巨大裂孔ヘルニアを合併したバレット食道腺癌に対して胸腔鏡・腹腔鏡補助下 に食道裂孔ヘルニア修復と食道切除再建術を施行した1 例

We report a case of Barrett adenocarcinoma with coexisting giant hiatal hernia presenting an upside-down stomach (UDS). Hiatal hernia repair and Ivor-Lewis esophagectomy were simultaneously performed by laparoscopic and thoracoscopic approaches. A 68-year-old man was given a diagnosis of type IV hiatal hernia with UDS. Upper gastrointestinal endoscopy revealed an early-stage adenocarcinoma in the long-segment Barrett esophagus. The operation was initiated with laparoscopy. It took time to reposition the herniated stomach because of severe intrasaccular adhesion and the massive greater omentum occupying the sac. The stomach was mobilized and repositioned after adhesiolysis and partial resection of the omentum. The cardia was transected and the gastric conduit was prepared extracorporeally. Crural repair was performed by interrupted sutures and reinforced with a prosthetic mesh. Then, the thoracoscopic part was performed in the prone position. The thoracic esophagus was mobilized and the specimen was retrieved after transecting the esophagus at the level of the azygos arch. Esophagogastrostomy was created with an endoscopic linear stapler and hand-sewn closure of the entry hole. From the viewpoint of pulmonary function and securing the visual field in the sac, minimally invasive surgery was useful.