腹腔鏡下Ladd手術で治療しえた成人腸回転異常症の1例

Laparoscopic Ladd procedure for intestinal malrotation in an adult patient : A case report

◆要旨：患者は70歳，男性．14歳時，急性虫垂炎で虫垂切除術を受けた既往歴がある．1年前から食後に腹痛が出現するようになり，精査目的に当院受診した．腹部CT検査で十二指腸水平脚は認めず，下行脚から直接空腸に移行，SMV rotation signも認めた．結腸は通常の位置にあり，その背側に空腸の大部分を認めたため，incomplete fixation typeの腸回転異常症と診断し，腹腔鏡下Ladd手術を施行した．肝結腸靱帯，右側結腸間膜と後腹膜の癒着を切離，小腸間膜根部の狭窄を開放し，小腸を右側に，結腸を左側に並べ手術終了した．成人腸回転異常症に対し，腹腔鏡下Ladd手術は安全に施行でき，有用と考える．

　Intestinal malrotation is a congenital disease caused by abnormal intestinal rotation and fixation during the early embryonic stage. Most onset occurs in the neonatal period, and rarely in adults. We report a case of laparoscopic Ladd procedure for intestinal malrotation in an adult patient. The patient, a 70-year-old male, underwent appendectomy for acute appendicitis at 14-years of age. One year prior to the current presentation, he had abdominal pain for the first time after a meal which continued thereafter. He visited our hospital for further examination. Abdominal CT showed absence of duodenal horizontal section ; the intestine instead transitioned directly from the descending section to the jejunum. The descending section and the jejunum were located in the right upper abdomen. Additionally, a superior mesenteric vein rotation sign was also observed in abdominal CT. The colon was located normally. Preoperative diagnosis was incomplete fixation type of intestinal malrotation. Laparoscopic Ladd procedure was performed to improve the symptoms. The hepatocolic ligament and the adhesion of the right colonic mesentery to retroperitoneum were cut. The stenosis of the small intestinal mesenteric root was dilated. The small intestine was returned to the right side, and the colon was positioned on the left side. The postoperative course was uneventful. In case of no intestinal dilation without necrosis, laparoscopic Ladd procedure is a safe and useful option for the intestinal malrotation in adults.