妊娠34週に腹腔鏡下胆囊摘出術を施行した急性胆囊炎の1例

A case of laparoscopic cholecystectomy for acute cholecystitis in 34th week of gestation

◆要旨：患者は初産婦の27歳の女性で，妊娠34週4日目に右季肋部痛を認めた．強い持続痛が改善せず，胆囊炎と診断し，腹腔鏡下胆囊摘出術を施行した．合併症なく終え，母子ともに問題なく経過している．妊娠後期では子宮底がせり上がるため，子宮損傷を防ぐには，術前に超音波で子宮底を確認すること，上腹部に1stポートを開腹法で挿入することや5mmの軟性鏡を使用することが肝要である．また子宮底のせり上がりによって横隔膜が挙上し，挿管チューブが予想より深く入り，換気困難になることがあり，注意が必要である．本邦で妊娠後期に腹腔鏡下胆囊摘出術を施行した報告は少なく，本症例は各種工夫により安全に手術を施行できた．

　A 27-year-old pregnant woman, who had suffered from constant right hypochondralgia, came to the emergency department at 34 weeks and 4 days of gestation. She was diagnosed as having acute cholecystitis and underwent laparoscopic cholecystectomy. The postoperative course was good and uneventful for both the mother and the fetus with no complications. As uterus usually rises up to the head side in the 3rd trimester, in order to prevent uterus injuries, it is important to examine the position of the fundus of uterus by ultrasound beforehand, and to insert the first trocar in the upper abdomen by open method using a 5mm flexible scope. Moreover, attention should be made on ventilation because gravid uterus elevates the diaphragm and intubation tube may go deeper than expected. In Japan, only a few cases of laparoscopic cholecystectomy in the 3rd trimester have been reported so far. We were able to perform laparoscopic cholecystectomy in the 3rd trimester safely with various ideas and efforts.