外膀胱上窩ヘルニアに対し腹腔鏡下ヘルニア修復術を施行した1例

A case of external supravesical hernia treated by transabdominal preperitoneal repair

◆要旨：膀胱上窩ヘルニアは日本ヘルニア学会分類Ⅱ-1とされ，頻度は低く確立された術式はない．術前に診断できた症例や，transabdominal preperitoneal repair（TAPP）による膀胱の癒着剝離・修復例も稀である．筆者らは膀胱脱出を伴う外膀胱上窩ヘルニアと術前診断でき，TAPPで修復しえた症例を経験した．患者は73歳の男性で，右鼠径部の膨隆と疼痛を認め，画像検査で膀胱の腹壁外への脱出が疑われた．触診で鼠径管の正中側にヘルニア囊を触れ，外膀胱上窩ヘルニアと診断しTAPPでの治療方針とした．恥骨結節近傍のヘルニア門に膀胱右壁の癒着を認め，膀胱前腔を腹腔鏡下に剝離し，メッシュで修復を行った．TAPPは膀胱背側，恥骨までの剝離が明瞭に行え，膀胱上窩ヘルニアに対し有用であった.

　Supravesical hernia is a rare entity and the standard surgical procedure has not been established yet. Furthermore, it is difficult to make a preoperative diagnosis. Likewise, supravesical hernia comprised of a sliding urinary bladder that is treated by transabdominal preperitoneal repair （TAPP） is also rare. We herein report a case of preoperatively diagnosed supravesical hernia treated by TAPP. A 73-year-old man with right inguinal bulging accompanied by pain was referred to our hospital with the provisional diagnosis of direct inguinal hernia. Since the hernia itself could be palpated more medially compared to the external inguinal ring, the hernia was diagnosed as supravesical hernia. Laparoscopic TAPP was chosen to obtain a view of the hernia site. Laparoscopic views clearly revealed the porta hernia located just close to the pubic nodule and the right wall of the urinary bladder sliding into it. After pulling out the adhered urinary bladder and dissecting the preperitoneal space, the porta hernia was widely covered by mesh. Laparoscopic procedure for supravesical hernia was useful because we were able to safely dissect the peritoneal space wide enough to cover the subpubic nodule without bladder injury.