内容紹介
A Case of Laparoscopic Repair of Internal Hernia after Laparoscope-Assisted Distal Gastrectomy with Antecolic Roux-en-Y Reconstruction
Summary
A 72-year-old woman had undergone laparoscope-assisted distal gastrectomy with D1 plus lymph node dissection and antecolic Roux-en-Y reconstruction for early gastric cancer. She visited our department outpatient clinic with left upper abdominal pain 1 year and 9 months after the surgery. CT revealed a spiral sign of the superior mesenteric arteriovenous branch. An internal hernia was suspected on hospitalization. Although abdominal symptoms were relieved by conservative treatment, the hernia persisted. Laparoscopic surgery was performed and revealed that almost entire small intestine had been affected due to Petersen's defect. Since no ischemic changes were observed, the defect was repaired laparoscopically with suture closure. There has been no recurrence of internal hernia after the laparoscopic surgery. Internal hernia after distal gastrectomy is relatively rare. However, the risk of internal hernia is high due to the gap between the elevated jejunum and transverse colon mesentery in Roux-en-Y reconstruction and can lead to intestinal necrosis. Since an internal hernia can occur in patients who have undergone gastric resection with Roux-en-Y reconstruction, suture closure of Petersen's defect should be performed to prevent this occurrence.
要旨
症例は72歳,女性。胃癌に対して腹腔鏡補助下幽門側胃切除術,D1+郭清,前結腸経路Roux-en-Y(R-Y)再建を施行した。術後1年9か月に左上腹部痛を主訴に当科外来を受診した。CTにて上腸間膜動静脈分枝の渦巻様サインを認めたため,内ヘルニアを疑い入院とした。絶飲食により腹部症状は軽快したが自然整復されなかったと判断し,腹腔鏡下手術を行った。腹腔鏡の観察では,ほぼ全小腸がPetersen's defectに入り込んでいた。虚血性変化を認めなかったため腹腔鏡下に整復し,間隙を縫縮した。内ヘルニアの再発はなく,外来通院中である。幽門側胃切除後の内ヘルニアは比較的まれであるが,R-Y法では挙上空腸と横行結腸間膜との間隙が生じることで内ヘルニアの危険性が高く,嵌頓壊死により重篤化し得る病態であり,内ヘルニアの発生を念頭に置く必要がある。確実なPetersen's defectの縫合閉鎖が内ヘルニアの発生を予防するために重要と考えられた。
目次
Summary
A 72-year-old woman had undergone laparoscope-assisted distal gastrectomy with D1 plus lymph node dissection and antecolic Roux-en-Y reconstruction for early gastric cancer. She visited our department outpatient clinic with left upper abdominal pain 1 year and 9 months after the surgery. CT revealed a spiral sign of the superior mesenteric arteriovenous branch. An internal hernia was suspected on hospitalization. Although abdominal symptoms were relieved by conservative treatment, the hernia persisted. Laparoscopic surgery was performed and revealed that almost entire small intestine had been affected due to Petersen's defect. Since no ischemic changes were observed, the defect was repaired laparoscopically with suture closure. There has been no recurrence of internal hernia after the laparoscopic surgery. Internal hernia after distal gastrectomy is relatively rare. However, the risk of internal hernia is high due to the gap between the elevated jejunum and transverse colon mesentery in Roux-en-Y reconstruction and can lead to intestinal necrosis. Since an internal hernia can occur in patients who have undergone gastric resection with Roux-en-Y reconstruction, suture closure of Petersen's defect should be performed to prevent this occurrence.
要旨
症例は72歳,女性。胃癌に対して腹腔鏡補助下幽門側胃切除術,D1+郭清,前結腸経路Roux-en-Y(R-Y)再建を施行した。術後1年9か月に左上腹部痛を主訴に当科外来を受診した。CTにて上腸間膜動静脈分枝の渦巻様サインを認めたため,内ヘルニアを疑い入院とした。絶飲食により腹部症状は軽快したが自然整復されなかったと判断し,腹腔鏡下手術を行った。腹腔鏡の観察では,ほぼ全小腸がPetersen's defectに入り込んでいた。虚血性変化を認めなかったため腹腔鏡下に整復し,間隙を縫縮した。内ヘルニアの再発はなく,外来通院中である。幽門側胃切除後の内ヘルニアは比較的まれであるが,R-Y法では挙上空腸と横行結腸間膜との間隙が生じることで内ヘルニアの危険性が高く,嵌頓壊死により重篤化し得る病態であり,内ヘルニアの発生を念頭に置く必要がある。確実なPetersen's defectの縫合閉鎖が内ヘルニアの発生を予防するために重要と考えられた。