腹腔鏡下修復術が可能であった小網裂孔ヘルニアの1例

A case of laparoscopic surgery for internal hernia through the lesser omentum

◆要旨：小網裂孔ヘルニアは内ヘルニアのなかでも稀な疾患である．症例は脳性麻痺既往，手術歴のない54歳，男性．上腹部痛，嘔吐を主訴に受診した．CTでは胃小彎と肝左葉の間に小腸の嵌入を認め，内ヘルニアの診断で緊急で腹腔鏡下手術を施行した．小網弛緩部に裂孔あり，裂孔より網囊内に小腸が嵌頓していた．小網を開放し小腸を整復後，小腸部分切除を施行した．術後経過は良好である．本症例は北岸分類Ⅰ型であった．これまで本邦で報告された小網裂孔ヘルニアの症例はすべて開腹手術を行っており，ほとんどの症例で裂孔の閉鎖を施行していた．小網裂孔の閉鎖・開放については十分なエビデンスがないのが現状である．本症例は腹腔鏡下で整復し，小網裂孔は開放した．文献的考察を加えて考察する．

　Internal hernias through the lesser omentum are extremely rare. We report the case of a 54-year-old male，with cerebral palsy and no history of laparotomy and abdominal trauma，complaining of upper

abdominal pain and vomiting．The computed tomography（CT）scan showed a dilated small intestine between the lesser curvature and left lobe of the liver．Following an emergency exploratory laparoscopy，the patient was diagnosed with an internal hernia through the lesser omentum，with a strangulated ileal segment passing through the orifice into the lesser sac．The surgical procedures included reduction of the herniated loop by wide-opening of the hernial orifice，ileal resection，and primary anastomosis．The postoperative course was uneventful．Most cases reported previously in Japan were performed by laparotomy followed by closure of the hernia orifice．However，the complete hernial orifice closure remains elusive．We herein report this case with detailed literature review.