thoracic cavity forced the surgery to be converted to hand-assisted laparoscopic approach, which allowed the hernia defect to be securely repaired under laparoscopy. To our knowledge, Bochdalek hernia repair and gastric cancer surgery performed simultaneously has not yet been reported. Hand-assisted laparoscopic surgery could be a choice for Bochdalek hernia repair.