まずは腹部のヘルニアを大まかに把握する
[ヘルニアの定義]
ヘルニアとは体内の臓器が本来あるべき位置から脱出した状態を指す。
[外ヘルニアと内ヘルニア]
外ヘルニア:体腔内臓器が異常に生じた裂隙を通じて体腔外に脱出してしまった状態を指す。
体腔外で起こるので基本的には体表から確認できる。鼠径部付近のヘルニアは外ヘルニアに分類される。
内ヘルニア：体腔内臓器が体腔内において異常に生じた裂隙などに入り込んでしまった状態を指す。体腔内で起こるので体表からは確認できない。大網裂孔ヘルニア・食道裂孔ヘルニア・網嚢孔ヘルニア(Winslow孔ヘルニア)などが内ヘルニアに分類される。
腹部の外ヘルニアはどのようにして形成されるのか
腹腔と腹膜の存在を把握する
腹腔内は腹膜に覆われている。
腹部には解剖学的に圧力が掛かりやすい弱点となる部分や血管や神経が腹腔内に出たり入ったりするための裂隙がある。
ヘルニア嚢の形成
腹膜が先天的な要因や圧力を受けた結果として裂隙や腹壁の弱い部分から伸びてしまいヘルニア嚢が形成される。
腹部外ヘルニアは腹腔内を覆っている腹膜が裂隙や腹壁の弱い部分から突出してヘルニア嚢を形成してしまった後にそこに腹腔内臓器が脱出した状態を指す。
初期
ヘルニア嚢ができた後の初期では重力が掛かる立位において腹腔内臓器が突出するようになるが、重力が掛からない仰臥位では還納する。また、症状が出ない。
嵌頓
脱出した腹腔内臓器が元の位置に戻らなくなることを嵌頓と呼び、絞扼性腸閉塞の状態となってしまうので緊急手術が必要となる。
鼠径部付近のヘルニアの治療は
実際の臨床では異なるかもしれないが、医師国家試験問題を解くにあたっては嵌頓の場合は絶対的に緊急手術と覚えるのが良いのではないかと考える。
全身状態が良好で嵌頓していないようであれば用手還納(徒手的還納)を試みる。
鼠径ヘルニアについて
鼠径管は男性により発達するので、鼠径ヘルニアは男性に多い。
体表から分かりやすいので身体診察(視診・触診)が有効となる。
鼠径管を理解する
鼠径管とは前壁(外腹斜筋腱膜)・上壁(内腹斜筋)・下壁(鼠径靭帯)、後壁(腹横筋筋膜)で構成されるトンネル状の空間である。
鼠径管の入口を内鼠径輪(深鼠径輪)と呼び、出口を外鼠径輪(浅鼠径輪)と呼ぶ。
「管」と名前についているので「管状」の構造なのかと思ってしまいがちだが、実際には鼠径靭帯の上側に「トンネル状の空間がぽっかりと存在する」というイメージであることに注意する必要がある。
鼠径管の名前の由来
精巣(睾丸)は胎生期に腹腔内で発生して出生近くになると鼠径管を通過して陰嚢に移動する。この精巣(睾丸)の動きを鼠になぞらえて、鼠径管というのは「鼠=精巣(睾丸)」の通り道になるという意味から名付けられた。
鼠径管を通過するもの
男性では精索(索状組織であり内部に精管・精巣動静脈などを含む)、女性では子宮円索(子宮を固定する線維組織)が通過する。
鼠径ヘルニアの分類
下腹壁動静脈よりも外側から突出するものを外鼠径ヘルニアと分類して、内側から突出するものを内鼠径ヘルニアと分類する。
外鼠径ヘルニア
先天的要因が大きく、幼児と若年成人に多い。
内鼠径輪から鼠径管に侵入して外鼠径輪を通って鼠径部皮下に脱出するものを指す。身体の外側(がいそく)よりに発生する。
内鼠径ヘルニア
後天的要因が大きく、高齢男性(特に腹圧が上昇しやすい肥満者)に多い。
Hesselbach三角(下腹壁動静脈・鼠径靭帯・腹直筋外側縁に囲まれた部分)に存在する鼠径後壁を構成している横筋筋膜ごとヘルニア嚢が鼠径管に侵入して直接外鼠径輪を通って鼠径部皮下に脱出するものを指す。身体の内側(ないそく)よりに発生する。
大腿ヘルニアについて
女性は骨盤が広いので、大腿ヘルニアは女性に多い。
体表から分かりやすいので身体診察(視診・触診)が有効となる。
高齢女性に多く、嵌頓しやすく、手術治療が原則となる。
大腿輪から大腿管に侵入して伏在裂孔を通って大腿部皮下に脱出するものを指す。
鼠径ヘルニアは鼠径靭帯の上に位置するのに対して、大腿ヘルニアは鼠径靭帯の下に位置する。
大腿管を理解する
大腿管とは入口を大腿輪として出口を伏在裂孔とする大腿静脈に沿った空間である。
入口である大腿輪は外側縁(大腿静脈)・前縁(鼠径靭帯)・内側縁(裂孔靭帯)で構成され、出口である伏在裂孔は大伏在静脈が通過する。
大腿管も鼠径管のように「管状」の構造というわけではなく、大腿静脈の内側に沿って「空間がぽっかりと存在する」というイメージである。
閉鎖孔ヘルニアについて
女性は骨盤が広いので、閉鎖孔ヘルニアは女性に多い。
高齢女性に多く、嵌頓しやすく、手術治療が原則となる。
閉鎖孔ヘルニアは腹腔内臓器が閉鎖孔を通って腹腔外に脱出したものであるので外ヘルニアに分類される。しかし、体表面からだと閉鎖孔ヘルニアの前面には恥骨筋がくるので体表からは確認するのが難しく身体診察(視診・触診)が有効となりにくい。
他の鼠径部付近の外ヘルニア(鼠径ヘルニア・大腿ヘルニア)は全て恥骨筋よりもさらに前面に発生するので体表面から確認するのが容易となり身体診察(視診・触診)が有効となるため、閉鎖孔ヘルニアは外ヘルニアであるにも関わらず体表面から確認するのが難しいという例外的な特徴を持つといえる。
閉鎖孔ヘルニアはCTが有効
閉鎖孔ヘルニアは恥骨筋と外閉鎖筋に滑り込むような形で閉鎖孔を通過するので、CTにおいて恥骨筋と外閉鎖筋に挟まれた閉鎖孔を認めるという分かりやすい特徴的なCT所見を呈するので身体診察よりもCTが有効となる。
鼠径ヘルニアと大腿ヘルニアをCT所見のみで鑑別する必要はない
医師国家試験レベルではCTからは閉鎖孔ヘルニアなのか［鼠径ヘルニア・大腿ヘルニア］なのかを区別できれば十分である。恥骨よりも身体の深層(うちがわ)に発生するのが閉鎖孔ヘルニアであり、身体の浅層(そとがわ)に発生するのが［鼠径ヘルニア・大腿ヘルニア］である。
鼠径ヘルニアと大腿ヘルニアは発生する位置が近いので1枚のCTスライスで鑑別するのは難しく、医師国家試験レベルではそこまで求められない。そもそも、鼠径ヘルニアと大腿ヘルニアは体表から分かりやすいので身体診察(視診・触診)の方が有効である。
閉鎖孔ヘルニアの症状
絞扼性イレウス(腹痛・嘔気)
通常、外ヘルニアは嵌頓による絞扼性腸閉塞の症状が出る前に体表が膨らむので見た目から気付かれることが多い。しかし、閉鎖孔ヘルニアは外ヘルニアの中で唯一体表からは確認しにくいので、絞扼性腸閉塞の症状で見つかることが多い。
Howship-Romberg徴候(大腿内側の疼痛)
閉鎖孔ヘルニアによって閉鎖神経が圧迫されてしまうことで閉鎖神経圧迫症状が起こる。
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