2014 July

Vol. 1

No. 1

日本ヘルニア学会誌
JOURNAL OF JAPANESE HERNIA SOCIETY

日本ヘルニア学会
Japanese Hernia Society
ISSN:2187-8153

―目

次―

⌮஦㛗ᣵᣜ䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈 㻞ᰙℨಙኴ㑻㸦⪷㊰ຍᅜ㝿⑓㝔࣊ࣝࢽ࢔ࢭࣥࢱ࣮ࠉᾘ໬ჾ୍࣭⯡እ⛉㸧ྡ㄃఍㛗ᣵᣜ䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈 㻟
෨Ọࠉຌኴ

【原

著】

㼁㻸㼀㻾㻭㻼㻾㻻㻖㻌㻼㼘㼡㼓 䜢⏝䛔䛯ᡂே⮖䝦䝹䝙䜰ಟ᚟⾡䛾᳨ウ㻌䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈 㻠➉ཎ⿱Ꮚ  㸪➉ཎΎே  㸪Ṋ⏣ࠉṇ  㸪᳃ᘅಇ᫛  㸪⏣୰ᒇᏹ∞  㸪㟷ᮌ⚽ᶞ  㸪➉ෆோྖ 㸦 ⊂❧⾜ᨻἲேࠉᅜ❧⑓㝔ᶵᵓࠉᒾᅜ་⒪ࢭࣥࢱ࣮ࠉእ⛉ࠊ ᒸᒣ኱Ꮫ኱Ꮫ㝔་ṑ⸆Ꮫ⥲ྜ◊✲⛉ࠉᾘ໬ჾእ⛉Ꮫ㸧⭡ቨ⒕⑞䝦䝹䝙䜰ಟ᚟⾡䛻䛚䛡䜛 㻰㼕㼞㼑㼏㼠㻌㻷㼡㼓㼑㼘㻌㻼㼍㼠㼏㼔 䛾᭷⏝ᛶ㻌 䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈 㻥㇂ᒸ฼ᮁࠊ㧗ᶫ࿘స㸦-$ ໭ᾏ㐨ཌ⏕㐃ࠉᮐᖠཌ⏕⑓㝔ࠉእ⛉㸧

【総説】⭡⭷๓⭍䛸䛿䛹䛣䛛䠛㻌䞊ṇ୰䜰䝥䝻䞊䝏 㼀㻱㻼㻔㼀㼛㼠㼍㼘㼘㼥㻌㻱㼤㼠㼞㼍㻼㼑㼞㼕㼠㼛㼚㼑㼍㼘㻌㼞㼑㼜㼍㼕㼞㻕 䛻䛚䛡䜛㐍ධ⤒㊰䛾ゎ๗䞊㻌䈈䈈䈈䈈䈈䈈䈈䈈㻝㻟ᮅⶱ┤ᶞ㸦ὠ⏣἟୰ኸ⥲ྜ⑓㝔ࠉእ⛉㸧【症例報告】Ꮚᐑ䚸 ᕥ௜ᒓჾ䜢䝦䝹䝙䜰ෆᐜ䛸䛩䜛Ꮚᐑወᙧ䜢ྜే䛧䛯ᕥእ㰡ᚄ䝦䝹䝙䜰⑕౛䛻ᑐ䛧䛶 㼀㻱㻼 䜢᪋⾜䛧䛯䠍౛㻌䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈㻝㻥ᐑᮏ⋹ዉ㸪⏣⏿ᬛ୔㸪బ⸨ࠉຌ㸪໭ⷵࠉᕑ㸪Ἀ⏣඘ྖ㸪Ỉ㇂ࠉ┿㸪༓㔝ె⚽㸪⯖⏣ㄔ஧㸪㔝⏣ὒ୍㸪⸨ᮧᫀᶞ㸦➨୍ᮾ࿴఍⑓㝔ࠉෆど㙾እ⛉ࢭࣥࢱ࣮㸧㰡ᚄ䝦䝹䝙䜰ᡭ⾡ 㻡 ᖺᚋ䛻Ⓨ⑕䛧䛯㐜Ⓨᛶ䝯䝑䝅䝳ឤᰁ䛾 㻝 ౛㻌 䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈㻞㻠୰す㤶௻  ᮃ᭶⬟ᡂ  ⚄ᓮ❶அ  ᶓᒣ⿱அ  ㇂ཱྀ೺ḟ㸦ᑠ∾ᕷẸ⑓㝔ࠉእ⛉㸧㛢㙐Ꮝ䝦䝹䝙䜰䜢ྜే䛧䛯኱⭣䝦䝹䝙䜰䛻ᑐ䛧䠈 㰡ᚄἲ䛻䜘䜛᰿἞⾡䜢᪋⾜䛧䛯䠍౛㻌 䈈䈈䈈䈈䈈䈈㻟㻜ἙྜΎ㈗㸦ஂ⨾ឡཌ⏕⑓㝔ࠉእ⛉㸧㼀㼛㼠㼍㼘㼘㼥㻌㻱㼤㼠㼞㼍㼜㼑㼞㼕㼠㼛㼚㼍㼘㻌㻱㼚㼐㼛㼟㼏㼛㼜㼕㼏㻌㻾㼑㼜㼍㼕㼞㻌㼛㼒㻌㻸㼡㼙㼎㼍㼞㻌㻴㼑㼞㼚㼕㼍㻦㻌㻭㻌㻯㼍㼟㼑㻌㻾㼑㼜㼛㼞㼠㻌㼣㼕㼠㼔㻌㻿㼜㼑㼏㼕㼍㼘㻌㻾㼑㼒㼑㼞㼑㼚㼏㼑㻌㼠㼛㻌㻿㼡㼞㼓㼕㼏㼍㼘㻌㼀㼞㼑㼍㼠㼙㼑㼚㼠㻌 䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈㻟㻠㔜ග♸ྖ  㸪⮃ᡤ᠇஧  㸪ᚚᡭὙ⩏ಙ  㸦 ⮃ᡤ⑓㝔ࠉእ⛉㸪 ᚚᡭὙ⑓㝔ࠉእ⛉㸧⭡⭍㙾ୗ⢭⣴㟼⬦⒗⤖⣻⾡ᚋ䛻Ⓨ⏕䛧䛯እ㰢ᚄ䝦䝹䝙䜰䛾୍౛㻌䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈㻟㻤㛵᰿㏿Ꮚ  㸪ㄶゼ຾ோ  㸪⩚⏕ࠉ೺  㸪㕥ᮌಇு  㸪ᒸᮏ཭ዲ  㸪▮Ọ຾ᙪ  㸦㸯㸧ᮾிឿᜨ఍་⛉኱Ꮫ㝃ᒓ➨୕⑓㝔ࠉእ⛉㸪㸰㸧ᮾிឿᜨ఍་⛉኱Ꮫእ⛉Ꮫㅮᗙ㸧㼀㻭㻼㻼 ᚋ䠈 ⭡⭷㝗พ䛾䛺䛔⭡⭷እᆺ⭤⬔䝦䝹䝙䜰䜢Ⓨ⑕䛧䛯୍౛㻌 䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈㻠㻝ຍ⸨ᜤ㑻㸪∵୸⿱㈗㸪㕥ᮌ኱⪽㸦ඵᑿᚨὪ఍⥲ྜ⑓㝔ࠉእ⛉㸧⭡⭍㙾ୗ㰡ᚄ䝦䝹䝙䜰ಟ᚟⾡ᚋ䛻䝯䝑䝅䝳┣⭠⒦䜢ᙧᡂ䛧䛯 㻝 ౛㻌䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈㻠㻢ᮏ㛫࿘స 㸧㸪ᯇ⏣భ㍜ 㸧㸪㛗ஂྜྷ㞝 㸧㸦㸧⊂❧⾜ᨻἲேᅜ❧⑓㝔ᶵᵓጲ㊰་⒪ࢭࣥࢱ࣮ࠉእ⛉㸪㸧಴ᩜ୰ኸ⑓㝔ࠉእ⛉㸧

⦅㞟ᚋグ䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈䈈㻡㻜᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

9RO1R

理事長挨拶Ḣ ᕞ 䠄㻳㻾㻱㻼㻭㻙㻱㼡㼞㼛㼜㼑㼍㼚㻌㻴㼑㼞㼚㼕㼍㻌㻿㼛㼏㼕㼑㼠㼥䠅 䛷 䛿 㻝㻥㻣㻥 ᖺ䚸 ⡿ ᅜ 䠄㻭㼙㼑㼞㼕㼏㼍㼚㻌㻴㼑㼞㼚㼕㼍㻌㻿㼛㼏㼕㼑㼠㼥䠅 䛷䛿 㻝㻥㻥㻣 ᖺ䛻⭡㒊䝦䝹䝙䜰䜢ᑓ㛛㡿ᇦ䛸䛧䛶ᢅ䛖䝦䝹䝙䜰Ꮫ఍䛜Ⓨ㊊䛧䚸 ㆟ㄽ䛜䛺䛥䜜䛶䛝䜎䛧䛯䛜䚸䜟䛜ᅜ䛷䛿ᑓ㛛Ꮫ⾡㞟ᅋ䛜䛺䛛䛳䛯䛯䜑䚸ᖹᡂ 㻝㻡 ᖺ 㻠 ᭶ 䇾᪥ᮏ䝦䝹䝙䜰◊✲఍䇿 䛜Ⓨ㊊䛧䚸 ➨䠍ᅇᏛ⾡㞟఍䛜㛤䛛䜜䜎䛧䛯䚹䛭䛾ᚋ䠑ᅇ䛾Ꮫ⾡㞟఍䜢⤒䛶䚸 ᖹᡂ 㻞㻜 ᖺ 㻠 ᭶ 㻝㻟 ᪥䛛䜙䛿 䛂᪥ᮏ䝦䝹䝙䜰Ꮫ఍㻔㻶㼍㼜㼍㼚㼑㼟㼑㻌㻴㼑㼞㼚㼕㼍㻌㻿㼛㼏㼕㼑㼠㼥㻕䛃 䛸ᨵྡ䛧䛶෌䝇䝍䞊䝖䜢ษ䜚䚸 Ꮫ⾡㞟఍䛿ᖺ 㻝 ᅇ䚸 㻞 ᪥㛫䛸䛺䜚䜎䛧䛯䚹 ᖹᡂ 㻞㻢 ᖺ 㻣 ᭶᫬Ⅼ䛷䛾ಶே఍ဨᩘ䛿 㻝㻜㻤㻣 ྡ䛸䛺䜚䚸 ᮏᖺ 㻢 ᭶䛾➨ 㻝㻞ᅇᏛ⾡㞟఍䛻䛚䛡䜛₇㢟ᩘ䛿 㻟㻡㻜 ௨ୖ䛷䚸 ཧຍ⪅䛿 㻣㻞㻣 ྡ䛸㡰ㄪ䛻ቑຍ䛧䛶䜎䛔䜚䜎䛧䛯䚹Ꮫ⾡㞟఍䛷䛾₇㢟䛺䛹◊✲ෆᐜ䜢බ⾲䛷䛝䜛䜘䛖䛻䛩䜉䛟Ꮫ఍ㄅ䛒䜛䛔䛿ఱ䜙䛛䛾グ㘓䜢☜ಖ䛩䜛䛣䛸䛜Ꮫ఍䛾౑࿨䛷䛒䜚䜎䛧䛯䛜䚸 䛣䜜䜎䛷䛿ᮏᏛ఍䛿Ꮫ఍ㄅ䛜䛷䛝䛶䛔䛺䛛䛳䛯䛯䜑䚸 Ꮫ⾡㞟఍䛾ᢒ㘓㞟䜢᪥ᮏእ⛉⣔㐃ྜᏛ఍㞧ㄅ䛻ᥖ㍕䛧䛶䛔䛯䛰䛔䛶䛚䜚䜎䛧䛯䚹ᖹᡂ䠎䠐ᖺ䜘䜚ᮏᏛ఍䛾Ꮫ఍ㄅ 䠄ᐇ㝿䛻䛿䜸䞁䝷䜲䞁䝆䝱䞊䝘䝹䠅 䛾Ⓨห䜢┠ᣦ䛧䛶䚸 ᑠᒣຬඛ⏕䜢Ꮫ఍ㄅጤဨ
㛗䛸䛧䛶ጤဨ䛾ⓙᵝ䛻‽ഛ䜢䛧䛶䛔䛯䛰䛔䛶䛚䜚䜎䛧䛯䚹䛣䛾䛯䜃ⓙᵝ䛾䛚䛛䛢䜢䜒䛱䜎䛧䛶䜘䛖䜔䛟➨䠍ᅇ䜸䞁䝷䜲䞁䝆䝱䞊䝘䝹䛾Ⓨห䛻⮳䜚䜎䛧䛯䚹௒ᚋ䛿ᖺ䠐ᅇ䛾Ⓨห䜢ணᐃ䛧䚸 㻶㻙㻿㼀㻭㻳㻱 䜔་Ꮫ୰ኸ㞧ㄅ䜈䛾཰㍕䜒౫㢗䛧䛶䛩䜛䛣䛸䜢ィ⏬୰䛷䛩䚹 䜎䛯௒ᚋᮏᏛ఍䜸䞁䝷䜲䞁䝆䝱䞊䝘䝹䜈䛾ᥖ㍕䛜እ⛉Ꮫ఍䚸 ⮫ᗋእ⛉Ꮫ఍䚸 ᾘ໬ჾእ⛉Ꮫ఍䛸䛔䛳䛯ᡃ䛜ᅜ䛾እ⛉㡿ᇦᏛ఍䛻䛚䛡䜛ᴗ⦼䛸䛧䛶䜒ㄆ䜑䜙䜜䜛䜘䛖䛻䛺䜛䛣䛸䜒ᮇᚅ䛥䜜䜎䛩䚹௒ᚋᮏᏛ఍䜸䞁䝷䜲䞁䝆䝱䞊䝘䝹䜢⫱䛶䛶䛔䛯䛰䛟䛻䛿䚸 ఍ဨ䛾ⓙᵝ䛾᪥䚻䛾⮫ᗋ⤒㦂䜢༢䛻Ꮫ⾡㞟఍䛷Ⓨ⾲䛧䛶⤊䜟䜚䛻䛩䜛䛾䛷䛿䛺䛟䚸 ㄽᩥ໬䛧䛶㈗㔜䛺Ꮫ⾡䝕䞊䝍䛸䛧䛶✚ᴟⓗ䛻ᢞ✏䛧䛶䛔䛯䛰䛟䛣䛸䜢䛚㢪䛔䛩䜛䛧䛛䛒䜚䜎䛫䜣䚹 䜎䛪䛿⑕౛ሗ࿌䛛䜙䛷䜒䛛䜎䛔䜎䛫䜣䛾䛷䚸 䛺䛻䛸䛮䜘䜝䛧䛟䛚㢪䛔⏦䛧ୖ䛢䜎䛩䚹ᑠᒣຬඛ⏕䛿䛨䜑Ꮫ఍ㄅጤဨ䛾ⓙᵝ䚸 ᢞ✏ཎ✏䛾ᰝㄞ䜢䛚㢪䛔䛩䜛ඛ⏕᪉䛻ᘬ䛝⥆䛔䛶䛾䛤༠ຊ䜢䜘䜝䛧䛟䛚㢪䛔⏦䛧䛒䛢䜎䛩䚹᪥ᮏ䝦䝹䝙䜰Ꮫ఍⌮஦㛗⪷㊰ຍᅜ㝿⑓㝔䝦䝹䝙䜰䝉䞁䝍䞊䚸 ᾘ໬ჾ 䞉 ୍⯡እ⛉௸ເ̮‫ٽ‬ᢹ᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

9RO1R

名誉会長挨拶
日本ヘルニア学会誌発行にあたって䛣䛾ᗘ䛔䜘䛔䜘᪥ᮏ䝦䝹䝙䜰Ꮫ఍ㄅ 䠄㟁Ꮚ䝆䝱䞊䝘䝹∧䠅 䛜Ⓨ⾜䛩䜛䛣䛸䛻䛺䜚䜎䛧䛯䚹䜎䛪䚸 ᑠᒣຬ᪥ᮏ䝦䝹䝙䜰Ꮫ఍ㄅ⦅㞟ጤဨ㛗䛿䛨䜑ጤဨ䛾ඛ⏕᪉䛾䛤ᑾຊ䛻ᚰ䜘䜚ឤㅰ⏦䛧ୖ䛢䜛ḟ➨䛷䛩䚹䛣䛾ᶵ఍䛻ᮏᏛ఍タ❧䛛䜙䛾⤒⦋䜢䛒䜙䛯䜑䛶᣺䜚㏉䜚䚸 ᮏᏛ఍䛾௒ᚋ䛾Ⓨᒎ䛻ྥ䛡䛶ᚰ䜢᪂䛯䛻䛧䛯䛔䛸ᛮ䛳䛶䛚䜚䜎䛩䚹 ➨䠎ᅇᅜ㝿䝦䝹䝙䜰Ꮫ఍ 㻞㼚㼐㻌㻵㼚㼠㼑㼞㼚㼍㼠㼕㼛㼚㼍㼘㻌㻴㼑㼞㼚㼕㼍㻌㻯㼛㼚㼓㼞㼑㼟㼟㻔㻞㻜㻜㻟㻕 ఍㛗䛾 㻼㼞㼛㼒㼑㼟㼟㼛㼞㻌㻭㼚㼐㼞㼑㼣㻌㻷㼕㼚㼓㼠㼔㼚㼛㼞㼠㼔 䛛䜙ᙜ᫬䛾ᖇி኱Ꮫ་Ꮫ
㒊㝃ᒓ⁁ཱྀ⑓㝔እ⛉ᩍᤵ䛾ᒣᕝ㐩㑻ᩍᤵ䜈᪥ᮏ䛾䝦䝹䝙䜰䛻㛵䛩䜛◊✲⤌⧊䛻㛵䛩䜛ၥ䛔ྜ䜟䛫䛜䛒䜚䚸 ᒣᕝ㐩㑻ඛ⏕䜢䛿䛨䜑䚸 ᙜ᫬௚䛾እ⛉⣔Ꮫ఍䛷䝦䝹䝙䜰䛻㛵䛧䛶✚ᴟⓗ䛺άື䜢䛧䛶䛚䜙䜜䛯ᰙ℩ಙኴ㑻ඛ⏕ 䠄⪷㊰ຍᅜ㝿⑓㝔䠅䚸 ᯇᮏ⣧ኵᩍᤵ䠄ᙜ᫬䚸 ⸨⏣ಖ೺⾨⏕኱Ꮫ➨஧ᩍ⫱⑓㝔እ⛉ᩍᤵ䠅 䛻䛤┦ㄯ䛧䛶䚸 䠎䠌䠌䠎ᖺ䛻᪥ᮏ䝦䝹䝙䜰◊✲఍䜢Ⓨ㊊䛩䜛᪉㔪䛸⮴䛧䜎䛧䛯䚹 ◊✲఍Ⓨ㊊䛾ᢡ䛾᱌ෆ䛻♧䛧䛶䛚䜚䜎䛩䜘䛖䛻䚸 䝦䝹䝙䜰䛾ᡭ⾡䛿ẚ㍑ⓗึᚰ⪅䛾ᡭ⾡䛸䛥䜜䛶䛝䜎䛧䛯䛜䚸 ᐇ㝿䛿෌Ⓨ䜔ྜే⑕䛺䛟ᐇ᪋䛩䜛䛻䛿䛭䜜䜋䛹ᐜ᫆䛺ᡭ⾡䛷䛿䛺䛟䚸 ༑ศ䛺ゎ๗ⓗ▱㆑䛸┦ᛂ䛾⤒㦂䜢ᚲせ䛸䛩䜛䛸⪃䛘䜙䜜䜎䛩䚹 ⭡⭍㙾ୗᡭ⾡䛾ᬑཬ䛸ྛ✀ 㼙㼑㼟㼔 䜢౑⏝䛧䛶ከᵝ䛺⾡ᘧ䛜᪋⾜䛥䜜䛶䛔䜛≧ἣ䛷䛧䛯䚹◊✲఍⤌⧊䛸䛧䛶䛿䚸 ᖖ௵ୡヰே఍䚸 ୡヰே఍䚸 ᪋タ఍ဨ䚸 ಶே఍ဨ䛛䜙ᡂ䜚䚸 Ⓨ㊊ᙜึ䛾ᙺဨ䛸䛧䛶䛿䚸 ௦⾲ୡヰே෨Ọຌኴ䚸 ᖖ௵ୡヰே䛿ᰙ℩ಙኴ㑻ඛ⏕䛸ᯇᮏ⣧ኵඛ⏕䚹 ୡヰே䛸䛧䛶䛿ᑠᒣຬඛ⏕ 䠄ᇸ⋢་⛉኱Ꮫ୍⯡እ⛉ᩍᤵ䠅 ௨ୗ䠎䠎ྡ䚸┘஦䛸䛧䛶䛿ᒣᕝ㐩㑻ඛ⏕䛸ᑠᰡὈஂඛ⏕ 䠄ᙜ᫬ᮾி་⛉኱Ꮫ➨୕እ⛉䠅 䛷䛒䜚䜎䛧䛯䚹◊✲఍఍๎䜢⟇ᐃ䛧䛶䛚䜚䜎䛩䛜䚸 ┠ⓗ䛸䛧䛶 䛂ᮏ఍䛿䚸 䝦䝹䝙䜰䛻㛵䛩䜛◊✲䛾㐍ṌⓎᒎ䛸ᬑཬ䚸 ఍ဨ┦஫䛾㐃⤡䛸ぶ╬䚸 䛺䜙䜃䛻ᅜ㝿ⓗ஺ὶ䜢ᅗ䜛䛃 䛸䛧䛶䛚䜚䜎䛩䚹 ➨䠍ᅇ᪥ᮏ䝦䝹䝙䜰◊✲఍䜢෨Ọ䛜ᙜ␒ୡヰே䛸䛧䛶䠎䠌䠌䠏ᖺ 䠄ᖹᡂ䠍䠑ᖺ䠅 䠐᭶䠎᪥㉥ᆏ䝥䝸䞁䝇䝩䝔䝹 䠄ᮾி䠅 䛻䛶㛤ദ䛔䛯䛧䜎䛧䛯䚹 ᙜ᫬䛾᪋タ఍ဨ䛿䠏䠐᪋タ䚸 ಶே఍ဨ䛿䠒䠔ྡ䛸グ㘓䛥䜜䛶䛚䜚䜎䛩䚹 䜎䛯ᛂເ₇㢟ᩘ䛿⣙䠓䠌㢟䛷䛒䜚䜎䛧䛯䚹 ➨䠎ᅇ䛿ᰙ℩ಙኴ㑻ඛ⏕䚸 ➨䠏ᅇ䛿ᯇᮏ⣧ኵඛ⏕䚸 ➨䠐ᅇᆏᮏṇ⩏ඛ⏕ 䠄୕஭グᛕ⑓㝔䠅䚸 ➨䠑ᅇᮌᮧὈ୕ඛ⏕ 䠄ᐩኈᐑᕷ❧⑓㝔䠅䚸 ➨䠒ᅇ୰ᓥ᫛ඛ⏕ 䠄᪥⏘ཌ⏕఍⋢ᕝ⑓㝔䠅 䛻䛿䠎᪥㛫䛾఍ᮇ䛸䛺䜚䜎䛧䛯䚹䠎䠌䠌䠔ᖺ䠐᭶䛻䛿◊✲఍䛷䝇䝍䞊䝖䛧䛯ᮏ఍䛿䛔䜘䛔䜘᪥ᮏ䝦䝹䝙䜰Ꮫ఍䛻Ⓨᒎᨵ⛠䛔䛯䛧䜎䛧䛯䚹 䛭䜒䛭䜒◊✲఍䛸Ꮫ఍䛾㐪䛔䛻㛵䛧䛶䚸 ᑡ䛺䛟䛸䜒⚾䛾▱䜛⠊ᅖ䛷䛿᫂☜䛻ᐃ⩏䛥䜜䛶䛿䛔䛺䛔䜘䛖䛷䛩䛜䚸 ◊✲఍䛿᪋タ఍ဨ䛜୺య䛾䛣䛸䛜ከ䛟䚸 Ꮫ఍䛿ಶே఍ဨ䛷ᵓᡂ䛥䜜䛶䛔䜛䜘䛖䛷䛩䚹 䜎䛯䚸 Ꮫ఍䛿ᐃᮇⓗ䛺Ꮫ఍ㄅ䜢Ⓨ⾜䛧䛶䛔䜛ሙྜ䛜ከ䛟䚸 䛭䛾ព࿡䛷䛿ᮏᏛ఍䜒䜘䛖䜔䛟ᐇ㉁䜢క䛳䛯Ꮫ఍䛻䛺䛳䛯䛸䜒䛔䛘䜎䛩䚹 ᭱㏆௚䛾Ꮫ఍䛿୍⯡ἲே໬䛾ഴྥ䛻䛒䜚䜎䛩䛾䛷䚸 ᮏᏛ఍䜒䛔䛪䜜ἲே໬䛾ᚲせᛶ䛜ㄽ㆟䛥䜜䜛ᚲせ䛜䛒䜛䜘䛖䛻ᛮ䛔䜎䛩䚹 Ꮫ఍ᙺဨ䛿⌮஦䚸ホ㆟ဨ䛸ྡ⛠䛿ኚ᭦䛸䛺䜚䜎䛧䛯䛜䚸 ◊✲఍ᙺဨ䛜䜋䛸䜣䛹䛭䛾䜎䜎⛣⾜⮴䛧䜎䛧䛯䚹 Ꮫ఍䛸䛧䛶䛿᭱ึ䛾➨䠓ᅇ᪥ᮏ䝦䝹䝙䜰Ꮫ఍䛿ᑠすᩄ㑻ඛ⏕ 䠄㻺㼀㼀 ᮾ᪥ᮏ㛵ᮾ⑓㝔䠅 䛜ᢸᙜ䛥䜜䚸 䠍䠐䠔㢟䛸₇㢟ᩘ䛜ቑຍ䛧䛶䛚䜚䜎䛩䚹 ➨䠔ᅇ䛿ᑠᒣຬඛ⏕ 䠄ᇸ⋢་⛉኱Ꮫᅜ㝿་⒪䝉䞁䝍䞊䠅 䛜ᢸᙜ䛥䜜₇㢟ᩘ䛜䠏䠎䠌㢟䛸㣕㌍ⓗ䛻ቑຍ䛧䜎䛧䛯䚹 ➨䠕ᅇ䛿Ụཱྀᚭඛ⏕ 䠄ཎ୕ಙ⑓㝔䠅䚸➨䠍䠌ᅇ䛿ᒣᮏ๛ྐඛ⏕ 䠄ᮅ᪥኱ᏛṑᏛ㒊௜ᒓ⑓㝔䠅䚸➨䠍䠍ᅇ䛿ᚨᮧᘯ⨾ඛ⏕ 䠄ᮾ໭ປ⅏⑓㝔䠅 䛜ᢸᙜ䛥䜜₇㢟ᩘ䛿䠐䠍䠎㢟䛸ቑຍ⮴䛧䜎䛧䛯䚹 ᮏᖺ䛾➨䠍䠎ᅇ䛿ᇳ⾜཭ᡂඛ⏕ 䠄ᇳ⾜䜽䝸䝙䝑䜽䠅 䛜఍㛗䛸䛧䛶ᮏᖺ䠒᭶䠒᪥䚸 䠓᪥䛻ணᐃ䛥䜜䛶䛚䜚䜎䛩䚹 䛺䛚䚸 ᭱᪂䛾㞟ィ䛷䛿఍ဨᩘ䛿 㻝㻘 䠌䠍䠌ྡ䛸ቑຍ䛧䛶䛔䜎䛩䚹䚷ᮏᏛ఍䛾௒ᚋ䛾ㄢ㢟䛸䛧䛶䛿䚸 ྛᆅ᪉ᨭ㒊䛸䛾㛵ಀ䚸 㛵㐃◊✲఍䛸䛾㛵㐃䚸 䜎䛯๓㏙䛾ἲே໬䛺䛹᳨ウ䛩䜉䛝ၥ㢟䛸⪃䛘䜙䜜䜎䛩䚹 ௒ᚋ䛿ᮏᏛ఍䛾䝩䞊䝮䝨䞊䝆䛸䛸䜒䛻ᮏᏛ఍ㄅ䛜䚸 ᮏᏛ఍఍ဨ䛾䜏䛺䜙䛪୍⯡እ⛉་䛾ඛ⏕᪉䛻䜒⭡㒊䝦䝹䝙䜰䛻㛵䛩䜛᝟ሗᥦ౪䛜䜘䜚඘ᐇ䛧䚸 䝦䝹䝙䜰་⒪䛾㐍ṌⓎᒎ䛻ᐤ୚䛷䛝䜛䛣䛸䜢ᮇᚅ䛧䛯䛔䛸Ꮡ䛨䜎䛩䚹᪥ᮏ䝦䝹䝙䜰Ꮫ఍ྡ㄃఍㛗ϧ൨ы‫ٽ‬
᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

9RO1R

原著
ULTRAPRO* Plug を用いた成人臍ヘルニア修復術の検討
 ⊂❧⾜ᨻἲேࠉᅜ❧⑓㝔ᶵᵓࠉᒾᅜ་⒪ࢭࣥࢱ࣮ࠉእ⛉ ᒸᒣ኱Ꮫ኱Ꮫ㝔་ṑ⸆Ꮫ⥲ྜ◊✲⛉ࠉᾘ໬ჾእ⛉Ꮫ

➉ཎ⿱Ꮚ



㸪➉ཎΎே 㸪Ṋ⏣ṇ 㸪᳃ᘅಇ᫛ 㸪⏣୰ᒇᏹ∞ 㸪㟷ᮌ⚽ᶞ 㸪➉ෆோྖ要旨࠙ࡣࡌࡵ࡟ࠚᡂே⮖࣊ࣝࢽ࢔ࡣᮏ㑥࡛ࡣẚ㍑ⓗࡲࢀ࡞⑌ᝈ࡛࠶ࡿ㸬἞⒪ࡣᡭ⾡ࡀཎ๎࡛㸪㏆ᖺ࡛ࡣ࣓ࢵࢩࣗࢆ⏝࠸ࡓಟ᚟⾡ࡀ⾜ࢃࢀ࡚࠸ࡿ㸬௒ᅇ㸪ᡃࠎࡣ༙྾཰ᛶ࣓ࢵࢩࣗ 8/75$352  3OXJ 833 ࢆ⏝࠸ࡓಟ᚟⾡ࢆ⾜࠸㸪Ⰻዲ࡞ᡂ⦼ࢆ
ᚓࡓࡢ࡛ሗ࿌ࡍࡿ㸬࠙᪉ἲࠚ ᖺ  ᭶㹼  ᖺ  ᭶࡟ᒾᅜ་⒪ࢭࣥࢱ࣮እ⛉ࢆཷデࡋࡓᡂே⮖࣊ࣝࢽ࢔ࡢෆ㸪࣊ࣝࢽ࢔㛛ࡀ FP ࡲ࡛ࡢ⑕౛ࢆᑐ㇟࡜ࡋ㸪833 ࢆ⏝࠸ࡓಟ᚟⾡ࢆ᪋⾜ࡋ࡚㸪ࡑࡢ⤖ᯝࢆ᳨ウࡋࡓ㸬࠙⤖ᯝࠚ⑕౛ࡣ⏨ᛶ  ౛㸪ዪᛶ  ౛࡛㸪ᖹᆒᖺ㱋  ṓ  㹼  ṓ 㸪㯞㓉ࡣ඲㌟㯞㓉  ౛㸪⭜᳝㯞㓉  ౛࡛࠶ࡗࡓ㸬࣊ࣝࢽ࢔㛛ࡢᚄࡣ  㹼 FP ࡛㸪 ౛࡟ 833 6 VL]H㸪 ౛࡟ / VL]H ࢆ౑⏝ࡋࡓ㸬 ౛࡟ᶓ⾜⤖⭠ᔐ㡻ࢆㄆࡵࡓ㸬඲౛࡟࠾࠸࡚⾡ᚋྜే⑕࠾ࡼࡧ෌Ⓨࡣㄆࡵ࡞࠿ࡗࡓ㸬ࡲࡓ㸪⮖❐ࡢᅛᐃ࡟ࡼࡾṚ⭍ࢆ࡞ࡃࡍ࡜࡜ࡶ࡟Ⰻዲ࡞⮖ᙧᡂࡀᚓࡽࢀࡓ㸬࠙⪃ᐹࠚ833 ࢆ⏝࠸ࡓಟ᚟⾡ࡢ฼Ⅼ࡜ࡋ࡚㸪 ⾡ᚋࡢ␗≀ឤࡸ⑊③ࡀᑡ࡞࠸㸪 ࢔࣮ࣥ࢝࡜࣒ࣜࡢ  ᒙᵓ㐀࡟ࡼࡾ㸪⬤ᙅ໬ࡋࡓ⭡ቨࢆ⭡⭷๓⭍࡜⭡┤➽㠧ୖ࡛  㔜࡟⿵ᙉ࡛ࡁࡿ㸪 ⭡⭍ෆ␃⨨ᆺ࣓ࢵࢩࣗࡢྜే⑕࡛࠶ࡿ࣓ࢵࢩࣗ࡬ࡢ⭠⟶ࡢ⒵╔ࡀ⏕ࡌ࡞࠸㸪 ᑗ᮶㸪㛤⭡ᡭ⾡ࢆせࡋࡓሙྜ࡟࣓ࢵࢩࣗࡀ㞀ᐖ࡜࡞ࡾ࡟ࡃ࠸㸪 ᡭᢏࡀẚ㍑ⓗ⡆౽࡛࠶ࡿ㸪
࡜࠸ࡗࡓⅬࡀᣲࡆࡽࢀࡿ㸬࣊ࣝࢽ࢔㛛ࡀ FP ⛬ᗘࡲ࡛ࡢ⑕౛࡟ᑐࡋ࡚㸪833 ࡣ᭷⏝࡛࠶ࡿ࡜⪃࠼ࡽࢀࡓ㸬࣮࣮࢟࣡ࢻ㸸ᡂே⮖࣊ࣝࢽ࢔㸪8/75$352 3OXJ㸪༙྾཰ᛶ࣓ࢵࢩࣗ

はじめに

手術手技

ᡂே⮖࣊ࣝࢽ࢔ࡣᮏ㑥࡛ࡣẚ㍑ⓗࡲࢀ࡞⑌ᝈ࡜ࡉࢀ࡚࠾

ᒁᡤ㯞㓉ࡶࡋࡃࡣ඲㌟㯞㓉ୗ࡟௮⮩఩࡟࡚ᡭ⾡ࢆ⾜࠺㸬ࡾ㸪ᚋኳⓗ࡟⫧‶㸪ዷፎ㸪⭡Ỉ࡞࡝ࡀཎᅉ࡛⏕ࡌ㸪᫬࡟ࡣ⮖ୗ⦕࡛⮖㍯࡟ἢࡗ࡚⓶⭵ษ㛤ࢆ࠾ࡁ㸪⓶ୗ⤌⧊ࢆษ㛤ࡋᔐ㡻ࡸ◚⿣ࢆࡁࡓࡋ㔜⠜࡞≧ែ࡜࡞ࡿࡇ࡜ࡀ࠶ࡿ



㸬㏆

࡚࣊ࣝࢽ࢔ᄞࢆ࿘ᅖ⤌⧊࠿ࡽ๤㞳ࡋ㸪࣊ࣝࢽ࢔㛛ࢆ☜ㄆᖺ࡛ࡣ㸪ᡂே⮖࣊ࣝࢽ࢔࡟ᑐࡋ࡚㸪ேᕤ⿵ᙉᮦ㸦࣓ࢵࢩࣗ㸧ࡍࡿ )LJ 㸬࣊ࣝࢽ࢔ᄞࢆ⭡⭍ෆ࡟㑏⣡ࡋ㸪⭡⭷๓⭍ࢆࢆ⏝࠸ࡓಟ᚟⾡ࡀᗈࡃ⾜ࢃࢀ࡚࠸ࡿ㸬௒ᅇ㸪ᡃࠎࡣ༙྾཰

๤㞳ࡋ࡚ 833 ࡢ࢔࣮ࣥ࢝㒊ศࢆ⭡⭷๓⭍࡟ᤄධ㸪࣒ࣜ㒊ศᛶ࣓ࢵࢩࣗ 8/75$352  3OXJ ௨ୗ㸪833 ࡜␎グࢆ⭡┤➽㠧ୖ࡟ᒎ㛤ࡋ࡚㸪࣒ࣜ㒊ศࡢෆ⦕࡜እ⦕ࢆ⭡┤➽ࢆ⏝࠸ࡓ㠧࡟྾཰⣒࡛ᅛᐃࡍࡿ )LJ  㸬࢜ࣥࣞ࢖ࣃࢵࢳࡣ౑

ಟ᚟⾡ࢆ⾜࠸㸪Ⰻዲ࡞ᡂ⦼ࢆᚓࡓࡢ࡛ሗ࿌ࡍࡿ ⏝ࡋ࡞࠸㸬⮖❐ࡢ᭱ࡶพࢇࡔ㒊ศࡢ┿⓶ࢆ 833 ࡢ୰ኸࡢ対象と方法 ᖺ  ᭶࠿ࡽ  ᖺ  ᭶ࡲ࡛࡟㸪ᒾᅜ་⒪ࢭࣥࢱ࣮እ⛉ࢆཷデࡋࡓᡂே⮖࣊ࣝࢽ࢔ࡢ  ౛ࡢෆ㸪⾡๓ࡢ⭡㒊༢❑ࡳ࡟  㔪ᅛᐃࡍࡿࡇ࡜࡛㸪⮖ᙧᡂࢆ⾜࠺  㸬ࢩ࢙࣮࣐ࢆ
)LJ ࡟♧ࡍ㸬

結⣧ &7 ᳨ᰝ࡟ࡼࡿホ౯࡟࡚㸪࣊ࣝࢽ࢔㛛ࡢᚄࡀ FP ࡲ࡛ࡢ⑕౛ࢆᑐ㇟࡜ࡋ࡚㸪833 ࢆ⏝࠸ࡓಟ᚟⾡ࢆ᪋⾜ࡋ㸪ࡑࡢ⤖ᯝ࡟ࡘ࠸᳨࡚ウࡋࡓ㸬ᑦ㸪ᝈ⪅࡟ᑐࡋ࡚ࡣᡭ⾡ᡭᢏ㸪ணᑐ㇟ᮇ㛫࡟ᒾᅜ་⒪ࢭࣥࢱ࣮እ⛉ࢆཷデࡋࡓᡂே⮖࣊ࣝࢽ࢔⑕౛ࡣ  ౛࡛㸪࠸ࡎࢀࡶ⾡๓ &7 ࡟࡚࣊ࣝࢽ࢔㛛ࡣࡉࢀࡿྜే⑕࠾ࡼࡧ

FP ௨ୗ࡛࠶ࡗࡓ㸬ࠕ⑕౛ሗ࿌ࢆྵࡴ་ᏛㄽᩥཬࡧᏛ఍◊✲఍Ⓨ⾲࡟࠾ࡅࡿᝈ

ᛶูࡣ⏨ᛶ  ౛㸪ዪᛶ  ౛࡛㸪ᖺ㱋ࡣ  㹼  ṓ⪅ࣉࣛ࢖ࣂࢩ࣮ಖㆤ࡟㛵ࡍࡿᣦ㔪ࠖ࡟ࡢࡗ࡜ࡾ㸪ࣉࣛ࢖ࣂᆒ  ṓࢩ࣮ಖㆤ࡟ࡘ࠸࡚ㄝ᫂ࢆ⾜࠸㸪ࡍ࡭࡚࡟ྠពࢆᚓࡓ㸬⑓ᝎᮇ㛫ࡣ  ࠿᭶㹼  ᖺ᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

果



ᖹ

࡛࠶ࡗࡓ㸬୺ッࡣ⮖㒊⭾㝯  ౛㸪⑊③  ౛࡛㸪୰ኸ್  ࠿᭶࡛࠶ࡗࡓ㸬%0,9RO1Rࡣ  㹼  ᖹᆒ  ࡛࠶ࡗࡓ㸬ేᏑ⑌ᝈࡣ & ᆺ⫢ࡢᙧᡂࡀ㑊ࡅࡽࢀࡿࡇ࡜ࡀᮇᚅࡉࢀ㸪ࡲࡓ༙྾཰ᛶࡢࡓࡵ◳ኚ  ౛㸪࢔ࣝࢥ࣮ࣝᛶ⫢⅖  ౛㸪࢔ࣝࢥ࣮ࣝᛶ⫢◳ኚ యෆ࡟ṧࡿ␗≀㔞ࢆᚲせ᭱ᑠ㝈࡟ᢚ࠼㸪⅖⑕཯ᛂࢆῶᑡࡉ

౛࡛࠶ࡗࡓ㸬㯞㓉ࡣ඲㌟㯞㓉  ౛㸪⭜᳝㯞㓉  ౛࡛࠶ࡗࡏࡿࡇ࡜ࡀᮇᚅ࡛ࡁࡿ࡜ࡉࢀࡿ㸬ࡓ㸬⾡୰デ᩿࡛ࡢ࣊ࣝࢽ࢔㛛ࡢ኱ࡁࡉࡣ  㹼 FP ᖹ

833 ࢆ⏝࠸ࡓ⮖࣊ࣝࢽ࢔ಟ᚟⾡ࡢ฼Ⅼ࡜ࡋ࡚㸪ձ⾡ᚋࡢᆒ FP ࡛㸪8336VL]Hࢆ  ౛࡟㸪/VL]Hࢆ  ౛࡟౑␗≀ឤࡸ⑊③ࡀᑡ࡞࠸㸪ղ࢔࣮ࣥ࢝࡜࣒ࣜࡢ  ᒙᵓ㐀࡟ࡼ⏝ࡋࡓ㸬 7DEOHࡾ㸪⬤ᙅ໬ࡋࡓ⭡ቨࢆ⭡⭷๓⭍࡜⭡┤➽㠧ୖ࡛  㔜࡟⿵ᙉ ౛ࡣᶓ⾜⤖⭠ࡀᔐ㡻ࡋ࡚࠾ࡾ㸪⥭ᛴᡭ⾡ࢆ᪋⾜ࡋࡓ㸬⭠ษ㝖ࡣ᪋⾜ࡋ࡚࠸࡞࠸㸬ే⑕࡛࠶ࡿ࣓ࢵࢩࣗ࡬ࡢ⭠⟶ࡢ⒵╔  ࡀ⏕ࡌ࡞࠸㸪մᑗ⾡ᚋࡢ⤒㐣ほᐹᮇ㛫ࡣᖹᆒ  ࠿᭶࡛㸪඲౛࡟࠾࠸࡚
⾡ᚋྜే⑕࠾ࡼࡧ෌Ⓨࡣㄆࡵ࡞࠿ࡗࡓ㸬考࡛ࡁࡿ㸪ճ⭡⭍ෆ␃⨨ᆺ࣓ࢵࢩࣗ㸦9HQWUDOH[ ࡞࡝㸧ࡢྜ᮶㸪௚⑌ᝈ࡛㛤⭡ᡭ⾡ࢆせࡍࡿሙྜ࡟࣓ࢵࢩࣗࡢᏑᅾࡀ
ᡭ⾡ࡢ㞀ᐖ࡜࡞ࡾ࡟ࡃ࠸㸪յᡭᢏࡀẚ㍑ⓗ⡆౽࡛࠶ࡿ㸪࡜
࠸ࡗࡓⅬࡀᣲࡆࡽࢀࡿ㸬833 ࡢ࢔࣮ࣥ࢝㒊ศࡣ┤ᚄࡀ FP察ᡂே⮖࣊ࣝࢽ࢔ࡣ㸪⮖㒊ࡢ⒕⑞⤌⧊ࡀఙᒎࡉࢀ⬤ᙅ໬ࡋ㸪ዷፎ㸪⫧‶㸪⭡Ỉ࡞࡝ࡢ⭡⭍ෆᅽୖ᪼ᅉᏊࡀຍࢃࡿࡇ࡜࡛
Ⓨ⏕ࡍࡿࡶࡢ࡜ࡉࢀࡿ  㸬Ḣ⡿࡛ࡣ  㹼  ṓ௦ࡢዪᛶ࡟
ࡼࡃࡳࡽࢀࡿ⑌ᝈ࡛࠶ࡿ  ࡀ㸪ᮏ㑥࡛ࡣẚ㍑ⓗࡲࢀ࡜ࡉࢀ࡚࠸ࡿ㸬⏬ീデ᩿࡜ࡋ࡚ࡣ㉸㡢Ἴ᳨ᰝࡸ⭡㒊 &7 ᳨ᰝࡀ᭷⏝࡛࠶ࡿ  㸬⏬ീデ᩿࡛ࡣ୍㒊Ḟᦆࡋࡓ⭡ቨࡼࡾ㐓⬺ࡋࡓ⭠⟶ࡶࡋࡃࡣ⭡⭍ෆ⬡⫫⧊ࡀᥥฟࡉࢀࡿ㸬⭡㒊 &7 ࡣ⮖㒊ࡢ࣊ࣝࢽ࢔㛛࡜ᔐ㡻ࡋࡓ⭠⟶ࡢ≧ែࡀᢕᥱ࡛ࡁ㸪᭷⏝࡞デ᩿᪉ἲࡢ୍ࡘ࡛࠶ࡿ  㸬἞⒪᪉㔪࡜ࡋ࡚ࡣ◚⿣⑕౛ࡸᔐ㡻⑕౛ࡣ⥭ᛴᡭ⾡ࡢ⤯ᑐⓗ㐺ᛂ࡛࠶ࡿ㸬ࡲࡓ㸪㠀ᔐ㡻⑕౛࡛ࡶᡂே࡛ࡣ⮬↛἞⒵ࡍ
ࡿࡇ࡜ࡀ࡞ࡃ㸪ᑗ᮶ᔐ㡻ࡢ༴㝤ᛶࡀ࠶ࡿࡓࡵ㸪඲㌟≧ែ࡟ၥ㢟ࡀ࡞ࡅࢀࡤᡭ⾡ࢆࡍࡿ࡭ࡁ࡛࠶ࡿ࡜⪃࠼ࡽࢀࡿ㸬ᡭ⾡ࡣᚑ᮶㸪༢⣧⦭ྜ㛢㙐ࡸ➽⭷⤌⧊ࢆ㔜ࡡྜࢃࡏࡿ᪉
ἲࡀ⾜ࢃࢀ࡚ࡁࡓࡀ㸪෌Ⓨ⋡ࡀ  㹼  ࡜㧗ࡃ  㸪㏆ᖺ࡛ࡣ࣓ࢵࢩࣗࢆ⏝࠸ࡓ WHQVLRQ IUHH ಟ᚟⾡ࡀᗈࡃ⾜ࢃࢀࡿࡼ࠺࡟࡞ࡗ࡚࠸ࡿ  㸬࣓ࢵࢩࣗ࡟ࡼࡿ⮖࣊ࣝࢽ࢔ಟ᚟
⾡ࡣ࣊ࣝࢽ࢔㛛ࡢ኱ࡁࡉ࡟࠿࠿ࢃࡽࡎ⦭ྜ㛢㙐ࡼࡾ෌Ⓨ⋡ࡀపࡃ㸪ྜే⑕ࡢⓎ⏕⋡࡟ࡣᕪࡀ࡞࠸ࡇ࡜ࡀሗ࿌ࡉࢀ࡚࠸ࡿ  㸬࡞࠾㸪෌Ⓨ⋡ࡀᑡ࡞࠸⌮⏤࡜ࡋ࡚ࡣ㸪࣓ࢵࢩࣗ࡟ࡼࡿ⬤ᙅ㒊఩ࡢ⿵ᙉࡸ⭡⭍ෆᅽࡢศᩓࡀ࠶ࡆࡽࢀࡿ㸬⮖ ࣊ ࣝ ࢽ ࢔ ࡟ ᑐ ࡍ ࡿ WHQVLRQ IUHH ಟ ᚟ ⾡ ࡜ ࡋ ࡚ ࡣ㸪
SRO\WHWUD㸛XRURHWK\OHQH ࡸ SRO\SURS\OHQH ࢆ ⏝ ࠸ ࡓ ࣓ ࢵࢩࣗࡀ౑ࢃࢀ࡚࠸ࡿ  㸬ᮏ㑥࡛ࡶࡇࢀࡲ࡛࡟ 3UROHQH
+HUQLD 6\VWHP  㸪&RPSRVL[ .XJHO 3DWFK  㸪'LUHFW.XJHO3DWFK 9HQWUDOH[ 3HU㸚[3OXJ ࡞࡝ࡢࢹࣂ

6PDOO 㸪FP 0HGLXP 㸪FP /DUJH ࡢࡶࡢࡀ࠶ࡾ㸪࣊ࣝࢽ࢔㛛ࡢ኱ࡁࡉ࡟ࡼࡗ࡚౑࠸ศࡅࡽࢀࡿ㸬࣊ࣝࢽ࢔㛛ࢆ⫼ഃ࠿ࡽ࢝ࣂ࣮ࡍࡿࡓࡵ࡟㸪࣊ࣝࢽ࢔㛛ࡢᚄࡼࡾࡶ኱ࡁ࠸
࢔࣮ࣥ࢝ᚄࡢࡶࡢࢆ౑⏝ࡍࡿ࡭ࡁ࡜⪃࠼ࡽࢀࡿ㸬ࡲࡓ࣒ࣜ㒊ศࡢ┤ᚄࡀ FP ࡛࠶ࡿࡓࡵ㸪࣊ࣝࢽ࢔㛛ࡢ┤ᚄࡀ FP ࢆ㉸࠼ࡿ⑕౛ࡣᮏἲࡢ㐺ᛂእ࡛࠶ࡾ㸪ᅛᐃ᫬ࡢ࣐࣮ࢪࣥࢆ⪃៖ࡍࡿ࡜㸪࣊ࣝࢽ࢔㛛ࡢ┤ᚄࡀ FP ⛬ᗘࡲ࡛ࡢ⑕౛ࡀᮏἲ
ࡢⰋ࠸㐺ᛂ࡛࠶ࡿ㸬࣒ࣜ㒊ศࡣᚲせ࡟ᛂࡌ࡚ࢺ࣑ࣜࣥࢢࡍ
ࡿࡇ࡜ࡶྍ⬟࡛࠶ࡿ㸬࢜ࣥࣞ࢖ࣃࢵࢳࡢ౑⏝ࡣᇶᮏⓗ࡟୙せ࡜⪃࠼࡚࠸ࡿ㸬ࡲࡓ㸪ࢻ࣮ࣞࣥࡶ୙せ࡛࠶ࡿ㸬ຍ࠼࡚㸪ࢥࢫࢺ㠃࡟ࡘ࠸࡚ࡣ 833 ࡢ㐺ᛂ࡛࠶ࡿ㰡ᚄ࣊ࣝࢽ࢔ࡢಖ㝤デ⒪Ⅼᩘᡂே⮖࣊ࣝࢽ࢔ࡢಟ᚟⾡ࡢಖ㝤デ⒪Ⅼᩘ ᖹᡂ  ᖺᗘ∧ࡣ㸪 Ⅼ࡛࠶ࡿ㸬⮖࣊ࣝࢽ࢔࡟࠾࠸࡚ࡶ 833 ࡣൾ㑏ㄳồࡣྍ⬟࡛࠶ࡾ㸪ൾ㑏౯᱁ࡣ  ෇࡛࠶ࡿࡓࡵࢥࢫࢺ
ୖࡢၥ㢟ࡣᑡ࡞࠸࡜⪃࠼ࡽࢀࡿ㸬་Ꮫ୰ኸ㞧ㄅ࡟࡚  ᖺ࠿ࡽ  ᖺ  ᭶ࡲ࡛ࡢᮇ㛫ࠕ࣓ࢵࢩࣗࠖࢆ࣮࣮࢟࣡
࡛㸪ࠕ⮖࣊ࣝࢽ࢔ࠖ
ࠕ8/75$352 3OXJࠖࢻ࡜ࡋ᳨࡚⣴ࡋࡓ࡜ࡇࢁ㸪⮖࣊ࣝࢽ࢔࡟ᑐࡋ 833 ࡟ࡼࡿಟ᚟⾡ࢆ⾜ࡗࡓᮏ㑥ㄽᩥሗ࿌౛ࡣࢃࢀࢃࢀࡀሗ࿌ࡋࡓ  ౛ࡢࡳ࡛࠶ࡗࡓ  㸬ᮏἲࡢ㛗ᮇᡂ⦼࡟ࡘ࠸࡚ࡣ௒ᚋࡢ⤒㐣ほᐹࡀᚲせ࡛࠶ࡿࡀ㸪833 ࡣᡂே⮖࣊ࣝࢽ࢔࡟ᑐࡍࡿಟ᚟ᮦ࡜
ࡋ࡚ࡶ᭷⏝࡛࠶ࡿ࡜⪃࠼ࡽࢀࡓ㸬ᮏ㑥࡛ࡣ㧗㱋໬ࡸ⫧‶౛ࡢቑຍ࡟క࠸㸪ᡂேࡢ⮖࣊ࣝࢽ࢔౛ࡣቑຍࡋࡘࡘ࠶ࡿࡀ㸪࣓ࢵࢩࣗࢆ⏝࠸ࡓ⮖࣊ࣝࢽ࢔ಟ
᚟⾡ࡢ᪋⾜౛ࡣᑡ࡞ࡃ㸪௒ᚋࡉࡽ࡞ࡿ⑕౛ࡢ᳨ウࡸ⾡ᘧࡢ᳨ウࡀᚲせ࡛࠶ࡿ㸬結࢖ࢫࢆ⏝࠸ࡓಟ᚟⾡ࡀሗ࿌ࡉࢀ࡚࠸ࡿࡀ㸪௒ᅇࢃࢀࢃࢀࡣ
 ᖺ  ᭶࡟ᅜෆⓎ኎ࡉࢀࡓ 833 ࢆ⏝࠸ࡓಟ᚟⾡ࢆ⾜ࡗࡓ㸬語ᡂே⮖࣊ࣝࢽ࢔࡟ᑐࡋ㸪833 ࢆ⏝࠸ࡓಟ᚟⾡ࢆ⾜࠸Ⰻዲ࡞⤖ᯝࢆᚓࡓࡢ࡛ሗ࿌ࡋࡓ㸬

833 ࡣ㸪 ḟඖᵓ㐀ࡢࣉࣛࢢ࡜㸪ࣇࣛࢵࢺ࡞࢜ࣥࣞ࢖ࣃࢵ
ࢳ࠿ࡽ࡞ࡾ㸪㠀྾཰ᛶࡢࣉ࣮ࣟࣜࣥ࡜㸪྾཰ᛶࡢࣔࣀࢡࣜ
ࣝ࡟ࡼࡾ⦅ᡂࡉࢀࡓࣁ࢖ࣈࣜࢵࢻᆺ࣓ࢵࢩ࡛ࣗ࠶ࡾ㸪୺࡟㰡ᚄ࣊ࣝࢽ࢔ࡢಟ᚟ࢆ┠ⓗ࡜ࡋ࡚⏝࠸ࡽࢀࡿ㸬࣓ࢵࢩࣗࡢ
Ꮝᚄࡀ኱ࡁ࠸ ODUJH SRUH ࡇ࡜࡟ࡼࡾ㸪㐣๫࡞⒕⑞⤌⧊᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍ᖹᡂ  ᖺᗘ∧  Ⅼ࡟ᑐࡋ࡚㸪文献 ᮌᮏㄔ஧㸪࿴⏣㐩㞝㸬᪂እ⛉Ꮫ኱⣔ %㸪⮖࣊ࣝࢽ࢔㸸ᒣ୰ฟ∧㸹㸬 ቑᒣ႐୍㸪ᰆᮌᚭ㸪ᒣ⏣᫂㸪㜿㒊せ୍㸬࢖ࣞ࢘ࢫࢆ࿊
ࡋࡓᡂே⮖࣊ࣝࢽ࢔ᔐ㡻ࡢ  ౛㸬᪥⭡㒊ᩆᛴ་఍ㄅ㸪9RO1R

-XQ   ᒣᮏ⿱㸪ྜྷ⏣༤அ㸪㣤㔝୚ᚿ⨾㸪ᆏ⏣㐨⏕㸪᳜⏣ṇ᫛㸬ᡂே⮖࣊ࣝࢽ࢔ᔐ㡻ࡢ  ౛㸬⮫ᗋእ⛉  $XJ   ▮྿Ύ୍㸬኱㔞⭡Ỉ࡟ࡼࡿ⮖࣊ࣝࢽ࢔◚⿣ࡢ  ౛㸬᪥⮫ እ ఍ ㄅ  2FW     &LWHG LQ
3XE0HG30,' 㧗ᶫ⚽๎㸪ྜྷ⏣ᆂ௓㸪᭤ῲ㐩㞝㸬⓶⭵ቯṚࢆకࡗࡓᡂ
ேᕧ኱⮖࣊ࣝࢽ࢔ᔐ㡻ࡢ  ⑕౛㸬᪥⭡㒊ᩆᛴ་఍ㄅ
㸹  㸸
 Ώ㎶ಖᖾ㸪ྂᕝ◊୍㑻㸪బ⸨඾ᏹ㸪኱㔛㝯㸪Ọῲ୍ග㸪ᶓ⏿࿴⣖㸪HW DO ⫢◳ኚ⑕࡟ࡼࡿ኱㔞⭡Ỉ࡟క࠺ᡂே
⮖࣊ࣝࢽ࢔ᔐ㡻ࡢ  ἞㦂౛㸬እ⛉  'HF    ๓⃝Ẏ㸪ᖹᰩᏛ㸪ⲡ㛫ᚊ㸪すᑿ⛅ே㸪Ᏻ㐩⎰㸪▼஭ᜨᏊ㸪
HW DO ࢔ࣝࢥ࣮ࣝᛶ⫢◳ኚ࡟ࡼࡿᕧ኱⮖࣊ࣝࢽ࢔◚⿣ࡢ  ౛㸬ᾘ໬ჾእ⛉-XO   ➉ཎΎே㸪᳃ᘅಇ᫛㸪⸨ཎ⿱Ꮚ㸪Ύ⏣ṇஅ㸪⏣୰ᒇᏹ∞㸪➉ෆோྖ㸬8/75$352 3OXJ ࢆ⏝࠸࡚ಟ᚟ࡋࡓᡂே⮖࣊ࣝࢽ࢔ࡢ୍౛㸬እ⛉἞⒪1RY   㸫  ἈỌຌኴ㸦⦅㸧 ࣊ࣝࢽ࢔ࡢࡍ࡭࡚  ࡬ࡿࡍฟ∧   $UUR\R $ *DUF¯D 3 3«UH] ) $QGUHX - &DQGHOD
)&DOSHQD55DQGRPL]HGFOLQLFDOWULDOFRPSDULQJVXWXUH DQG PHVK UHSDLU RI XPELOLFDO KHUQLD LQ
DGXOWV %U - 6XUJ  2FW    
&LWHGLQ3XE0HG30,'   9 H Q F O D X V N D V  /   6 L O D Q V N D L W H  -   . L X G H O L V0 8PELOLFDO KHUQLD IDFWRUV LQGLFDWLYH RI
UHFXUUHQFH 0HGLFLQD .DXQDV      &LWHGLQ3XE0HG30,'

᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

 .KHUD*%HUVWRFN'$,QFLVLRQDOHSLJDVWULFDQG
XPELOLFDOKHUQLDUHSDLUHXVLQJWKH3UROHQH+HUQLD
6\VWHP+HUQLDࠉ$XJ  &LWHGLQ
3XE0HG30,'  6LQKD 61 .HLWK 7 0HVK SOXJ UHSDLUH IRUSDUDXPELOLFDOKHUQLD6XUJHRQ$SU  &LWHGLQ3XE0HG30,'  ୰ᕝᅜ฼  㕥ᮌᖾṇ  ㇏ᓥ㝯  ᱈㔝ဴ  బࠎᮌ㝧ᖹ  ᡭᓥ㈆୍  3UROHQH +HUQLD 6\VWHP ࢆ⏝࠸ࡓ⮖࣊ࣝࢽ࢔ಟ᚟⾡㸬ᡭ⾡ࠉ-XO㸸   ୰ᕝᅜ฼㸪⸈ෆఙ୍㸪ᑠᯘ↷ᛅ㸪㐲⸨බே㸪㕥ᮌᖾṇ㸪᱈㔝ဴ㸬࣓ࢵࢩ࡛ࣗಟ᚟ࡋࡓᡂே㰡ᚄ࣊ࣝࢽ࢔౛ࡢ᳨
ウ㸬እ⛉-DQ    ᒸᓮㄔ㸪ᱵᮏ೺ྖ㸪ᖹሯṇᘯ㸸ࢥ࣏ࣥࢪࢵࢡࢫ .XJHOࣃࢵࢳࢆ౑⏝ࡋࡓᡂே⮖࣊ࣝࢽ࢔ࡢ  ᡭ⾡౛㸬እ⛉'HF  㸸  Ỉ ἟ ࿴ அ㸪 ୰ ሯ ༤ ᩥ㸪 ⸨ 㧗 Ⴙ ⏕  ୰ ᓥ ┿ ኴ 㑻㸬
'LUHFW .XJHO ࣃࢵࢳࢆ⏝࠸ࡓ⮖࣊ࣝࢽ࢔ࡢ୍ᡭ⾡౛㸬እ⛉἞⒪ 0DU  㸸  㧗ஂ⚽ဢ㸪ụ⏣┤ဢ㸪㛗಴ᡂ᠇  㕥ᮌಇ⦾  㰺⡢ⱥಇ ࠉ9HQWUDOH[ ࢆ⏝࠸ࡓ⮖࣊ࣝࢽ࢔ಟ᚟⾡ࡢ୍౛㸬እ⛉἞⒪ 0D\  㸸㸬  ዟ⏣┤ே㸪Ἑྜ⣧㸪Ọ஭ᬛ㸬ࣉࣛࢢࢆ⏝࠸࡚ಟ᚟ࡋࡓᡂே㰡ᚄ࣊ࣝࢽ࢔ᔐ㡻ࡢ  ౛㸬እ⛉  2FW     0 X \ V R P V  ) (   % R Q W L Q F N  -   3 O H W L Q F N [  3 
&RPSOLFDWLRQVRIPHVKGHYLFHVIRULQWUDSHULWRQHDOXPELOLFDO KHUQLD UHSDLU D ZRUG RI FDXWLRQ+HUQLD  $XJ     &LWHG LQ
3XE0HG30,'

9RO1R)LJࠉ833 ࡢ࣒ࣜࢆ⭡┤➽㠧࡟⦭ྜᅛᐃࡋࡓ㸬)LJࠉ࣊ࣝࢽ࢔ᄞࢆ࿘ᅖ⤌⧊࠿ࡽ๤㞳ࡋࡓ㸬

)LJࠉ⾡ᘧࡢࢩ࢙࣮࣐ᩥ⊩  ࡼࡾᨵኚ

)LJࠉ833 ࡢ࢔࣮ࣥ࢝ࢆ⭡⭷๓⭍࡟ᤄධࡋࡓ㸬

1
2
3
4
5
6

ᖺ㱋 ᛶู
㻡㻥
㻲
㻡㻢
㻲
㻣㻣
㻲
㻡㻣
㻲
㻡㻣
㻹
㻢㻠
㻹

㯞㓉ἲ
඲㌟㯞㓉
⭜᳝㯞㓉
඲㌟㯞㓉
⭜᳝㯞㓉
⭜᳝㯞㓉
⭜᳝㯞㓉

୺ッ
⮖㒊⭾㝯
⮖㒊⭾㝯
⮖㒊⭾㝯
⮖㒊⭾㝯
⑊③
⮖㒊⭾㝯

⑓ᝎᮇ㛫
㻝䛛᭶
㻝ᖺ
㻡ᖺ
㻝䛛᭶
㻞䛛᭶
㻠䛛᭶

BMI
27.1
25.1
31.5
27.6
25.4
23.1

ేᏑ⑌ᝈ

⭡Ỉ

䝦䝹䝙䜰㛛䛾኱䛝䛥

UPP

㻝㻚㻡㼏㼙

㻯ᆺ⫢◳ኚ
⢾ᒀ⑓
Cᆺ⫢◳ኚ
䜰䝹䝁䞊䝹ᛶ⫢◳ኚ䜰䝹䝁䞊䝹ᛶ⫢⅖

䛺䛧
䛒䜚
䛺䛧
䛒䜚
䛒䜚
䛺䛧

㻿㻌㼟㼕㼦㼑
㻿㻌㼟㼕㼦㼑
㻸㻌㼟㼕㼦㼑
㻿㻌㼟㼕㼦㼑
㻿㻌㼟㼕㼦㼑
㻿㻌㼟㼕㼦㼑

0.8cm

㻠㼏㼙
2.5cm

㻝㼏㼙
㻞㻚㻡㼏㼙

ഛ⪃

ᶓ⾜⤖⭠ᔐ㡻䜢Ⓨ⑕

7DEOHࠉ⮖࣊ࣝࢽ࢔ಟ᚟⑕౛

᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

9RO1R

Adult umbilical hernias repaired with ULTRAPRO* Plug
1)Surgery, National Hospital Organization Iwakuni Clinical Center
2)Gastroenterological Surgery, Okayama University
1,2)

Yuko Takehara , Kiyoto Takehara 1,2) , Sho Takeda 1) , Toshiaki Morihiro 1) ,Koji Tanakaya 1) , Hideki Aoki 1) , Hitoshi Takeuchi 1)
Abstract
Umbilical hernia is relatively rare in Japan. From June 2010 to June 2011, we treated six umbilical hernia patientswith ULTRAPRO* Plug (UPP). Two patients were male and four were female. The average age was 61.7 (56–77)
years. We performed surgery for two patients under total anesthesia and for four patients under lumbar anesthesia. The
        

         

patient had an incarcerated hernia. None of our patients had either postoperative complications or recurrence.
We demonstrate herein the advantages of the UPP procedure; 1) Patients experience minimal foreign-bodysensations and pain. 2) UPP can doubly reinforce a weak abdominal wall in the pre-peritoneal space and the rectus
sheath based on the double-layered structure of the anchor and rim. 3) This procedure avoids adhesion of mesh to theintestine. 4) UPP is minimally obstructive to laparotomy when necessary. 5) The UPP procedure is simple.
We expect UPP to be recognized as a useful procedure for umbilical hernia repair when the hernia diameter is lessthan 4 cm.
Key words:adult umbilical hernia, ULTRAPRO* Plug, mesh䠎䠌䠍䠏ᖺ䠕᭶䠎䠐᪥ཷࠉ⌮᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

9RO1R原著
腹壁瘢痕ヘルニア修復術における Direct Kugel Patch の有用性-$ ໭ᾏ㐨ཌ⏕㐃ࠉᮐᖠཌ⏕⑓㝔ࠉእ⛉㇂ᒸ฼ᮁࠊ㧗ᶫ࿘స要旨࠙┠ⓗࠚ㰡ᚄ࣊ࣝࢽ࢔ಟ᚟⾡࡟࠾ࡅࡿ࣓ࢵࢩࣗࡢ  ࡘ࡟ 'LUHFW .XJHO 3DWFK ௨ୗࢲ࢖ࣞࢡࢺࢡ࣮ࢤࣝ ࡀ࠶ࡿࠋࢫ
ࢺࣛࢵࣉ࡜ᙧ≧グ᠈ࣜࣥࢢ࡟ࡼࡾ๓᪉࢔ࣉ࣮ࣟࢳ࡟࠾ࡅࡿ࣓ࢵࢩࣗࡢᒎ㛤࡜ᅛᐃࢆᐜ᫆࡟ࡋ࡚࠸ࡿࠋࡑࡢ≉ᚩࢆ฼⏝ࡋ࡚ࠊᙜ⛉࡛ࡣ⭡ቨ⒕⑞࣊ࣝࢽ࢔࡟ᑐࡋ࡚ࢲ࢖ࣞࢡࢺࢡ࣮ࢤࣝࢆ⏝࠸ࡓಟ᚟ἲࢆ⾜࠸Ⰻዲ࡞ᡂ⦼ࢆᚓ࡚࠸ࡿࠋ࠙᪉ἲࠚ
 ᖺ  ᭶࠿ࡽ  ᖺ  ᭶ࡲ࡛࡟ᙜ⛉࡛⾜ࢃࢀࡓ⭡ቨ⒕⑞࣊ࣝࢽ࢔ಟ᚟⾡ࡣ  ౛ࢆᑐ㇟࡟ࠊᝈ⪅⫼ᬒࠊᡭ⾡ᡂ⦼࡟ࡘ࠸᳨࡚ウࡋࡓࠋࢲ࢖ࣞࢡࢺࢡ࣮ࢤࣝࢆ⏝࠸ࡓᡭ⾡࡛ࡣࠊࡍ࡭࡚࣊ࣝࢽ࢔㛛ࡼࡾ࣊ࣝࢽ࢔ᄞࢆ๤㞳࣭㑏⣡ࡋࡓᚋ࡟ࢲ
࢖ࣞࢡࢺࢡ࣮ࢤࣝࢆᤄධࡋ࡚࠸ࡿࠋࢲ࢖ࣞࢡࢺࢡ࣮ࢤࣝࡢᤄධ㒊఩ࡣ⭡⭷๓ࡶࡋࡃࡣ➽⫗࡞࠸ࡋࡣ⭝⭷ୗ࡛࠶ࡾࠊࢫ
ࢺࣛࢵࣉࢆ➽⭷ࡶࡋࡃࡣ⭝⭷ୖ࡛ᅛᐃࡋ࡚࠸ࡿࠋ࠙⤖ᯝࠚ඲  ౛ࡢෆࠊ ౛  ࡟࣓ࢵࢩࣗࢆ⏝࠸ࡓಟ᚟ࢆ᪋⾜ࡋࠊࡑࡢ࡞࠿ࡢ  ౛  ࡟ࢲ࢖ࣞࢡࢺࢡ࣮ࢤࣝࢆ⏝࠸ࡓಟ᚟ἲࢆ᪋⾜ࡋࡓࠋ ౛ࡢᖹᆒᖺ㱋ࡣ  ṓࠊᖹᆒ %0, %RG\
0DVV ,QGH[ ࡣ ࠊᖹᆒᡭ⾡᫬㛫ࡣ  ศࠊᖹᆒฟ⾑㔞ࡣ PO ࡛࠶ࡗࡓࠋ๓ᅇࡢᡭ⾡ࡣࠊ㛤⭡ᡭ⾡࡟క࠺ṇ୰๰ࡀ  ౛ࠊ
⹸ᆶษ㝖⾡࡟క࠺஺ᕪษ㛤๰ࡀ  ౛ࠊࢻ࣮ࣞࣥ๰ࡀ  ౛࡛࠶ࡗࡓࠋ඲  ⑕౛୰ࡢ  ౛  ࡟෌Ⓨࢆㄆࡵࡓࡀࠊ
ࢲ࢖ࣞࢡࢺࢡ࣮ࢤࣝࢆ౑⏝ࡋࡓ  ౛࡟ࡣ෌Ⓨࡣㄆࡵ࡞࠿ࡗࡓࠋ
࠙⤖ㄒࠚ⭡ቨ⒕⑞࣊ࣝࢽ࢔ಟ᚟⾡࡟࠾࠸࡚ࢲ࢖ࣞࢡࢺࢡ࣮
ࢤࣝࡣ᭷⏝࡞࣓ࢵࢩࣗࡢ  ࡘ࡜⪃࠼ࡿࠋ࣮࣮࢟࣡ࢻ㸸⭡ቨ⒕⑞࣊ࣝࢽ࢔㸪ࢲ࢖ࣞࢡࢺࢡ࣮ࢤࣝ

⒕⑞࣊ࣝࢽ࢔ಟ᚟⾡ࡣ  ⑕౛ࢆᑐ㇟࡜ࡋࡓࠋ

はじめに⭡ቨ⒕⑞࣊ࣝࢽ࢔ࡣ㛤⭡ᡭ⾡࡟࠾ࡅࡿ⾡ᚋྜే⑕ࡢ  ࡘ࠙ࢲ࢖ࣞࢡࢺࢡ࣮ࢤࣝ࡟ࡼࡿಟ᚟ἲࠚ
ᡭ⾡ࡣࡍ࡭࡚࣊ࣝࢽ࢔㛛ࡼࡾ࣊ࣝࢽ࢔ᄞࢆ๤㞳࣭㑏⣡ࡋ࡛࠶ࡾࠊࡑࡢⓎ⏕㢖ᗘࡣ  ⛬ᗘ࡜ゝࢃࢀ࡚࠸ࡿ  ࠋಟ᚟ἲ࡟ࡣᵝࠎ࡞᪉ἲࡀ࠶ࡿࡀࠊ༢⣧⦭ྜ㛢㙐ἲࡼࡾࡶࡁࡉࡣࠊ᭱ప FP ࣊ࣝࢽ࢔㛛ࢆ࣮࢜ࣂ࣮ࣛࢵࣉྍ⬟࡞ࢧ࢖࣓ࢵࢩࣗࢆ⏝࠸ࡓಟ᚟ἲࡢ᪉ࡀ෌Ⓨ⋡ࡣప࠸  ࠋ㰡ᚄ࣊ࣝࢽ࢔ࡢಟ᚟࡟⏝࠸ࡿ࣓ࢵࢩࣗࡢ  ࡘ࡟ 'LUHFW.XJHO 3DWFKp ௨ୗࢲ࢖ࣞࢡࢺࢡ࣮ࢤࣝ

ࡓᚋ࡟ࢲ࢖ࣞࢡࢺࢡ࣮ࢤࣝࢆᤄධࡋ࡚࠸ࡿࠋ࣓ࢵࢩࣗࡢ኱

ࡀ࠶ࡿࠋࡇࢀ

ࡣࢫࢺࣛࢵࣉ࡜ᙧ≧グ᠈ࣜࣥࢢ࡟ࡼࡾ๓᪉࢔ࣉ࣮ࣟࢳ࡟
ࡼࡿ⭡⭷๓⭍࡬ࡢ࣓ࢵࢩࣗࡢᒎ㛤࡜ᅛᐃࢆᐜ᫆࡟ࡋ࡚࠸
ࡿࠋࡑࡢ≉ᚩࢆ⏕࠿ࡋᙜ⛉࡛ࡣ⭡ቨ⒕⑞࣊ࣝࢽ࢔࡟ᑐࡋ࡚

ࢬࢆ㑅ᢥࡋ࡚࠸ࡿࠋ࣓ࢵࢩࣗࡢᤄධ㒊఩ࡣ⭡⭷๓ࡀᮃࡲࡋ
࠸ࡀࠊ๓ᅇࡢᡭ⾡᧯స࡟ࡼࡿ⒵╔࡟ࡼࡾ⭡⭷๓⭍ࡢ༑ศ࡞๤㞳ࡀᅔ㞴࡞ሙྜࡀ࠶ࡿࠋࡑࡢ㝿ࡣ➽⭷ࡶࡋࡃࡣ⭝⭷ࡢୗ࡜ࡋ࡚࠸ࡿࠋࢫࢺࣛࢵࣉࡣ➽⭷ࡶࡋࡃࡣ⭝⭷ୖ࡟྾཰⣒ࢆ⏝࠸࡚ᅛᐃࡋ࡚࠸ࡿࠋ
ᐇ㝿ࡢ⑕౛࡜࡜ࡶ࡟ᡭ⾡ᡭᢏࢆ࿊♧ࡍࡿࠋ⑕౛ࡣ  ṓࢲ࢖ࣞࢡࢺࢡ࣮ࢤࣝࢆ⏝࠸ࡓಟ᚟ἲࢆ⾜࠸Ⰻዲ࡞ᡂ⦼ࢆ

ࡢዪᛶ࡛ࠊ⣙  ᖺ๓࡟ཷࡅࡓ⫹⟶✵⭠࿀ྜ⾡ࡢࢻ࣮ࣞࣥᚓ࡚࠸ࡿࠋᙜ⛉࡛⾜ࡗࡓ⭡ቨ⒕⑞࣊ࣝࢽ࢔ᡭ⾡࡟ᑐࡍࡿ௚ࡢಟ᚟ἲ

࢔㛛ࡢ኱ࡁࡉࡣ   FP ࡛࠶ࡾࠊ❧఩ࡸ⭡ᅽ࡛࣊ࣝࢽ࢔

࡜ࡢᡂ⦼ࢆẚ㍑᳨ウࡋሗ࿌ࡍࡿࠋ目๰࡟⏕ࡌࡓ⭡ቨ⒕⑞࣊ࣝࢽ࢔࡛࠶ࡗࡓ )LJD ࠋ࣊ࣝࢽࡢ⬺ฟࢆㄆࡵࡿࡀࠊ⮩఩࡛ࡣ㑏⣡ྍ⬟࡛࠶ࡗࡓࠋ⭡㒊 &7

的࡛⬺ฟࡋࡓ⭠⟶ࢆ☜ㄆ࡛ࡁࡓ )LJE ࠋ⭠⟶ࡢᦆയ࡟␃

⭡ቨ⒕⑞࣊ࣝࢽ࢔ಟ᚟⾡࡟࠾࠸࡚ࠊࢲ࢖ࣞࢡࢺࢡ࣮ࢤࣝ

ពࡋ࡞ࡀࡽࠊ࣊ࣝࢽ࢔ᄞࢆ๤㞳ࡋࠊ㑏⣡ࡋゎ๗ࢆ☜ㄆࡋ࡟ࡼࡿಟ᚟ἲࢆ௚ࡢ᪉ἲ࡜ẚ㍑ࡋࠊࢲ࢖ࣞࢡࢺࢡ࣮ࢤࣝࢆࡓ )LJ ࠋ࣓ࢵࢩࣗࡢ኱ࡁࡉࡣ┤ᚄ FP ࡢ / ࢧ࢖ࢬ⏝࠸ࡓಟ᚟ἲࡢ᭷⏝ᛶࢆ᳨ウࡍࡿࠋࢆ㑅ᢥࡋࡓࠋ๓ᅇᡭ⾡ࡢ⒵╔࡟ࡼࡾ⭡⭷๓⭍ࡢ๤㞳ࡣᅔ

方法㞴࡛࠶ࡗࡓࡓࡵࠊእ⭡ᩳ➽ࡢୗ࡬࣓ࢵࢩࣗࢆ␃⨨ࡋࡓᚋࠊ࠙ᑐ㇟ࠚ ࡢ྾཰⣒ࢆ⏝࠸࡚➽⭷࡬ࢫࢺࣛࢵࣉࢆᅛᐃࡋ㛢๰ࡋࡓ ᖺ  ᭶࠿ࡽ  ᖺ  ᭶ࡲ࡛࡟ᙜ⛉࡛⾜ࡗࡓ⭡ቨ)LJ ࠋ᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

9RO1R結࡟࡛ࡶ⡆౽࡟ࡑࡋ࡚☜ᐇ࡟ᢅ࠼ࡿࡇ࡜ࡀࠊ⾡ᚋࡢ෌Ⓨ⋡ࢆ果඲  ౛ ࡢ ᖹ ᆒ ᖺ 㱋 ࡣ  ṓࠊ ᖹ ᆒ %0, %RG\ 0DVV,QGH[ ࡣ ࠊᖹᆒᡭ⾡᫬㛫ࡣ  ศ࡛࠶ࡗࡓࠋಟ᚟ἲ
ࡣ༢⣧⦭ྜ㛢㙐ἲࠊ࣓ࢵࢩࣗࢆ⏝࠸ࡓಟ᚟ἲ࡜ࡶ࡟  ౛࡛࠶ࡗࡓࠋಟ᚟࡟⏝࠸ࡽࢀࡓ࣓ࢵࢩࣗࡢ✀㢮ࡣࠊ&RPSRVL[.XJHO0HVKp ࡀ  ౛ࠊ'LUHFW.XJHO3DWFKp ࡀ  ౛ࠊ.XJHO3DWFKp ࡀ  ౛ࠊࡑࡢ௚  ౛࡛࠶ࡗࡓࠋᖹᆒᖺ㱋  ṓࠊᖹᆒ %0,ࠊᖹᆒᡭ⾡᫬㛫 ศࠊᖹᆒฟ⾑㔞PO࡛࠶ࡗࡓࠋ࣓ࢵࢩࣗ౑⏝ࡢ᭷↓ࠊ౑⏝ࡋࡓ࣓ࢵࢩࣗࡢ✀㢮࡞࡝࡛ࠊࡑࢀࡒࢀࡢᡂ⦼࡟ᕪࢆㄆࡵ࡞࠿ࡗࡓࠋ෌Ⓨࡣ
&RPSRVL[ .XJHO 0HVKp ࢆ⏝࠸ࡓ㸯౛  ࡟ࡢࡳㄆࡵࡓ
ࡀࠊࡑࡢ௚ࡢ⑕౛࡛ࡣㄆࡵ࡞࠿ࡗࡓ 7DEOH  ࠋࢲ࢖ࣞࢡ
ࢺࢡ࣮ࢤࣝࢆ⏝࠸ࡓ  ౛ࡢᖹᆒᖺ㱋ࡣ  ṓࠊᖹᆒ %0,పୗࡉࡏࡿ᭱ࡶ㔜せ࡞Ⅼ࡛࠶ࡿ࡜⪃࠼࡚࠸ࡿࡓࡵࠊࡑࡢⅬ࡟࠾࠸࡚ࢲ࢖ࣞࢡࢺࢡ࣮ࢤࣝࡣ⌮࡟㐺ࡗ࡚࠸ࡿ࣓ࢵࢩࣗ
࡛࠶ࡿࠋ␃ពⅬ࡜ࡋ࡚ࡣࠊ࣓ࢵࢩࣗࡢ኱ࡁࡉࡀ / ࢧ࢖ࢬ࡛ࡶ FP ࡛࠶ࡾࠊ࣊ࣝࢽ࢔㛛ࡢ࣮࢜ࣂ࣮ࣛࢵࣉࢆ FP ࡜⪃࠼ࡿ࡜ࠊ࣊ࣝࢽ࢔㛛ࡢ኱ࡁࡉࡀ FP ⛬ᗘ࡟ไ㝈ࡉࢀࡿࡇ࡜ࠊ⭡⭍ෆ࡞࡝࣓ࢵࢩࣗࡀ⭠⟶࡟᥋ࡍࡿᙧ࡛ࡣ␃⨨࡛ࡁ࡞࠸ࡇ࡜ࡀᣲࡆࡽࢀࡿࠋࡲࡓࠊ࣓ࢵࢩࣗ␃⨨ࡢࡓࡵ࡟๤㞳᧯సࡀᚲせ࡜࡞ࡿࡓࡵࠊ๓ᅇ๰ࡀᑠࡉ࡞ሙྜࡣᩚᐜᛶࢆᦆ࡞
࠺ᜍࢀࡀ࠶ࡿࠋࡋ࠿ࡋ㐺ᛂࢆ㑅࡭ࡤࠊࢡ࣮ࢤࣝࣃࢵࢳࡣ⡆౽࠿ࡘ☜ᐇ࡟౑⏝ྍ⬟࡛࠶ࡾࠊᡂ⦼ࡢⅬ࡛௚ࡢ࣓ࢵࢩࣗ࡟
ຎࡽ࡞࠸ࡓࡵࠊ⭡ቨ⒕⑞࣊ࣝࢽ࢔ಟ᚟⾡࡟࠾࠸࡚ࡶ㠀ᖖ࡟᭷⏝࡞࣓ࢵࢩࣗ࡜࠸࠼ࡿࠋࡣ ࠊᖹᆒᡭ⾡᫬㛫ࡣ  ศࠊᖹᆒฟ⾑㔞ࡣ PO ࡛

文࠶ࡗࡓࠋ๓ᅇࡢᡭ⾡ࡣࠊ㛤⭡ᡭ⾡࡟క࠺ṇ୰๰ࡀ  ౛ࠊ⹸ᆶษ㝖⾡࡟క࠺஺ᕪษ㛤๰ࡀ  ౛ࠊࢻ࣮ࣞࣥ๰ࡀ  ౛࡛࠶ࡗࡓࠋ⾡ᚋほᐹᮇ㛫ࡣ᭱ప࡛  ᖺ࡛࠶ࡗࡓ 7DEOH  ࠋྛ⾡ᘧࡢ≉ᚩࢆ⾲࡟ࡋࡓ 7DEOH ࠋ

考察㛤⭡ᡭ⾡ᚋࡢ⭡ቨ⒕⑞࣊ࣝࢽ࢔ࡢⓎ⏕⋡ࡣࠊ ࠥ ࡜࠸࠺ሗ࿌ࡀ࠶ࡾࠊࡑࡢᩘ್ࡣỴࡋ࡚ప࠸ࡶࡢ࡛ࡣ࡞࠸ ࠋ⭡ቨ⒕⑞࣊ࣝࢽ࢔࡟ᑐࡍࡿಟ᚟ἲ࡟ࡣᵝࠎ࡞᪉ἲࡀ
࠶ࡿࡀࠊ࣓ࢵࢩࣗࢆ⏝࠸࡞࠸༢⣧㛢㙐ἲ࡜ࠊ࣓ࢵࢩࣗࢆ
⏝࠸ࡓ WHQVLRQ IUHH ἲࡢ኱ࡁࡃ  ✀㢮࡟ศ࠿ࢀࡿࠋಟ᚟
⾡ᚋࡢ෌Ⓨ⋡ࡣ༢⣧㛢㙐ἲ࡛ࡣ  ࡛࠶ࡿࡢ࡟ᑐࡋࠊ
WHQVLRQ IUHH ἲ࡛ࡣ  ࡜ప࠸್࡛࠶ࡾࠊ࣓ࢵࢩࣗࡢ
౑⏝࡟ࡼࡾᡂ⦼ࡣ኱ࡁࡃᨵၿࡍࡿ  ࠋࡋ࠿ࡋ࣓ࢵࢩࣗ
ࡢ౑⏝࡟ࡼࡿᵝࠎ࡞ྜే⑕ࡶሗ࿌ࡉࢀ࡚ࡁ࡚࠾ࡾ  ࠊ࣓ࢵࢩࣗࡢ౑⏝ἲࠊ㑅ᢥἲ࡟ࡶ᫂☜࡞ᇶ‽ࡣタࡅࡽࢀ࡚࠸
࡞࠸ࠋࡑࡇ࡛ᙜ⛉࡛ࡣࢲ࢖ࣞࢡࢺࢡ࣮ࢤࣝࢆ౑⏝࣓ࢵࢩࣗࡢ㑅ᢥࡢ  ࡘ࡜ࡋ࡚࠸ࡿࠋࢲ࢖ࣞࢡࢺࢡ࣮ࢤࣝࡣ㰡ᚄ࣊ࣝࢽ࢔
ಟ᚟⾡࡟࠾࠸࡚㛗ᖺࡢ౑⏝ᐇ⦼ࡀ࠶ࡾࠊࡑࡢᏳᐃᛶ࡜Ᏻ඲
ᛶࡣ༑ศ࡟ಖドࡉࢀ࡚࠸ࡿ   ࠋࢲ࢖ࣞࢡࢺࢡ࣮ࢤࣝ
ࡢ≉ᚩ࡜ࡋ࡚ࡣࠊձࢫࢺࣛࢵࣉ࡟ࡼࡾ࣓ࢵࢩࣗࡢ఩⨨Ỵࡵࠊ␃⨨ࠊᅛᐃࡀ⡆౽࠿ࡘᏳᐃࡋ࡚⾜࠼ࡿࡇ࡜ࠊղ࣏ࢪࢩࣙ
ࢽࣥࢢ࣏ࢣࢵࢺࡀ࣓ࢵࢩࣗࡢ㐍ᒎ⿵ຓ࡟ᙺ❧ࡘࡇ࡜ࠊճࣜ
ࢥ࢖ࣝࣜࣥࢢ࡟ࡼࡾ࣓ࢵࢩࣗࡢᙧ≧ࡀ⥔ᣢࡉࢀࠊࡑࢀ࡟ࡼ

献 YDQ W 5LHW 0 6WH\HUEHUJ ( : 1HOOHQVWH\Q -
%RQMHU+--HHNHO-0HWDDQDO\VLVRIWHFKQLTXHVIRU FORVXUH RI PLGOLQH DEGRPLQDO LQFLVLRQV 7KH%ULWLVKMRXUQDORIVXUJHU\  
 %XUJHU - : /XLMHQGLMN 5 : +RS : & +DOP - $
9HUGDDVGRQN(*-HHNHO-/RQJWHUPIROORZXSRID UDQGRPL]HG FRQWUROOHG WULDO RI VXWXUH YHUVXV
PHVK UHSDLU RI LQFLVLRQDO KHUQLD $QQDOV RI
VXUJHU\  GLVFXVVLRQ
 /XLMHQGLMN 5 : +RS : & YDQ GHQ 7RO 0 3 GH
/DQJH ' & %UDDNVPD 0 0 -1 , - HW DO $
FRPSDULVRQ RI VXWXUH UHSDLU ZLWK PHVK UHSDLU IRULQFLVLRQDO KHUQLD 7KH 1HZ (QJODQG MRXUQDO RI
PHGLFLQH   ᆏ㒊㱟ኴ㑻  బ⸨ᖾ㞝  బ఑ಟ஧  ྥ⏣⚽๎  ᖹᯘ┤ᶞ ከᗄᒣ΅ &RPSRVL[.XJHO3DWFK ࢆ⏝࠸ࡓ⭡ቨ
⒕⑞࣊ࣝࢽ࢔ಟ᚟⾡ࡢ᳨ウ  ᪥ᮏ⮫ᗋእ⛉Ꮫ఍㞧ㄅ   
 ከ㈡ㄔ  Ᏺ㯞⌮Ꮚ  ᑠᓥ࿴ே  ᘅᒸᫎ἞  ὸ㔝༤ ⠛ሯᮃ  ⭡ቨ⒕⑞࣊ࣝࢽ࢔⾡ᚋࡢ₢ᾮ⭘ࡢ᳨ウ  እ
⛉    ᯘ㐩ஓ  ᐑᓮ຾  ఀ⸨༤  ㄶゼᩄ୍  ఀྂ⏣ຬே ⭡ቨ⒕⑞࣊ࣝࢽ࢔࣓ࢵࢩࣗಟ᚟⾡ᚋ  ᖺ࡛࣓ࢵࢩࣗᑠ
⭠✸㏻ࢆࡁࡓࡋࡓ  ౛  ⮫ᗋእ⛉     ௒ὠᾈ႐ ቑ஭฼ᙪ 'LUHFW.XJHOSDWFK ࢆ⏝࠸ࡓ㰡ᚄ࣊ࣝࢽ࢔ᡭ⾡ ⮫ᗋእ⛉    ▼ ᓮ 㞞 ᾈ  㧗 ᔱ ᡂ ㍤  ᯇ ᒸ Ḡ ஓ  'LUHFW .XJHO3DWFK '. ἲ ࢆ౑⏝ࡋࡓ࣊ࣝࢽ࢔᰿἞⾡̾3+6 ἲ 0HVK3OXJ ἲ࡜ࡢẚ㍑̾ᡭ⾡   

ࡾ⬤ᙅࡋࡓ⭡ቨࡢ⿵ᙉࡀ⾜࠼ࡿࡇ࡜࡞࡝ࡀᣲࡆࡽࢀࡿࠋㄡ

᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

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Usefulness of Direct Kugel Patch repair for abdominal incisional
hernia#  <E9^$ q  !

Q Q{E< {Q{ 
Abstract
Background: Direct Kugel Patch is one of the mesh for abdominal incisional hernia. The strap and re-coil ring!  "   "          ! # $ ! %for the abdominal incisional hernia.
&' +  /  8 8 &  ! !  9<=>?# &=@=8 # $ ! E  E8!         Q8   # $ ! Q      !E ? 
under-aponeurosis.
% ! +V!!/  E    @X  ZX[\E # $ ! X  Z@]>[\^  8 ]_]< ?! E & <   "8 =/E^    8 ]_   &! ! 8 / !   8   !  &  !  <E   
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cases of Direct Kugel Patch repair.
Conclusion: The abdominal incisional hernia repair using Dierect Kugel Patch is a useful procedure.

$<8  !E# $ ! 䠎䠌䠍䠏ᖺ䠍䠌᭶䠔᪥ཷࠉ⌮᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍
᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍



9RO1R総説
腹膜前腔とはどこか？ ー正中アプローチ TEP(Totally ExtraPeritoneal repair) における進入経路の解剖ー
津田沼中央総合病院 外科

朝蔭直樹
要

旨

ヘルニア修復術を行うにあたっていくつかのごく単純な共通認識を持てば、前方アプローチ、経腹腔内アプロー
チ（Transabdominal preperitoneal repair : TAPP）、経腹膜外腔アプローチ（Totally extraperitoneal repair :TEP）いずれにおいても適切な層に到達できると考える。大切なことは腹膜前腔と Retzius 腔との関係、この 2 つの腔を包埋している腹膜外腔の広がりを三次元にイメージすることである。腹膜前腔は腹膜前腔浅葉・深葉とでもいうべき境界面に包まれた疎性結合組織に満たされた間隙であり、Retzius 腔は横筋筋膜・腹膜前腔浅葉間の間隙であって、Retzius 腔と腹膜前腔は腹膜前腔浅葉面で境界されていることを理解するべきである。

キーワード：腹膜前腔，Retzius 腔，腹膜外腔

緒言

腹膜前腔の浅葉面を突破（split、分け入るイメージ）し

我々鼠径ヘルニア修復術に携わる臨床外科医を悩ませる骨盤内臓側筋膜の層構造の難解さを解決するためには、体壁筋と腹膜の間の疎性結合組織に満たされた間隙（以下 areolar tissue cavity） である腹膜外腔（Extraperitoneal space）の理解が重要である。さらに Retzius
腔と腹膜前腔（Pre-peritoneal space）という 2 つの間隙
（佐藤 1) は「腔」は明瞭な空間、内部に疎性結合組織や脂肪を含む空所を「隙」とし space と cavity の使い分けが必要と述べているので、以下 cavity と記載）の存在を明

腹膜前腔に進入する（Fig.1 赤矢印、Fig.2 a,b）。次に、
これまで慣用的に膜のごとく認識されてきた浅葉というボリュームのある疎性結合組織層を体壁側に残すよう壁在化（Parietalization）する（Fig.2 c）。そして、ヘルニア嚢をこれまで慣用的に深葉と認識されてきた疎性結合組織層から剥離脱転し、Retzius 腔・腹膜前腔にまたがる空間（下腹壁動静脈を境に内側は体壁筋を覆った横筋筋
膜面、外側は体壁筋を覆った横筋筋膜・腹膜前腔疎性結合
組織面となる）を確保して（Fig.2 d）メッシュを展開する（Fig.3 赤線）4)。ただ従来の慣用的な浅葉・深葉といらかにし、正しい共通認識を持つことが必要である。
我々は腹腔鏡下鼠径ヘルニア修復術を単孔式（以下TANKO）Totally extraperitoneal repair（以下 TEP）で行っている。一般的に TEP の進入経路としては、腹直筋・腹直筋後鞘（弓状線より尾側は横筋筋膜由来の腹直筋筋膜へ移行 2））間の cavity を腹膜外腔拡張バルーンを利用して剥離する経腹直筋前鞘アプローチが多い。それに対し我々は、白線を切開し腹直筋後鞘（前述のごとく尾側では横筋筋膜へ移行）・浅葉間の Retzius 腔に通じる cavity を剥離していく正中アプローチを行っている3,4)。これまで、進う 解 剖 学 的 用 語 の 概 念 で は、Retzius 腔 と 腹 膜 前 筋 膜（Preperitoneal fascia）群を包埋した腹膜前腔との相互関係を理解するために整合性を欠く面がある3)。これまで
鼠径ヘルニア手術を論じる上で、浅葉と深葉の間隙とされる腹膜前腔の概念、特に浅葉・深葉という解剖学的用語の定義を再検討する必要があると述べてきた3,4,5)。そこで本論では浅葉・深葉という解剖学的用語の曖昧さを明らかにし再検討するために、「腹膜前腔とはどこか？」という視点で考察する。

入 経 路 と な る Retzius 腔 は 横 筋 筋 膜（Transversalis

なぜ腹膜前腔が腹膜前筋膜浅葉・深葉の間隙か？

fascia）・浅葉間で、腹膜前腔とは浅葉面を境界（以下

腹膜前腔が腹膜前筋膜浅葉（Superficial layer of theboundary surface：腹膜前腔というボリュームのある三次

preperitoneal fascia）と腹膜前筋膜深葉（Deep layer

元空間構造の表面、従って浅葉・深葉自体には厚さはない

of the preperitoneal fascia）の間隙であるという認識という認識）とした非交通性の異なった cavity であるこは、1975 年 の Fowler6) の知見と 1980 年の佐藤7) の知見が3,4)とを述べてきた

日本ヘルニア学会（Fig.1、2）。TEP では Retzius 腔から組み合わされたものである。

- 13 -

2014 Vol.1 / No.1

 ᖺ )RZOHU ࡣᶓ➽➽⭷࡜⭡⭷ࡢ㛫࡟  ᒙࡢ➽⭷ࡀࡤ㞄ࡾྜ࠺  ࡘࡢ⭡⭷๓➽⭷ࡀ᥋ࡋ࡚࠸ࡿ㒊ศ࡛ࡣ⭡⭷๓Ꮡ ᅾ ࡋࠊ ࡑ ࡢ ᶓ ➽ ➽ ⭷ ഃ ࢆ SUHSHULWRQHDO IDVFLD ̽➽⭷ὸⴥ࣭῝ⴥࡀ࣑ࣝࣇ࢕ࣘ≧ࡢከᒙ㔜」ᵓ㐀࡜࡞ࡾࠊ⭡PHPEUDQRXV OD\HUࠊ ⭡ ⭷ ഃ ࢆ SUHSHULWRQHDO IDVFLD ̽⭷๓➽⭷ὸⴥ࣭῝ⴥࡢ㛫㝽ࡀ⭡⭷๓⭍࡛࠶ࡿ࡜࠸࠺ᐃ⩏࡟

DUHRODUOD\HU ࡜⛠ࡋࠊࡇࡢ  ᒙࡢ SUHSHULWRQHDOIDVFLDᑐࡋ▩┪ࡀ⏕ࡌࡿࠋᚑࡗ࡚⭡⭷๓➽⭷ὸⴥ࣭῝ⴥࡀ⭡⭷๓ࡢ㛫ࡀ⭡⭷๓⭍࡛࠶ࡿ࡜㏙࡭ࡓࠋࡉࡽ࡟  ᖺబ⸨ ࡀ⭍࡜࠸࠺ FDYLW\ ࢆᵓ⠏ࡍࡿつᐃᅉᏊ࡟ࡣ࡞ࡾ࠼࡞࠸ࡢ࡛

ྠࡌࡃᶓ➽➽⭷࡜⭡⭷ࡢ㛫࡟ࠊᶓ➽➽⭷ഃࢆ⭈➽⭷ᚋⴥᨵ࠶ࡿࠋࡋ࠿ࡋ⭡⭷๓⭍ࡀ⭡⭷๓➽⭷ὸⴥ࣭῝ⴥࡢ㛫㝽࡛ࡣࡵ⭡⭷ୗ➽⭷ὸⴥࠊ⭡⭷ഃࢆ⭈➽⭷๓ⴥᨵࡵ⭡⭷ୗ➽⭷῝࡞ࡃࠊࡇࡢ  㡿ᇦࡢ⭡⭷๓➽⭷⩌ࡀ␯ᛶ⤖ྜ⤌⧊ࡢቃ⏺ࢆⴥ࡜࠸࠺  ᒙࡢ⭡⭷ୗ➽⭷ࡀᏑᅾࡍࡿ࡜㏙࡭ࠊ⭡ቨࡢᒙᵓᙧᡂࡋ⭡⭷๓⭍࡜࠸࠺ FDYLW\ ࡟ໟᇙࡉࢀ࡚࠸ࡿ࡜⌮ゎࡍᡂ࡞ࡽࡧ࡟ࡑࡢὸ㒊㸦እ⟄㸧࡜῝㒊㸦ෆ⟄㸧ࡢᑐᛂ㛵ಀࢆࢀࡤࠊࣃࢬࣝࡢࣃ࣮ࢶࡢࡼ࠺࡟࠾஫࠸࡟᥋ࡋ࡚Ꮡᅾࡋ࡚࠸♧ࡋࡓࠋࡿ ࡑ ࢀ ࡒ ࢀ ࡢ 㡿 ᇦ ࡢ 㐃 ࡞ ࡾ ࢆ ▩ ┪ ࡞ ࡃ ᵓ ⠏ ࡛ ࡁ ࡿ ᖺᰙℨ ࡀబ⸨ࡢ▱ぢࢆࡶ࡜࡟⭡ቨᒙᵓ㐀㸦బ⸨Ặ㸦)LJ㸧ࠋࡢ⌮ㄽࡢᅗᘧ໬㸧ࡢࢩ࢙࣮࣐ࢆ♧ࡋࠊࡉࡽ࡟ )RZOHU ࡢ )RZOHU ࡢ࠸࠺  ᒙࡢ➽⭷ࡣࡑࡢぢゎ࠿ࡽ⭡⭷๓⭍ࡢ᭱ᒙࡢ➽⭷ࡣబ⸨ࡢ⭡⭷ୗ➽⭷ὸⴥ࣭῝ⴥ࡟┦ᙜࡍࡿ࡜㏙࡭እഃቃ⏺࡛࠶ࡾࠊబ⸨ࡢ࠸࠺⭡⭷๓➽⭷ὸⴥ࣭῝ⴥࡣ⭡⭷ࡓ㸦ࡑࡢᚋᰙℨࡀ⭡⭷ୗ➽⭷ὸⴥ࣭῝ⴥࢆ⭡⭷๓➽⭷ὸⴥ࣭๓➽⭷ࡢᵓᡂせ⣲࡛࠶ࡗ࡚ᮏ᮶ྠ୍ࡢゎ๗ᵓ㐀࡛ࡣ࡞࠸ࠋ

῝ⴥ࡜ᨵྡ㸧ࠋࡇࢀ௨ᚋ PHPEUDQRXVOD\HU ࡀ⭡⭷๓➽⭷ὸࡋ ࠿ ࡋ PHPEUDQRXV OD\HU ࡀ ⭡ ⭷ ๓ ➽ ⭷ ὸ ⴥࠊDUHRODUⴥࠊDUHRODU OD\HU ࡀ⭡⭷๓➽⭷῝ⴥ࡟ᑐᛂࡍࡿ࡜ㄆ㆑ࡉOD\HU ࡀ⭡⭷๓➽⭷῝ⴥ࡛࠶ࡿ࡜ࡉࢀࡓࡇ࡜࡟ࡼࡗ࡚ࠊ୕

ࢀࡿࡼ࠺࡟࡞ࡾࠊ⭡⭷๓⭍ࡣ⭡⭷๓➽⭷ὸⴥ࣭῝ⴥࡢ㛫㝽ẁㄽἲⓗ࡟⭡⭷๓⭍㸻⭡⭷๓➽⭷㸦⭡⭷๓➽⭷ὸⴥ࣭῝ⴥ࡜ᐃ⩏ࡉࢀࡿࡼ࠺࡟࡞ࡗࡓࠋ

㛫ࡀ⭡⭷๓⭍࡜ࡍࢀࡤࠊ⭡⭷๓⭍ࡣ⭡⭷๓➽⭷࡞ࡢ㸽㸧࡜

本当に腹膜前腔が腹膜前筋膜浅葉・深葉の間隙か？

࠸࠺ㄗゎ࣭ΰ஘ࡀ⏕ࡌ࡚࠸ࡿࡢ࡛࠶ࡿ㸦ᐇ㝿బ⸨ ࡣ⭡⭷బ⸨ࡣ⭡⭷๓➽⭷࡜ࡣࠊ␯ᛶ⤖ྜ⤌⧊✵㛫ෆࢆ⭈⮚ࡸ⢭ᕢࠊ⮖ື⬦ࡀ⛣ືࠊఙᒎࡋࡑࡢ࿘ᅖ࡟ᙧᡂࡉࢀࡓ␯ᛶ⤖ྜ⤌⧊ࡢᐦ࡞ᵓ㐀࡛࠶ࡾ㸦)LJ㸧ࠊ⭈➽⭷࠿ࡽ  ศⴥ໬ࡋࡓ
⬦⟶⭍ᵓ㐀ࢆໟࡳ㎸ࡴࡶࡢ )LJ ᕥഃࡢ࢖࣓࣮ࢪ࡛࠶ࡾࠊ
࣮࣒࣎ࣜࣗࡢ࠶ࡿ୕ḟඖࡢᵓ㐀࡜⌮ゎ࡛ࡁࡿ ࡛࠶ࡿ࡜㏙
࡭࡚࠸ࡿ ࠋࡑࡢୖ࡛⭈➽⭷㸦5HQDO IDVFLD㸧㸪⢭⟶࣭⢭ᕢື㟼⬦➽⭷㸦7HVWLFXORGHIHUHQWLDOIDVFLD㸪6WRSSDࡽ 㸧ࡢ VSHUPDWLF VKHDWK ࡟ ┦ ᙜ ࡍ ࡿ 㸧㸪 ⭤ ⬔ ୗ ⭡ ➽ ⭷㸦9HVLFRK\SRJDVWULF IDVFLD㸪 ࠶ ࡿ ࠸ ࡣ ⮖ ⭤ ⬔ ๓ ➽ ⭷㸸$SRQÕYURVH RPELOLFRSUÕYÕVLFDOH㸧࡜࠸࠺  㡿ᇦࡢ⭡⭷እ⭍ࡢᴫᛕࡣᥦၐࡋ࡚࠸ࡿࡀࠊពእ࡞ࡇ࡜࡟⭡⭷๓⭍࡜࠸࠺ᴫᛕ࡟ࡣ඲ࡃゝཬࡋ࡚࠸࡞࠸㸧ࠋ࠶ࡃࡲ࡛ࡶ⭡⭷๓➽⭷⩌ࡣ⭡⭷๓⭍ෆ࡟ໟᇙࡉࢀࡓᵓ㐀࡛࠶ࡾࠊ⭡⭷๓⭍࡜ࡣ୍⮴ࡋ࡞࠸㸦)LJ㸧ࠋᚑࡗ࡚ )RZOHU ࡢ࠸࠺  ᒙࡢ OD\HU࡟⭡⭷๓➽⭷ὸⴥ࣭῝ⴥࡀ┦ᙜࡍࡿ࡜࠸࠺ぢゎࡣ␗ᒙ࡜࡞
ࡾ▩┪ࡍࡿࡢ࡛࠶ࡿࠋ
ࡘࡲࡾὸⴥ࣭῝ⴥ࡜࠸࠺ゎ๗⏝ㄒࢆ )RZOHU ࡜బ⸨ࡢ♧ࡋࡓ␗࡞ࡗࡓゎ๗ᵓ㐀࡟ྠ⩏࡟⏝࠸࡚࠸ࡿࡇ࡜ࡀࠊ࣊ࣝࢽ
࢔ᡭ⾡࡟࠾ࡅࡿ㦵┙ෆ⮚ഃ➽⭷ࡢᒙᵓ㐀ࡢ⌮ゎࢆጉࡆࡿཎᅉࡢ୍ࡘ࡞ࡢ࡛࠶ࡿࠋ

๓➽⭷⩌ࢆࡑࢀࡒࢀ๗ฟ࡛ࡁࡿࡇ࡜ࢆ♧ࡋࡓ ࠋὀពࡀᚲ

腹膜外腔のとらえ方

せ࡞ࡢࡣࠊబ⸨ࡣ⭈➽⭷ࢆ༢࡞ࡿ⭈࿘ᅖࡢ➽⭷࡛ࡣ࡞ࡃ⭡㦵┙ෆ⮚ഃ➽⭷ᒙᵓ㐀ࢆ⌮ゎࡍࡿୖ࡛ࠕ⭡⭷እ⭍ࠖࡢᴫ⭷ᚋ᪉ࡢ኱ࡁ࡞ෆ⮚⾑⟶㠧࡜ࡋ࡚࡜ࡽ࠼࡚࠾ࡾ ࠊࡇࢀࡣ㸧ᛕࡣ㔜せ࡛࠶ࡿࠋబ⸨ ࡣ⭡ቨ➽࠾ࡼࡧ㦵┙㝸⭷ࡢෆ᪉࠿

6WRSSD ࡽ ࡢᒀ⏕Ṫ➽⭷㸦8URJHQLWDO IDVFLD㸧࡟㏆࠸ཎࡘ⭡⭷ࡢእ᪉ࢆࠕ⭡⭷እ⭍ࠖ࡜ᐃ⩏ࡋ࡚࠸ࡿࠋ⭡⭷እ⭍࡜ึࡢ➽⭷࡜ࡶ࠸࠼ࡿᴫᛕ࡞ࡢ࡛࠶ࡿ ࡇࡇ࡟ࡸࡸΰ஘ࡢࡶ

ࡣ␯ᐦࡢᕪࡢ࠶ࡿ DUHRODUWLVVXHFDYLW\ ࡛࠶ࡾࠊ᭱ὸᒙ

࡜ࡀ࠶ࡾࠊ⭈➽⭷࡜࠸࠺ྡ⛠࡟ࡣ⭈ࡢ⛣ື࡟క࠺⊃⩏ࡢ⭡㸦యቨ➽ഃ㸧ࡢᐦ࡞ᒙࡀᶓ➽➽⭷ࠊ᭱῝ᒙ㸦⭡⭷ഃ㸧ࡢᐦ⭷๓➽⭷࡜࠸࠺ഃ㠃࡜ࠊศⴥ໬๓ࡢᗈ⩏ࡢཎึ➽⭷࡜࠸࠺࡞ᒙࡀᚑ᮶ࡢ῝ⴥ࡜࡞ࡿ㸦)LJ㸧ࠋࡉࡽ࡟ᶓ➽➽⭷࡜࠸࠺ 㠃ᛶࡀ࠶ࡿࡇ࡜ࢆᢎ▱ࡋ࡚࠾ࡃ࡭ࡁ࡛࠶ࡿࠋబ⸨ࡣ⭈࣭ᐦ࡞⤖ྜ⤌⧊ᒙ࡜⭡⭷࡜ࡢ㛫㝽࡟ὸⴥ㠃ࢆቃ⏺࡜ࡋࡓࡀࠊ

5HW]LXV ⭍࡜⭡⭷๓⭍ࡀෆໟࡉࢀ࡚࠸ࡿ 㸦)LJ㸸ᒀ⟶࠿ࡽ⭤⬔࡟㐃࡞ࡿ➽⭷ࢆᒀ⟶ୗ⭡㸦⚄⤒㸧➽⭷࡜ࡋ࡚)LJ ࡛ࡣὸⴥ㠃㸦ղ㸧ࡀ ERXQGDU\ VXUIDFH ࡜࡞ࡾࠊ᫂

ᒀ⟶࣭⭤⬔࿘ᅖࡢ➽⭷ࡣ୍㐃࡛࠶ࡿ࡜㏙࡭࡚࠸ࡿศ㞳๗ฟࡋ࡚࠸ࡿ



ࡽ࠿࡟ 5HW]LXV ⭍࡜⭡⭷๓⭍࡜ࢆศࡅ࡚࠸ࡿࡇ࡜ࡀᐇឤ࡛

ࠋࡉ࡚ࡇࡇ࡛⭡⭷๓⭍ࡀ⌧ᅾ୍⯡ⓗ࡟ཷࡅ࠸ࢀࡽࢀ࡚࠸ࡿ

ࡁࡿ㸧ࠋబ⸨ ࡣᶓ➽➽⭷࡜ࡣ⭡ᶓ➽ࡢ➽⭷࡜࠸ࡗࡓᒁᡤ

ࡼ࠺࡟⭡⭷๓➽⭷ὸⴥ࣭῝ⴥࡢ㛫㝽ࡔ࡜௬ᐃࡍࡿࠋࡉࡽ࡟ࠊ

ⓗ࡞ᵓ㐀࡛ࡣ࡞ࡃࠊᶓ㝸⭷ୗ࡟㐃࡞ࡿᗈࡃయቨ➽ࢆ⿬ᡴࡕబ⸨ࡢ๗ฟࡋࡓ  㡿ᇦࡢ⭡⭷๓➽⭷⩌ࡢᏑᅾࢆ⫯ᐃࡍࡿࠋࡋ࡚࠸ࡿ⭷ᵓ㐀࡜㏙࡭࡚࠸ࡿࠋࡲࡓࠊ)RZOHU  ࡣୗ⭡ቨື⭈➽⭷ࡀᶓ➽➽⭷࡜⭡⭷ࡢ㛫࡟௓ᅾࡋ⭡⭷๓➽⭷ὸⴥ࣭῝㟼 ⬦ ࡣ ᶓ ➽ ➽ ⭷ ࡜ SUHSHULWRQHDO IDVFLD ̽ PHPEUDQRXV

ⴥ࡛ᙧᡂࡉࢀ࡚࠸ࡿ

ࡢ࡛࠶ࢀࡤࠊ௚ࡢ⭡⭷๓➽⭷⩌OD\HU ࡢ㛫ࢆ㉮⾜ࡍࡿ࡜㏙࡭࡚࠸ࡿࠋࡋ࠿ࡋᡃࠎࡢࡇࢀࡲ

࡟ࡶࡑࢀࡒࢀὸⴥ࣭῝ⴥࡀᏑᅾࡍࡿࡣࡎ࡛࠶ࡿࠋࡔ࡜ࡍࢀ࡛ࡢほᐹ࡛ࡣࠊᶓ➽➽⭷ࡣ⭡⭷ࡢࡼ࠺࡞୰⓶⣽⬊ᒙ࡜୰⓶᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍



9RO1R

ୗᒙ࡛ᵓᡂࡉࢀࡿ᫂ᛌ࡞⭷࡜࠸࠺⤌⧊ᵓ㐀࡜ࡣ␗࡞ࡾࠊୗᶓ➽➽⭷῝ᒙࡢ⭡⭷๓⭍ࡢ ERXQGDU\ VXUIDFHࠊDUHRODU⭡ቨື㟼⬦ࢆໟᇙࡋࡓ⭡⭷እ⭍᭱እഃࡢᐦ࡞␯ᛶ⤖ྜ⤌OD\HU ࡟࠶ࡓࡿ῝ⴥ࡜ࡣ⭡⭷ὸᒙࡢ⭡⭷๓⭍ࡢ ERXQGDU\⧊ᒙ࡛࠶ࡿ㸦)LJ ⣸ᒙ㸧ࠋࡑࡋ࡚⭈⮚ࡸ⢭ᕢࠊ⮖ື⬦

VXUIDFH ࡜࡜ࡽ࠼ࡿ࡭ࡁ࡛࠶ࡾࠊ࠶࠼࡚㸦෌ᗘ࠸࠺ࠕ࠶࠼

ࡢ⛣ືࠊఙᒎ࡟క࠺  㡿ᇦࡢ⭡⭷๓➽⭷⩌ࡣࠊὸⴥ࣭῝ⴥ࡚ࠖ㸧ࡇࢀࡲ࡛ࡢ័⏝࡟ೌ࠸ὸⴥ࣭῝ⴥ࡜࠸࠺ゎ๗⏝ㄒࢆ࡜࠸࠺ᐦ࡞ቃ⏺㠃࡟ໟࡲࢀࡓ⭡⭷๓⭍࡜࠸࠺␯ᛶ⤖ྜ⤌౑࠺࡜ࡍࢀࡤ⭡⭷๓⭍ὸⴥ㸦6XSHU㸚FLDO OD\HU RI WKH⧊✵㛫ෆࡢᐦ࡞ᵓ㐀࡛ࠊ஫࠸࡟␯ᛶ⤖ྜ⤌⧊ࡢቃ⏺ࢆᙧᡂ

SUHSHULWRQHDO VSDFH㸧࣭ ⭡ ⭷ ๓ ⭍ ῝ ⴥ㸦'HHS OD\HU RI

ࡋࣃࢬࣝࡢࣃ࣮ࢶࡢࡼ࠺࡟᥋ࡋ࡚཰ࡲࡗ࡚࠸ࡿࡢ࡛࠶ࡿ

WKH SUHSHULWRQHDO VSDFH㸧࡜࡛ࡶ࠸࠺࡭ࡁࡶࡢ࡜⪃࠼ࡿ㸦)LJ㸧ࠋ㸦)LJ㸧ࠋࠉࡉࡽ࡟⭡⭷๓⭍࡟ໟᇙࡉࢀ࡚࠸ࡿ⭈➽⭷㸦ᒀ⟶ୗ⭡➽

結果膜బ ⸨ ࡣࠊIDVFLD ࡜ࡣࠕ➽⭷ࠖ࡜࿴ヂࡉࢀ࡚࠸ࡿࡀࠊ
ᮏ᮶ࡣࠕໟࡴࡶࡢࠖࢆព࿡ࡍࡿ࡜ᛕࢆᢲࡋ࡚࠸ࡿ㸦ࡘࡲࡾ➽⭷࡜ࡣ⭷࡛ࡣ࡞࠸㸧ࠋ➽⭷࡜ࡣ⫙╔ࡢࡼ࠺࡟⮚ჾ࣭⬦⟶ࢆໟࡳ㎸ࡴ࣮࣒࣎ࣜࣗࡢ࠶ࡿ୕ḟඖࡢ␯ᛶ⤖ྜ⤌⧊ᒙ࡛࠶ ࡾࠊ ቃ ⏺ 㠃 ࢆ ᙧ ᡂ ࡍ ࡿ ⭷ ≧ ᵓ 㐀 ࡛ ࡣ ࡞ ࠸ ࡢ ࡛ ࠶ ࡿ⭷㸧࡟ෆໟࡉࢀࡿ⮖㠌ᖏࠊ⭤⬔ୗ⭡➽⭷࡟ෆໟࡉࢀࡿ⮖ື⬦⣴ࡣࠊᏊᐑ╔ᗋᚋࡢ⫾⏕ึᮇࡼࡾẕయ࡜ࡢ஺㏻㊰࡜࡞ࡿ
⮖⣴ෆࢆఙᒎࡋ࡚࠸ࡃᒀ⭷⟶ࠊ⮖ື⬦࡛࠶ࡿࡇ࡜࡟ὀ┠ࡍࡿ࡜ࠊ⮖⣴ࡀ⭡⭷๓⭍ࡢᙧᡂ㐣⛬࡟㛵ಀࡋ࡚࠸ࡿࡢ࡛ࡣ࡞
࠸࠿࡜ᛮࢃࢀࡿࠋ

腹膜前筋膜浅葉・深葉は存在するのか？

㸦)LJ㸧ࠋࡲࡓࠊ➽⭷ࡢᒙᵓ⠏ࡢ᳨⣴ࡣᶆᮏࡢಶయᕪࠊ
ᢏἲ࣭ᢏ⾡ࡢᕪ࡟ࡼࡾᡤぢࡀ␗࡞ࡾࠊ ࠎ࡟ࡋ࡚࠿ࡳྜࢃ
࡞࠸㆟ㄽࢆᣍࡁࠊࡉࡽ࡟⏝ㄒࡢ୙⤫୍࠿ࡽၥ㢟ࡀ」㞧໬ࡋࡇ࠺ࡋ࡚⪃ᐹࢆ㐍ࡵ࡚ࡃࡿ࡜㸯ࡘࡢ␲ၥ࡟ᛮ࠸⮳ࡿࠋ⭡⭷๓➽⭷ὸⴥ࣭῝ⴥࡣᏑᅾࡍࡿࡢ࠿㸽࡚࠸ࡿ࡜㆙㚝ࢆ㬆ࡽࡋ࡚࠸ࡿ ࠋ㦵┙ෆ⭡⭷እ⭍ࡣ DUHRODUWLVVXHFDYLW\ ࡛࠶ࡾࠊ⬡⫫どぬ☜ㄆࡀᚲせ࡞ FDGDYHU㸦ᅛᐃฎ⌮ࢆ᪋ࡉࢀࡓࡈ㑇య㸧⤌⧊ࡀΰᅾࡋࡓ␯ᐦ࡞⤖ྜ⤌⧊ࡀࣇ࢓ࢪ࣮࡟⒵ྜ࣭ศ㞳ࢆ฼⏝ࡋࡓゎ๗࡜࠸࠺ᡭἲ࡟ࡼࡿ࡜ࠊ⭡⭷እ⭍࡜࠸࠺ᮏ᮶

ࡍࡿ✵㛫࡜࠸࠼ࡿࠋᚑࡗ࡚ඖ᮶ࠕ⭍ࠖࡸࠕ⭷ࠖࡣᏑᅾࡏ

ࡣ␯࡞ FDYLW\ ࡟࠾ࡅࡿࠕ๤㞳ྍ⬟࡞ᒙ㸦␯࡞ቃ⏺㸧ࠖࢆேࡎࠊ࠶ࡿព࿡ゎ๗Ꮫ⪅ࡸእ⛉་ࡀసࡾฟࡋࡓࡶࡢ࡛࠶ࡾࠊ

Ⅽⓗ࡟๤㞳ࡍࡿࡇ࡜࡟ࡼࡗ࡚ࠊᐦ࡟࡞ࡗࡓ␯ᛶ⤖ྜ⤌⧊ࡀ

5HW]LXV ⭍ࡸ⭡⭷๓⭍ࡶᡃࠎࡀ⤖ᯝ⭷ࢆᙧᡂࡋㄆ㆑࡛ࡁࡿ

⭡⭷๓➽⭷࡜ࡋ࡚ศ㞳ᙧᡂどㄆࡉࢀࡿࡢ࡛࠶ࡿࠋ㛗㇂ᕝࡽࡼ࠺࡟ࡋࡓࡔࡅࡢᵓ㐀࠿ࡶࡋࢀ࡞࠸ࠋࡲࡋ࡚Ọᖺ࡟ࢃࡓࡗ

࡚ᡃࠎࡀཷࡅධࢀ࡚ࡁࡓࠕ⭡⭷๓➽⭷ὸⴥ࣭῝ⴥࠖࡢᏑᅾ

ࡶ㏙࡭࡚࠸ࡿࡀࠊゎ๗Ꮫⓗᡭἲ࡛どㄆࡉࢀࡿὸⴥ࣭῝ⴥࡸ⭡⭷๓➽⭷⩌ࡣࠊゎ๗Ꮫ⪅࠶ࡿ࠸ࡣእ⛉་ࡀᐦ࡞㒊ศࢆ⮬యࡀࠊ୕ḟඖࡢᵓ⠏࡛ࡣ↓⌮ࡀ࠶ࡿࠋຍ⸨ࡽ ࡶ㏙࡭࡚࠸ࡿࡼ࠺࡟ࠊ⭡⭷๓➽⭷ὸⴥ࣭῝ⴥ࡜ศ㞳ᙧᡂࡋࡓ⤖ᯝึࡵ࡚ㄆ㆑ࡉࢀࡿᵓ㐀ࠊࡍ࡞ࢃࡕࠕ⤖ᯝ⭷ࠖ㸦FDYLW\ ࠿ࡽసࡾฟࡉࢀࡓᵓ㐀㸧࡜ゝ࠼ࡿ ࠋࡣ࠶ࡃࡲ࡛஧ḟඖ࡛ࡢᴫᛕ࡟㐣ࡂࡎࠊ୕ḟඖ࡛ࡣ⭡⭷๓➽ඖ᮶ࠊὸⴥ࣭῝ⴥࡶ⭡⭷๓➽⭷⩌ࡶ⭡⭷๓⭍ෆࡢ␯ᛶ⤖ྜ⤌⧊ࡢᐦ࡞ᵓ㐀࡞ࡢ࡛࠶ࡗ࡚ࠊ࠸ࢃࡺࡿ⭷㸦ࢩ࣮ࢺ≧ࡢ⭷ࢆᵓᡂࡍࡿὸⴥ࣭῝ⴥ࡜࠸࠺ᵓ㐀ࡣᏑᅾࡋ࡞࠸࡜⪃࠼ࡓ᪉ࡀࡼ࠸࡜ᛮࡗ࡚࠸ࡿ ࠋᵓ㐀㸧࡛ࡣ࡞࠸ࡇ࡜ࢆㄆ㆑ࡍࡿ࡭ࡁ࡛࠶ࡿࠋ

結

腹膜前腔とはどこか？

語ࣁ࢖ࣅࢪࣙࣥࢫࢥ࣮ࣉ࡛ᚓࡽࢀࡿᣑ኱ࡉࢀࡓ㩭᫂࡞⾡୰⭡⭷๓⭍ࢆ஧ḟඖࡢᒙᵓ㐀࡛ࡣ࡞ࡃࠊ&RUULGRU㸦బ⸨ࡢ㸧ᡤぢࡣࠊFDGDYHU ࡟ࡼࡿᚑ᮶ࡢゎ๗Ꮫⓗ▱ぢ࡜ࡣ␗࡞ࡿ⏕㸧࡜ࡋ࡚యࡢ⤌⧊ᵓ⠏ࢆᇉ㛫ぢࡏ࡚ࡃࢀࡿࡼ࠺࡟࡞ࡗࡓࠋࡑࢀ࡟క

୕ḟඖࡢ FDYLW\ ࡜ㄞࡳゎࡁ෌ᵓ⠏ࡍࡿ࡜ࠊᮏ᮶ࡣ࣮࣎ࣜࣗ

࠸⚾㐩ࡣࡇࢀࡲ࡛ࡢࠕ⭷ࡢຌ⨥ࠖࢆ㢳ࡳ࡚ࠊ㦵┙ෆ⭡⭷እ࣒ࡢ࠶ࡿᵓ㐀࡛⭡⭷๓➽⭷ὸⴥࡶ῝ⴥࡶ୍㐃ࡢྠ୍␯ᛶ

⭍ࡢᴫᛕࢆ᳨ド෌⪃ࡍࡿᚲせࡀ࠶ࡿࠋ࠸࠺⬦⟶⚄⤒ᅇᗯ㸦QHXURYDVFXODUFRUULGRU㸧⤖ྜ⤌⧊✵㛫࡜࡞ࡾࠊᶓ᩿ᅗ࡛♧ࡉࢀࡿࡼ࠺࡞༢⣧࡞⋢ࡡ኱ษ࡞ࡇ࡜ࡣ⭡⭷๓⭍࡜ 5HW]LXV ⭍࡜ࡢ㛵ಀࠊࡇࡢ ࡘࡢ FDYLW\ ࢆໟᇙࡋ࡚࠸ࡿ⭡⭷እ⭍ࡢᗈࡀࡾࢆ୕ḟඖ࡟㸦)LJ㸧ࠋࡘࡲࡾ⭡⭷๓⭍࡜ࡣ␯࡞㒊ศࠊᐦ࡞㒊ศࡀΰ࢖࣓࣮ࢪࡍࡿࡇ࡜࡛࠶ࡿࠋ⭡⭷๓⭍ࡣ ERXQGDU\ VXUIDFH

ᅾࡋࡓ DUHRODU WLVVXH FDYLW\ ࡛࠶ࡾࠊ ᯛࡢ⭷࡟ໟࡲࢀ࡛ ࠶ ࡿ ⭡ ⭷ ๓ ⭍ ὸ ⴥ࣭ ῝ ⴥ ࡟ ໟ ࡲ ࢀ ࡓ DUHRODU WLVVXH

ࡓࡾቃࢆࡉࢀࡓࡾࡋ࡚࠸ࡿࡢ࡛ࡣ࡞ࡃࠊேⅭⓗ࡟ศ㞳ᙧᡂ

FDYLW\ ࡛࠶ࡾࠊ⭡⭷๓⭍ὸⴥ㠃࡛ 5HW]LXV ⭍࡜ቃ⏺ࡉࢀࡍࡿ࡜⤖ᯝ⭷࡜࡞ࡿࡼ࠺࡞ᐦ࡞㒊ศ࡟ቃ⏺ࡉࢀ࡚࠸ࡿ✵࡚࠸ࡿ࡜࡜ࡽ࠼ࡿ࡭ࡁ࡛࠶ࡿࠋ࣊ࣝࢽ࢔ಟ᚟⾡ࢆ⾜࠺࡟࠶㛫࡜࠸࠼ࡿࠋ

ࡓࡗ࡚ࡇࢀࡽࡢࡈࡃ༢⣧࡞ඹ㏻ㄆ㆑ࢆᣢ࡚ࡤࠊ౛࠼࢔ࣉ

ࡂ≧ࡢᒙᵓ㐀࠶ࡿ࠸ࡣ  ᯛࡢ⭷ᵓ㐀࡟ࡣ࡞ࡾ࠼࡞࠸

ࠉᚑࡗ࡚⭡⭷๓⭍ࡢ⠊ᅖࢆつᐃࡍࡿὸⴥ࣭῝ⴥ࡜࠸࠺ゎ๗⏝ㄒࡣࠊ⭡⭷๓➽⭷ὸⴥ࣭῝ⴥ࡜ࡣ༊ูࡍࡿ࡭ࡁ࡞ࡢ࡛

࣮ࣟࢳἲࡀ๓᪉࢔ࣉ࣮ࣟࢳ࡛ࡶ 7$33ࠊ7(3 ࡛ࡶ฿㐩Ⅼࡣྠࡌ࡟࡞ࡾ࠺ࡿ࡜⪃࠼࡚࠸ࡿࠋ࠶ࡿࠋ)RZOHU ࡢ࠸࠺ PHPEUDQRXV OD\HU ࡟࠶ࡓࡿὸⴥ࡜ࡣ

᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍



᭱ᚋ࡟ࠊ⚾ࡣ⭡⭷እ⭍ࢆ⌮ゎࡍࡿ㘽ࡣୗ⭡ቨື㟼⬦ࢆໟ9RO1R

ᇙࡋ࡚࠸ࡿᶓ➽➽⭷࡛࠶ࡿ࡜⪃࠼࡚࠸ࡿࠋ௒ᚋࡣⓎ⏕Ꮫࡶ
㋃ࡲ࠼ࡓ⭡⭷እ⭍࡟࠾ࡅࡿ⫾⏕ᮇࡢ୰⬇ⴥ⤌⧊ࡢࢲ࢖ࢼ
࣑ࢬ࣒ࢆᛕ㢌࡟ࡋ࡚ࠊᶓ➽➽⭷ࡸ⭡⭷๓⭍ࡀ࠸࠿࡟ࡋ࡚ᙧ
ᡂࡉࢀࡓ࠿ࢆ⪃ᐹࡋ࡚࠸ࡃᚲせࢆឤࡌ࡚࠸ࡿࠋ

文献 బ⸨㐩ኵ㸸ㅮᗙ  Ἢᒀჾᡭ⾡࡟ᚲせ࡞ᒁᡤゎ๗࣭ࠉ
⭡⭷እ⭍㸬⮫ᗋἪᒀჾ⛉   
 $QVRQ %- 0F9D\ &% $EGRPLQDO ZDOO ,Q 6XUJLFDODQDWRP\:%6DXQGHUV&R3KLODGHOSKLD
 ᮅⶱ┤ᶞ㸸5HW]LXV ⭍࡜ࡣ࡝ࡇ࠿㸽  ṇ୰࢔ࣉ࣮ࣟࢳ
7(3 WRWDOO\([WUD3HULWRQHDOUHSDLU ࡟࠾ࡅࡿ㐍ධ⤒㊰ࡢゎ๗ 㸬㡰ኳᇽ㓾஦㞧ㄅ    ᮅ ⶱ ┤ ᶞ㸸 ≉ 㞟 㰡 ᚄ ࣊ ࣝ ࢽ ࢔ ࡢ ᪂ ࡋ ࠸ ἞ ⒪ ἲ
ࠉ7(3 ἲ㸦 ༢ Ꮝ 㸧 㸫 ⭡ ⭷ እ ⭍ ࢆ ព ㆑ ࡋ ࡓ 7$1.2
WRWDOO\ H[WUDSHULWRQHDO UHSDLU 㸫㸬 ᾘ ໬ ჾ እ ⛉   ᮅ ⶱ ┤ ᶞ㸸 ⭷ ࡢ ຌ ⨥ 㸫 㰡 ᚄ ࣊ ࣝ ࢽ ࢔ ἞ ⒪ ࡟ ࠾ ࡅ ࡿ⭡ ⭷ እ ⭍ ࡢ ᤊ ࠼ ᪉ 㸫㸬 ➨  ᅇ ⮫ ᗋ ゎ ๗ ◊ ✲ ఍ グ 㘓 )RZOHU 5 7KH DSSOLHG VXUJLFDO DQDWRP\ RI WKH᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

SUHSHULWRQHDO IDVFLD RI WKH JURLQ DQG WKH
͆VHFRQGDU\͇ LQWHUQDO ULQJ $XVW 1= - 6XUJ బ⸨㐩ኵ㸸యቨ࡟࠾ࡅࡿ➽⭷ࡢᒙᵓᡂࡢᇶᮏタィ㸬་Ꮫࡢ࠶ࡺࡳ    ᰙ ℨ ಙ ኴ 㑻㸸 ⭡ ቨ ➽ ⭷ ࡢ ᒙ ᵓ 㐀㸬 ⮫ ᗋ እ ⛉   బ⸨㐩ኵ㸸≉㞟 㸸㦵┙ෆゎ๗ 㦵┙እ⛉ゎ๗ᗎㄽ㸬-DSDQHVH-RXUQDORI(QGRXURORJ\ 6WRSSD 5 'LDUUD % 0HUW 3 7KH UHWURSHULWRQHDOVSHUPDWLF VKHDWK ̽ $Q DQDWRPLFDO VWUXFWXUHV RI
VXUJLFDOLQWHUHVW+HUQLD బ⸨㐩ኵ㸸ㅮᗙ  Ἢᒀჾᡭ⾡࡟ᚲせ࡞ᒁᡤゎ๗࣭Ϩ  ⭈ ⮚ % ⭈ ➽ ⭷㸬 ⮫ ᗋ Ἢ ᒀ ჾ ⛉    బ⸨㐩ኵ㸸ㅮᗙ  Ἢᒀჾᡭ⾡࡟ᚲせ࡞ᒁᡤゎ๗࣭
㦵┙ෆࡢ➽⭷㸬⮫ᗋἪᒀჾ⛉    㛗㇂ᕝഔ㸪Ἑ⏣೺஧㸪ᒣ⏣⌮኱㸪኱㉺㤶Ụ㸪ຍ⸨ ⁠㸪ᆏ஭⩏἞㸸ෆど㙾እ⛉᫬௦ࡢ┤⭠እ⛉ゎ๗㸬➨  ᅇ⮫ᗋゎ๗◊✲఍グ㘓  ຍ⸨཭ᗣ㸪㕥ᮌ೺ே㸪ᒣཱྀஂ⨾Ꮚ㸪⛅⏣ᜨ୍㸸ዪᛶᚋ⭡⭷㡿ᇦࡢ➽⭷ᵓ㐀࡟ࡘ࠸࡚㸬➨  ᅇ⮫ᗋゎ๗◊✲఍グ㘓 



9RO1R)LJࠉ㦵┙ෆ⭡⭷እ⭍ࡢᴫほ)LJࠉ⭡⭷እ⭍ෆࡢ⭡⭷๓⭍࡜⭡⭷๓➽⭷⩌ࡢ㛵ಀձ㸸⭡⭷๓⭍ղ㸸5HW]LXV ⭍ճ㸸⭡⭍մ㸸⭡⭷յ㸸ᶓ➽➽⭷ն㸸యቨ➽շ㸸⭈➽⭷ո㸸⭤⬔ୗ⭡➽⭷չ㸸⢭⟶࣭⢭ᕢື㟼⬦➽⭷ձ㸸ᶓ➽➽⭷ղ㸸ୗ⭡ቨື㟼⬦ճ㸸⭡⭷๓⭍ὸⴥմ㸸⭡⭷๓⭍յ㸸⭡⭷๓⭍῝ⴥն㸸యቨ➽շ㸸⭤⬔ո㸸⭡⭷չ㸸5HW]LXV ⭍պ㸸⭤⬔ୗ⭡➽⭷ջ㸸⢭⟶࣭⢭ᕢື㟼⬦➽⭷ռ㸸⭈➽⭷㉥⥺㸸࣓ࢵࢩࣗࡀᒎ㛤ࡉࢀࡿ఩⨨)LJࠉ7(3 ࡟࠾ࡅࡿ P\RSHFWLQHDORUL㸚FH ᕥഃ
D㸸⭡⭷๓⭍࡬ࡢ㐍ධࠉE㸸⭡⭷๓⭍ὸⴥ㠃ࡢᗈࡀࡾࠉ
F㸸⭡⭷๓⭍ෆ␯ᛶ⤖ྜ⤌⧊ࡢቨᅾ໬ࠉG㸸࣓ࢵࢩࣗࢆᒎ㛤ࡍࡿ 5HW]LXV ⭍࣭⭡⭷๓⭍࡟ࡲࡓࡀࡿ✵㛫ձ㸸ୗ⭡ቨື㟼⬦ղ㸸⭡⭷๓⭍ὸⴥ㠃ճ㸸⭡⭷⦕ 3( մ㸸እ㦵ື㟼⬦յ㸸&RRSHU 㠌ᖏն㸸㰡ᚄ⟶ᚋቨշ㸸VSHUPDWLFVKHDWK㸦⢭⟶࣭⢭ᕢື㟼⬦➽⭷㸧ո㸸⭡⭷๓⭍չ㸸5HW]LXV ⭍᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

)LJࠉ⭡⭷እ⭍ࡢ࡜ࡽ࠼᪉
ձ㸸⭡⭷๓➽⭷ղ㸸⭡⭷๓⭍ճ㸸⭡⭷እ⭍մ㸸యቨ➽յ㸸ᶓ➽➽⭷ն㸸⭡⭷๓⭍ὸⴥ㸦)RZOHU ࡢ
SUHSHULWRQHDOIDVFLDPHPEUDQRXVOD\HU ࡟┦ᙜ㸧շ㸸బ⸨ࡢ⭡⭷๓➽⭷ὸⴥո㸸బ⸨ࡢ⭡⭷๓➽⭷῝ⴥչ㸸⭡⭷๓⭍῝ⴥ㸦)RZOHU ࡢ SUHSHULWRQHDOIDVFLDDUHRODUOD\HU ࡟┦ᙜ㸧պ㸸⭡⭷

9RO1R

Where is the Pre-peritoneal Space Located?
ー The Anatomy of Penetrating Route in Median Approach TEP(Totally ExtraPeritoneal Repair) ーTsudanuma Central General Hospital, Department of Surgery

Naoki Asakage
Abstract
When having some simple common knowledge of performing inguinal hernioplasty, we think that it is possible
to reach the appropriate layer through the use of any of the anterior, transabdominal preperitoneal (TAPP) andtotally extraperitoneal (TEP) approaches. In order to understand the relation between preperitoneal space andRetzius space, it is important to have the three-dimensional image of extraperitoneal space, which embeds these two   !  !   < &<& <  !  !< of the preperitoneal space. On the other hand, Retzius space is a cavity located between transversalis fascia and the!!< ! QE  ! &      & <%     !    !!<  ! Key wordspre-peritoneal space, Retzius space, extra-peritoneal space䠎䠌䠍䠐ᖺ䠍᭶䠍䠑᪥ཷࠉ⌮᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍
᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍



9RO1R

症例報告
子宮、左付属器をヘルニア内容とする子宮奇形を合併した左外鼠径ヘルニア症例に対して TEP を施行した１例➨୍ᮾ࿴఍⑓㝔ࠉෆど㙾እ⛉ࢭࣥࢱ࣮ᐑᮏ⋹ዉࠊ⏣⏿ᬛ୔ࠊబ⸨ࠉຌࠊ໭ⷵࠉᕑࠊἈ⏣඘ྖࠊỈ㇂ࠉ┿ࠊ༓㔝ె⚽ࠊ⯖⏣ࠉㄔ஧ࠊ㔝⏣ὒ୍ࠊ⸨ᮧᫀᶞ
要旨⑕౛ࡣ  ṓዪᛶࠋ ṓࡈࢁࡼࡾᕥ㰡ᚄ㒊ࡢ⭾㝯ࢆㄆࡵ࡚࠾ࡾࠊ᭱㏆③ࡳ࡜㑏⣡ࡋ࡙ࡽࡉࢆ⮬ぬࡋᙜ⛉⤂௓ཷデࠊᕥ㰡ᚄ࣊ࣝࢽ࢔ࡢデ᩿࡛⭡⭍㙾ୗ࣊ࣝࢽ࢔ᡭ⾡࡜࡞ࡗࡓࠋ⭡⭍ෆほᐹࡍࡿ࡜ᕥ㦵┙ෆ࡟㐟㞳ࡋࡓወᙧᏊᐑࠊᕥ௜ᒓჾࢆ
ㄆࡵࠊࡑࢀࢆෆᐜ࡜ࡍࡿᕥእ㰡ᚄ࣊ࣝࢽ࢔ࢆㄆࡵࡓࠋ⭡⭍ෆࡼࡾᏊᐑࠊᕥ௜ᒓჾࢆᘬࡁฟࡋࠊ㰡ᚄ⟶ෆᐜࢆ✵⹫࡟ࡋࡓ≧ែ࡛⭡⭷๓⭍ࡼࡾ࢔ࣉ࣮ࣟࢳࡋࠊ⭡⭍㙾ୗ࣊ࣝࢽ࢔᰿἞⾡ 7(3 ࢆ᪋⾜ࡋࡓࠋᮏ⑕౛ࡣ 0¾OOHU ⟶⏤᮶ࡢᏊᐑ࡜⭼ࡢୖ  ࡜ᒀ⏕ṪὝ⏤᮶ࡢ⭼ୗ  ࡢ⒵ྜ୙඲࡟ࡼࡿᏊᐑወᙧࢆྜేࡋࡓ࣊ࣝࢽ
࢔⑕౛࡛㈗㔜࡞⑕౛࡛࠶ࡾⱝᖸࡢᩥ⊩ⓗ⪃ᐹࢆຍ࠼࡚ሗ࿌ࡍࡿࠋ

࣮࣮࢟࣡ࢻ㸸⭡⭍㙾ᡭ⾡㸪㰡ᚄ࣊ࣝࢽ࢔㸪Ꮚᐑወᙧᕥ㦵┙ෆ࡟㐟㞳ࡋ࡚࠾ࡾࠊᕥ௜ᒓჾ࡜࡜ࡶ࡟ෆ㰡ᚄ㍯ࡼࡾ

はじめにᙜ㝔࡛ࡣ⭡⭍㙾ୗ࣊ࣝࢽ࢔ಟ᚟⾡ 7(3 ࡟࠾࠸࡚ಟ᚟๓
࡜ಟ᚟ᚋ࡛⭡⭍ෆほᐹࢆ⾜࠺ࠋ௒ᅇࢃࢀࢃࢀࡣᏊᐑወᙧࢆ
ྜేࡋࠊᏊᐑ࡜ᕥ௜ᒓჾࢆ࣊ࣝࢽ࢔ෆᐜ࡜ࡍࡿᕥእ㰡ᚄ࣊ࣝࢽ࢔ࢆ⤒㦂ࡋࡓࠋಟ᚟๓ࡢ⭡⭍ෆࡢほᐹ࡛⬺ฟࡋ࡚࠸ࡿ
⮚ჾࡀᕥ㦵┙ෆ࡟㐟㞳ࡋ࡚࠸ࡿወᙧᏊᐑࠊᕥ௜ᒓჾ࡛࠶ࡿ
ࡇ࡜ࡀุ᫂ࡋࠊ⭡⭍ෆࡼࡾࡑࢀࡽࢆ≌ᘬࡍࡿࡇ࡜࡛⭡⭷๓⭍࡛ࡢ᧯సࢆᏳ඲࡟㐙⾜࡛ࡁࠊࡉࡽ࡟ಟ᚟ᚋࡢ⭡⭍ෆほᐹ࡛࣊ࣝࢽ࢔ࡀಟ᚟ࡋᚓ࡚࠸ࡿࡇ࡜ࠊ⬺ฟ⮚ჾࡢᕳࡁ㎸ࡳࡢ⬺ฟࡋ࡚࠸ࡿ≧ែ࡛࠶ࡗࡓ

ᅗ DEF ࠋྑ௜ᒓჾࡣṇᖖࡢ఩⨨࡟࠶ࡗࡓࡀᏊᐑ࡜ࡣ᏶඲࡟㞳ࢀ࡚࠸ࡿ≧ែ࡛࠶ࡗࡓᅗ G ࠋᕥ௜ᒓჾ࡜ወᙧᏊᐑࢆෆᐜ࡜ࡋࡓᕥእ㰡ᚄ࣊ࣝࢽ࢔࡜デ᩿ࡋࡓࠋ⭡⭍ෆࡼࡾᏊᐑࠊᕥ௜ᒓჾࢆෆ㰡ᚄ㍯ࡼࡾᘬࡁᡠࡋࠊ㰡ᚄ⟶ෆᐜࢆ✵⹫࡟ࡋࡓ≧ែ࡛⭡⭷๓⭍ࡼࡾ࢔ࣉ࣮ࣟࢳࡋࠊ⭡⭍㙾ୗ࣊ࣝࢽ࢔᰿἞⾡ 7(3 ࢆ᪋⾜ࡋࡓࠋᏊᐑ෇㠌ᖏࢆษ㞳ࡋࡓ࡜ࡇࢁᘬࡁ㎸ࡲࢀ࡚࠸ࡓᕥ௜ᒓ
ჾ࡜ወᙧᏊᐑࡣ⭡⭍ෆ࡟␃ࡲࡿࡼ࠺࡟࡞ࡗࡓࠋಟ᚟ᚋࡢ⭡⭍ෆほᐹ࡛Ꮚᐑࠊᕥ༸ᕢ༸⟶ࡀ⭡⭍ෆ࡟Ꮡᅾࡋ࡚࠾ࡾࠊ࣊

࡞࠸ࡇ࡜ࡀ☜ㄆ࡛ࡁࡓࠋ
Ꮚᐑወᙧࢆྜేࡋࠊᕥ㦵┙ෆ࡟㐟㞳ࡋࡓᏊᐑ࡜ᕥ௜ᒓჾ
ࡀ㰡ᚄ࣊ࣝࢽ࢔ࡢෆᐜ≀࡟࡞ࡗ࡚࠸ࡿ⑕౛ࡣሗ࿌౛ࡀ࡞ᅗ  ࠋ⾡୰ࡢෆデ࡛ࡣ⭼ࡣ┣➃࡛⤊ࢃࡗ࡚࠸ࡓࠋ⾡ᚋ➨  ⑓᪥࡟㍍ᛌ㏥
㝔࡜࡞ࡗࡓࠋ⾡ᚋ㦵┙ 05, ᪋⾜ࡋࡓ࡜ࡇࢁᕥ㦵┙ෆ࡟ᑠࡉ

ࡃࠊ㈗㔜࡞⑕౛࡛࠶ࡿ࡜⪃࠼ሗ࿌ࡍࡿࠋ

症ࣝࢽ࢔ࡀಟ᚟ࡋᚓ࡚࠸ࡿࡇ࡜ࢆ☜ㄆࡋࡓ࡞ᏊᐑࢆㄆࡵࡓࡀᏊᐑࡢෆ⭷ࡣㄆࡵࡽࢀࡎᏊᐑ➽⭘ࡢྜ

例

ేࢆㄆࡵࡓ

ᅗ DE ࠋ⾡ᚋ VHURPD ࡢྜేࢆࡳ࡜ࡵࡓࡶ

⑕౛㸸 ṓዪᛶࠋࡢࡢಖᏑⓗ࡟㍍ᛌࡋࠊ⾡๓ࡢ③ࡳࡣᾘኻࡋࡓࠋ⾡ᚋ㸰ᖺ࡛᪤ Ṕ㸸≉グ஦㡯࡞ࡋࠋዷፎṔ࡞ࡋࠋ⏕᮶↓᭶⤒ࠋ⌧ᅾࡢ࡜ࡇࢁ෌Ⓨࡢ඙ೃࡣ࡞࠸ࠋ

⌧⑓Ṕ㸸 ṓࡈࢁࡼࡾᕥ㰡ᚄ㒊ࡢ⭾㝯ࢆㄆࡵ࡚࠾ࡾ⮬ᕫᩚ考᚟ࡋ࡚࠸ࡓࠋ᭱㏆࡟࡞ࡾ③ࡳ࡜㑏⣡ࡋ࡙ࡽࡉࢆ⮬ぬࡋࡓࡓ察་୰ㄅ࡟࡚ࠕᏊᐑወᙧࠖ
ࠊࠕ࣊ࣝࢽ࢔ࠖࢆ࣮࣮࢟࣡ࢻ࡜ࡋ

ࡵᕥ㰡ᚄ࣊ࣝࢽ࢔ࡢデ᩿࡛ᙜ⛉⤂௓ཷデࡋࠊᡭ⾡┠ⓗ࡛ධ᳨࡚⣴ࡋࡓ࡜ࡇࢁࠊ༢ゅᏊᐑࢆྜేࡋᕥ༸⟶Ỉ⭘ࢆ࣊ࣝࢽ㝔࡜࡞ࡗࡓࠋ
ධ㝔᫬⌧⑕㸸ᕥ㰡ᚄ㒊࡟㭜༸኱ࡢ◳࠸⭘⒗ࢆㄆࡵࠊ⏝ᡭⓗ࡟㑏⣡ࡋᚓࡿࡀ⭡ᅽୖ᪼᫬࡟ࡣᐜ᫆࡟⬺ฟࡋ࡚ࡃࡿ≧ἣ࢔ෆᐜ࡜ࡋࡓ㛤⭡ᡭ⾡⑕౛ࡣㄆࡵࡓࡀࠊወᙧࢆྜేࡋࡓᏊ
ᐑࡑࡢࡶࡢࢆ࣊ࣝࢽ࢔ෆᐜ࡜ࡋࡓ⑕౛࡛⭡⭍㙾ᡭ⾡ࢆ᪋⾜ࡋࡓ⑕౛ࡣ᳨⣴ࡋᚓࡓ⠊ᅖ࡛ࡣ࡞࠿ࡗࡓ  ࠋ࡛࠶ࡗࡓࠋዪඣࡢ㰡ᚄ࣊ࣝࢽ࢔࡛༸ᕢࠊ༸⟶ࢆ࣊ࣝࢽ࢔ෆᐜ࡜ࡍࡿ

ᡭ⾡ᡤぢ㸸⭡⭍ෆࢆほᐹࡍࡿ࡜Ꮚᐑࡣ⭼࡜⒵ྜࡋ࡚࠾ࡽࡎ

ࡇ࡜ࡣࡼࡃ࠶ࡿࡇ࡜࡛ዪඣ㰡ᚄ࣊ࣝࢽ࢔ࡢ  㹼 㸣ࢆ༨᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍



9RO1R

ࡵࡿ࡜࠸ࢃࢀ࡚࠸ࡿ  ࠋᏊᐑࢆ࣊ࣝࢽ࢔ෆᐜ࡜ࡍࡿሗ࿌

࡛࣊ࣝࢽ࢔ࡀಟ᚟ࡋᚓ࡚࠸ࡿࡇ࡜ࢆ☜ㄆ࡛ࡁࡿࠋᮏ⑕౛࡟

౛ࡶㄆࡵࡿࡀࠊᏊᐑወᙧࡢྜేሗ࿌ࡣ࡞࠸ࠋᏊᐑወᙧࡢデ࠾࠸࡚ࡶ⬺ฟ⮚ჾࡢ㑏⣡ࡀྍ⬟࡛ಟ᚟ᚋࡢᕳࡁ㎸ࡳࡢ࡞᩿┠ⓗ࡟⭡⭍㙾᳨ᰝࡀ᭷⏝࡛࠶ࡿࠋ࠸ࡇ࡜ࠊ࣊ࣝࢽ࢔ࡀಟ᚟ࡋ࠼࡚࠸ࡿࡇ࡜ࢆ☜ㄆ࡛ࡁ᭷⏝࡛ᮏ⑕౛࡟࠾࠸࡚ࡶ⾡୰ࡢ⭡⭍ෆほᐹ࡛Ꮚᐑ࡜⭼ࡢ⒵ྜ୙

࠶ࡗࡓࠋ඲ࠊྑ௜ᒓჾ࡜Ꮚᐑࡢ⒵ྜ୙඲ࢆデ᩿࡛ࡁࠊ࠿ࡘࡑࡢወᙧ

おわりにᏊᐑ࡜ᕥ௜ᒓჾࢆ⬺ฟ⮚ჾ࡜ࡋ࡚࠸ࡿࡇ࡜ࡀุ᫂ࡋࡓࠋ⭡⭍ෆ᧯సࡼࡾᏊᐑࠊᕥ௜ᒓჾࢆᘬࡁᡠࡋ⭡⭷๓⭍࠿ࡽࡢ᧯సࢆᏳ඲࡟㐙⾜࡛ࡁࡓࠋྑ༸ᕢࡢ☜ㄆࡶ࡛ࡁࠊ⾡ᚋಟ᚟ࡢ≧ែࡢ☜ㄆࡶ࡛ࡁࡓࠋ
Ꮚᐑወᙧࡢࢱ࢖ࣉ࡟ࡣᵝࠎ࡞ࡶࡢࡀ࠶ࡿࠋ⫾⏕ᮇࡢ
0¾OOHU ⟶ࡼࡾ༸⟶ࠊᏊᐑ࡜⭼ࡢୖ  ࡀⓎ⏕ࡋࠊᒀ⏕ṪὝࡼࡾ⭼ୗ  ࡀⓎ⏕ࡍࡿࠋࡑࡢࡉࡲࡊࡲ࡞ẁ㝵ࡢ⒵ྜ୙
඲࡟ࡼࡾᵝࠎ࡞Ꮚᐑወᙧࡢᙧែࡀ⏕ࡌࡿ    ࠋዪᛶࡢሙ
ྜࡣ :ROII ⟶ࡢ㉮⾜࡟ἢࡗ࡚༸ᕢᅛ᭷㠌ᖏ࡜෇㠌ᖏࡀᙧᡂ௒ᅇࢃࢀࢃࢀࡣᏊᐑወᙧࢆྜేࡋࡓᕥእ㰡ᚄ࣊ࣝࢽ࢔⑕
౛ࢆ⤒㦂ࡋࡓࠋᏊᐑወᙧࡣ⛥࡞⑌ᝈ࡛ࠊࡉࡽ࡟࣊ࣝࢽ࢔ෆ
ᐜࡀࡑࡢᏊᐑࠊᕥ௜ᒓჾ࡛࠶ࡿ⑕౛ࡣሗ࿌౛ࡀ࡞ࡃࠊ㈗㔜
࡛࠶ࡿ࡜⪃࠼ࡽࢀࡓࠋಟ᚟๓ࠊಟ᚟ᚋ࡜ࡶ࡟⭡⭍ෆࢆほᐹࡍࡿࡇ࡜࡛࣊ࣝࢽ࢔ෆᐜ≀ࡢ☜ㄆ࡜ࡉࡽ࡟ಟ᚟ࡢ᏶ᡂࢆ
☜ㄆ࡛ࡁᮏ⑕౛࡟࠾࠸࡚ࡶ᭷⏝࡛࠶ࡗࡓࠋ
࡞࠾ࠊᮏㄽᩥࡢせ᪨ࡣ➨  ᅇ᪥ᮏෆど㙾እ⛉Ꮫ఍⥲఍ ᖺ  ᭶ᶓ὾

文ࡉࢀ࡚ࡃࡿࠋ⏨ᛶࡢሙྜࠊ:ROII ⟶ࡣ⢭ᕢᑟᖏ࡜࡞ࡗ࡚⢭ᕢࢆ㝜ᄞ࡬ࡴ࠿ࡗ࡚≌ᘬࡋࠊ㰡ᚄ㍯ࢆ㏻㐣ࡋ࡚ୗ㝆ࡋ࡚࠸
ࡃࠋⓎ⏕Ꮫⓗ࡞ほⅬ࠿ࡽ⪃࠼ࡿ࡜Ꮚᐑወᙧ࡟ࡼࡾᕥ㦵┙ෆ࡟㐟㞳ࡋࡓᏊᐑࠊᕥ௜ᒓჾࡀᕥ෇㠌ᖏ࡟ࡼࡾ㰡ᚄ⟶ෆ࡟≌ᘬࡉࢀ࣊ࣝࢽ࢔ෆᐜ࡜࡞ࡾ㑏⣡ࡋ࡙ࡽࡃ࡞ࡗ࡚ࡁࡓ࡜᥎
ࡉࢀࡿࠋ࢔࣓ࣜ࢝୙ዷᏛ఍ $)6 ࡢ࣑࣮ࣗࣛ⟶⏤᮶ჾᐁࡢወᙧศ㢮࡛ࡣϨ࡜ϩࡢ୰㛫ᆺ࡜⪃࠼ࡽࢀࡿࡀࠊࡇࡢศ㢮ࡢၥ㢟࡜ࡋ࡚୰㛫ᆺ࡟ࡘ࠸࡚ࡣゝཬࡋ࡚࠸࡞࠸ࡇ࡜ࡀ࠶
ࡆࡽࢀ࡚࠸ࡿ   ࠋᙜ᪋タ࡛ࡣ࣊ࣝࢽ࢔ಟ᚟๓ᚋ࡛⭡⭍ෆほᐹࢆే⏝ࡍࡿ
7(3 ࢆ᪋⾜ࡋ࡚࠸ࡿࠋಟ᚟๓ࡢ⭡⭍ෆほᐹ࡛࣊ࣝࢽ࢔ࡢデ

࡟࠾࠸࡚Ⓨ⾲ࡋࡓࠋ献 ᒸ ᇉࠉ ❳ ࿃ࠊ ┿ ᔱࠉ ᕞ ୍ࠊ 㔝 ཱྀࠉ ㆡ ἞ࠊ ௚㸸 Ꮚ ᐑ ወᙧ࡟ྜేࡋࡓ༸⟶Ỉ⭘ࢆෆᐜ࡜ࡍࡿ㰡ᚄ࣊ࣝࢽ࢔ࡢ ౛  ᪥⏘፬㛵ᮾ㐃఍ሗ➨ 㸸 ⸨ྜྷࠉၨ㐀  ჆ᮧࠉᩄ἞㸸ᛶჾࡢᙧែ␗ᖖ㸸఩⨨␗ᖖ  ᪥⏘፬఍ㄅ 㸸 ᒸᇉࠉ❳࿃ࠊỌ⏣୍㑻㸸ᏊᐑⓎ⏕࡜Ꮚᐑወᙧ࡟㛵ࡍࡿ᪂ࡋ࠸⪃࠼᪉  ⏘⛉࡜፬ே⛉ 㸸
 $PHULFDQ )HUWLOLW\ 6RFLHW\7KH $PHULFDQࠉ)HUWLOLW\ࠉ6RFLHW\ࠉFODVVLILFDWLRQVࠉRIࠉ
DGQH[DO DGKHVLRQVGLVWDOࠉWXEDOࠉRFFOXVLRQWXEDORFFOXVLRQ VHFRQGDU\ WR WXEDO OLJDWLRQWXEDOSUHJQDQFLHVP¾OOHULDQ DQRPDOLHV DQG LQWUDXWHULQHDGKHVLRQV)HUWLO6WHULO

᩿ࠊ࣊ࣝࢽ࢔ෆᐜࡢ᭷↓ࢆ☜ㄆ࡛ࡁࠊಟ᚟ᚋࡢ⭡⭍ෆほᐹ᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍



9RO1R)LJD ᕥෆ㰡ᚄ㍯ࡼࡾᕥ㦵┙ෆ࡟㐟㞳ࡋࡓወᙧᏊᐑࠊᕥ
௜ᒓჾࡀ⬺ฟࡋ࡚࠸ࡿ≧ែ

)LJGࠉྑ௜ᒓჾࡣṇᖖࡢ఩⨨࡟Ꮡᅾࡋ࡚࠸ࡓࡶࡢࡢᏊᐑ
࡜ࡣ㞳ࢀ࡚Ꮡᅾࡋ࡚࠸ࡿ

)LJEࠉ⭡⭍ෆࡼࡾወᙧᏊᐑࠊᕥ௜ᒓჾࢆᘬࡁᡠࡋࡓ
࡜ࡇࢁ

)LJ ࣊ࣝࢽ࢔ಟ᚟ᚋ෌ᗘ⭡⭍ෆࢆほᐹࡋࠊ࣊ࣝࢽ࢔ࡢ
ಟ᚟ලྜࠊ⬺ฟ⮚ჾࡢᕳࡁ㎸ࡳࡢ࡞࠸ࡇ࡜ࢆ☜ㄆࡋࡓ

)LJF ࡉࡽ࡟ወᙧᏊᐑ࡜ᕥ௜ᒓჾࢆᘬฟࡋ㰡ᚄ⟶ࢆ✵⹫࡟ࡋࡓ≧ែ࡛⭡⭷๓⭍ࡼࡾ࢔ࣉ࣮ࣟࢳࡋࡓ

᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍



9RO1R)LJDEࠉ⾡ᚋࡢ㦵┙ 05, ࡛ࡣᏊᐑෆ⭷ࡣᏑᅾࡋ࡚࠾ࡽࡎࠊᏊᐑ➽⭘ࡢྜేࡀ☜ㄆ࡛ࡁࡓ᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍



9RO1R

A Case of totally extraperitoneal preperitoneal repair for externalinguinal hernia contain with malformed uterus and left adnexa
Laparoscopic Surgery Center, Daiichi Towakai Hospital

Reina Miyamoto, Tomotake Tabata, Isao Satou, Iwao Kitazono, Atushi Okita, Makoto
Mizutani, Yoshihide Chino, Seiji Masuda, Youichi Noda, Masaki Fujimura
Abstract
A 70-year-old woman was referred to our hospital for admission with left inguinal hernia. She underwent
laparoscopic surgery. Observation of the abdominal cavity revealed external inguinal hernia contained in a malformed
uterus and left adnexa. We pulled out the malformed uterus and left adnexa in the abdominal cavity and undertook
totally extraperitoneal preperitoneal repair of the left external inguinal hernia.
We reported this very rare inguinal hernia merged with a malformed uterus and left adnex where the uterus andupper vagina originating from Müllerian ducts failed to fuse with the lower vagina originating from urogenital sinus.
Key wordslaparoscopic surgery, inguinal hernia, malformed uterus䠎䠌䠍䠏ᖺ䠕᭶䠍䠓᪥ཷࠉ⌮᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍
᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍



9RO1R

症例報告
鼠径ヘルニア手術 5 年後に発症した遅発性メッシュ感染の 1 例ᑠ∾ᕷẸ⑓㝔ࠉእ⛉୰す㤶௻  ᮃ᭶⬟ᡂ  ⚄ᓮ❶அ  ᶓᒣ⿱அ  ㇂ཱྀ೺ḟ要旨⑕౛ࡣ  ṓࠊ⏨ᛶࠋ ᖺ  ᭶࡟௚㝔࡛ᕥ㰡ᚄ࣊ࣝࢽ࢔࡟ᑐࡋ࡚࣓ࢵࢩ࣭ࣗࣉࣛࢢἲ࡟ࡼࡿಟ᚟⾡ࡀ᪋⾜ࡉࢀࡓࠋ ᖺ  ᭶ࠊ✺↛ࡢᕥ㰡ᚄ㒊③࡜Ⓨ㉥ࡀฟ⌧ࡋᙜ㝔⤂௓࡜࡞ࡗࡓࠋ⭡㒊㐀ᙳ㹁㹒᳨ᰝࢆ᪋⾜ࡋࡓ࡜ࡇࢁࠊ࣓ࢵࢩࣗ࿘
ᅖࡢ⓶ୗ࠿ࡽ⭡⭍ෆ࡬✺ฟࡍࡿ⮋⒆ᙧᡂࢆㄆࡵࡓࠋὀ⭠᳨ᰝ࡛ࡣ⭠⟶࡜ࡢ᫂ࡽ࠿࡞஺㏻ࡀ࡞ࡃࠊಖᏑⓗ἞⒪ࢆヨࡳࡓࡀ⑕≧ᨵၿࡀஈࡋࡃࠊእ⛉ⓗฎ⨨ࡀᚲせ࡜ุ᩿ࡋࡓࠋᡭ⾡ᡤぢ࡛ࡣ⭡⭷๓⭍࡟⮋⒆⭍ࢆࡳ࡜ࡵࠊ኱⥙ࡀ⒵╔ࡋ࡚࠸ࡓࠋ⒦Ꮝࡣㄆࡵࡎࠊࣉࣛࢢࠊ࢜ࣥࣞ࢖ࣃࢵࢳࢆྍ⬟࡞㝈ࡾ㝖ཤࡋࡓࠋ⾡ᚋ⤒㐣࡟ၥ㢟࡞ࡃ⾡ᚋ  ᪥┠࡟㍍ᛌ㏥㝔ࡋࡓࠋ⮋ࡢᇵ㣴࠿ࡽ 6WDSK\ORFRFFXV DXUHXV ࡀ᳨ฟࡉࢀࡓࠋ⾡ᚋ㸯ᖺ༙⤒㐣ࡍࡿࡀ௒ࡢ࡜ࡇࢁ෌Ⓨࢆㄆࡵ࡚࠸࡞࠸ࠋ௒ᅇࠊ㰡ᚄ࣊ࣝࢽ࢔⾡ᚋ㐜Ⓨᛶࡢ࣓ࢵࢩࣗឤᰁࢆࡁࡓࡋࡓ⛥࡞  ౛ࢆ⤒㦂ࡋࡓࡢ࡛ሗ࿌ࡍࡿࠋ

࣮࣮࢟࣡ࢻ㸸㰡ᚄ࣊ࣝࢽ࢔㸪࣓ࢵࢩ࣭ࣗࣉࣛࢢឤᰁ㸪㐜Ⓨᛶ࢞ࢫࢺࣟࢢࣛࣇ࢕ࣥὀ⭠᳨ᰝᡤぢ㸸6 ≧⤖⭠࡟ቨእ࠿ࡽ

はじめに㰡 ᚄ ࣊ ࣝ ࢽ ࢔ ᡭ ⾡ ࡟ ࠾ ࠸ ࡚ࠊSURVWKHVLV ࢆ ⏝ ࠸ ࡓ
WHQVLRQIUHHUHSDLU ࡣࠊᚑ᮶ἲ࡟ẚ㍑ࡋ࡚෌Ⓨ⋡ࡀపࡃࠊ࠿ࡘ⡆౽࡟᪋⾜ྍ⬟࡞ࡓࡵ᪥ᖖデ⒪࡟࠾࠸࡚ࡣᗈࡃཷࡅ
ධࢀࡽࢀ࡚࠸ࡿࠋࡑࢀ࡟క࠸ SURVWKHVLV ࡟㛵㐃ࡋࡓྜే⑕ࡶሗ࿌ࡉࢀࡿࡼ࠺࡟࡞ࡗࡓࠋࡑࡢ࡞࠿࡛ SURVWKHVLV ࡬ࡢឤᰁࡢ㢖ᗘࡣ  㹼 㸣   ࡜ሗ࿌ࡉࢀ㠀ᖖ࡟⛥࡛࠶ࡿࡀ࠸ࡗࡓࢇ㉳ࡇࡿ࡜἞⒪࡟㞴῰ࡍࡿሙྜࡀከ࠸ࠋ௒ᅇࠊ
㰡ᚄ࣊ࣝࢽ࢔ᡭ⾡  ᖺᚋ࡟⭡⭷๓⭍࡬ࡢ⮋⒆ᙧᡂ࡟࡚Ⓨ⑕ࡋࡓ㐜Ⓨᛶ࣓ࢵࢩࣗឤᰁࡢ  ౛ࢆ⤒㦂ࡋࡓࡢ࡛ሗ࿌ࡍࡿࠋ

症

ࡢᅽ᤼ᡤぢࢆㄆࡵࡓࡀࠊ⮋⒆⭍࡜ࡢ஺㏻ࡣㄆࡵ࡞࠿ࡗࡓ
)LJ ࠋ⾑ᾮ᳨ᰝ⤖ᯝ㸸ⓑ⾑⌫  ȣ Oࠊ&53PJGO ࡜⅖
⑕ᡤぢࢆㄆࡵࡿ௚࡟␗ᖖࡣ࡞࠿ࡗࡓࠋ
ᒀ᳨ᰝ⤖ᯝ㸸≉࡟␗ᖖ࡞ࡋࠋ
ཷデᚋ⤒㐣㸸௨ୖࡢ⤖ᯝ࠿ࡽ㐜Ⓨᛶ࣓ࢵࢩࣗឤᰁ࡜デ᩿ࡋࡓࠋࣉࣛࢢ࡟ࡼࡿ⭠⟶ᦆയࡢྍ⬟ᛶࡶ⪃៖ࡋࡓࡀࠊ⭡⭷่⃭⑕≧ࡣ࡞ࡃࠊᢠ⳦⸆࡟ࡼࡿಖᏑⓗ἞⒪ࢆ㛤ጞࡋࡓࠋಖᏑ
ⓗ἞⒪㛤ጞ࠿ࡽ  㐌㛫⤒㐣ࡋࡓ᫬Ⅼ࡛⮫ᗋᡤぢࡢᨵၿ࡞ࡃ
ᡭ⾡㐺ᛂ࡜ุ᩿ࡋࡓࠋ

例ᡭ⾡ᡤぢ㸸඲㌟㯞㓉ୗ࡟ୗ⭡㒊ṇ୰ษ㛤࡛㛤⭡ࡍࡿ࡜ࠊᕥ

ᝈ⪅㸸 ṓࠊ⏨ᛶࠋෆ㰡ᚄ㍯௜㏆࡟኱⥙ࡀ⒵╔ࡋ࡚࠸ࡓ )LJ ࠋࣉࣛࢢࡣ⭡୺ッ㸸ᕥ㰡ᚄ㒊③࡜ྠ㒊⓶⭵ࡢⓎ㉥ࠋ⭍ෆ࡟ࡣ✸㏻ࡋ࡚࠾ࡽࡎࠊ⮋⒆ࡢ୺యࡣ⭡⭷๓⭍࡟࠶ࡾ᪤ Ṕ㸸ᑠඣႍᜥࠋ

⭡⭷ࢆ௓ࡋ࡚኱⥙࡜⒵╔ࡋ࡚࠸ࡓࠋ⭡⭷ࢆษ㛤ࡍࡿ࡜⮋ࡢ⌧⑓Ṕ㸸 ᖺ  ᭶ࠊ௚㝔࡟࡚ᕥእ㰡ᚄ࣊ࣝࢽ࢔࡟ᑐࡋ

ὶฟࢆㄆࡵࡓࠋ⮋⒆⭍ෆ࡟ࣉࣛࢢࢆㄆࡵ )LJ ࠊ⭡⭍ഃ࣓ࢵࢩ࣭ࣗࣉࣛࢢἲ㸦ࣉࣛࢢ㸩࢜ࣥࣞ࢖ࣃࢵࢳ㸧࡟ࡼࡿಟࡼࡾࣉࣛࢢࡢ᦬ฟࢆ⾜ࡗࡓࠋ6 ≧⤖⭠࡟᫂ࡽ࠿࡞⒦Ꮝࡣ࡞

᚟⾡ࢆཷࡅࡓࠋ⾡ᚋ᪩ᮇ࡟ࡣឤᰁࡢྜేࢆㄆࡵ࡞࠿ࡗࡓࠋ

࠿ࡗࡓࠋ⥆࠸࡚๓᪉࢔ࣉ࣮ࣟࢳ࡟࡚ᕥ㰡ᚄ㒊ࢆษ㛤ࡋࠊ࢜ ᖺ  ᭶࡟✺↛ࡢᕥ㰡ᚄ㒊③࡜ྠ㒊⓶⭵ࡢⓎ㉥ࡀ࠶ࡾࠊࣥࣞ࢖ࣃࢵࢳࡢ㝖ཤࢆ⾜ࡗࡓ )LJ ࠋ㰡ᚄ⟶ᚋቨࡣ◳๓་ࢆཷデࡋᕥ㰡ᚄ࣊ࣝࢽ࢔෌Ⓨࡢ␲࠸࡟࡚ᙜ㝔⤂௓࡜

ࡃ⒕⑞⤌⧊໬ࡋ࡚࠾ࡾࠊ࢜ࣥࣞ࢖ࣃࢵࢳ㝖ཤ᫬࡟኱ࡁࡃḞ࡞ࡗࡓࠋᦆࡋࡓࡀእ⭡ᩳ➽⭝⭷ࢆ⦭ྜ㛢㙐ࡍࡿ࡟࡜࡝ࡵᚋቨࡢ⿵

ึ デ ᫬ ㌟ య ᡤ ぢ㸸 య Υࠊ ⾑ ᅽ PP+Jࠊ ⬦ ᢿಟࡣ⾜ࢃ࡞࠿ࡗࡓࠋ㛢㙐ᘧࢻ࣮ࣞࣥࢆ⭡⭷๓⭍࡜㰡ᚄ⟶ෆ ศࠊᩚࠋᕥ㰡ᚄ㒊࡟ᡭ⾡⑞ࢆㄆࡵࠊᡭ⾡๰ࡸࡸᑿഃࡢ

࡟␃⨨ࡋᡭ⾡ࢆ⤊஢ࡋࡓࠋ⭘⬽ࠊⓎ㉥ࢆㄆࡵࡓࠋ

᦬ฟᶆᮏᡤぢ㸸ࣉࣛࢢ࠾ࡼࡧ࢜ࣥࣞ࢖ࣃࢵࢳࡣ◳࠸⫗ⱆ⤌⭡㒊㐀ᙳ㹁㹒᳨ᰝ㸸ᕥ㰡ᚄ㒊⓶ୗࡢ⬡⫫⧊⃰ᗘࡢୖ᪼࡜⭡⧊࡟そࢃࢀ࡚࠾ࡾࠊࣉࣛࢢ࡟ࡣ⮋ⱏࡀ௜╔ࡋ࡚࠸ࡓࠋ

⭍ෆ࡟㎶⦕ࡀᙉࡃ㐀ᙳࡉࢀࡿ⮋⒆ࢆ␲ࢃࡏࡿᡤぢࢆㄆࡵ⮋ᇵ㣴⤖ᯝ㸸6WDSK\ORFRFFXV DXUHXV ௨ୗ 6DXUHXV ࡀࡓࠋࡲࡓࠊ⮋⒆⭍ࡣ㹑≧⤖⭠࡟㏆᥋ࡋ࡚࠸ࡓ )LJ㸧ࠋ᳨ฟࡉࢀࡓࠋ

᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍



9RO1R

⾡ᚋ⤒㐣㸸⤒㐣ࡣⰋዲ࡛⾡ᚋ  ᪥┠࡟㏥㝔ࡋࡓࠋ⾡ᚋ㸯

6DXUHXV ࡣ⓶⭵⾲ᅾ⳦࡛࠶ࡾࠊ㐲㝸㌿⛣࡜࠸࠺ࡼࡾࡣ๰

ᖺ༙⤒㐣ࡍࡿࡀ௒ࡢ࡜ࡇࢁ࣊ࣝࢽ࢔෌Ⓨࡸឤᰁ෌⇞ࡣㄆࡵ㒊࠿ࡽΰධࡋࡓྍ⬟ᛶࡀ᭱ࡶ␲ࢃࢀࡿࠋࡲࡓ 6DXUHXV࡚࠸࡞࠸ࠋࡀ ྠ ᐃ ࡉ ࢀ ࡓ  ౛ ࡣ ࡍ ࡭ ࡚ ⾡ ᚋ  ᖺ ௨ 㝆 ࡟ Ⓨ ⑕ ࡋ ࡓ考⑕ ౛ ࡛ ࠶ ࡾࠊ-H]XSRUV ࡽ ࡢ ሗ ࿌ ྠ ᵝࠊ ࿘ ⾡ ᮇ ࡟ ࠾ ࡅ ࡿ察㰡ᚄ࣊ࣝࢽ࢔࡟ᑐࡍࡿᡭ⾡ࡣᚑ᮶ἲ࡟ẚ㍑ࡋ࡚⾡ᚋ෌Ⓨ⋡ࡢపࡉࠊ࠾ࡼࡧ⾡ᚋ⑊③ࡢᑡ࡞ࡉ࠿ࡽࠊSURVWKHVLV ࢆ⏝࠸ࡓ WHQVLRQIUHH ࡢ࣊ࣝࢽ࢔ಟ᚟⾡ࡀ  ᖺ௦࠿ࡽᛴ
㏿࡟ᬑཬࡋࠊ⌧ᅾ࡛ࡣ᪥ᖖデ⒪࡟࠾࠸࡚ᗈࡃ⾜ࢃࢀ࡚࠸ࡿࠋ
㰡ᚄ࣊ࣝࢽ࢔ᡭ⾡ᚋࡢྜే⑕࡜ࡋ࡚ࡣ⾑⭘ᙧᡂࠊឤᰁࠊ៏
ᛶ⑊③࡞࡝ࡀᣲࡆࡽࢀࡿࡀࠊSURVWKHVLV ౑⏝࡟㛵㐃ࡍࡿ≉᭷࡞ྜే⑕࡜ࡋ࡚⭡⭍ෆ࡟✺ฟࡋࡓࣉࣛࢢ࡟ࡼࡿ⭠⟶ᦆയࡢሗ࿌ࡶ࠶ࡿ  ࠋឤᰁ࡟㛵ࡋ࡚ࡣ⾡ᚋ᪩ᮇ࡟Ⓨ⏕ࡍࡿ⾲ᒙࡢ๰ឤᰁࡀከࡃ
ࢆ༨ࡵࡿࡀࠊᮏ⑕౛ࡢࡼ࠺ SURVWKHVLV ࡬ࡢឤᰁࡢሗ࿌ࡶ
ࡳࡽࢀࡿࠋཎᅉࡣࠊ⾡୰ởᰁࡸ㐲㝸㒊఩࠿ࡽࡢ⾑⾜ᛶࠊࣜࣥࣃ⾜ᛶࡢྍ⬟ᛶࡀᣦ᦬ࡉࢀ࡚࠸ࡿ  ࠋ㐜Ⓨᛶឤᰁ࡟㛵ࡋ࡚ࡣ⾡ᚋ᪩ᮇឤᰁࡢ᪤ ࡀ࡞࠸๰࡟
㉳ࡇࡿ⒦Ꮝࡸ῝㒊ࡢ⮋⒆࡜ᐃ⩏ࡉࢀ  ࠊⓎ⏕⋡ࡣ 1HJUR ࡽࡣ  ౛୰  ౛  ࠊ7D\ORU ࡽ  ࡣ  ୰ ౛ 㸣࡜ሗ࿌ࡋ࡚࠸ࡿࠋࡋ࠿ࡋᡭ⾡࠿ࡽⓎ⏕ࡲ࡛ࡢᮇ㛫࡟㛵ࡋ࡚ࡣ᫂☜࡟ᐃ⩏ࡉࢀ࡚࡞࠸ࠋ&'& ࡢ࢞࢖ࢻࣛ࢖ࣥ  ࡟ᚑ࠼ࡤࠕ᪩ᮇ๰ឤᰁ࡜ࡣேᕤ≀ࡢᇙࡵࡇࡳࡀ⾜ࢃࢀ࡞࠿ࡗࡓሙྜ࡟ࡣ⾡ᚋ㸱㸮᪥௨ෆࠊ⛣᳜ேᕤ≀ࡀṧࡉࢀࡓሙྜ࡟ࡣ⾡ᚋ㸯ᖺ௨ෆ࡟ᡭ⾡࡟㛵㐃ࡋ࡚ឤᰁࡀ㉳ࡇࡿࡶSURVWKHVLV ࡬ࡢឤᰁࡀ₯ᅾᛶ࡟⥅⥆ࡋఱࡽ࠿ࡢㄏᅉ࡟ࡼ
ࡾ㢧ᅾ໬ࡋⓎ⑕ࡋࡓ࡜᥎ᐹࡉࢀࡿࠋ
ண㜵⟇ࡣ๰㒊࠿ࡽࡢ⳦ࡢΰධࢆ㜵ࡄࡓࡵ࡟ &'& ࡢ࢞࢖ࢻࣛ࢖ࣥࡢᡭ⾡㒊఩ឤᰁᑐ⟇ࢆ㡰Ᏺࡍࡿࡇ࡜ࡣࡶࡕࢁࢇࡢࡇ
࡜ࠊ⾡୰ឡㆤⓗ࡞ฎ⨨࡟ࡼࡾ⤌⧊ࡢᦆയࢆ᭱ᑠ㝈࡟ᢚ࠼ࠊឤᰁࡢᇵᆅ࡜࡞ࡿ⾑⭘ࢆసࡽ࡞࠸ࡓࡵṆ⾑ฎ⨨ࢆ☜ᐇ࡟ࡍࡿࡇ࡜ࡀ㔜せ࡜⪃࠼ࡿࠋ἞⒪࡟㛵ࡋ࡚ཎ๎ SURVWKHVLV ࡢ㝖ཤࡀᚲせ࡛࠶ࡾࠊ௒ᅇࡢ᳨ウ࡛ࡶ᭱⤊ⓗ࡟඲౛ᡭ⾡ࡀ᪋⾜ࡉࢀ࡚࠸ࡓࠋ≉࡟ཎᅉ⳦ࡀࠊ6DXUHXV ࡛࠶ࡗࡓሙྜࠊ6DXUHXV ࡣ ELR㸚OP ࢆᙧᡂࡍࡿࡓࡵᢠ⏕๣ࡢຠᯝࡀஈࡋࡃ㞴἞໬ࡋࡸࡍ࠸ࠋࡇ
ࡢࡓࡵ 6DXUHXV ឤᰁ࡜デ᩿ࡀࡘ࠸ࡓ᫬Ⅼ࡛ SURVWKHVLV᦬ฟࢆ᪩ࡵ࡟⪃៖ࡋࡓ࡯࠺ࡀࡼ࠸࠿ࡶࡋࢀ࡞࠸ࠋࡲࡓSURVWKHVLV 㝖ཤᚋࡣ෌Ⓨࡀ༴᝹ࡉࢀࡿࡀ୍⯡ⓗ࡟ࡣ෌Ⓨண㜵ࡢࡓࡵࡢಟ᚟ࠊ⿵ಟࡣ୙せ࡜ࡢሗ࿌ࡀከ࠸ࠋࡇࢀࡣឤ
ᰁࢆዎᶵ࡟⭡⭷ࡢ⫧ཌࠊ㰡ᚄ⟶࿘ᅖࡢ⥺⥔໬ࡸ⒵╔ࡀ㐍⾜ࡍࡿࡓࡵࠊᚲࡎࡋࡶ෌Ⓨࡢ༴㝤ࡣ㧗ࡃ࡞࠸ࡓࡵ࡜⪃ᐹࡉࢀࡿࡇ࡜࡟ࡼࡿ   ࠋ⮬㦂౛࡟࠾࠸࡚ࡶᚋቨ⿵ᙉࡣ⾜ࡗ࡚࠸࡞࠸ࡀࠊ⾡ᚋ㸯ᖺ༙⤒㐣ࡍࡿࡀ௒ࡢ࡜ࡇࢁ࣊ࣝࢽ࢔ࡢ෌Ⓨࡣㄆࡵ࡚࠸࡞࠸ࠋ

結ࡢࠖ࡜ࡉࢀ࡚࠾ࡾࠊ㐜Ⓨᛶឤᰁ࡜ࡣ⾡ᚋ  ᖺ௨ୖ⤒㐣ࡋ࡚
࠿ࡽⓎ⑕ࡋࡓࡶࡢ࡜ࡍࡿࡢࡀጇᙜ࡜⪃࠼ࡽࢀࡿࠋ

語࣓ࢵࢩࣗࢆ⏝࠸ࡓ㰡ᚄ࣊ࣝࢽ࢔ಟ᚟ᚋࠊ㐜Ⓨᛶ࡟࣓ࢵ௒ᅇࠊ་Ꮫ୰ኸ㞧ㄅ࡛  ᖺ࠿ࡽ  ᖺࡲ࡛ࡢᮇ㛫࡛ࢩࣗឤᰁࢆࡁࡓࡋࠊ࣓ࢵࢩࣗ㝖ཤ࡟࡚἞⒵ࡋࡓ⑕౛ࢆ⤒㦂ࠕ㰡ᚄ࣊ࣝࢽ࢔ࠖࠊࠕ࣓ࢵࢩࣗឤᰁࠖࢆ࣮࣮࢟࣡ࢻ᳨࡛⣴ࡋࡋࡓࠋ௒ᚋࠊ࣓ࢵࢩࣗಟ᚟⾡ࡢ୍⯡໬࡟క࠸ࠊྠᵝࡢ⑕౛ࡓ⤖ᯝࠊ⮬㦂౛ࢆྵࡵ࡚  ౛ࡢሗ࿌ࢆㄆࡵࡓ㸦఍㆟㘓ࢆࡀቑ࠼࡚ࡃࡿ࡜ண᝿ࡉࢀὀពࡀᚲせ࡛࠶ࡿࠋ㝖ࡃ㸧ࠋࡇࢀࡽࡢ࠺ࡕ⾡ᚋ  ᖺ௨㝆࡟Ⓨ⏕ࡋࠊ⾡ᚋ᪩ᮇ࡟ឤᰁࡢ᪤ ࡢ࡞࠸⑕౛ࡣ  ౛࡛࠶ࡗࡓ WDEOH ࠋᮏ㑥ሗ࿌౛ࡢෆヂ࡜ࡋ࡚ࡣࠊ⏨ᛶ  ౛ࠊዪᛶ  ౛࡛࠶ࡗࡓࠋⓎ⑕᫬ᖹᆒᖺ㱋ࡣ  ṓࠊ⾡ᚋឤᰁⓎ⑕ࡲ࡛ࡢᮇ㛫ࡣᖹᆒ ࠿᭶ࠊ⾡ᚋ  ᖺࢆ⤒㐣ࡋ࡚Ⓨ⑕ࡋࡓ⑕౛ࡶㄆࡵࡓࠋ
ឤᰁ⤒㊰࡟ࡘ࠸࡚ࡣᵝࠎ࡞ぢゎࡀ࠶ࡾ᫂☜࡞ࡇ࡜ࡣ୙᫂
࡛࠶ࡿࠋ0DQQ ࡽ  ࡣ VHURPD ࡜ࡢ㛵㐃ࢆ♧၀ࡋࠊ-H]XSRUVࡽ  ࡣ⾲ᅾ⳦ࡢ⾡୰ࢥࣥࢱ࣑ࢿ࣮ࢩࣙࣥ࡟ࡼࡿ₯ᅾᛶࡢឤᰁࡀㄏᅉ࡜ሗ࿌ࡋ࡚࠸ࡿ  ࠋࡲࡓ 7D\ORU ࡽ  ࡣ௚㒊఩ࡢឤᰁᕢ࠿ࡽࡢ⾑⾜ᛶឤᰁࢆ♧၀ࡋ࡚࠸ࡿࠋேᕤ≀࡟ᑐࡍࡿឤᰁ࡟ࡘ࠸࡚ࡣࠊேᕤ㛵⠇ࢆᑐ㇟࡜ࡋࡓ᳨ウࡀ࠶ࡿࠋࡇ
ࡢ୰࡛ࡣ⾡ᚋ  ࠿᭶ࡢឤᰁࡣ⾡୰ࡢࢥࣥࢱ࣑ࢿ࣮ࢩࣙ
ࣥ࡜ᐟ୺ࡢච␿ຊࡢపୗࡀࠊ ࠿᭶௨㝆ࡢឤᰁࡣ㐲㝸㒊఩࠿ࡽࡢ⾑⾜ᛶឤᰁࡀཎᅉ࡜࡞ࡿࡇ࡜ࡀከ࠸࡜ሗ࿌ࡉࢀ࡚࠸ࡿ  ࠋ௒ ᅇ ࡢ ᳨ ウ ࡛ ࡣࠊ ཎ ᅉ ⳦ ࡣ  ౛ ୰  ౛ ࡛
6WDSK\ORFRFFXV DXUHXV᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

௨ ୗ 6DXUHXV ࡛ ࠶ ࡗ ࡓࠋ文献 )DZROH $6 &KDSDUDOD 53 $PEURVH 16)DWH RI WKHLQJXLQDO KHUQLD IROORZLQJ UHPRYDO RI LQIHFWHG
SURVWKHWLFPHVK+HUQLDࠉ
 7UDEXFFR ((7KH RIILFH KHUQLRSODVW\ DQG WKH7UDEXFFRUHSDLU$QQ,WDO&KLU ఀ⸨ᾈ᫂  ⯪ᶫၨ⮧  㓇ྥ⊛௚㸸㰡ᚄ࣊ࣝࢽ࢔᰿἞⾡ᚋࠊ࣓ࢵࢩࣗࣉࣛࢢ࡟ࡼࡿ኱⭠✸㏻ࢆࡁࡓࡋࡓ  ౛  ᪥⮫እ఍ㄅ ᰙ℩ಙኴ㑻㸸㰡ᚄ࣊ࣝࢽ࢔⾡ᚋࡢ๰ឤᰁ࡜࣓ࢵࢩࣗឤᰁ  ᡭ⾡
 1HJUR 3'̓$PRUH / *RV-VHWWL ) HW DO /DWH
LQIHFWLRQ DIWHU PHVKSOXJ LQJXLQDO KHUQLRSODVW\$P-6XUJ 7D\ORU 6*2̓'Z\HU 3-&KURQLF JURLQ VHSVLVIROORZLQJWHQVLRQIUHHLQJXLQDOKHUQLRSODVW\%U-
6XUJ
 0DQJUDP$-+RUDQ7&3HDUVRQ0/HWDO*XLGHOLQH
IRU WKH 3UHYHQWLRQ RI 6XUJLFDO 6LWH ,QIHFWLRQ$P-,QIHFW&RQWURO
 0DQQ '9 3URXW - +DYUDQHN (HW DO /DWHRQVHW

9RO1R

GHHS SURVWKHWLF LQIHFWLRQ IROORZLQJ PHVK UHSDLU
RILQJXLQDOKHUQLD$P-6XUJ
 -H]XSRUV$0LKHOVRQV07KH$QDO\VLVRI,QIHFWLRQDIWHU3RO\SURS\OHQH0HVK5HSDLURI$EGRPLQDO:DOO
+HUQLD:RUOG-6XUJ
 'HOLNRXNRV 6 7]RYDUDV * /LDNRX 3HW DO /DWH
RQVHW GHHS PHVK LQIHFWLRQ DIWHU LQJXLQDO KHUQLDUHSDLU+HUQLD ⏣ ⏿ ᬛ ྐ  㛗 ㇂ ᕝ ὒ  ᆏ ᮏ ⱥ ⮳ ௚㸸 ࣓ ࢵ ࢩ ࣗ 㝖 ཤࢆせࡋࡓ㰡ᚄ࣊ࣝࢽ࢔⾡ᚋ㐜Ⓨᛶឤᰁࡢ  ౛  ⮫እ ᖾ኱㍜  ୕㇂┾ᕭ  ⏣୰┤௚㸸㰡ᚄ࣊ࣝࢽ࢔⾡ᚋ࡟㐜
Ⓨᛶ࣓ࢵࢩࣗឤᰁࢆࡁࡓࡋࠊ࣓ࢵࢩࣗ㝖ཤࢆ᪋⾜ࡋࡓ ౛  ྡྂᒇ⑓⣖ࠉ ୰ᕝᅜ฼  ᮧୖὈ௓  㐲⸨බே௚㸸࣓ࢵࢩࣗ᦬ฟࢆせࡋࡓ㰡ᚄ࣊ࣝࢽ࢔⾡ᚋ㐜Ⓨᛶឤᰁࡢ  ౛  ᪥እ⛉⣔㐃఍ㄅ బ⸨ᗣ  ୰ᔱ᫛  ᕝᮧᚭ௚㸸ᡂே㰡ᚄ࣊ࣝࢽ࢔ࡢデ⒪
⾡ᚋྜే⑕࡜ࡑࡢண㜵ἲ  ⮫እ 

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 Ἑྜ㝯அ  ᮔὈ⠊  Ἑᮏ࿴ᖾ௚㸸㰡ᚄ࣊ࣝࢽ࢔⾡ᚋ ᖺ┠࡟Ⓨ⑕ࡋࡓ࣓ࢵࢩࣗឤᰁࡢ  ౛  ᪥⮫እ఍ㄅࠉ
  7 U D P S X ]  $   = L P P H U O L  :  3 U R V W K H W L F  M R L Q WLQIHFWLRQXSGDWH LQ GLDJQRVLV DQG WUHDWPHQW6ZLVV0HG:NO\



9RO1R)LJ ⭡㒊㐀ᙳ &7 ᳨ᰝᡤぢ▮༳ $ ⮋⒆⭍ࠉ▮༳ %㸸6 ≧⤖⭠⮋⒆ᙧᡂ࡜ᛮࢃࢀࡿീࡀ࠶ࡾࠊ6 ≧⤖⭠࡟㏆᥋ࡋ
࡚࠸ࡿ

)LJ ⾡୰ᡤぢ㸦⭡⭍ෆ㸧▮༳ $㸸ࣉࣛࢢࠉࠉ▮༳ %㸸6 ≧⤖⭠⭡⭷๓⭍ࡢ⮋⒆⭍ࢆ㛤ᨺࡋࡓ࡜ࡇࢁࠊ⭍ෆ࡟ࣉࣛࢢࢆㄆࡵࡓ

)LJ ⾡୰ᡤぢ㸦๓᪉࢔ࣉ࣮ࣟࢳ㸧▮༳ $ ⢭⣴ࠉ▮༳ %㸸࢜ࣥࣞ࢖ࢩ࣮ࢺ

)LJ ࢞ࢫࢺࣟࢢࣛࣇ࢕ࣥὀ⭠㐀ᙳ᳨ᰝᡤぢ▮༳㸸6 ≧⤖⭠࡟ቨእ࠿ࡽࡢᅽ᤼ീࢆㄆࡵࡿࠋ⒦Ꮝࡣㄆࡵ࡞࠸

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A CASE OF LATE-ONSET MESH-PLUG INFECTION 5 YEARSAFTER INGUINAL HERNIOPLASTY
Department of surgery, Komaki city Hospital

Koki Nakanishi, Yoshinari Mochizuki, Akiyuki Kanzaki,
Hiroyuki Yokoyama , Kenji Taniguchi
Abstract
The case is a 44 years old man. Hernioplasy with mesh-plug was performed for other hospital in November,2006. He had sudden onset of a pain in the left groin region in January, 2012. The abdominal enhanced computed
tomography(CT) demonstrated the abscess formation in abdominal cavity from pre-peritoneal space around the meshplug. It was suspiciously concerned in the injury of the bowel, but barium enema did not indicated the perforated
bowel. Hence we tried conservative medical treatment, whose effectiveness was so poor that surgical intervention wasQ    8    8 &  !&      ?! E88  with the greater omentum and spread to pre-peritoneal space. So the adjacent bowel was intact, we opened abscesscavity and removed a mesh- plug and sheet. Postoperative course was good. Staphylococcus aureus was detected byculture of the pus. Meanwhile, no sign of recurrence of hernia and infection have occurred. We present our case with areview of the literature.
Key words: inguinal hernia, mesh infection, late onset䠎䠌䠍䠏ᖺ䠕᭶䠍䠓᪥ཷࠉ⌮᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍
᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍



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症例報告
閉鎖孔ヘルニアを合併した大腿ヘルニアに対し，鼠径法による根治術を施行した１例
ஂ⨾ឡཌ⏕⑓㝔እ⛉

ἙྜΎ㈗
要

旨

⑕౛ࡣ  ṓࡢዪᛶ࡛㸪ᕥ㰡ᚄ㒊⭘⬽ࢆక࠺⭡③ࢆ୺ッ࡟ཷデࡋ㸪⌮Ꮫⓗᡤぢ࠿ࡽᕥ኱⭣࣊ࣝࢽ࢔࡜デ᩿ࡋࡓ㸬ྠ᪥᪋⾜ࡋࡓ &7 ࡛ྠഃࡢ㛢㙐Ꮝ࣊ࣝࢽ࢔ࢆㄆࡵࡓࡀ㸪࠸ࡎࢀࡶᔐ㡻ᡤぢࢆㄆࡵࡎ㸪ᚅᶵⓗ࡟ᡭ⾡ࢆ᪋⾜ࡋࡓ㸬඲㌟㯞㓉ୗ࡟㰡ᚄἲ࡟ࡼࡿ࢔ࣉ࣮ࣟࢳࢆ⾜࠸㸪Ⰻど㔝ୗ࡟୧࣊ࣝࢽ࢔ᄞࢆᘬࡁฟࡋࡓ㸬⭡⭷๓⭍ෆ࡛ 'LUHFWࠉ.XJHOࠉ3DWFK ࢆᗈࡆࡿࡇ࡜࡟ࡼࡾ㸪㛢㙐Ꮝ࡜ P\RSHFWLQHDO RUL㸚FH ࢆ࢝ࣂ࣮ࡋᶓ➽➽⭷࡟ᅛᐃࡋࡓ㸬኱⭣࣊ࣝࢽ࢔࡟ྜేࡋࡓ㛢㙐Ꮝ࣊ࣝࢽ࢔ࡢሗ࿌ࡣᩘᑡ࡞࠸㸬ࡋ࠿ࡋ㏆ᖺࡢ㧗㱋໬࡟క࠸₯ᅾⓗ࡟୧⪅ࢆྜేࡍࡿ⑕౛ࡣቑຍࡍࡿྍ⬟ᛶࡀ࠶ࡾ㸪኱⭣࣊ࣝࢽ࢔࠶ࡿ࠸ࡣ㛢㙐Ꮝ࣊ࣝࢽ࢔࡟ᑐࡍࡿ 'LUHFWࠉ.XJHOࠉ3DWFK ࢆ⏝࠸ࡓ㰡ᚄἲ࡟ࡼࡿ WRWDO KHUQLD UHSDLU ࡣ᭷⏝࡞⾡ᘧ࡜⪃࠼ࡽࢀࡓ㸬࣮࣮࢟࣡ࢻ㸸኱⭣࣊ࣝࢽ࢔㸪㛢㙐Ꮝ࣊ࣝࢽ࢔㸪㰡ᚄἲࢆకࢃࡎ㸪࣊ࣝࢽ࢔ᄞࡣᐜ᫆࡟ᘬࡁฟࡋࡀྍ⬟࡛࠶ࡗࡓ㸬

はじめに㛢㙐Ꮝ࣊ࣝࢽ࢔ࡣẚ㍑ⓗࡲࢀ࡞⑌ᝈ࡜ࡉࢀ࡚ࡁࡓࡀ㸪㏆ᖺࡢ㧗㱋໬࡜⏬ീデ᩿ᶵჾࡢ㐍Ṍ࡟క࠺⾡๓デ᩿⋡ࡢྥୖ࡟ࡼࡾ 㸧 ࡑࡢሗ࿌౛ࡣቑຍࡋ࡚ࡁ࡚࠸ࡿ㸬ࡋ࠿ࡋ࡞ࡀ

⭡⭷๓⭍ෆ࡛ 'LUHFWࠉ.XJHOࠉ3DWFK㸦෇ᙧ 0㸧ࢆᗈࡆ㸦ᅗ
&㸧㸪ᶓ➽➽⭷࡟ᅛᐃࡋࡓ㸬⤒㐣Ⰻዲ࡛⾡ᚋ➨  ⑓᪥࡟㏥
㝔࡜࡞ࡗࡓ㸬

考ࡽ㸪኱⭣࣊ࣝࢽ࢔࡟ྜేࡋࡓ㛢㙐Ꮝ࣊ࣝࢽ࢔ࡢሗ࿌ࡣᩘᑡ

察࡞࠸㸬኱⭣࣊ࣝࢽ࢔ࡢ⾡๓࡟᪋⾜ࡋࡓ &7 ࡛↓⑕ೃᛶࡢྠ

㛢㙐Ꮝ࣊ࣝࢽ࢔ࡣẚ㍑ⓗࡲࢀ࡞⑌ᝈ࡜ࡉࢀ࡚ࡁࡓࡀ㸪㧗ഃ㛢㙐Ꮝ࣊ࣝࢽ࢔ࡢྜేࢆデ᩿ࡋ㸪㰡ᚄἲ࡟ࡼࡿ 'LUHFW㱋໬ࡸ⏬ീデ᩿ᶵჾࡢ㐍Ṍ࡟క࠺⾡๓デ᩿⋡ࡢྥୖ࡟ࡼ.XJHO3DWFK ࢆ⏝࠸ࡓ᰿἞ᡭ⾡ࢆ᪋⾜ࡋࡓࡢ࡛ሗ࿌ࡍࡿ㸬ࡾ 㸧 ࡑࡢሗ࿌౛ࡣቑຍࡋ࡚ࡁ࡚࠸ࡿ㸬ࡋ࠿ࡋ㸪་୰ㄅ࡛症

᳨⣴ࡋ࠼ࡓ⠊ᅖ㸦࣮࣮࢟࣡ࢻ㸸ࠕ㛢㙐Ꮝ࣊ࣝࢽ࢔ࠖ㸪ࠕ኱⭣例࣊ࣝࢽ࢔ࠖ㸪఍㆟㘓ࢆ㝖ࡃ㸧࡛ࡣ኱⭣࣊ࣝࢽ࢔ࢆྜేࡋࡓ

ᝈ⪅㸸 ṓ㸪ዪᛶ㛢㙐Ꮝ࣊ࣝࢽ࢔ࡣࡲࢀ࡜ሗ࿌ࡉࢀ࡚࠸ࡿ 㸧㹼 㸧㸬ࡑࡢ୍᪉࡛㸪୺ッ㸸ᕥ㰡ᚄ㒊⭘⬽㸪⭡③ᡭ⾡᫬࡟୧⪅ࡢྜేࢆデ᩿ࡋࡓሗ࿌౛ 㸧㹼 㸧ࡸ㸪࣊ࣝࢽ࢜᪤ Ṕ㸸 ṓ᫬࡟⹸ᆶษ㝖⾡ࢆ᪋⾜ࢢࣛࣇ࢕࣮࡟ࡼࡿ㛢㙐Ꮝ࣊ࣝࢽ࢔ࡢデ᩿࡛ࡣ㸪ẚ㍑ⓗ㧗⋡⌧⑕㸸FP㸪NJ㸪%0,
⌧⑓Ṕ㸸ࡓࡧࡓࡧᕥ㰡ᚄ㒊⭘⬽ࢆక࠺⭡③ࢆ⮬ぬࡋࡓࡓࡵ࡟₯ᅾᛶࡢ኱⭣࣊ࣝࢽ࢔ࢆྜేࡍࡿ࡜ࡶሗ࿌ࡉࢀ࡚࠸ࡿ㸧ᙜ⛉ࢆཷデࡋ㸪⌮Ꮫⓗᡤぢ࠿ࡽᕥ኱⭣࣊ࣝࢽ࢔࡜デ᩿ࡋ㸬ᮏ⑕౛ࡣ኱⭣࣊ࣝࢽ࢔デ᩿᫬࡟᪋⾜ࡋࡓ &7 ࡛↓⑕≧ࡢࡓ㸬ྠ᪥᪋⾜ࡋࡓ &7 ࡛ྠഃࡢ㛢㙐Ꮝ࣊ࣝࢽ࢔ࢆㄆࡵࡓ㸦ᅗ㸯㸧㸬࠸ࡎࢀࡢ࣊ࣝࢽ࢔ࡶᔐ㡻ᡤぢࢆㄆࡵࡎ㸪ᚅᶵⓗ࡟ᡭ⾡ࢆ᪋⾜ࡋࡓ㸬࡞࠾⑓Ṕ⫈ྲྀ࡟࠾࠸࡚ +RZVKLS 㸫 5RPEHUJࡵ࡞࠿ࡗࡓࡓࡵ࡟ᚅᶵⓗ࡟ᡭ⾡ࢆ᪋⾜ࡋࡓ㸬*UD\ ࡢ㛢㙐Ꮝ࣊ࣝࢽ࢔ᙧᡂㄝ 㸧࡟ࡼࢀࡤ㸪 ᮇ㸸SLORW WDJ㸦⭡⭷๓ᚩೃࡣㄆࡵ࡞࠿ࡗࡓ㸬ᡭ⾡ᡤぢ㸸඲㌟㯞㓉ୗ࡟㰡ᚄἲ࡛ᡭ⾡ࢆ᪋⾜ࡋࡓ㸬೺ᖖ࡞ᶓ➽➽⭷ࢆษ㛤ࡍࡿ࡜኱⭣㍯࠿ࡽ⬺ฟࡍࡿ࣊ࣝࢽ࢔ᄞࢆ
ㄆࡵࡓ㸦ᅗ $㸧㸬࣊ࣝࢽ࢔ෆᐜࢆకࢃࡎ㸪࣊ࣝࢽ࢔ᄞࡣᐜ
᫆࡟ᘬࡁฟࡋࡀྍ⬟࡛࠶ࡗࡓ㸬ḟ࠸࡛ &RRSHU 㠌ᖏ⫼ഃ࡬࡜⭡⭷๓⭍ࡢ๤㞳ࢆ㐍ࡵࡿ࡜㸪㛢㙐Ꮝ࠿ࡽ⬺ฟࡍࡿ࣊ࣝࢽ
࢔ᄞࢆㄆࡵࡓ㸦ᅗ %㸧㸬኱⭣࣊ࣝࢽ࢔ྠᵝ࡟࣊ࣝࢽ࢔ෆᐜ
᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

ྠഃ㛢㙐Ꮝ࣊ࣝࢽ࢔ࢆデ᩿ࡋ㸪࠸ࡎࢀࡶ࣊ࣝࢽ࢔ෆᐜࢆㄆ

⬡⫫㸧ࡢ㛢㙐⟶ෆ࡬ࡢ㐍ධ㸪 ᮇ㸸⭡⭷ࡢ GLPSOLQJ ࡢᙧᡂ㸪 ᮇ㸸࣊ࣝࢽ࢔ࡢᙧᡂࡀ࠶ࡾ㸪㸯ᮇ࠿ࡽ 㸪 ᮇ࡬ࡢ⛣⾜࡟ࡣࡿ࠸⑭ࡸ⭡ᅽࡢୖ᪼ࡀ୙ྍḞ࡜ࡉࢀ࡚࠸ࡿ 㸧㸬ࡇࢀࡣ㛢㙐Ꮝ࣊ࣝࢽ࢔㸪኱⭣࣊ࣝࢽ࢔࡜ࡶయ㉁ⓗ⣲ᅉࡣඹ㏻ࡋ
࡚࠸ࡿࡓࡵ㸪୧⪅ࡢ₯ᅾⓗ࡞ྜేࡸ␗᫬ᛶⓎ⏕ 㸧ࡢྍ⬟ᛶࢆᨭᣢࡍࡿࡶࡢ࡛࠶ࡾ㸪኱⭣࣊ࣝࢽ࢔ࡢ἞⒪࡟ࡼࡾ₯

9RO1R

ᅾᛶ㛢㙐Ꮝ࣊ࣝࢽ࢔ࡀ㢧ᅾ໬ࡍࡿྍ⬟ᛶࡀ࠶ࡿࡇ࡜ࢆ♧ࡋ࡚࠸ࡿ㸬㛢㙐Ꮝ࣊ࣝࢽ࢔ࡣ㧗㱋⪅࡟ዲⓎࡋ㸪࡯࡜ࢇ࡝ࡢ
⑕౛ࡀᔐ㡻ࡋ࡚ึࡵ࡚デ᩿ࡉࢀࡿࡇ࡜ࢆ㚷ࡳࢀࡤ㸪኱⭣࣊ࣝࢽ࢔἞⒪᫬࡟㛢㙐Ꮝࡲ࡛࢝ࣂ࣮ࡍࡿࡇ࡜ࡀ࡛ࡁࡿ WRWDOKHUQLDUHSDLU ࡀ⌮᝿ⓗ࡞⾡ᘧ࡜ゝ࠼ࡿ㸬㏆ᖺࡢ㛢㙐Ꮝ࣊ࣝࢽ࢔ᮏ㑥ሗ࿌౛ࡢ㞟ィ࡟ࡼࢀࡤ㸪฿㐩ἲ࡜ࡋ࡚ࡣ㛤⭡ἲࡀ᭱ከ 㸧 ࡛࠶ࡿࡀ㸪ࡇࢀࡣ⭠ษ㝖ࢆせࡍࡿྍ⬟ᛶࡀ࠶ࡿࡓࡵ࡜⪃࠼ࡽࢀࡿ㸬ࡋ࠿ࡋ୰ᔱࡽࡣ㰡ᚄἲ࡛ࡶ㛤⭡⾡࡜ྠᵝࡢほᐹࡸ⭠⟶ษ㝖࣭࿀ྜࡀྍ⬟࡛࠶ࡾ㸪⭡⭷⅖ྜే౛ࢆ㝖ࡅࡤ⾡๓デ᩿ྍ⬟࡞⑕౛ࡍ࡭࡚ࢆ㐺ᛂ࡜ࡍࡿࡇ࡜ࡀ࡛ࡁࡿ 㸧࡜୺ᙇࡋ࡚࠾ࡾ㸪ࡑࡢప౵くᛶ࠿ࡽࣁ࢖ࣜࢫࢡ⑕౛࡟ᑐࡍࡿᒁᡤ㯞㓉ୗᡭ⾡ 㸧ࡶሗ࿌ࡉࢀ࡚࠸ࡿ㸬୍᪉㸪㰡ᚄἲࡢࢹ࣓ࣜࢵࢺ࡜ࡋ࡚ࡣᑐഃࢆほᐹ࡛ࡁ࡞࠸Ⅼࡀᣲࡆࡽࢀࡿ㸬₯ᅾⓗ࡟୧ഃࢆྜేࡍࡿ࡜ࡢሗ࿌ࡸ 㸧㸪␗᫬ᛶ୧ഃ㛢㙐Ꮝ࣊ࣝࢽ࢔ࡢሗ࿌ 㸧㸧 ࡣᩓぢࡉࢀ࡚࠾ࡾ㸪⾡๓ &7 ⏬ീ࡛ᑐഃࡢホ౯ 㸧ࢆ༑ศ࡟⾜࠺ᚲせࡀ࠶ࡿ㸬⾡๓ &7 ࡛₯ᅾࡍࡿᑐഃ㛢㙐Ꮝ࣊ࣝࢽ࢔ࢆ␲ࡗ
ࡓሙྜ࡟࠾࠸࡚ࡣ㸪㛤⭡ἲ࡟ࡼࡾ⾡୰࡟ほᐹࡍࡿ࡜࠸࠺㑅ᢥ⫥ࡶ࠶ࡿࡀ㸪୧ഃ㰡ᚄἲ࡟ࡼࡿ᰿἞⾡ࡶ㑅ᢥ⫥࡜࡞ࡾ࠺ࡿ㸬㛢㙐Ꮝࡢฎ⌮࡜ࡋ࡚ࡣ༢⣧⦭ྜ㛢㙐ࡀ᭱ከ 㸧࡛࠶ࡿࡀ㸪 ᗘࡢ෌Ⓨࢆ᮶ࡓࡋࡓሗ࿌ 㸧 ࡶ࠶ࡾ࣓ࢵࢩࣗࢆ⏝࠸ࡓᡭ⾡ࡀ᭱ၿ࡛ࡣ࠶ࡿ 㸧ࡶࡢࡢ㸪⭠ษ㝖⑕౛࡟࠾ࡅࡿ࣓ࢵࢩࣗ
ࡢ␃⨨࡟㛵ࡋ࡚ࡣ༑ศ࡟᳨ウࡍࡿᚲせࡀ࠶ࡿ㸬'LUHFWࠉ.XJHOࠉ3DWFK ࡣ㛢㙐Ꮝ࡜ P\RSHFWLQHDO RUL㸚FH ࢆ࢝ࣂ࣮ࡍࡿ࡟༑ศ࡞ᙧ≧࡜኱ࡁࡉ࡛࠶ࡾ㸪ᙧ≧グ᠈ࣜࣥࢢࡣ㰡ᚄἲ࡟࠾࠸࡚⭡⭷๓⭍࡛ࡢᒎ㛤ࡀᐜ࡛᫆࠶ࡿ 㸧㸬ࡲࡓ
SRVLWLRQLQJ VWUDS ࡟ࡼࡿᅛᐃࡣ࣓ࢵࢩࣗࣉࣛࢢࡢᤄධ࡟
ࡼࡿ㛢㙐⚄⤒ࡢᅽ㏕ࡸ࣓ࢵࢩࣗࢩ࣮ࢺᅛᐃࡢ㝿ࡢ㛢㙐⚄⤒ᦆയ࡜࠸ࡗࡓྜే⑕ࢆ㜵ࡄࡇ࡜ࡀ࡛ࡁࡿ㸬ᮏ⑕౛ࡢࡈ࡜
ࡃ୧⪅ࢆྜేࡍࡿሙྜࡢࡳ࡞ࡽࡎ㸪₯ᅾࡍࡿ㛢㙐Ꮝ࣊ࣝࢽ࢔࠶ࡿ࠸ࡣ኱⭣࣊ࣝࢽ࢔ࡢண㜵࡟ࡶ᭷⏝࡞ࣉࣟࢫࢸ࣮ࢩ
ࢫ࡛࠶ࡿ࡜⪃࠼ࡽࢀࡿ㸬㏆ᖺࡢ㧗㱋໬࡟క࠸₯ᅾⓗ࡟୧⪅ࢆྜేࡍࡿ⑕౛ࡣቑຍࡍࡿྍ⬟ᛶࡀ࠶ࡾ㸪኱⭣࣊ࣝࢽ࢔࠶
ࡿ࠸ࡣ㛢㙐Ꮝ࣊ࣝࢽ࢔࡟ᑐࡍࡿ 'LUHFWࠉ.XJHOࠉ3DWFK ࢆ⏝࠸ࡓ㰡ᚄἲ࡟ࡼࡿ WRWDOKHUQLDUHSDLU ࡣ᭷⏝࡞⾡ᘧ࡜⪃࠼ࡽࢀࡓ㸬

文献 Ἑ㔝ဴኵ㸪᪥ྥ⌮㸪ᮏ⏣ຬ஧㸸㛢㙐Ꮝ࣊ࣝࢽ࢔㸫᭱㏆ ᖺ㛫ࡢᮏ㑥ሗ࿌  ౛ࡢ㞟ィ᳨ウ㸫㸬᪥ᮏ⮫ᗋእ⛉Ꮫ఍㞧ㄅࠉ㸹㸸 㸫  ㍍㒊⚽᫂㸪ቑ⏣ⱥᶞ㸪▼஭ᩗᇶ࡯࠿㸸⾡๓࡟デ᩿ࡋ࠼ࡓ኱⭣࣊ࣝࢽ࢔ᔐ㡻ࢆྜేࡋࡓ㛢㙐Ꮝ࣊ࣝࢽ࢔ࡢ  ౛㸬᪥ᮏ⮫ᗋእ⛉Ꮫ఍㞧ㄅࠉ㸹㸸 㸫 ᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍ ▼⏣ၿᩗ㸪ᘅ℩ᏹ୍㸪Ἑ໭බᏕ࡯࠿㸸.XJHOSDWFK ࡜࣓ࢵࢩࣗࣉࣛࢢࢆే⏝ࡋࡓ㛢㙐Ꮝ࣊ࣝࢽ࢔࣭኱⭣࣊ࣝࢽ࢔ྠ᫬ಟ᚟ࡢ  ౛㸬ᡭ⾡ࠉ㸹㸸 㸫  Ⳣ἟฼⾜㸪㛗㇂࿴⏕㸪㆑ྡᩔ࡯࠿㸸⹸ᆶࢆ࣊ࣝࢽ࢔ෆ
ᐜ࡜ࡍࡿ኱⭣࣊ࣝࢽ࢔࡜㛢㙐Ꮝ࣊ࣝࢽ࢔ࡀేᏑࡋࡓ ౛㸬᪥ᮏ⮫ᗋእ⛉Ꮫ఍㞧ㄅࠉ㸹㸸 㸫  ከ⏣┿࿴㸪㔠୸ὒ㸪ᇼỤⰋᙲ࡯࠿㸸ෆど㙾ୗ㰡ᚄ㒊࣊ࣝࢽ࢔ಟ᚟⾡㸫እ㰡ᚄ㸪኱⭣ཬࡧ㛢㙐Ꮝ࣊ࣝࢽ࢔ࢆྜేࡋࡓ  ౛㸬᪥ᮏෆど㙾እ⛉Ꮫ఍㞧ㄅࠉ㸹㸯㸸㸫  ụ⏣ṇோ㸪஧ᐑ⦾⏕㸪ᱜ஭┿ே࡯࠿㸸⭡⭷እ⭍࢔ࣉ࣮ࣟࢳ࡟ࡼࡿ⭡⭍㙾ୗ㰡ᚄ࣊ࣝࢽ࢔ಟ᚟⾡̿኱⭣㸪እ⭤⬔ୖ❐㸪ෆ㰡ᚄ㸪㛢㙐Ꮝࡢ  ✀ΰྜ࣊ࣝࢽ࢔ࡢ  ౛㸫㸬
0HGLFDOࠉ3RVWJUDGXDWHVࠉ㸹㸸 㸫  ㉺ᬛㄔ㸪⁽ཎ㈗㸪டᒸ⛱࡯࠿㸸⭡⭍㙾࡛デ᩿ࡋ⭡⭷๓⭍㙾ୗಟ᚟⾡ࢆ᪋⾜ࡋࡓ୧ഃ㛢㙐Ꮝ࣊ࣝࢽ࢔࣭኱⭣࣊ࣝࢽ࢔ࡢ  ౛㸬ᡭ⾡ࠉ㸹㸸 㸫  す⏣༑⣖ே㸪ᐑ⏣ྜྷᬕ㸪⸨⏣ᩄᛅ࡯࠿㸸ྑ኱⭣࣊ࣝࢽ࢔ᔐ㡻࡜㸪㨶㦵ࡀཎᅉ࡜⪃࠼ࡽࢀࡿᕥ㛢㙐Ꮝ࣊ࣝࢽ࢔
ᔐ㡻࢖ࣞ࢘ࢫࡀేᏑࡋࡓ  ౛㸬⮫ᗋእ⛉ࠉ㸹㸸 㸫  㧗ᒣᐶே㸪ᯇୗၨ஧㸪ᓥ⏣Ⰻ࡯࠿㸸⭡⭍ෆ㸪እ࢔ࣉ࣮ࣟ
ࢳࢆే⏝ࡋ࡚㙾どୗ࡟἞⒪ࡋࡓ㛢㙐Ꮝ࣊ࣝࢽ࢔ᔐ㡻ࡢ ౛㸬᪥ᮏ⮫ᗋእ⛉Ꮫ఍㞧ㄅࠉ㸹㸸 㸫  ୰ᔱ᫛㸪బ⸨ᗣ㸪ᩧ⸨⿱அ࡯࠿㸸࣊ࣝࢽ࢜ࢢࣛࣇ࢕࣮
࡟ࡼࡿ㛢㙐Ꮝ࣊ࣝࢽ࢔ࡢデ᩿࡜἞⒪㸬⭡㒊ᩆᛴデ⒪ࡢ㐍Ṍࠉ㸹㸸 㸫  *UD\ 6: 6NDQGDODNLV -( 6RULD 5( HW DO㸸
6WUDQJXODWHG REWXUDWRU KHUQLD 6XUJHU\ 㸹㸸̿ ᖹᓥᚓ㊰㸪ᒣᇛᏲஓ㸸㛢㙐Ꮝ࣊ࣝࢽ࢔㸬෨Ọຌኴ㸪࣊ࣝࢽ࢔ࡢࡍ࡭࡚㸪➨㸯∧㸪࡬ࡿࡍฟ∧㸪ᮾி㸪㸪
S̿ ⋢⯋⨾ᬛኵ㸪ྜྷ⏣㝯ᾈ㸪⏣୰༓ᘯ࡯࠿㸸㰡ᚄ㸪኱⭣࣊ࣝࢽ࢔ᡭ⾡ᚋ࡟Ⓨ⑕ࡋࡓྠഃ㛢㙐Ꮝ࣊ࣝࢽ࢔ࡢ୍౛㸬㧗ᒣ㉥༑Ꮠ⑓㝔⣖せࠉ㸹㸸 㸫  ୰ᔱ᫛㸪బ⸨ᗣ㸪᪂஭೺ᗈ࡯࠿㸸㛢㙐Ꮝ࣊ࣝࢽ࢔ࡢ㰡ᚄἲ࡟ࡼࡿಟ᚟⾡㸬ᡭ⾡ 㸹㸸 㸫  ୰ᓥᗣ᫭㸪୰ᔱ᫛㸪బ⸨ᗣ࡯࠿㸸ᒁᡤ㯞㓉㸪㰡ᚄἲࡢᡭ⾡࡟ࡼࡗ࡚἞⒪ࡋࡓ㛢㙐Ꮝ࣊ࣝࢽ࢔ࡢ  ౛㸬᪥ᮏ⮫ᗋእ⛉Ꮫ఍㞧ㄅ 㸹㸸 㸫  ⊦⊁බᏹ㸪⸛ཎ᭷ᘯ㸪ⴠྜ㧗ᚨ࡯࠿㸸␗᫬ᛶ㛢㙐Ꮝ࣊ࣝࢽ࢔ࡢ  ౛㸬᪥ᮏ⮫ᗋእ⛉Ꮫ఍㞧ㄅ 㸹㸸㸫 
 ୕㍯▱ᘯ㸪ᇼ᫂ὒ㸪᳃ᒸ῟࡯࠿㸸␗᫬ᛶ୧ഃ㛢㙐Ꮝ࣊ࣝࢽ࢔ᔐ㡻ࡢ  ౛㸬᪥ᮏ⮫ᗋእ⛉Ꮫ఍㞧ㄅࠉ㸹㸸 㸫  ఀ⸨㔜⩏㸪ஂಖ❶㸪ᒣෆẎ㸸 ᅇ෌Ⓨࡋࡓ㛢㙐Ꮝ࣊ࣝࢽ࢔ࡢ  ౛㸬᪥ᮏ⮫ᗋእ⛉Ꮫ఍㞧ㄅ 㸹㸸 㸫 ⊦㔝‶㸪኱▼᫴㸪Ṋෆಇ࡯࠿㸸㛢㙐Ꮝ࣊ࣝࢽ࢔⾡ᘧࡢ᳨ウ㸫  ౛ࡢ⤒㦂࠿ࡽ㸫㸬᪥ᮏ⮫ᗋእ⛉Ꮫ఍㞧ㄅ㸹㸸 㸫  Ỉ἟࿴அ㸪୰ሯ༤ᩥ㸪⸨㧗Ⴙ⏕࡯࠿㸸㛢㙐Ꮝ࣊ࣝࢽ࢔
࡟ᑐࡋ 'LUHFW .XJHO ࣃࢵࢳࢆ⏝࠸ಟ᚟ࡋࡓ  ἞㦂౛㸬ᗈᓥ་Ꮫ 㸹㸸 㸫 

9RO1R)LJ%㸸&RRSHU 㠌ᖏ㸦㸨㸧⫼ഃࡢ๤㞳ࢆ㐍ࡵࡿ࡜㛢㙐Ꮝ㸦▮㢌㸧࠿ࡽ⬺ฟࡍࡿ࣊ࣝࢽ࢔ᄞࢆㄆࡵࡓ㸬)LJ㸸ᕥ኱⭣࣊ࣝࢽ࢔㸦▮༳㸧࡜ྠഃ㛢㙐Ꮝ࣊ࣝࢽ࢔㸦▮㢌㸧ࢆㄆࡵࡓ㸬)LJ%㸸&RRSHU 㠌ᖏ㸦㸨㸧⫼ഃࡢ๤㞳ࢆ㐍ࡵࡿ࡜㛢㙐Ꮝ㸦▮㢌㸧࠿ࡽ⬺ฟࡍࡿ࣊ࣝࢽ࢔ᄞࢆㄆࡵࡓ㸬)LJ$㸸኱⭣㍯㸦▮㢌㸧࠿ࡽ⬺ฟࡍࡿ࣊ࣝࢽ࢔ᄞࢆㄆࡵࡓ㸬
㸦㸨㸸&RRSHU 㠌ᖏ㸧)LJ&㸸⭡⭷๓⭍ෆ࡛㛢㙐Ꮝ㸦▮༳㸧ࢆ࢝ࣂ࣮ࡍࡿࡼ࠺࡟
'LUHFW.XJHO3DWFK ࢆᗈࡆᶓ➽➽⭷࡟ᅛᐃࡋࡓ㸬
㸦㸨㸸&RRSHU 㠌ᖏ㸧᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍



9RO1RA case of hernia repair via inguinal approach for femoral hernia
complicated with obturator hernia
Department of Surgery, Kumiai Kousei Hospital

Kiyotaka Kawai
Abstract
A 64-year-old women complained abdominal pain with left inguinal swelling and diagnosed left femoral hernia fromphysical examination. And abdominal CT scan revealed the obturator hernia of the ipsilateral side. These hernia were
not incarcerated so operation was performed electively via inguinal approach under general anesthesia. Direct Kugel  &     < !  !  "      ! 
fascia. There are few reports of femoral hernia complicated with obturator hernia. However, both hernia complicate
potentially and might increase with recent aging.Total hernia repair via inguinal approach with Direct Kugel Patch forfemoral hernia or obturator hernia is thought with a useful method.
Key words: femoral hernia, obturator hernia, inguinal approach䠎䠌䠍䠐ᖺ䠍᭶䠍䠑᪥ཷࠉ⌮᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍
᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍



9RO1R

症例報告
Totally Extraperitonal Endoscopic Repair of Lumbar Hernia:
A Case Report with Special Reference to Surgical Treatment
1) Department of surgery, Zeze hospital, 1-11-3 Kanaike-machi, Oita, Japan
2) Department of surgery, Mitarai hospital, 2215-9 Kamaeura, Saiki, Japan

Yuji Shigemitsu 1) , Kenji Zeze 1) , Yoshinobu Mitarai 2)
Abstract
Acquired lumbar hernia is a rare entity in adult abdominal wall hernia. The repair of this hernia has been atherapeutic challenge to surgeons. Encouraged by application of laparoendoscopic procedures to urological disorders
and lumbar sympathectomy using an extraperitoneal approach, we attempted the repair of a primary superior triangle
lumbar hernia using the overlapping synthetic mesh technique while remaining entirely in an extraperitoneal plane. A!    @<      !8  
Running title: Extraperitoneoscopic lumbar hernia repair
Key words:Lumbar hernia, prosthetic mesh, TEPP

Introduction

made at the “Mac Burny”’ point. The dissection thenThe repair of acquired lumbar hernia has challenged

proceeded through the frank musculature, using muscle-

surgeons for more than three hundred years. In recent

splitting technique until the peritoneum was visualized.

years, several surgical procedures have been applied via

To preserve peritoneal integrity, a preperitoneal distension

various approaches with a variety of synthetic meshes (1).

balloon (PDB, Covidien Ltd., Mansfield, MA) was     !!<"  ! 

inserted posterolaterally and inflated to separate thelumbar hernia repair and contribute important advice on

peritoneum from the transversalus muscle, with special

how to treat this challenging clinical problem.

attention to extending the plane inferior to the iliac crestand superior to the edge of the 12th rib under vision. A

The Case

10-mm blunt tip trocar (BTT, Covidien Ltd., Mansfield,

A 70 year-old man presented to the department ofMA) was placed through the incision after removal ofsurgery of Mitarai hospital with an intermittent, dull right

PDB. Under 30-degree endoscopic guidance, one 5-mmback pain and a 9 x 8 cm bulge without gastrointestinal

trocar was placed in the midaxillary line above the BTT

symptoms. Thirty years earlier, he had undergone righttrocar. An additional, gentle, one-handed instrument

upper pneumonectomy for pulmonary tuberculosis. A

dissection of the extraperitoneal plane was easily

diagnostic computed tomography (CT) scan and barium

accomplished under direct visualization. The superior

enema revealed a right-sided superior triangle lumbar! &8     /"/   Z /\E

hernia with unincarcerated terminal ileum (Fig.1 & 2),

and the fat incarceration was reduced. A 3-cm overlapping

so his hernia was classified as a primary one due to thepolypropylene mesh repair was completed. The anterior

absence of trauma or previous surgery. The patient wasedge of the graft was reinforced with a spiral tacking

referred for elective surgical therapy in May, 1998.

device (Tucker, Covidien Ltd., Mansfield, MA). The

Operative techniqueoperative time was 59 min. The patient was discharged

With the patient in a semi-lateral left decubitus positionon postoperative day 7, followed by full resumption ofand a lumbar roll in place, a 12-mm skin incision was

daily activities and work. At the 15-year follow-up, he is᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍



9RO1Rsymptom-free without evidence of recurrent hernia.

Because we had already applied endoscopic inguinal
hernia repair by a transextraperitoneal preperitoneal

Discussion
Lumbar hernias are infrequent and occur in the broad
anatomic area bounded by the 12th rib, inferior to theiliac crest, medial to the erector spinae, and lateral to theexternal oblique muscle. There are three types of lumbar
hernia: congenital, acquired, and incisional. The latest
published article concerning the etiology of lumbar hernia
has documented that primary hernia is predominant (2).
The difficulty in identifying a successful technique ! &     
techniques that have been proposed, such as simple
closure, rotational musculofacial pedicle flap graft, freegrafts, facial strip repair, and various synthetic meshrepairs because of the weakness of surrounding tissues,complicated anatomical boundaries, and a lack of "8     <     Z@\
With the success of laparoendoscopic surgery,minimally invasive surgical techniques have been enlisted
to address this challenging surgical problem.
At the time of the presentation of our case, only 10
cases of successful laparoendoscopic lumbar hernioplasty
had been reported in the literature since Matsuda’s initial
Japanese paper in 1995 (3, 4, 5, 6, 7). This approachallows an exact visualization of the anatomical defectso that damage to boundary structures such as the ureterand nerves, can be avoided. It is minimally invasive, withless postoperative pain, minimal morbidity, a shortened
hospital stay, and better cosmetic results and minimal
lifestyle intrusion (8). Additionally, the laparoscopic
technique provides a method to repair the defect at the
deepest layer of the posterior abdominal wall, which!!8  !        defect without a large incision. But this transperitoneal
intraperitoneal onlay mesh (IPOM) method needs astrong transmuscular fixation of the mesh. Moreover,because there is direct contact between the mesh and theintraperitoneal content laparoscopic IPOM essentially    "  !<   <!
(ePTFE) or compounded dual ePTFE and polypropylene(PP) mesh. Even if the transabdominal preperitoneal(TAPP) approach is applied, it requires an additional
peritoneal opening and closing besides the abovementioned procedure, resulting in longer operative timeand requirement for more equipment.
᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

(TEPP) approach (9) and were encouraged by theapplication of endoscopic techniques to various urologicaldisorders and lumbar sympathectomy by a retroperitoneal
approach (10, 11), we elected to approach the superior
lumbar triangle hernia entirely extraperitoneally. We
initially incised skin at McBurney's’ point to have remote
access to the hernial defect, a procedure that was familiar
to us in connection with appendectomy. Subsequently, we
gained adequate working space and thorough visualizationof the hernial defect by using PDB and a gentle blunt
dissection via an additional 5-mm trocar. To secure the PP
mesh, we used several tacks around the hernia margin andthe anterior aspect of the PP mesh. Unlike a repair using
an IPOM procedure, such as the TAPP procedure, we had
repaired lumbar hernia in the extraperitoneal layer, which
is one layer shallower than the deepest layer. This is why
the abdominal pressure will be applied to the mesh on
the lumbar wall according to Pascal’s principle, if a wide
mesh with more than 3-cm margins can be used. Besides,
unlike the more extensive time required for the TAPP
procedure, we finished this operation within one hour
without peritoneal opening and closing (12).
^ "E!<  &
described in the literature (13, 14, 15, 16, 17). Four ofthe five cases, including our own, were primary lumbar
hernias and one was a case of recurrent postoperative
hernia. As lumbar hernias have no adhesion in theextraperitoneal space, the repair by the TEPP approach isconsidered as the best treatment modality.
While the follow-up interval is relatively short in thepreviously published literature, that time in our case isover 10 years, enough to evaluate a potential recurrence.
Therefore, our repair by the TEPP approach is reliable.
Moreno-Egea A et al (2) have proposed a newclassification based on 6 categories and 4 types. They
recommend a hernioplasty via the anterior approachor extraperitoneal laparoscopy on small defects withextraperitoneal contents (type A); the transabdominal
approach on moderate defects with paraperitoneal or
intraperitoneal hernias (type B); and an anterior repair
with a double mesh in cases of recurrence or diffuse
hernias larger than 15 cm (type C) and pseudoherniaassociated muscular atrophy or major deformity (type

9RO1R

D). Because the quality of the affected tissues cannot be
assessed reliably during surgery, they do not recommend
autoplasty or the use of mesh plugs. Although our case
 !   <^E  Q
might be indicated when the extraperitoneal space is notadherent or is only slightly adherent, regardless of any
hernia size, location, impacted content, and etiology.
In conclusion, the extraperitoneal approach seems to be
the best option for treating this challenging problem, and &          
References
1) Geis WP, Saletta JD. Lumbar hernia. In: Nyhus LM, Condon
RE, eds. Hernia. 3rd ed. Philadelphia, Pa: JBLippinclott
1989; 401-15.
2) Moreno-Egea A, Baena EG, Calle MC, Martinez JAT,
Albasini JLA. Controversies in the current management oflumbar hernias. Arch Surg 2007;142:82-8.
3) Matsuda M, Hirata Y, Sugi K, Takahashi M, Takahashi S.
A case of inferior lumbar hernia treated by laparoscopic
herniorrhaphy (in Japanese with English abstract).
Nihon Rinsho Geka Gakkai Zasshi (J Jpn Surg Assoc)
1995;56:2477-94) Burrick AJ, Parascandola SA. Laparoscopic repair of a
traumatic lumbar hernia. J Laparoendosc Surg 1996;5:259-62
5) Bickel A, Haj M, Eitan A. Laparoscopic management oflumbar hernia. Surg Endosc 1997;11: 1129-30
6) Heniford BT, Iannitti DA, and Gagner M. Laparoscopic
inferior and superior lumbar hernia repair. Arch Surg᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

1997;132:1141-4
7) Arca MJ, Heniford BT, Pokorny R, Wilson R, Meyes J,
Gadner M. Laparoscopic repair of lumbar hernia. J Am Coll
Surg 1998;187:147-52
8) Moreno-Egea A, Torralba-Martinez A, Morales G, AguayoAlbasini JL. Open vs laparoscopic repair of secondary lumbar
hernias. Surg Endosc 2005;19:184-7
9) Ikeda M, Shigemitsu Y. Laparoscopic inguinal hernia repair
by extraperitoneal approach -Usefulness of peritoneal edge
oriented method-.ࠉSurg Endosc 1998;12:593
10)Gaur DD. Laparoscopic operative retroperitoneoscopy ; Useof new device. J Urol 1992;148: 1137-9
11) Hourly P, Vangertruden G, Verduyckt F, et al. Endoscopic
extraperitoneal lumbar sympathectomy. Surg Endosc 1995;9:
530-312) Shekarriz B, Graziottin TM, Gholami S, Lu HF, Yamada H,
Duo QY, et al. Transperitoneal preperitoneal laparoscopic
lumbar incisional herniorrhaphy. J Urol 2001;166:1267-9
13) Woodard AM, Flint LM, Ferrara JJ. Laparoscopic
retroperitoneal repair of recurrent postoperative lumbar
hernia. J Laparoendosc Adv Surg Tech A 1999;181:181-6
14) Postema RR, Bonjer HJ. Endoscopic extraperitoneal repairof a Glynfeltt hernia. Surg Endosc 2002;16:716-7
15) Habib E. Retroperitoneoscopic tension-free repair of lumbar
hernia. Hernia 2003;7:150-2
16) Meinke AK. Totally extraperitoneal laparoendoscopic repairof lumbar hernia. Surg Endosc 2003;17:734-7
17) Grauls A, Lallemand B, Krick M. The retroperitoneoscopic
repair of a lumbar hernia of Petit. case report and review ofliterature. Acta chir belg 2004;104:330-4



9RO1R

Fig.1CT demonstrating right superior lumbar hernia with fat
and ileo-cecal incarceration (arrow).

Fig.3

Endoscopic view demonstrating the lumbar defect after
reducing extraperitoneal fat (arrow).

Fig.2ࠉBarium enema showing ileal protrusion through superior
lumbar hernia (arrow).

䠎䠌䠍䠐ᖺ䠍᭶䠍䠑᪥ཷࠉ⌮᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍
᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

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9RO1R症例報告
腹腔鏡下精索静脈瘤結紮術後に発生した外鼡径ヘルニアの一例
 ᮾிឿᜨ఍་⛉኱Ꮫ㝃ᒓ➨୕⑓㝔ࠉእ⛉ ᮾிឿᜨ఍་⛉኱Ꮫእ⛉Ꮫㅮᗙ㛵᰿㏿Ꮚ 㸪ㄶゼ຾ோ 㸪⩚⏕ࠉ೺ 㸪㕥ᮌಇு 㸪ᒸᮏ཭ዲ 㸪▮Ọ຾ᙪ
要旨⭡⭍㙾ୗ⢭⣴㟼⬦⒗⤖⣻⾡᪋⾜Ṕࡢ࠶ࡿ  ṓࡢ⏨ᛶ㸬③ࡳࢆక࠺ᕥ㰢ᚄ㒊③ࢆ୺ッ࡟ᙜ㝔ࢆཷデࡋ㸪ᕥ㰡ᚄ࣊ࣝࢽ࢔ࡢデ᩿࡛ᡭ⾡ࢆ᪋⾜ࡋࡓ㸬ᡭ⾡ᡤぢ࡛ࡣ㸪࣊ࣝࢽ࢔ࢱ࢖ࣉࡣእ㰡ᚄᆺ㸦᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍ศ㢮 , ᆺ㸧࡛ෆ㰡ᚄ࣊ࣝࢽ࢔㸪኱⭣࣊ࣝࢽ࢔ࡢྜేࡣࡳࡽࢀ࡞࠿ࡗࡓ㸬ᩘᮏࡢ㔠ᒓࢡࣜࢵࣉࡀ⢭ᕢ㟼⬦࡟࠿ࡅࡽࢀ࡚࠾ࡾ㸪ࡇࢀ࡟ࡼࡗ࡚⢭ᕢ⾑⟶࡜⭡⭷࡟ᙉᅛ࡞⥺⥔ᛶ⒵╔ࡀࡳࡽࢀࡓ㸬๓་࡛ࡢᡭ⾡グ㘓࡛ࡣ⭡⭍㙾ᡭ⾡᫬࡟㰡ᚄ࣊ࣝࢽ࢔ࡢྜేࡣࡳ࡜ࡵ࡚
࠾ࡽࡎ㸪௒ᅇࡢ㰡ᚄ࣊ࣝࢽ࢔ࡣ⭡⭍㙾ᡭ⾡࡟ࡼࡿෆ㰢ᚄ㍯࿘ᅖࡢ⭡⭷๓⭍๤㞳ࡀཎᅉ࡛࠶ࡿ࡜⪃࠼ࡽࢀࡓ㸬᰿἞ⓗ᜝㦵ᚋ๓❧⭢᦬ฟ⾡ࡣ⭡⭷๓⭍๤㞳ࡀᗈ⠊࡜࡞ࡿࡓࡵ㰡ᚄ࣊ࣝࢽ࢔ࡢࣜࢫࢡせᅉ࡛࠶ࡿࡇ࡜ࡣࡼࡃ▱ࡽࢀ࡚࠸ࡿ㸬ࡋ࠿ࡋ࡞ࡀࡽ㸪⭡⭍㙾ୗ⢭⣴㟼⬦⒗⤖⣻⾡ࡢࡼ࠺࡞ᑠ⠊ᅖࡢ⭡⭷๓⭍๤㞳࡛ࡶ㰡ᚄ࣊ࣝࢽ࢔ࡢཎᅉ࡟࡞ࡾ࠺ࡿ
࡜⪃࠼ࡽࢀࡓ㸬͆㰡ᚄ࣊ࣝࢽ࢔͇㸪͆ࣜࢫࢡせᅉ͇㸪͆⭡⭍㙾ୗ⢭⣴㟼⬦⒗⤖⣻⾡͇ࢆ NH\ ZRUG ࡟  ᖺ࠿ࡽ  ᖺ ᭶ࡲ࡛ࡢᮇ㛫࡛ 3XE0HG ࠾ࡼࡧ་୰ㄅࢆ᳨⣴ࡋࡓ࡜ࡇࢁ㸪ᮏ⑕౛ࡢࡼ࠺࡞ሗ࿌ࡣ࡞࠿ࡗࡓ㸬ᮏ⑕౛࡛ࡣᑠ⠊ᅖ࡛ࡶ⭡⭷๓⭍๤㞳ᚋ࡟ࡣ㰢ᚄ⟶ᚋቨ⿵ᙉࡢᚲせᛶࡀ♧၀ࡉࢀࡓ㸬࣮࣮࢟࣡ࢻ㸸㰢ᚄ࣊ࣝࢽ࢔㸪ࣜࢫࢡせᅉ㸪⢭⣴㟼⬦⒗⤖⣻⾡࡟ࣂࣝࢧࣝࣂἲ࡛⭡⭍ෆ࠿ࡽ㰢ᚄ⟶ෆ࡟⬺ฟࡍࡿ⬡⫫⧊

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ཎᅉ࡜࡞ࡿྍ⬟ᛶࢆ♧ࡍ஦౛࡜⪃࠼ሗ࿌ࡍࡿ㸬症࠿ࡗࡓࡓࡵ  ⢭⣴㟼⬦⒗⤖⣻⾡ᚋࡢⓎ⏕࡜⪃࠼ࡽࢀࡓ㸬例考ᝈ⪅ࠉ㸸ࠉ ṓ㸪⏨ᛶ㸬

553 ࡣ㰢ᚄ࣊ࣝࢽ࢔ࡢࣜࢫࢡᅉᏊ࡜ࡋ࡚▱ࡽࢀ㸪⾡ᚋࡢ

୺ッࠉ㸸ࠉᕥ㰢ᚄ㒊⭾㝯㸪ᕥ㰢ᚄ㒊③㸬᪤ Ṕ㸸ࠉᕥ⢭⣴㟼⬦⒗㸦 ᖺ๓ࠉ⭡⭍㙾ୗ⢭⣴㟼⬦⒗⤖

㰢ᚄ࣊ࣝࢽ࢔ࡢⓎ⏕⋡ࡣ  㹼  ࡜㧗㢖ᗘ࡛࠶ࡿ      㸬
553 ᚋࡢ㰢ᚄ࣊ࣝࢽ࢔ࡣ㸪㧗㱋࡛࠶ࡿ࡯࡝Ⓨ⑕ࡋࡸࡍࡃ   㸪⣻⾡㸧㸬⌧⑓Ṕ㸸ࠉᕥ㰢ᚄ㒊⭾㝯࡜ྠ㒊఩⑊③ࡢࡓࡵ๓་ཷデ㸬ᕥ

Ⓨ⑕᫬ᮇࡣ⾡ᚋ  ᖺ௨ෆࡀከ࠸࡜ࡉࢀ  㹼  㸪ࡑࡢ኱༙ࡀ
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ࡢቑᙉࢆㄆࡵࡿ㸬⭡㒊㉸㡢Ἴ᳨ᰝᡤぢ察ᅗ 㸪 㸸ࠉᕥୗ⭡ቨື㟼⬦ࡢෆഃ⪃࠼ࡽࢀ࡚࠸ࡿ   㸬ࠉࠉᚑ᮶ࡢ⢭⣴㟼⬦⒗⤖⣻⾡ࡣ๓᪉฿㐩ἲ࡛⾜ࢃࢀ࡚࠸ࡓࡓ

᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

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VWUXFWXUHSURWUXGLQJIURPWKHDEGRPLQDOFDYLW\LQWRWKHLQJXLQDOFDQDOODWHUDOWRWKHOHIWLQIHULRUHSLJDVWULFDUWHU\᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

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9RO1RA case of inguinal hernia after laparoscopic varicocele ligation@\#  <E# q  !EQ9{  <! 

=\#  <EQ9{  <! 

Chikako Sekine 1) , Katsuhito Suwa 1) ,Ken Hanyu 1) EQ {{ 1) ,Q < {   1) , Katsuhiko Yanaga 2)
Abstract
A 34-year-old male who had undergone laparoscopic varicocele ligation at another institution presented at our
hospital complaining of a left groin bulge with pain. A diagnosis of left inguinal hernia was made and the Lichtenstein
repair was performed. Operative findings revealed that the hernia was indirect type, classified into type I-2 by
the Japanese Hernia Society classification. No concomitant direct or femoral hernia was found by preperitoneal
"! !  !!!   !!  8   ' &   ! ! E
which made tight fibrous adhesion between the testicular vessels and the peritoneum. According to the operation   &<    !E 8   ! !<Q E  !
of this case was considered to be caused by the previous laparoscopic preperitoneal dissection around the internalinguinal ring.
Radical retropubic prostatectomy has been well-known as a risk factor of inguinal hernia because of extensive
preperitoneal dissection. However, even laparoscopic varicocele ligation, which needs minimal preperiotneal
dissection, seems to predispose to the development of inguinal hernia. PubMed and Japan Medical Abstracts Society
search with key words of "Inguinal hernia" , "Risk factor" and "Laparoscopic varicocele ligation" from 1983 to  &=@/!    Q      <  

!! !  !   Key words:Inguinal hernia , Risk factor, Laparoscopic varicocele ligation䠎䠌䠍䠐ᖺ䠍᭶䠍䠑᪥ཷࠉ⌮᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍
᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍



9RO1R

症例報告
TAPP 後，腹膜陥凹のない腹膜外型膀胱ヘルニアを発症した一例
ඵᑿᚨὪ఍⥲ྜ⑓㝔ࠉእ⛉ຍ⸨ᜤ㑻㸪∵୸⿱㈗㸪㕥ᮌ኱⪽要旨⑕౛ࡣ  ṓ⏨ᛶࠋྑ㰡ᚄ㒊⭾㝯ࢆ୺ッ࡟ᙜ㝔ࢆཷデ㸪ྑ ,, ࡢ㰡ᚄ࣊ࣝࢽ࢔࡟ᑐࡋ࡚ 7$33 ࢆ⾜ࡗࡓࠋ ᖺ  ࣨ᭶ᚋ࡟෌ࡧྑ㰡ᚄ㒊⭾㝯ࢆ୺ッ࡟᮶㝔ࡋࡓࠋ௚ぬⓗ࡟⭾㝯ࡣ࡞࠿ࡗࡓࡀ㸪⭡㒊㉸㡢Ἴ᳨ᰝ࡛࣊ࣝࢽ࢔ࡢ෌Ⓨࡀ␲ࢃࢀࡓࠋ
෌ 7$33 ┠ⓗ࡛⭡⭍㙾ࢆ⾜ࡗࡓࡀ㸪⭡⭷㝗พࡀ᫂ࡽ࠿࡛࡞ࡃほᐹࡢࡳ࡛⤊஢ࡋࡓࠋ ࣨ᭶ᚋ㸪ྑ㰡ᚄ㒊⭾㝯ࢆ୺ッ࡟᮶㝔㸪ࡇࡢ࡜ࡁࡣ௚ぬⓗ࡟᫂ࡽ࠿࡞⭾㝯ࢆㄆࡵࡓࠋ⭡㒊㉸㡢Ἴ᳨ᰝ㸪&7 ࡛⭤⬔⬺ฟࡀ␲ࢃࢀࡓࠋ⭡⭍㙾ୗࡢほᐹ࡛ࡣ௒ᅇࡶ
⭡⭷㝗พࡣ࡞࠿ࡗࡓࡀ㸪⏬ീᡤぢ࡜࠶ࢃࡏ࡚⭡⭷እᆺ⭤⬔࣊ࣝࢽ࢔࡜ุ᩿ࡋࡓࠋ࣓ࢵࢩࣗෆ⦕࡛⭡⭷ࢆษ㛤ࡋ㸪⭤⬔ࢆᘬࡁฟࡋ࡚㛛ࢆ☜ㄆࡋ㸪࣓ࢵࢩࣗࢆ⏝࠸࡚ಟ᚟ࡋࡓࠋ⾡ᚋ  ᖺ  ࣨ᭶෌Ⓨࢆㄆࡵ࡚࠸࡞࠸ࠋ7$33 ᚋ࡟㰡ᚄ㒊⭾㝯ࢆࡁࡓࡋࡓሙྜ㸪⭡⭍㙾࡛デ᩿࡛ࡁ࡞࠸⭡⭷እᆺ⭤⬔࣊ࣝࢽ࢔ࡢྍ⬟ᛶࡶ⪃៖ࡋ㸪㌟యᡤぢ㸪⏬ീᡤぢࢆ༑ศ࡟᳨ウࡋࡓୖ࡛ᡭ⾡࡟⮫ࡴጼໃࡀ㔜せ࡜ᛮࢃࢀࡓࠋ

࣮࣮࢟࣡ࢻ㸸7$33⭤⬔࣊ࣝࢽ࢔㸪⭡⭷㝗พࡢ࡞࠸࠿ࡋ⭡⭷࡟᫂ࡽ࠿࡞㝗พࡀ࡞࠿ࡗࡓࡓࡵほᐹࡢࡳ࡛⤊஢

はじめに㰡ᚄ࣊ࣝࢽ࢔࡟ᑐࡍࡿ⭡⭍㙾ୗ㰡ᚄ࣊ࣝࢽ࢔ಟ᚟⾡ࡋࡓࠋ ᖺ  ᭶㸪ྑ㰡ᚄ㒊⭾㝯ࢆ୺ッ࡟᮶㝔ࡋࡓࠋᒀ㈓␃

㸦7UDQVDEGRPLQDO SUHSHULWRQHDO UHSDLU㸸௨ୗ㸪7$33 ࡜␎グࡣ㸪ࡑࡢඃࢀࡓⅬࡀ⌮ゎࡉࢀࡿ࡟ࡘࢀ㸪ࢃࡀᅜ࡛ࡶ

ᖺࠎᡭ⾡௳ᩘࡀቑຍࡋ࡚ࡁ࡚࠸ࡿࠋ7$33 ࡢඃࢀࡓⅬ࡜ࡋ࡚ࡣ㸪⾡ᚋࡢ⑊③ࡸ㐪࿴ឤࡢᑡ࡞࠸ࡇ࡜ࡸ㸪デ᩿ࡀ☜ᐇ࡞ࡇ࡜ࡀ࠶ࡆࡽࢀࡿࠋ࡜ࡃ࡟෌Ⓨ౛࡛ࡢデ᩿ࡢ᭷⏝ᛶࡀࡑࡢ࡜㰡ᚄ㒊⭾㝯࡜ࡢ㛵ಀࡣ࡞࠿ࡗࡓࠋ᤼ᒀ㞀ᐖ㸪஧ẁ᤼ᒀࡶ࡞࠿ࡗࡓࠋࡇࡢ࡜ࡁࡣ௚ぬᡤぢ࡜ࡋ࡚ࡶ❧఩࡛㰡ᚄ㒊࡟᫂ࡽ࠿࡞⭾㝯ࢆㄆࡵࡓࠋ⭡㒊㉸㡢Ἴ᳨ᰝ㸪&7㸦FRPSXWHUDVVLVWHGWRPRJUDSK\㸪௨ୗ &7 ࡜␎グ㸧࡛ࡣ⭤⬔ࡀ⬺ฟࡋࡓᙧࡢ࣊ࣝࢽ࢔෌Ⓨࡀ␲ࢃࢀࡓ㸦)LJ㸧ࠋ฼Ⅼࡢ୍ࡘ࡜ࡋ࡚࠶ࡆࡽࢀࡿࡇ࡜ࡶከ࠸ࠋ

7$33 ┠ⓗ࡛  ᅇ┠ࡢ⭡⭍㙾ࢆ⾜ࡗࡓࠋ ᅇ┠ࡢᡭ⾡᫬௒ᅇ㸪7$33 ᚋ࡟㰡ᚄ㒊⭾㝯ࢆࡁࡓࡋ㸪⭡⭍㙾࡛ほᐹࡋ࡚ࡶ⭡⭷㝗พࡀ࡞࠸㰡ᚄ㒊⭡⭷እᆺ⭤⬔࣊ࣝࢽ࢔ࢆぢⴠ࡜ࡋࡓ⑕౛ࢆ⤒㦂ࡋࡓࠋᩍカ࡟ᐩࡴ⑕౛࡜ᛮࢃࢀࡓࡢ࡛ᩥ

ࡢ &7 ࡢᡤぢ࡛࣓ࢵࢩࣗෆഃ࠿ࡽࡢ⭤⬔ࡢ⬺ฟࡀ᫂ࡽ࠿
࡛࠶ࡗࡓࡓࡵ㸪⭡⭷እᆺ⭤⬔࣊ࣝࢽ࢔ࡀ࠶ࡿ࡜ุ᩿ࡋ

⊩ⓗ⪃ᐹࢆຍ࠼࡚ሗ࿌ࡍࡿࠋ

症

࡜ྠᵝ㸪⭡⭷࡟ࡣ᫂ࡽ࠿࡞㝗พࡣ࡞࠿ࡗࡓࠋࡋ࠿ࡋ⾡๓ࡓࠋ࣓ࢵࢩࣗࡢෆ⦕࡟ἢࡗ࡚⭡⭷ࢆษ㛤ࡋࡓ㸦)LJ㸧ࠋ⭤例⬔ࢆྠᐃࡋ㸪ᘬࡁฟࡋ࡚ࡃࡿ࡜࣊ࣝࢽ࢔㛛ࡀ☜ㄆ࡛ࡁࡓᝈ⪅㸸 ṓ⏨ᛶ㸦)LJ㸧ࠋ࣊ࣝࢽ࢔㛛ࢆ඲࿘࡟ࢃࡓࡗ࡚๤㞳ࡋࡓ㸦)LJ᪤ Ṕ㸸ࣃ࣮࢟ࣥࢯࣥ⑓࡛ෆ᭹἞⒪୰ࠋṌ⾜ࡀࡸࡸᅔ㞴࡛㸧ࠋ⭤⬔␃⨨࢝ࢸ࣮ࢸࣝ࠿ࡽ⏕⌮㣗ሷỈࢆὀධࡋ࡚⭤⬔ᦆ࠶ࡿࠋയࡢ࡞࠸ࡇ࡜ࢆ☜ㄆࡋࡓ㸦)LJ㸧ࠋ࣊ࣝࢽ࢔㛛ࢆそ࠺ࡼ࠺⌧⑓Ṕ㸸࡟࣓ࢵࢩࣗࢆ࠾ࡁ㸪྾཰ᛶࢱࢵࢡ࡛ෆഃࡣ࣊ࣝࢽ࢔㛛ෆഃ ᖺ  ᭶㸪ྑ㰡ᚄ㒊⭾㝯ࢆ୺ッ࡟ᙜ㝔ࢆཷデࡋࡓࠋ࡟㸪እഃࡣ๓ᅇࡢ࣓ࢵࢩࣗୖ࡟ᅛᐃࡋ㸪⭡⭷ࢆ⦭ྜ㛢㙐ࡋྑ ,, ᆺࡢ㰡ᚄ࣊ࣝࢽ࢔࡟ᑐࡋ࡚ 7$33 ࢆ⾜ࡗࡓࠋ୍ᯛ┠ࡓ㸦)LJ㸧ࠋ⾡ᚋ⤒㐣Ⰻዲ࡛⩣᪥࡟㏥㝔ࡋࡓࠋ⌧ࡢ࣓ࢵࢩ࡛ࣗ࣊ࣝࢽ࢔㛛ࡢ⭡ഃ࡬ࡢ࣮࢜ࣂ࣮ࣛࢵࣉࡀ༑ᅾࡲ࡛  ᖺ  ࣨ᭶ࡀ⤒㐣ࡋࡓࡀ෌Ⓨࡣㄆࡵ࡚࠸࡞࠸ࠋ

ศ࡜ࢀ࡞࠿ࡗࡓࡓࡵ࡟࣓ࢵࢩࣗࢆ஧ᯛ౑⏝ࡋࡓ )LJ ࠋ

考 ᖺ  ᭶㸪ྑ㰡ᚄ㒊⭾㝯ࢆ୺ッ࡟᮶㝔ࡋࡓࠋእ᮶デ⭡⭷㝗พࡢ࡞࠸㰡ᚄ࣊ࣝࢽ࢔࡟ࡘ࠸࡚ࡣ㸪7$33 ࡀከࡃᐹ᫬࡟ࡣ㰡ᚄ㒊⭾㝯ࡣ᫂ࡽ࠿࡛࡞࠿ࡗࡓࡀ㸪⭡㒊㉸㡢Ἴ᳨ᰝ࡛ࡣ⭠⟶࠶ࡿ࠸ࡣ኱⥙ࡢ⬺ฟࡀ␲ࢃࢀࡓࠋᝈ⪅࡜┦ㄯࡢୖ㸪デ᩿ࢆ᫂ࡽ࠿࡟ࡍࡿ┠ⓗࡶවࡡ࡚⭡⭍㙾ࢆ⾜ࡗࡓࠋࡋ᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

察⾜ࢃࢀ࡚࠸ࡿḢ⡿࠿ࡽ࠸ࡃࡘ࠿ࡢሗ࿌ࡀ࠶ࡿࠋ+ROOLQVN\
ࡽࡣ㌟యᡤぢ࡛㰡ᚄ㒊⭾㝯ࡀ᫂ࡽ࠿࡞  ౛࡟ 7$33 ┠

9RO1Rⓗ࡛⭡⭍㙾ࢆ⾜ࡗࡓ࡜ࡇࢁ㸪 ౛  ࡛⭡⭷㝗พࡀ࡞ࡑࡢ⬺ฟ⮚ჾࢆồࡵ࡚ 7$33 ࢆ⥆⾜ࡍࡿ࠿㸪㰡ᚄ㒊ษ㛤ࢆ࠿ࡗࡓ࡜ࡋ࡚࠸ࡿ ࠋᙼࡽࡣ⢭⣴⬡⫫⭘ࡸ⭡⭷๓⬡⫫ࡀ

㏣ຍࡋ࡚ᡭ⾡ࢆ᏶㐙ࡍ࡭ࡁ࡛࠶ࡿࠋ⾡๓࡟㰡ᚄ㒊⭾㝯ࡀ᫂⭡⭷ࡢ㝗พࢆకࢃࡎ࡟⬺ฟࡋࡓ VDFOHVV VOLGLQJ IDWW\ࡽ࠿࡛࡞ࡃ㸪⾡๓⏬ീデ᩿ࡀ୙༑ศ࡛࠶ࡗࡓሙྜࡣ࠶ࡽࡓLQJXLQDO KHUQLD ࡛࠶ࡗࡓ࡜ㄝ᫂ࡋ࡚࠸ࡿࠋࡑࡢ௚࡟ࡶ⭡ࡵ࡚⏬ീデ᩿ࢆ⾜࠸┤ࡋ࡚࠿ࡽᡭ⾡࡟⮫ࡴࡢࡀᏳ඲࡛࠶ࢁ

⭷㝗พࡀ࡞ࡃ㸪⬡⫫⭘ࡀ㰡ᚄ㒊⭾㝯ࡢཎᅉ࡜࡞ࡗࡓ⑕౛ࡢ

࠺ࠋ

㸧

ࠋᙜ㝔࡛ࡣ  ᖺ  ᭶࡟ 7$33 ࢆᑟᙜ㝔࡛ࡣ 7$33 ᑟධึᮇࡢ㡭ࡣ࡯࡜ࢇ࡝ࡢ⑕౛࡛⭡㒊㉸ධࡋ㸪⌧ᅾࡲ࡛࡟⣙  ౛ࡢᡭ⾡ࢆ⾜ࡗࡓࠋ+ROOLQVN\ ࡽ㡢Ἴ᳨ᰝ㸪&7 ࢆ⾜ࡗ࡚࠸ࡓࠋࡋ࠿ࡋ⑕౛ࢆ㔜ࡡࡿ࡟ࡘࢀ㸪ࡢ࠸࠺ࡼ࠺࡞⭡⭷㝗พࡀ࡞ࡃ⬡⫫⭘ࡀཎᅉ࡛࠶ࡗࡓ⑕౛ࡣ

⭡㒊㉸㡢Ἴ᳨ᰝࡸ &7 ࡛ࡣ㰡ᚄ࣊ࣝࢽ࢔ࡢศ㢮ࡸᑐഃ⑓ኚ

⤒㦂ࡋࡓࡇ࡜ࡀ࡞࠸ࠋ⬡⫫⭘ࡢ㢖ᗘ㸪኱ࡁࡉ࡞࡝ࡣே✀࡟ࡢ᭷↓ࢆṇࡋࡃホ౯࡛ࡁ࡚࠸࡞࠸ሙྜࡶከ࠸࡜ឤࡌࡿࡼ࠺

ࡼࡿᕪࡶ࠿࡞ࡾ࠶ࡿ࡜ᛮࢃࢀ㸪᪥ᮏே࡛ࡣ㢖ᗘࡀᑡ࡞࠸ྍ

࡟࡞ࡗࡓࠋḟ➨࡟⾡๓ࡢ⏬ീデ᩿ࡼࡾࡶ⭡⭍㙾࡛ほᐹࡍࡿ⬟ᛶࡀ⪃࠼ࡽࢀࡓࠋ

ࡇ࡜ࡀ᭱ࡶࡍࡄࢀࡓデ᩿ἲ࡛࠶ࡿ࡜⪃࠼ࡿࡼ࠺࡟࡞ࡗ࡚࠸ሗ࿌ࡣᩓぢࡉࢀࡿ

୍᪉㸪⭤⬔࣊ࣝࢽ࢔ࡣ୍⯡࡟⭡⭷ഃᆺ㸦SDUDSHULWRQHDOࡓࠋࡋ࠿ࡋ㸪௒ᅇࡢ⑕౛ࡢࡼ࠺࡟⭡⭷㝗พࡀ࡞ࡃ㸪⭡⭍㙾⭤⬔࡜⭡⭷ࡀ࡜ࡶ࡟⁥⬺㸧㸪⭡⭷እᆺ㸦H[WUDSHULWRQHDO࡛デ᩿࡛ࡁ࡞࠸⑕౛ࡶ࠶ࡿࡇ࡜ࢆ⤒㦂ࡋࡓࠋ௒ᅇࡢ⑕౛ࡶ㸪⭡ ⭷ ࢆ క ࢃ ࡎ ࡟ ⭤ ⬔ ࡢ ࡳ ࡀ ⁥ ⬺ 㸧㸪 ⭡ ⭷ ෆ ᆺᑡ࡞ࡃ࡜ࡶ  ᅇ┠ࡢᡭ⾡๓࡟ &7 ࢆ⾜ࡗ࡚⭤⬔⬺ฟࢆ☜ㄆ

㸦LQWUDSHULWRQHDO⭡⭷ࢆ࠿ࡪࡗࡓ⭤⬔ࡀ⁥⬺㸧ࡢ  ᆺ࡟࡛ࡁ࡚࠸ࢀࡤ↓㥏࡞  ᅇ┠ࡢᡭ⾡ࢆ㑊ࡅࡿࡇ࡜ࡀ࡛ࡁࡓ࡜

ࢃࡅࡽࢀ࡚࠸ࡿࠋࡇࡢ࠺ࡕ⭡⭷እᆺࡣ᭱ࡶࡲࢀ࡛㸪⭤⬔࣊ᛮࢃࢀࡓࠋ㰡ᚄ࣊ࣝࢽ࢔⑕౛඲౛࡟ &7 ࢆ᧜ᙳࡍࡿࡢࡣ་

ࣝࢽ࢔ࡢ࠺ࡕࡢ  ⛬ᗘ࡜ࡉࢀ࡚࠸ࡿ  ࠋᮏ⑕౛ࡢ  ᅇ┠⒪⤒῭ⓗ㸪࠶ࡿ࠸ࡣ⿕⇿ࡢၥ㢟ࡶ࠶ࡾ㸪㈶ྰ୧ㄽࡀ࠶ࡿ࡜

ࡢᡭ⾡᫬ࡢᡤぢࡣࡇࡢ⭡⭷እᆺ⭤⬔࣊ࣝࢽ࢔࡟┦ᙜࡋࡓࠋᛮࢃࢀࡿࠋࡋ࠿ࡋ㸪௒ᅇࡢࡼ࠺࡞෌Ⓨ౛࡞࡝」㞧࡞⑓ែࡶࢃࡀᅜࡢ㐣ཤࡢሗ࿌౛࡛ࡣ㰡ᚄ࣊ࣝࢽ࢔ᔐ㡻ᩚ᚟ᚋ࡟⭤ྰᐃ࡛ࡁ࡞࠸⑕౛࡛ࡣ㸪ᛕධࡾ࡞㌟యᡤぢࢆ࡜ࡿࡇ࡜࡜㸪⬔࣊ࣝࢽ࢔ᔐ㡻ࡀṧᏑࡋࡓ⑕౛ 㸪⭡⭷ഃᆺ⭤⬔࣊ࣝࢽ࢔&7 ࢆྵࡴ⏬ീ᳨ᰝࢆ༑ศ⾜࠺ࡇ࡜ࢆᛰࡽࡎ࡟ᡭ⾡࡟⮫ࡴࡢ⭡⭷㒊ศࡢࡳࢆಟ᚟ࡋ⾡ᚋ  ࣨ᭶࡛⭤⬔࣊ࣝࢽ࢔ࡀฟ⌧ጼໃࡀ㔜せ࡜ᛮࢃࢀࡓࠋ

ࡋࡓ⑕౛࡞࡝ࡀ࠶ࡗࡓ ࠋࢃࢀࢃࢀࡢ⑕౛ࡢึᅇ 7$33 ᫬࡟⭤⬔ࡀ㛵୚ࡋ࡚࠸ࡓ࠿࡝࠺࠿ࡣ⾡๓ࡢ &7 ࢆ᧜ࡗ࡚࠸࡞
࠿ࡗࡓࡓࡵ࡟୙࡛᫂࠶ࡿࠋࡋ࠿ࡋึᅇᡭ⾡ᚋ  ᖺ  ࣨ᭶㛫㰡ᚄ㒊⭾㝯ࡀᾘኻࡋ࡚࠸ࡓࡇ࡜ࢆ⪃࠼ࡿ࡜㸪ึᅇᡭ⾡᫬࠿ࡽࡍ࡛࡟⭤⬔ࡀ⬺ฟࡋ࡚࠸࡚ࡑࢀࢆಟ᚟࡛ࡁ࡚࠸࡞࠿ࡗࡓ
࡜࠸࠺ྍ⬟ᛶࡣప࠸࡜ᛮࢃࢀࡓࠋᮏ⑕౛ࡣ⾡୰⭡⭍㙾ᡤぢ㸦)LJ㸧࡟♧ࡋࡓ࡜࠾ࡾ㸪࣊ࣝࢽ࢔㛛࿘ᅖࡢⓑⰍ⒕⑞ࡀᙉ
ࡃึᅇᡭ⾡࡛ࡢ๤㞳ࡣ࠿࡞ࡾ㞴ࡋ࠿ࡗࡓࠋࡉࡽ࡟ᮏ⑕౛ࡀ
ᙜ㝔ࡢ 7$33 ࡢẚ㍑ⓗึᮇࡢ⑕౛࡛࠶ࡗࡓࡇ࡜ࡶ࠶ࡾ㸪⭤⬔ᦆയࢆᜍࢀ࡚ෆഃ๤㞳ࢆ༑ศ࡟࡛ࡁ࡞࠿ࡗࡓࠋࡇࢀࡽࡢ
ࡇ࡜ࡀᚋࡢ⭤⬔࣊ࣝࢽ࢔ࡢཎᅉ࡜࡞ࡗࡓྍ⬟ᛶࡀ࠶ࡗࡓࠋ
ึᅇᡭ⾡࡛ෆഃࡢ๤㞳ࡀ୙༑ศ࡛࠶ࡗࡓࡓࡵ࡟㸪⾡ᚋ࡟ࡑࡇ࠿ࡽ⭤⬔ࡀᚎࠎ࡟⬺ฟࡋ㸪࣓ࢵࢩ࡛ࣗ⿵ᙉࡉࢀࡓ⭡⭷࡟ࡣ㝗พࢆࡁࡓࡉࡎ㸪⭡⭷እᆺࡢ⭤⬔⬺ฟ࡜࠸࠺ᙧែࢆ♧ࡋࡓࡶࡢ࡜⪃࠼ࡽࢀࡓࠋ
⾡୰࡟ᮏ⑕౛ࡢࡼ࠺࡞ VDFOHVV KHUQLD ࢆ␲ࡗࡓሙྜࡢ
ᑐฎ࡜ࡋ࡚ࡣ㸪⾡๓࡟㰡ᚄ㒊⭾㝯ࡀ௚ぬᡤぢ࡛᫂ࡽ࠿࡛࠶
ࡾ㸪⏬ീୖ⬡⫫⭘ࡸ⭤⬔ࡀෆᐜ࡜ࡢᡤぢࡀᚓࡽࢀ࡚࠸ࢀࡤ

᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

文献㸧+ROOLQVN\ & 6DQGEHUJ 6 &OLQLFDOO\ GLDJQRVHG
JURLQ KHUQLDV ZLWKRXW VDF DW ODSDURVFRS\ ̽ ZKDWWRGR"7KH$P-6XUJ  /LOO\ 0& $UUHJXL 0( /LSRPDV RI WKH FRUG DQGURXQGOLJDPHQW$QQDOVRI6XUJ
 *HUVLQ.6+HQLIRUG%7*DUFLD5XL]$3RQVN\-/
0LVVHGOLSRPDRIWKHVSHUPDWLFFRUG6XUJ(QGRVF

 1DVDU$27RUPH\6:DOVK71/LSRPDRIWKHFRUG
DQG URXQG OLJDPHQW DQ RYHUORRNHG GLDJQRVLV"
+HUQLD
 5HDG 5& 6FKDHIHU 5) /LSRPD RI WKH VSHUPDWLF
FRUG IDWW\ KHUQLDWLRQ OLSRVDUFRPD  +HUQLD
 6RORZD\ +0 3RUWQH\ ) .DSODQ $ +HUQLD RI WKHEODGGHU-8URO ᳃⏣ὒᖹ㸪ᒣᮏ㞞⏤㸪ᒣ⏣ᆂ୍㸪Ọ஭೺ኴ㑻㸪ዟ⏣ὒ୍㸬⾡๓࡟ᑠ⭠࣭⭤⬔ᔐ㡻ࢆデ᩿ࡋ࠼ࡓ㰡ᚄ࣊ࣝࢽ࢔ࡢ  ౛㸬⮫ᗋእ⛉ ࠉ ⚄ཎᖖோ㸪㎷஭ಇᙪ㸪ྜྷ⏣ㅬ୍㑻㸬ྑ㰡ᚄ࣊ࣝࢽ࢔᰿
἞⾡ᚋ࡟Ⓨ⏕ࡋࡓ㰡ᚄ㒊⭤⬔࣊ࣝࢽ࢔ࡢ  ౛㸬⮫ᗋἪᒀჾ⛉ 

9RO1R)LJ ึᅇ 7$33 ᫬ࡢ⾡୰෗┿ࢆࡋࡵࡍࠋྑ ,, ᆺࡢ㰡ᚄ࣊ࣝࢽ࢔࡟ᑐࡋ㸪࣓ࢵࢩࣗࢆ஧ᯛ⏝࠸࡚ಟ᚟ࢆ
⾜ࡗࡓ

)LJ ⭤⬔ࢆྠᐃࡋ≌ᘬࡋࡓ

)LJ &7 ࡛ࡣ࣊ࣝࢽ࢔ෆᐜࡀ⭤⬔࡛࠶ࡿྑ㰡ᚄ࣊ࣝࢽ
࢔ࡢ෌Ⓨࡀ␲ࢃࢀࡓ㸦‫ڸ‬㸧

)LJ ึᅇ 7$33 ᫬࡜ྠᵝࡢ఩⨨࡟࣊ࣝࢽ࢔㛛ࢆㄆࡵࡓ)LJ  ᅇ┠ࡢᡭ⾡᫬ࡢ⭡⭍㙾ᡤぢ࡛ࡣ⭡⭷㝗พࢆㄆࡵ࡞࠿ࡗࡓࠋ๓ᅇࡢ࣓ࢵࢩࣗࡢෆ⦕࡟ἢࡗ࡚⭡⭷ษ㛤ࢆ⾜ࡗࡓ)LJ ࣊ࣝࢽ࢔㛛࿘ᅖࢆྍ⬟࡞㝈ࡾ๤㞳ࡋࡓ᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍



9RO1R)LJ ⭤⬔␃⨨ࣂ࣮ࣝࣥ࠿ࡽ⏕⌮㣗ሷỈࢆὀධࡋ㸪⭤⬔ᦆയࡢ࡞࠸ࡇ࡜ࢆ☜ㄆࡋࡓ

)LJ ࣓ࢵࢩࣗࡢእഃࡣ๓ᅇࡢ࣓ࢵࢩࣗୖ࡟྾཰ᛶࢱࢵ
ࢡ࡛ᅛᐃࡋࡓ

)LJ ࣓ࢵࢩࣗෆഃࢆ࣊ࣝࢽ࢔㛛ෆഃ࡟྾཰ᛶࢱࢵࢡ࡛
ᅛᐃࡋࡓ

)LJ ⭡⭷ࢆ㐃⥆⦭ྜࡋ࡚ᡭ⾡ࢆ⤊࠼ࡓ᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍



9RO1R

The case of bladder hernia without peritoneal sac after TAPP
procedure
Department of Surgery, Yao Tokushukai General Hospital

Yasuro Kato, Yuki Ushimaru, Hiroaki Suzuki
Abstract
We report the case of a 65-year-old man with Parkinson disease. He was admitted to our hospital because of rightinguinal bulging. We performed the TAPP (Transabdominal pre-peritoneal mesh repair) procedure for his inguinal
hernia. One year and 7 months later, he came to our hospital with symptoms of right inguinal bulging again. We could    !&!  &' !<E& !   "   8   &! <   !    ! <    E& 8!  !  !   &  !<E88!  &!   Q^    ! E    !8  <   !&!  ^     E8   !&!  &' !<

Ultrasonography and a CT scan showed the bladder protrusion. We performed a third laparoscopy. We could not locate
the peritoneal dent again, but according to a CT representation, we cut the peritoneum along the medial side of the       &!

E8!    !   !8   &< { E !     8      8 Q &  @< @   V      {8 " &! Q^          &   !

Key words:TAPP, Bladder hernia, Sacless䠎䠌䠍䠐ᖺ䠏᭶䠎䠐᪥ཷࠉ⌮᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍
᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍



9RO1R症例報告
腹腔鏡下鼠径ヘルニア修復術後にメッシュ盲腸瘻を形成した 1 例㸧⊂❧⾜ᨻἲேᅜ❧⑓㝔ᶵᵓጲ㊰་⒪ࢭࣥࢱ࣮ࠉእ⛉㸧಴ᩜ୰ኸ⑓㝔ࠉእ⛉ᮏ㛫࿘స㸧㸪ᯇ⏣భ㍜㸧㸪㛗ஂྜྷ㞝㸧
要旨⑕౛ࡣ  ṓࡢ⏨ᛶ࡛୧ഃ㰡ᚄ࣊ࣝࢽ࢔࡟ᑐࡋ࡚⭡⭍㙾ୗ㰡ᚄ࣊ࣝࢽ࢔ಟ᚟⾡㸦ODSDURVFRSLF WUDQVDEGRPLQDO
SUHSHULWRQHDO UHSDLU㸸௨ୗ 7$33㸧ࡀ᪋⾜ࡉࢀࡓ㸬⾡ᚋ  ᪥┠࡟࢖ࣞ࢘ࢫࢆⓎ⑕ࡋࡓࡓࡵ⭡⭍㙾ୗᡭ⾡ࢆ᪋⾜ࡋࡓ㸬ྑ㰡ᚄ㒊ࡢ⭡⭷⦭ྜࡀ㞳㛤ࡋ㟢ฟࡋࡓ࣓ࢵࢩࣗ࡟ᑠ⭠ࡀ⒵╔ࡋ࡚࢖ࣞ࢘ࢫࢆ㉳ࡇࡋ࡚࠸ࡓ㸬⒵╔๤㞳ࢆ⾜࠸㸪㟢ฟࡋࡓ࣓ࢵࢩࣗࡢୖ࡟ &RPSRVL[ .XJHO 3DWFK ࢆ㈞௜ࡋࡓ㸬ࡑࡢ  ᖺ  ࣨ᭶ᚋ㸪೺デ┠ⓗ࡛ཷࡅࡓୗ㒊ᾘ໬⟶ෆど㙾᳨ᰝࢆዎᶵ࡟࣓ࢵࢩࣗ┣⭠⒦ࡀุ᫂ࡋࡓ㸬⒦Ꮝࢆྵࡴ┣⭠ࢆ㒊ศษ㝖ࡋ㸪࣓ࢵࢩࣗ࠾ࡼࡧ࿘ᅖ⭡ቨࢆ୍ሢ࡟ษ㝖ࡋࡓ㸬
7$33 ࡣᩚᐜᛶ࡟ඃࢀ࡚࠸ࡿࡔࡅ࡛࡞ࡃ㸪」㞧࡞࣊ࣝࢽ࢔࡛࠶ࡗ࡚ࡶ☜ᐇ࡟ಟ᚟࡛ࡁࡿ࡜࠸࠺฼Ⅼࡀ࠶ࡾ㏆ᖺ⑕౛ᩘࡀ
ቑ࠼࡚࠸ࡿ㸬ࡋ࠿ࡋ㸪௚ࡢ࣊ࣝࢽ࢔ᡭ⾡࡜ྠᵝ㸪࣓ࢵࢩࣗ㛵㐃ྜే⑕ࡢࣜࢫࢡࡣ㑊ࡅࡽࢀ࡞࠸㸬௒ᅇᡃࠎࡣ㸪7$33 ⾡ᚋ࡟࣓ࢵࢩࣗ┣⭠⒦ࢆᙧᡂࡋࡓ⑕౛ࢆ⤒㦂ࡋࡓࡢ࡛ሗ࿌ࡍࡿ㸬࣮࣮࢟࣡ࢻ㸸7$33㸚VWXOD㸪PHVKLQIHFWLRQ ᖺ  ᭶࠾ࡼࡧ  ᭶࡟ࡶྠᵝࡢ⑕≧ࡀ࠶ࡗࡓࡀ࠸ࡎࢀ

はじめに⭡ ⭍ 㙾 ୗ 㰡 ᚄ ࣊ ࣝ ࢽ ࢔ ಟ ᚟ ⾡㸦ODSDURVFRSLFࡶಖᏑⓗ἞⒪࡛㍍ᛌࡋࡓ㸦ᅗ 㸧㸬 ᖺ  ᭶㸪೺デ┠ⓗ࡛ୗ㒊ᾘ໬⟶ෆど㙾᳨ᰝࢆཷࡅ㸪WUDQVDEGRPLQDO SUHSHULWRQHDO UHSDLU㸸௨ୗ 7$33㸧ࡣ⭡⭍ෆ࠿ࡽほᐹࡍࡿࡇ࡜࡛࣊ࣝࢽ࢔㛛ࡢ఩⨨㸪ᩘࡀṇ☜࡟ᢕᥱ࡛ࡁ㸪」㞧࡞࣊ࣝࢽ࢔࡛࠶ࡗ࡚ࡶ☜ᐇ࡟ಟ᚟࡛ࡁࡿ࡜࠸
࠺฼Ⅼࡀ࠶ࡿ㸬ࡲࡓᩚᐜᛶ࡟ࡶඃࢀ࡚࠾ࡾ㏆ᖺ⑕౛ᩘࡣቑ
ຍഴྥ࡛࠶ࡿ㸬ࡋ࠿ࡋ㸪࣓ࢵࢩࣗࢆ⏝࠸ࡓᡭ⾡࡛࠶ࡿ௨ୖ㸪࣓ࢵࢩࣗ࡟㛵㐃ࡍࡿྜే⑕ࡢࣜࢫࢡࡣ㑊ࡅࡽࢀ࡞࠸㸬௒ᅇ㸪7$33 ⾡ᚋ࡟࣓ࢵࢩࣗ┣⭠⒦ࢆᙧᡂࡋ㸪࣓ࢵࢩࣗឤᰁ

࠶ࡾዟࡣ✵Ὕᵝ࡜࡞ࡗ࡚࠸ࡓ㸬┤ᚋࡢ⭡㒊 &7 ᳨ᰝ࡛ྑ㰡ᚄ㒊࡟ DLU ࢆక࠺㌾㒊⤌⧊ᙳ࡜࿘ᅖࡢ⬡⫫⧊⃰ᗘୖ᪼ࢆㄆ
ࡵࡓ㸬┣⭠✸㏻࡟ࡼࡿ࣓ࢵࢩࣗឤᰁ࡜デ᩿ࡋᡭ⾡┠ⓗ࡛ධ㝔࡜࡞ࡗࡓ㸬
⌧⑕㸸ྑ㰡ᚄ㒊࡟◳⤖ࢆゐࢀ㸪ྠ㒊࡟ᅽ③ࢆㄆࡵࡓ㸬Ⓨ⇕ࡣㄆࡵ࡞࠿ࡗࡓ㸬ࢆ⧞ࡾ㏉ࡋࡓ⑕౛ࢆ⤒㦂ࡋࡓࡢ࡛ሗ࿌ࡍࡿ㸬症┣⭠࡟␗ฟ⾑ᛶࡢ୙ᩚ࡞⢓⭷ࢆㄆࡵࡓ㸬ࡑࡢ୰ᚰ࡟ࡣᏍࡀ

⾑ᾮ᳨ᰝᡤぢ㸸⅖⑕ᡤぢࢆྵࡴ⾑⟬࣭⏕໬Ꮫ᳨ᰝ࡟␗ᖖᡤ

例ぢࡣㄆࡵ࡞࠿ࡗࡓ㸬ᝈ⪅㸸 ṓ㸪⏨ᛶୗ㒊ᾘ໬⟶ෆど㙾᳨ᰝᡤぢ㸸┣⭠࡟␗ฟ⾑ᛶࡢ୙ᩚ࡞⢓⭷୺ッ㸸ྑ㰡ᚄ㒊ࡢ⑊③ࢆㄆࡵ㸪୰ᚰ࡟ᏍࡀᏑᅾࡋ㸪ࡑࡢዟࡣ✵Ὕ࡜࡞ࡗ࡚࠸ࡓ㸦ᅗ᪤ Ṕ㸸 ᖺ  ᭶㸪๓❧⭢⒴࡟ᑐࡋ࡚๓❧⭢඲᦬⾡᪋⾜㸬㸧㸬ᐙ᪘Ṕ㸸≉グࡍ࡭ࡁࡇ࡜࡞ࡋ

⭡㒊 &7 ᡤぢ㸸ྑ㰡ᚄ㒊࡛࣓ࢵࢩࣗ࡜ᛮࢃࢀࡿ⥺≧ࡢ㧗྾⌧⑓Ṕ㸸 ᖺ  ᭶㸪୧ഃ㰡ᚄ࣊ࣝࢽ࢔࡟ᑐࡋ࡚ 7$33 ࢆ཰ᇦࡣᒅ᭤ࡋ㸪⭠⟶࡜᥋ࡋ࡚࠸ࡓ㸬࿘ᅖࡢ⬡⫫⧊⃰ᗘࡀୖ᪋⾜ࡋࡓ㸬⾡ᚋ  ᪥┠࡟⒵╔ᛶ࢖ࣞ࢘ࢫࢆⓎ⑕ࡋ෌ධ㝔㸪᪼ࡋ JDV ീࢆㄆࡵࡓ㸦ᅗ 㸧㸬⭠⟶ࢆῶᅽࡉࡏࡓᚋ࡟⭡⭍㙾ୗᡭ⾡ࢆ᪋⾜ࡋࡓ㸬ྑ㰡ᚄ㒊௨ୖࡼࡾ࣓ࢵࢩࣗឤᰁ㸪࣓ࢵࢩࣗ┣⭠⒦ᙧᡂ࡜デ᩿ࡋᡭࡢ⭡⭷⦭ྜ㒊ෆഃ  ࡀ㞳㛤ࡋ㸪㟢ฟࡋࡓ࣓ࢵࢩࣗ࡟ᑠ

⾡ࢆ᪋⾜ࡋࡓ㸬⭠ࡀ⒵╔ࡍࡿࡇ࡜࡛࢖ࣞ࢘ࢫࢆⓎ⑕ࡋ࡚࠸ࡓ㸬⭡⭍㙾ୗ࡟ᡭ⾡ᡤぢ㸸ྑഐṇ୰ษ㛤࡛㛤⭡ࡋࡓ㸬ྑ㰡ᚄ㒊ࡣ㧗ᗘࡢ⅖⒵╔ࢆ๤㞳ࡋ㸪㟢ฟࡋࡓ࣓ࢵࢩࣗࡢୖ࡟ &RPSRVL[ .XJHO⑕ࡢࡓࡵⴭ᫂࡟◳໬ࡋ࡚࠾ࡾ㸪࣓ࢵࢩࣗ࡟ࡼࡿ⅖⑕ᛶ⭘⒗

3DWFK㸦௨ୗ &.3㸧ࢆ㈞௜ࡋ࡚ಟ᚟ࡋࡓ㸦ᅗ 㸧㸬 ᖺ  ᭶㸪ࢆᙧᡂࡋ࡚࠸ࡓ㸬࣓ࢵࢩࣗ࡜┣⭠እഃ࡜ࡀᙉᅛ࡟⒵╔ࡋ࡚ྑ㰡ᚄ㒊③ࢆ᮶ࡓࡋ⭡㒊 &7 ᳨ᰝ࡛࣓ࢵࢩࣗឤᰁࡀ␲ࢃࢀ

࠸ࡓࡀ㸪⹸ᆶᇶ㒊ࡸୖ⾜⤖⭠㸪%DXKLQ ᘚ࡟ࡣᙳ㡪ࡣཬࢇࡓ㸬ᢠ⏕๣࡟ࡼࡿಖᏑⓗ἞⒪ࢆ⾜࠸  㐌㛫࡯࡝࡛㍍ᛌࡋࡓ㸬࡛࠸࡞࠿ࡗࡓ㸬⹸ᆶᇶ㒊ࢆྵࡴ┣⭠ࢆ୍㒊ྜేษ㝖ࡋ㸪⭘᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍



9RO1R

⒗࡜໬ࡋࡓ  ᯛࡢ࣓ࢵࢩࣗࢆ᦬ฟࡋࡓ㸬⢭⟶ࡸ⢭ᕢື㟼⬦⑞࣊ࣝࢽ࢔ᡭ⾡࡟౑⏝ࡉࢀ㸪Ⰻዲ࡞ᡭ⾡ᡂ⦼ࡀሗ࿌ࡉࢀ࡚

࡞࡝ࡢᵓ㐀≀ࡣᏑࡋᚓࡓ㸬㰡ᚄ㒊⤌⧊ࡢ⅖⑕ᛶኚ໬ࡀᙉ

࠸ࡿ㸧㸬ࡋ࠿ࡋ୙༑ศ࡞࣓ࢵࢩࣗࡢᅛᐃࡸ㸪᪥ᖖ⏕ά࡟࠾ࡃ࣊ࣝࢽ࢔෌Ⓨண㜵ࡢಟ᚟࣭⿵ᙉࡣᅔ㞴࡜⪃࠼ࡽࢀࡓࡓ

ࡅࡿ⭡ቨࡢ㐠ື࡟ࡼࡿ࣓ࢵࢩࣗࡢṍࡳ࡞࡝㸪ఱࡽ࠿ࡢཎᅉ

ࡵ㸪ෆ㰡ᚄ㍯ࢆ⦭⦰ࡍࡿ࡟␃ࡵࡓ㸬ᡭ⾡᫬㛫ࡣ  ᫬㛫  ศ㸪࡛ 3RO\SURS\OHQH 㠃ࡀ⭡⭍ෆ࡟㟢ฟࡍࡿࡇ࡜࡛⭠⟶࡜⒵╔ฟ⾑㔞ࡣ J ࡛࠶ࡗࡓ㸬ࡋ㸪⒦Ꮝࢆᙧᡂࡋࡓ࡜࠸࠺ሗ࿌ࡀᮏ㑥࡟࠾࠸࡚ࡶᩓぢࡉࢀ᦬ฟᶆᮏ㸸&.3 ࡣᒅ᭤ࡋ㸪➃ࡢ୍㒊ࡀ┣⭠ෆ࡟㟢ฟࡋ࡚⒦ࡿ 㹼㸧㸬ᮏ⑕౛࡛ࡣ⒵╔ᛶ࢖ࣞ࢘ࢫ࡟ᑐࡍࡿ⭡⭍㙾ୗᡭᏍࢆᙧᡂࡋ࡚࠸ࡓ㸦ᅗ 㸧㸬⾡ࡢ㝿㸪㟢ฟࡋࡓ࣓ࢵࢩࣗࢆ෌ᗘ⭡⭷࡛⿕そࡍࡿࡇ࡜ࡀᅔ

⾡ᚋ⤒㐣㸸⾡ᚋ๰㒊ឤᰁࢆⓎ⑕ࡋ἞⒪࡟㞴῰ࡋࡓࡀಖᏑⓗ㞴࡛࠶ࡗࡓࡓࡵ &.3 ࢆ⏝࠸࡚ಟ᚟ࡋࡓ㸬⭡ቨ⒕⑞࣊ࣝࢽ࢔

἞⒪࡛㍍ᛌࡋ㸪⾡ᚋ  ᪥┠࡟㏥㝔ࡋࡓ㸬⌧ᅾࡲ࡛࣊ࣝࢽ

ᡭ⾡࡛ࡣ࣓ࢵࢩࣗࡢᅛᐃࢆᐦ࡟ࡍࡿࡇ࡜࡛࣓ࢵࢩࣗࡢṍ

࢔ࡢ෌Ⓨࡣㄆࡵ࡚࠸࡞࠸㸬ࡳࡸࡓࢃࡳࢆ㜵ࡄࡇ࡜ࡀྍ⬟ࡔࡀ㸪㰡ᚄ㒊࡛ࡣ LOLRSXELF

考WUDFW ࡢ⫼ഃ࡟㔜せ࡞⬦⟶㸪⚄⤒ࡀ㉮⾜ࡋ࡚࠸ࡿࡓࡵ㸪察⭡ ⭍ 㙾 ୗ 㰡 ᚄ ࣊ ࣝ ࢽ ࢔ ಟ ᚟ ⾡㸦ODSDURVFRSLFWUDQVDEGRPLQDO SUHSHULWRQHDO UHSDLU㸸௨ୗ 7$33㸧ࡣᩚᐜᛶ࡟ඃࢀ࡚࠸ࡿࡔࡅ࡛࡞ࡃ㸪⭡⭍ෆ࠿ࡽほᐹࡍࡿࡇ࡜࡛
」㞧࡞࣊ࣝࢽ࢔࡛࠶ࡗ࡚ࡶ☜ᐇ࡟ಟ᚟࡛ࡁࡿ࡜࠸࠺฼Ⅼ
ࡀ࠶ࡾ㏆ᖺ⑕౛ᩘࡣቑຍഴྥ࡛࠶ࡿ㸧㸬ࡋ࠿ࡋ㸪࣓ࢵࢩࣗࢆ⏝࠸ࡓᡭ⾡࡛࠶ࡿ௨ୖ㸪࣓ࢵࢩࣗ࡟㛵㐃ࡍࡿྜే⑕ࡢࣜ
ࢫࢡࡣ㑊ࡅࡽࢀ࡞࠸㸬㰡ᚄ࣊ࣝࢽ࢔࡟ᑐࡍࡿ⭡⭍㙾ୗᡭ⾡࡟࠾ࡅࡿ࣓ࢵࢩࣗឤᰁࡢ㢖ᗘࡣ 㸣࡜ప⋡࡛࠶ࡿࡀ 㸧㸪୍᪦Ⓨ⑕ࡍࡿ࡜࣓ࢵࢩࣗ㝖ཤࢆవ൤࡞ࡃࡉࢀࡿሙྜࡀከࡃ ᝈ ⪅ ࡢ ୙ ฼ ┈ ࡣ ኱ ࡁ ࠸㸬 ᮏ ⑕ ౛ ࡛ ࡣ &RPSRVL[ .XJHO3DWFK㸦௨ୗ &.3㸧ࡢ୍㒊ࡀ┣⭠ෆ࡟㟢ฟࡋ࡚࠸ࡓࡇ࡜࠿ࡽ㸪

7$33 ࡟࠾࠸࡚࣓ࢵࢩࣗࢆᅛᐃࡍࡿ㝿࡟ࡣὀពࡀᚲせ࡛࠶ࡿ㸧㸬ᮏ⑕౛࡛ࡣ LOLRSXELFWUDFW ࡢ⫼ഃ࡛ࡣ⬦⟶ࡢᦆയࡸ⚄⤒ࡢᕳࡁ㎸ࡳࡀ࡞࠸ࡼ࠺㆙ᡄࡋࡘࡘ  ࡢ྾཰⣒ࢆ⏝࠸࡚⤖⠇⦭ྜᅛᐃࢆ⾜ࡗࡓ㸬ࡋ࠿ࡋ㸪⾡ᚋఱࡽ࠿ࡢཎᅉ࡛
࣓ࢵࢩࣗࡀᒅ᭤ࡋ㸪㟢ฟࡋࡓ 3RO\SURS\OHQH 㠃࡬┣⭠ࡀ⒵╔ࡋ࡚⒦Ꮝࡀᙧᡂࡉࢀࡓࡶࡢ࡜⪃࠼ࡽࢀࡓ㸬௒ᚋ 7$33 ࡢ㐺ᛂࡀᣑ኱ࡉࢀࡿ࡟ࡘࢀ࡚ H37)( ࣓ࢵࢩࣗࡢ౑⏝㢖ᗘࡶቑ࠼࡚ࡃࡿ࡜ᛮࢃࢀࡿ㸬࣓ࢵࢩࣗࡢᒅ᭤ࡸṍࡳ࡞࡝࡟ࡼࡾ⭠⟶ࡀ⒵╔ࡋ⒦Ꮝࢆᙧᡂࡍࡿྍ⬟ᛶࡀ࠶ࡿࡇ࡜ࢆᛕ㢌࡟⨨ࡁ㸪H37)( ࣓ࢵࢩࣗࢆᅛᐃࡍࡿ㝿࡟ࡣὀព࡜ᕤኵࡀᚲせ࡜⪃࠼ࡿ㸬

文࣓ࢵࢩࣗ࡜┣⭠࡜ࡢ㛫࡟ᙧᡂࡉࢀࡓ⒦Ꮝ࠿ࡽ⭠ෆᐜ≀ࡀὶฟࡋ࣓ࢵࢩࣗឤᰁࢆᘬࡁ㉳ࡇࡋࡓࡶࡢ࡜⪃࠼ࡽࢀࡓ㸬⒦ᏍࡢᏑᅾࡀ᫂ࡽ࠿࡟࡞ࡿࡲ࡛࡟  ᅇ࣓ࢵࢩࣗឤᰁࢆ⏕ࡌ࡚࠸ࡓࡀ㸪࠸ࡎࢀࡢ᫬Ⅼ࡛ࡶ⭡㒊 &7 ᳨ᰝୖ࣓ࢵࢩࣗᾘ໬⟶⒦ࢆ␲࠺ᡤぢࡣㄆࡵ࡞࠿ࡗࡓ㸬࣓ࢵࢩࣗឤᰁࢆ⧞ࡾ㏉ࡋࡓࡇ࡜࠿ࡽ  ᖺ  ᭶ࡢ᫬Ⅼ࡛ᚤᑠ࡞⒦Ꮝࡀᙧᡂࡉࢀ࡚࠸
ࡓྍ⬟ᛶࡣ࠶ࡿࡀ㸪ヲ⣽ࡣ୙࡛᫂࠶ࡿ㸬࣓ࢵࢩࣗᾘ໬⟶⒦ࡣ 7$33 ⾡ᚋ࣓ࢵࢩࣗឤᰁࡢཎᅉࡢ୍ࡘ࡜ࡋ࡚⪃៖ࡍ࡭ࡁ࡛࠶ࡿ࡜ࡉࢀ࡚࠸ࡿࡀ 㸧㸪ࡑࡢⓎ⏕㢖ᗘࡸⓎ⏕᫬ᮇ࡞࡝
୙᫂࡞Ⅼࡣከ࠸㸬་Ꮫ୰ኸ㞧ㄅ࡟࠾࠸࡚ࠕ⭡⭍㙾ୗ㰡ᚄ࣊ࣝࢽ࢔ಟ᚟⾡ࠖ࠾ࡼࡧࠕᾘ໬⟶⒦ࠖ࠶ࡿ࠸ࡣࠕ⒦Ꮝࠖࡸࠕ⭠⒦ࠖࢆ࣮࣮࢟࣡ࢻ࡟᳨⣴ࡋࡓࡀ㸪఍㆟㘓ࢆྵࡵࡇࢀࡲ࡛࡟
ᮏ㑥࡛ࡢሗ࿌ࡣ࡞ࡃ㸪ᮏ⑕౛ࡀึ࡜⪃࠼ࡽࢀࡿ㸬
7$33 ࡛౑⏝ࡍࡿ࣓ࢵࢩࣗࡢ⣲ᮦ࡜ࡋ࡚ࡣ 3RO\SURS\OHQH
ࡀ⏝࠸ࡽࢀࡿࡇ࡜ࡀከ࠸㸬3RO\SURS\OHQH 〇࣓ࢵࢩࣗࡣ⭠⟶࡜⒵╔ࡍࡿࣜࢫࢡࡀ࠶ࡿࡓࡵ㸪࣓ࢵࢩࣗࡀ㟢ฟࡋ࡞࠸ࡼ
࠺࡟⭡⭷ࢆ⦭ྜ㛢㙐ࡋ࡞ࡅࢀࡤ࡞ࡽ࡞࠸㸬๓❧⭢⒴⾡ᚋࡸ෌Ⓨ㰡ᚄ࣊ࣝࢽ࢔ࡢ⑕౛࡞࡝࡟࠾࠸࡚ࡣࡋࡤࡋࡤ⭡⭷㛢㙐ࡀᅔ㞴࡜࡞ࡿሙྜࡀ࠶ࡿࡀ㸪ࡑࡢࡼ࠺࡞᫬࡟ &.3 ࡀ᭷⏝࡛࠶ࡿ࡜᪩ᕝࡣ㏙࡭࡚࠸ࡿ㸧㸬&.3 ࡣ H[SDQGHG 3RO\WHWUD㸛XRURHWK\OHQH㸦௨ୗ H37)(㸧
࡜ 3RO\SURS\OHQH ࠿ࡽ࡞ࡿ  ᒙᛶ࣓ࢵࢩ࡛ࣗ࠶ࡿ㸬H37)(ࡣṤ࡝⭠⟶࡜⒵╔ࡋ࡞࠸ࡓࡵ H37)( 㠃ࢆ⭡⭍ഃ࡬ྥࡅࡿࡇ
࡜࡛⭡⭍ෆ࡟␃⨨ࡍࡿࡇ࡜ࡀྍ⬟࡜࡞ࡗࡓ㸧㸬୺࡟⭡ቨ⒕᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

献㸧᪥ᮏෆど㙾እ⛉Ꮫ఍⦅㸸ෆど㙾እ⛉ᡭ⾡࡟㛵ࡍࡿ࢔ࣥࢣ࣮ࢺㄪᰝ̿➨  ᅇ㞟ィ⤖ᯝሗ࿌̿㸬᪥ᮏෆど㙾እ⛉Ꮫ఍㞧ㄅ㸬㸹㸸㸬㸧0LOOHU . -XQJHU : ,OHRFXWDQHRXV ILVWXODIRUPDWLRQ IROORZLQJ ODSDURVFRSLF SRO\SURS\OHQH
PHVKKHUQLDUHSDLU6XUJ(QGRVF
㸧.OHLQ $0 %DQHYHU 7& (QWHURFXWDQHRXV 㸚VWXOD DV
D SRVWRSHUDWLYH FRPSOLFDWLRQ RI ODSDURVFRSLF
LQJXLQDO KHUQLD UHSDLU 6XUJ /DSDURVF (QGRVF

㸧᪩ᕝဴྐ㸬⭡⭍㙾ୗ㰡ᚄ࣊ࣝࢽ࢔ಟ᚟⾡㸫ࡉࡲࡊࡲ࡞
7$33㸦WUDQVDEGRPLQDO SUHSHULWRQLDU UHSDLU㸧 ἲ 㸫㸬ᡭ⾡㸬㸹㸸㸬㸧ᐑᓮᜤ௓㸪ᡂ⏣ྜྷ᫂㸪୰ᮧᩥ㝯㸪࡯࠿㸬%DUG&RPSVL[ τ
0HVK ࡟ ࡼ ࡿ ⭡ ቨ ⒕ ⑞ ࣊ ࣝ ࢽ ࢔ ಟ ᚟ ⾡㸬 ᡭ ⾡㸬㸹㸸㸬㸧,DQQLWWL'$+RSH::1RUWRQ+-HWDO7HFKQLTXH
DQG RXWFRPHV RI DEGRPLQDO LQFLVLRQDO KHUQLDUHSDLUXVLQJDV\QWKHWLFFRPSRVLWHPHVKDUHSRUWRIFDVHV-$P&ROO6XUJ
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ࢽ࢔ಟ᚟࡟⏝࠸ࡓ⭡⭍ෆ␃⨨ᆺ࣓ࢵࢩࣗ࡟ࡼࡿᑠ⭠⓶⭵⒦ࡢ  ౛㸬᪥ᮏ⮫ᗋእ⛉Ꮫ఍㞧ㄅ㸬㸹㸸
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Cecum ﬁstula following laparoscopic transabdominal
preperitoneal repair
1) Department of Surgery, NHO Himeji Medical Center2) Department of Surgery, Kurashiki Central Hospital

Shusaku Homma 1) , Yusuke Matsuda 1) , Yoshio Nagahisa 2㸧
Abstract
A 72-year-old man who had undergone laparoscopic transabdominal preperitoneal repair (TAPP) was admitted tothe hospital for ileus. Laparoscopic surgery was performed and it was revealed that ileus was caused by an adhesion
between the small bowel and the mesh which was exposed because of peritoneal suture dehiscence. We chose
Composix Kugel Patch (CKP) and applied it to the exposed mesh after removal of the adhesion. Two years and ten
months later, colon fiberscopy and abdominal computed tomography showed fistula between cecum and the CKP.
We performed an en-block resection of a part of cecum and the abdominal wall including two meshes. There is anincreasing number of TAPP because it is not only having a cosmetic advantage but we can also repair exactly despite acomplicated inguinal hernia however, we have to have a risk of mesh related complications. We report a case of mesh  ! Q^$<8 +Q^E !E   䠎䠌䠍䠐ᖺ䠏᭶䠎䠐᪥ཷࠉ⌮᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

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䚷ᮏᏛ఍ㄅ䛷䛿䚸 ⑕౛ሗ࿌䛜ከ䛟䛺䜛䛣䛸䛿ண᝿䛧䛶䛔䜎䛩䚹 ㏆ᖺ䚸 ⑕౛ሗ࿌䜢ᥖ㍕䛩䜛Ꮫ⾡㞧ㄅ䛜ᑡ䛺䛟䛺䛳䛶䛝䜎䛧䛯䚹 ⑕౛ሗ࿌䛭䛾䜒䛾䛾䜶䝡䝕䞁䝇䝺䝧䝹䛿ప䛔䜒䛾䛷䛩䛜䚸 ⮫ᗋ䛿䛭䛾䜘䛖䛺⑕౛䛾✚䜏㔜䛽䛻䜘䛳䛶㐍Ṍ䛧䛶䛔䛟䜒䛾䛸ಙ䛨䛶䛔䜎䛩䚹 ᐇᆅ⮫ᗋ䛾ඛ⏕᪉䛜䛚஫䛔䛾⤒㦂䜢ඹ᭷䛩䜛䛸䛔䛖ព࿡䛷䚸 䛬䜂䛯䛟䛥䜣䛾⑕౛ሗ࿌䜢ᢞ✏䛧䛶㡬䛝䛯䛔䛸㢪䛳䛶䛔䜎䛩䚹 䜎䛯䚸 ୍᪉䚸 Ꮫ఍ㄅ䛾䝺䝧䝹䛿Ꮫ఍䛾䝺䝧䝹䜢⾲䛩䛸䛔䛳䛶䜒㐣ゝ䛷䛿䛒䜚䜎䛫䜣䚹 ᪥ᮏ䛷䝦䝹䝙䜰䛻㛵䛩䜛ඃ䜜䛯⮫ᗋ◊✲䛜⏕䜎䜜䛶䚸 ୡ⏺䛻Ⓨಙ䛩䜛䜶䝡䝕䞁䝇䜔ᡭ⾡ᡭᢏ䚸 䛒䜛䛔䛿ᡭ⾡ᮦᩱ䛜⏕䜎䜜䛶䛟䜛䛣䛸䜢㢪䛳䛶䛔䜎䛩䚹 ᮏᏛ఍ㄅ䛜ᑡ䛧䛷䜒䛭䛾䛚ᡭఏ䛔䛜䛷䛝䜜䜀䚸 Ꮫ఍ㄅ䛾⦅㞟ጤဨ㛗䛸䛧䛶䛣䛾ୖ䛺䛔႐䜃䛷䛩䚹 ᮏᏛ఍ㄅ䜢⫱䛶䛶䛔䛟䛾䛿䜎䛥䛻Ꮫ఍఍ဨ䛾ⓙᵝ䛷䛩䚹 Ꮫ఍ဨ䛾✚ᴟⓗ䛺ᢞ✏䜢䛚ᚅ䛱䛧䛶䛔䜎䛩䚹᪥ᮏ䝦䝹䝙䜰Ꮫ఍ㄅ⦅㞟ጤဨ㛗䚷‫⅙ޛݱ‬џ᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍

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9RO1R⦅㞟ጤဨఀ⸨ࠉዎࠊ✄ⴥࠉẎࠊୖᮧెኸࠊᑠᒣࠉຬ ࠊᔱ⏣ࠉඖࠊᓥ⏣㛗ேࠊᏵࠉᆂ⏨ࠊෆ⸨ࠉ⛱ࠉすᮧඖ୍ࠊ⻏㡲㈡୔༤ࠊ୕⃝೺அࠊ࿴⏣๎ோ㸦 ⦅㞟ጤဨ㛗㸧䛂᪥ᮏ䝦䝹䝙䜰Ꮫ఍ㄅ䛃 ➨ 㻝 ᕳ➨䠍ྕ䚷䠎䠌䠍䠐ᖺ䠓᭶䠎䠌᪥Ⓨ⾜⦅㞟⪅㸸ᑠᒣࠉຬ
Ⓨ⾜⪅㸸ᰙℨಙኴ㑻Ⓨ⾜ᡤ㸸ࠛ ࠉᮾி㒔ᯈᶫ༊ຍ㈡ 
᪥ᮏ࣊ࣝࢽ࢔Ꮫ఍
㟁ヰ㸸ࠉ)$;㸸

日本ヘルニア学会事務局〒 173-8605

東京都板橋区加賀 2-11-1（帝京大学外科教室内）

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