腹腔鏡にて治療しえた成人左側Bochdalek孔ヘルニアの1例

A case of an adult Bochdalek hernia treated by laparoscopic surgery

◆要旨：比較的稀な成人のBochdalek孔ヘルニアを経験した．患者は36歳，男性．4か月ほど前から左側胸部の鈍痛と軽い呼吸困難があり，精査目的で紹介受診となった．CTおよびMRI検査では，大網の一部が左横隔膜の背側の裂孔を通じて，胸腔内へ脱出していた．左側Bochdalek孔ヘルニアと診断し，腹腔鏡下にヘルニア修復術を施行した．術後経過は良好であった．本症は胸腹の境に発生する疾患のため，経腹的と経胸的な術式があるが，その選択には一定の基準はない．また，腹腔鏡下手術は近年積極的に適応されているが，開腹手術への移行例など，困難例の報告もある．Bochdalek孔ヘルニアに対しては，画像所見，術前検査所見，患者体型を考慮した手術計画を立て，必要時には胸腹部両側からアプローチできる手術準備をすることが重要である．

An adult Bochdalek hernia is a relatively rare clinical condition. A 36-year-old man was referred to our hospital because of a left-sided dull chest pain and dyspnea which began 4 months ago. CT and MRI revealed that a part of the greater omentum had protruded into the thoracic cavity from the dorsal part of the left diaphragm. An adult “Bochdalek Hernia” was diagnosed, and laparoscopic surgery was performed. The patient was discharged without any complications. Since Bochdalek hernia occurs at the diaphragm, the operative approaches are divided into mainly 2 different ways（trans-abdominal, trans-thoracic）. Currently, there are no definitive criteria on how to select an approach method. Recently there have been increasing reported cases where laparoscopic surgery was performed. Though, in some cases the laparoscopic method proved to be difficult and challenging, thus a conversion to a laparotomy for repair was necessary. It is important to take all data（imaging data, laboratory data and patient's physical physique） into account to select an appropriate method for surgery. In addition, like all other procedures, it is critical to thoroughly plan the operation and be able to switch between the different approaches if necessary.