腹腔鏡下直腸切除における完全鏡視下腹膜外経路ストーマ造設法

Laparoscopic permanent colostomy via extraperitoneal route after rectal cancer resection

◆要旨：当科における完全鏡視下腹膜外経路ストーマ造設法について報告する．腹腔内より腹膜下スペースを剝離した後，体表ストーマサイトより切開して腹直筋後腔に達する．ラッププロテクター^TM，E・Zアクセス^®を装着後，5mmトロッカーを3本留置して単孔式操作を開始する．半月線内側で腹直筋後鞘，背側の腹横筋を切開して腹膜外経路内の剝離を行う．腹腔内と交通させ，腸管を挙上する．直腸癌手術4例に本法を適応し，腹膜外経路作製から結腸挙上完了までの平均時間は23.5±5.2分であった．全例で手術時合併症は認められなかった．本法は良好な視野で安全に施行可能であり，腹膜外経路作製時合併症を軽減する可能性がある．

　We describe a novel technique for laparoscopic permanent colostomy via extraperitoneal route after rectal cancer resection. An extraperitoneal space was laparoscopically separated from the inner aspect of the abdominal cavity. The rectus abdominis muscle at the site of the stoma in the skin was split for exposure of the posterior fascia. Lap-Protector^TM and EZ Access^® devices were placed in the space of the posterior fascia. Using a single-incision laparoscopic approach, the extraperitoneal route was enlarged after dissection of the posterior layer of the rectus abdominis sheath and the transverse abdominis muscle inside the semilunar line. The extraperitoneal space was opened to the inner aspect of the abdominal cavity, and an end-stoma was constructed via extraperitoneal route by drawing a stump of the sigmoid colon back into the skin incision laparoscopically. We performed laparoscopic colostomy via the extraperitoneal route using this technique in four patients who underwent rectal cancer resection. The mean operative time for creating the extraperitoneal stoma route was 23.5±5.2 min. We observed no surgical or stoma-related complications during a median follow-up period of 4.5 months（range 2-8 months）. We recommend this approach as a safe technique that can minimize surgical complication associated with extraperitoneal stoma route creation.