意思疎通不能の重症心身障害者に対し全腹腔鏡下子宮全摘術を施行した１例 ―早期退院を目指した術式の工夫と多職種連携の必要性―

抄録

Introduction: Gynecological surgery of patients with severe motor and intellectual disabilities (SMID) carry specific risks associated with the difficulties in gynecological examination, the presenting symptoms, and the demands of adapting to the inpatient environment. We report on a SMID patient who underwent a total laparoscopic hysterectomy (TLH) after information pertaining to her condition was shared between the multidisciplinary team and the resident facility staff.

Case: Our patient was a 45-year-old nulliparous female with SMID. She was unable to walk and communicate; and had been institutionalized since childhood. She had undergone abdominal bilateral adnexectomy for primary ovarian cancer two years prior at our department. Postoperative restlessness persisted, and the perioperative management posed difficulty. Abnormal vaginal bleeding was observed during the postoperative follow-up of ovarian cancer, an endometrium biopsy under intravenous anesthesia confirmed the diagnosis of endometrial cancer. A TLH was planned as a curative surgery, because of the challenges associated with the requirements of gynecological procedures and institutional care. Surgery was performed after patient information was shared between the multidisciplinary team and the resident facility staff. Surgical time was 131 minutes, with minor hemorrhaging. During the surgery, development of the retroperitoneal space was minimized, and the vaginal pipe was inserted carefully with attention to the narrow vaginal wall. Although, lacerations of the hymen ring and perineum occurred during the vaginal retrieval of the uterus, requiring suture repair; she did not become restless and was discharged as scheduled.

Conclusion: During laparoscopic surgery for a SMID patient, use of a surgical method that reduces postoperative pain and multidisciplinary collaboration are necessary.