麻酔覚醒時に再発し再度腹腔鏡下修復術を行った肥満成人のBochdalek孔ヘルニアの1例

Reoperation for a Bochdalek hernia in an obese adult due to recurrence on awakening from anesthesia with delirium : A case report

◆要旨：Bochdalek孔ヘルニアは横隔膜ヘルニアの1つで新生児期に多いが，稀に成人例も存在する．45歳男性が呼吸苦の精査で撮影したCTで横隔膜左側が欠損し腹腔内臓器が左胸腔に脱出し，Bochdalek孔ヘルニアとして腹腔鏡下手術を行った．脱出臓器を戻し，横隔膜の一部縫縮とタッキングによるメッシュ固定を行ったが，術直後の麻酔覚醒時にヘルニアが再発したためすぐに再手術を行った．タッカー固定が外れ再度腹腔内臓器が脱出していたため，臓器を戻しメッシュを非吸収糸で固定し，術後は鎮静したままICUに入室，翌日慎重に麻酔覚醒を行い抜管した．その後，再発なく退院した．メッシュ固定と麻酔覚醒には注意を要する．

　A Bochdalek hernia, classified as a diaphragmatic hernia, generally occurs in the neonatal period but rarely occurs in adults. A 45-year-old male presented with shortness of breath. A computed tomography scan revealed that his stomach, transverse colon, spleen, and pancreas had moved into the left thoracic cavity through a defect in the diaphragm, which was diagnosed as a Bochdalek hernia. We performed laparoscopic surgery, pulled the abdominal organs down, stitched up the hole in the diaphragm, and then tacked it down with a mesh. However, he became delirious on waking, and the hernia recurred ; hence, repeat surgery was required. We discovered that the tacking had come loose, and the organs had reentered the thoracic cavity. We repositioned them and refixed the mesh with non-absorbable threads. The patient was admitted to the intensive care unit, and the following day, we cautiously awakened and extubated him. The hernia has not occurred since then.