転倒による鼠径ヘルニア囊内小腸穿孔に対し腹腔鏡補助下に縫合閉鎖しえた1例

Laparoscopy-assisted repair for small intestinal perforation in the inguinal hernia sac caused by minor blunt abdominal trauma : A case report

◆要旨：68歳の女性．歩行中に転倒し，腹部を打撲した．2時間後に吐血し，救急搬送された．腹部所見は乏しかったが，CTで上腹部主体のfree air，胃壁の肥厚，左鼠径ヘルニアを認めた．胃穿孔を疑い腹腔鏡手術を実施したが，胃は正常であった．鼠径ヘルニア囊内に食物残渣の貯留と近傍の回腸に1cmの穿孔を認めたため，直視下で穿孔部をトリミングし，縫合閉鎖した．その他に明らかな臓器損傷は認めず，腹部打撲時の急激な腹圧上昇によって鼠径ヘルニア囊内の小腸が穿孔したと判断した．経過良好で，1か月後に腹腔鏡下ヘルニア修復術を施行した．

　軽微な転倒による腹圧上昇が腸管穿孔の誘因となる報告は珍しく，文献的考察を加え報告する．

　A 68-year-old woman, who had been aware of left inguinal bulging, was transported to our hospital because of nausea and hematemesis after she fell while walking. There was no remarkable abdominal tenderness although she felt nausea. Computed tomography showed free air in the upper abdomen and thickened gastric wall. A left-sided direct inguinal hernia was also detected, but there was no intestinal incarceration. Emergency laparoscopic surgery was performed for the suspected gastric perforation ; a 1-cm perforation was found in the small intestine near the left groin hernia but not in the stomach. Food residue was present inside the groin hernia sac, and so we presumed that the fall caused small intestinal perforation inside the sac. We trimmed the periphery of the perforated area and sutured it closed. She was discharged with no problem and underwent laparoscopic transabdominal preperitoneal repair 1 month later. This rare case suggested that the small intestinal perforation can be caused by pressure differences inside a hernia sac in association with a sudden increase in abdominal pressure caused by a fall.