䛂㧗㞴ᗘ᪂つ་⒪ᢏ⾡䛾ᑟධ䝥䝻䝉䝇䛻ಀ䜛デ⒪䜺䜲䝗䝷䜲䞁➼䛾ホ౯䞉ྥୖ䛻㛵䛩䜛≉ู

ᖹᡂ 28 ᖺᗘ

ཌ⏕ປാ⾜ᨻ᥎㐍ㄪᰝ஦ᴗ㈝⿵ຓ㔠

◊✲ሗ࿌᭩

䛂㧗㞴ᗘ᪂つ་⒪ᢏ⾡䛾ᑟධ䝥䝻䝉䝇䛻ಀ䜛デ⒪䜺䜲䝗䝷䜲䞁➼䛾ホ౯䞉ྥୖ䛻㛵䛩䜛≉ู

◊✲䛃ศᢸ◊✲ሗ࿌᭩

ᅜෆእ䛷䛾㧗㞴ᗘ᪂つ་⒪ᢏ⾡䛻㛵䛩䜛䜺䜲䝗䝷䜲䞁䛾⌧ἣ䜢᝟ሗ཰㞟ᩚ⌮

◊✲ศᢸ⪅㻌 Ἑ㔝㻌 ᾈ஧㻌 㻌 㻌 ⚟ᓥ┴❧་⛉኱Ꮫ་Ꮫ㒊ᾘ໬⟶እ⛉Ꮫ㻌 㻌 ᩍᤵ

◊✲༠ຊ⪅ ༡ᕝ㻌 ୍ኵ㻌 ⚟ᓥ┴❧་⛉኱Ꮫ་⒪◊✲᥎㐍䝉䞁䝍䞊㻌 ≉௵ᩍᤵ㻌 㻌 㻌 㻌 㻌 㻌 ዟᮧ㻌 ᫭Ꮚ 㻌 බ┈㈈ᅋἲே᪥ᮏ་⒪ᶵ⬟ホ౯ᶵᵓ EBM ་⒪᝟ሗ㒊

䠄Minds䠅ㄢ㛗 㻌 㻌 㻌 㻌 㻌 㻌

◊✲せ᪨

ᮏ◊✲䛿䚸㧗㞴ᗘ་⒪ᢏ⾡䛻㛵䛩䜛䜺䜲䝗䝷䜲䞁䛾ྥୖ䛻ྥ䛡䛯ᥦゝ䜢⾜䛖䛯䜑䚸ᅜෆእ䛾㧗 㞴ᗘ་⒪ᢏ⾡䛻㛵䛩䜛㛵㐃ᩥ᭩䜢཰㞟䞉ศᯒ䛩䜛➼䛾ㄪᰝ䛻䜘䜚䚸㧗㞴ᗘ་⒪ᢏ⾡䛻㛵䛩䜛䜺䜲 䝗䝷䜲䞁䛾ᅜෆእ䛾ᐇែᢕᥱ䜢⾜䛳䛯䚹ලయⓗ䛻䛿䚸㧗㞴ᗘ᪂つ་⒪ᢏ⾡䛻㛵䛩䜛ᇶᮏⓗ䛺⪃

䛘᪉䛾⟇ᐃ䛻䛒䛯䛳䛶཰㞟䛥䜜䛯ᅜෆ䛾㛵㐃ᩥ᭩ཬ䜃ᾏእ䛻䛴䛔䛶䛿⡿ⱥ䛾බⓗᶵ㛵䛜ಖ᭷

䛩䜛デ⒪䜺䜲䝗䝷䜲䞁䝕䞊䝍䝧䞊䝇䛾⥙⨶ⓗ䛺᳨⣴➼䛻䜘䜚☜ㄆ䛥䜜䛯㛵㐃ᩥ᭩䛾ศᯒ䜢⾜䛳䛯䚹 ᅜෆ䜺䜲䝗䝷䜲䞁➼䛾ㄪᰝ䛻䜘䜚䚸㧗㞴ᗘ་⒪ᢏ⾡䛾㛵㐃ᩥ᭩䛻䛿䚸䛂䜺䜲䝗䝷䜲䞁䛃䛾䜋䛛䚸䛂ᐇ

᪋ᇶ‽䛃䚸䛂ᥦゝ䛃䛸䛔䛳䛯ྡ⛠䛾ᩥ᭩䜒䛒䜚䚸䜎䛯䚸Ꮫ఍ဨ㝈ᐃ䛷බ㛤䛥䜜䛶䛔䜛ᩥ᭩䜒䛒䛳䛯䚹ᾏ እ䜺䜲䝗䝷䜲䞁䛾ㄪᰝ䛻䜘䜚䚸≉ᐃ䛾་⒪ᢏ⾡䠄౛䛘䜀䝻䝪䝑䝖ᡭ⾡䠅䛻㛵䛩䜛㛵㐃ᩥ᭩䛻䛴䛔䛶䚸

⡿ᅜ䛷䛿Ꮫ఍䝺䝧䝹䛷ᥦၐ䛩䜛ᣦ㔪䚸ⱥᅜ䛷䛿ᅜ❧ಖ೺་⒪◊✲ᡤ䛜⟇ᐃ䛩䜛䜺䜲䝎䞁䝇䛜ᑡ

ᩘ౛☜ㄆ䛥䜜䛯䚹䜎䛯䚸ᮏศᢸ◊✲⌜䛜ㄪᰝ䛧䛯㝈䜚䚸ᾏእ䛾≧ἣ䛸䛧䛶䚸㧗㞴ᗘ᪂つ་⒪ᢏ⾡

䛾ᑟධ䛩䜛䛻䛒䛯䛳䛶ᨻᗓ䝺䝧䝹䛷ᐃ䜑䜛ໟᣓⓗ䛺㔪䛿☜ㄆ䛷䛝䛺䛛䛳䛯䚹

௨ୖ䜢㋃䜎䛘䜛䛸䚸ᡃ䛜ᅜ䛻䛚䛔䛶㧗㞴ᗘ་⒪᪂つ་⒪ᢏ⾡䛾ᑟධ䛻㛵䛩䜛䚸ᨻᗓ䝺䝧䝹䛷 䛾⤫୍ⓗ䛺䝹䞊䝹䜢ᐃ䜑䛯䛣䛸䛿䚸኱ኚ᭷ព⩏䛷䛒䜚㠉᪂ⓗ䛺ྲྀ⤌䛸ゝ䛘䜛䚹㛵㐃Ꮫ఍䜢୰ᚰ䛻 䛥䜙䛻඘ᐇ䛧䛯㧗㞴ᗘ᪂つ་⒪ᢏ⾡䛻㛵㐃䛩䜛䜺䜲䝗䝷䜲䞁➼䛾ᩚഛཬ䜃࿘▱䜢ᅗ䛳䛶䛔䛝䚸䜎 䛯䚸་⒪ᶵ㛵䛻䛚䛔䛶䛣䜜䜙䛾ไᗘ䜢㐺ṇ䛻㐠⏝䛩䜛䛣䛸䛻䜘䜚䚸᪥ᮏ䛾་⒪䛾ྥୖ䛻ᐤ୚䛩䜛䛣 䛸䛜ᮇᚅ䛥䜜䜛䚹

䠝䠊◊✲┠ⓗ

ཌ⏕ປാ┬䛿䚸኱Ꮫ㝃ᒓ⑓㝔➼䛻䛚䛔䛶䚸

་⒪Ᏻ඲䛻㛵䛩䜛㔜኱䛺஦᱌䛜┦ḟ䛔䛷Ⓨ

⏕䛧䛶䛔䜛䛣䛸䜢䛖䛡䚸♫఍ಖ㞀ᑂ㆟఍་⒪ศ

⛉఍䛜ᖹᡂ 27 ᖺ䠐᭶䛻䛸䜚䜎䛸䜑䛯䛂≉ᐃᶵ⬟

⑓㝔➼䛾་⒪Ᏻ඲⟶⌮యไ䛻㛵䛩䜛ពぢ䛃 䠄௨ୗ䛂ពぢ᭩䛃䛸䛔䛖䚹䠅䛾ෆᐜ䜒㋃䜎䛘䚸2016 ᖺ 6 ᭶ 10 ᪥䚸་⒪ἲ᪋⾜つ๎➼䜢ᨵṇ䛧䚸㧗

㞴ᗘ་⒪᪂つ་⒪ᢏ⾡䜢ᑟධ䛩䜛䛻䛒䛯䛳䛶 䛾䝥䝻䝉䝇䛻⤫୍ⓗ䛺䝹䞊䝹䜢ᐃ䜑䜛䛣䛸䛻䛺 䛳䛯䚹ពぢ᭩䛻䛚䛔䛶䛿䚸䛂㧗㞴ᗘ䛾᪂つ་

⒪ᢏ⾡䠄௨ୗ䛂㧗㞴ᗘ᪂つ་⒪ᢏ⾡䛃䛸䛔䛖䚹䠅 䛻㛵㐃䛧䛶Ṛஸ஦᱌䛜┦ḟ䛔䛷Ⓨ⏕䛧䛯䛣䛸 䜢㋃䜎䛘䚸㛵ಀᏛ఍䛻ᑐ䛧䚸㧗㞴ᗘ᪂つ་⒪

ᢏ⾡䛾ᑟධ䜢᳨ウ䛩䜛䛻ᙜ䛯䛳䛶䛾䚸䜲䞁䝣䜷 䞊䝮䝗䞉䝁䞁䝉䞁䝖䛾ᅾ䜚᪉䚸⾡⪅䛾ᢏ㔞䜔ᣦ

75

ᑟయไ䛺䛹䛾䚸་⒪Ᏻ඲䛻㛵䛩䜛ᇶᮏⓗ䛺⪃

䛘᪉䜢᳨ウ䞉ᩚ⌮䛩䜛䛣䛸䜢せㄳ䛩䜛䛃䛸䛥䜜䛶 䛚䜚䚸ᙜヱ䝹䞊䝹䜢ㄝ᫂䛩䜛་ᨻᒁ㛗㏻▱䛻 䛚䛔䛶䜒䛂㧗㞴ᗘ᪂つ་⒪ᢏ⾡䛾ᥦ౪䛾䝥䝻 䝉䝇䛻㛵䛩䜛つ⛬䜢⟇ᐃ䛩䜛䛸䛝䛿䚸㛵ಀᏛ

఍䛛䜙♧䛥䜜䜛䛂㧗㞴ᗘ᪂つ་⒪ᢏ⾡䛾ᑟධ 䛻ᙜ䛯䛳䛶䛾ᇶᮏⓗ䛺⪃䛘᪉䛃䜔䜺䜲䝗䝷䜲䞁

➼䜢ཧ⪃䛻䛩䜛䛣䛸䛃䛸䛥䜜䛶䛔䜛䚹

ᮏ◊✲䛿䚸䛣䜜䜙䜢⫼ᬒ䛻䚸ᅜෆእ䛾㧗㞴 ᗘ᪂つ་⒪ᢏ⾡䛻㛵䛩䜛䜺䜲䝗䝷䜲䞁➼䛾ෆ ᐜ䜢ㄪᰝ䛩䜛䛣䛸䛻䜘䜚䚸ᐇែᢕᥱ䜢䛩䜛䛸䛸䜒 䛻䚸௒ᚋ䛾㧗㞴ᗘ་⒪ᢏ⾡䛻㛵䛩䜛䜺䜲䝗䝷 䜲䞁䛾ྥୖ䛻ྥ䛡䛯ᥦゝ䜢⾜䛖䛣䛸䜢┠ⓗ䛸䛩 䜛䚹

䠞䠊◊✲᪉ἲ

䠍䠅ᅜෆ䜺䜲䝗䝷䜲䞁䛾ㄪᰝ

䛂㧗㞴ᗘ᪂つ་⒪ᢏ⾡䛾ᇶᮏⓗ⪃䛘᪉䛃䛾

⟇ᐃ⤒⦋䛾୰䛷䚸ᅧᅵ◊✲⌜䛾⌜ဨ䛾༠ຊ 䜢ᚓ䛶㞟䜑䜙䜜䛯ᅜෆ䛾㧗㞴ᗘ᪂つ་⒪ᢏ

⾡䛾ᑟධ䝥䝻䝉䝇䛻㛵㐃䛩䜛䛸⪃䛘䜙䜜䜛ᅜ ෆ䛾ᣦ㔪䞉䜺䜲䝗䝷䜲䞁 25 ௳䚸᪥ᮏ་Ꮫ఍䜢

㏻䛨䛶䚸ᇶᮏ 18 㡿ᇦ䛾㛵ಀᏛ఍䛻ᑟධ䝥䝻 䝉䝇䛻㛵㐃䛩䜛䛸⪃䛘䜙䜜䜛ᣦ㔪䞉䜺䜲䝗䝷䜲 䞁➼䛾ᥦ౪䜢ồ䜑䛶㞟䜎䛳䛯 13 ௳䛾㛵㐃ᩥ

᭩䠄௨ୗ䛂㛵㐃ᩥ᭩䛃䛸䛔䛖䚹䠅䛾䛖䛱䚸Web ୖ 䛷බ㛤䛥䜜䛶䛔䜛 32 ௳䛻䛴䛔䛶䚸㧗㞴ᗘ᪂ つ་⒪ᢏ⾡䛾ᑟධ䛻䛒䛯䛳䛶ᚲせ䛸䛥䜜䛶 䛔䜛䛂⾡⪅䛾せ௳䛃䚸䛂ᣦᑟయไ䛃䚸䛂䛭䛾௚་

⒪Ᏻ඲䛻㛵䛩䜛஦㡯䛃䚸䛂䜲䞁䝣䜷䞊䝮䝗䞉䝁䞁 䝉䞁䝖䛻㛵䛩䜛஦㡯䛃䛾グ㍕䠄䠄௨ୗ䛂㛵㐃グ

㍕䛃䛸䛔䛖䚹䠅䛾᭷↓➼䛻䛴䛔䛶ᩥ⊩ㄪᰝ䜢⾜

䛳䛯䚹

䠎䠅ᾏእ䜺䜲䝗䝷䜲䞁䛾ㄪᰝ

ᡭ⾡䞉ᡭᢏ䛻㛵䛩䜛ᅜእ䛾デ⒪䜺䜲䝗䝷䜲 䞁➼䛻䛴䛔䛶ᩥ⊩ㄪᰝ䜢⾜䛔䚸䛭䛾グ㍕㡯

┠䜔⟇ᐃ᪉ἲ䚸䜶䝡䝕䞁䝇䛾཰㞟᪉ἲ➼䛻 䛴䛔䛶ㄪᰝ䛧䛯䚹ලయⓗ䛻䛿䚸ⱥ⡿䛻䛚䛡䜛 බⓗᶵ㛵䠄⡿ᅜ㻌 ་⒪◊✲ရ㉁ᗇ (Agency

for Healthcare Research and Quality䠄௨ୗ

䛂AHRQ䛃䛸䛔䛖䚹䠅)䚸ⱥᅜ㻌 ᅜ❧ಖ೺་⒪◊

✲ᡤ䠄National Institute for Health and Care㻌 Excellence䠄௨ୗ䛂NICE䛃䛸䛔䛖䚹䠅䠅䜔Ꮫ⾡ᅋ య➼䛜ᥖ㍕䛧䛶䛔䜛ᡭ⾡䞉ᡭᢏ➼䛾䜺䜲䝗䝷 䜲䞁䛾᭷↓ཬ䜃䚸䛭䛾グ㍕㡯┠➼䜢☜ㄆ䛧 䛯䚹䜎䛯䚸䝅䞁䜺䝫䞊䝹኱Ꮫ䛷ᐇ᪋⮫ᗋ䜢⾜

䛳䛯Ἑ㔝䛾⤒㦂䛛䜙䚸䝅䞁䜺䝫䞊䝹ᅜ❧኱

Ꮫ䛻䛚䛡䜛㧗㞴ᗘ᪂つ་⒪ᢏ⾡䛾ᑟධ䛻㛵 䛩䜛⌧≧䜢ሗ࿌䛧䚸䜎䛯䚸䝅䞁䜺䝫䞊䝹ᅜ❧

኱Ꮫእ⛉ᩍᤵ 2 ྡ䜘䜚䚸ᮏ௳䛻㛵䛩䜛⪺䛝ྲྀ

䜚㠃ㄯㄪᰝ䜢⾜䛳䛯䚹

(೔⌮㠃䜈䛾㓄៖)

೔⌮㠃䛷䛸䛟䛻㓄៖䛩䜛䜉䛝ၥ㢟Ⅼ䛿䛺䛔䚹

䠟䠊◊✲⤖ᯝ

䠍䠅ᅜෆ䜺䜲䝗䝷䜲䞁䛾ㄪᰝ⤖ᯝ

32 ௳䛾㛵㐃ᩥ᭩䛾୰䛷䚸㧗㞴ᗘ་⒪ᢏ

⾡䛾ᑟධ䝥䝻䝉䝇䛻㛵䛩䜛グ㍕㡯┠䚸䐟䛂⾡

⪅䛾せ௳䛃䚸䐠䛂ᣦᑟయไ䛃䚸䐡䛂䛭䛾௚་⒪

Ᏻ඲䛻㛵䛩䜛஦㡯䛃䛾䛔䛪䜜䛛䜢ྵ䜣䛷䛔䜛 䜺䜲䝗䝷䜲䞁䛿 22 ௳䛒䛳䛯䚹㻌 䛣䛾䛖䛱䛂⾡⪅

䛾せ௳䛃䛿 22 ௳䚸ᣦᑟయไ䛿䚸11 ௳䚸䛂䛭䛾

௚་⒪Ᏻ඲䛻㛵䛩䜛஦㡯䛃䛿 13 ௳䛻ྵ䜎䜜 䛶䛔䛯䚹䛣䜜䜙䛾㛵㐃グ㍕䛿䚸䜺䜲䝗䝷䜲䞁䛾

⥲ㄽ䛾୍㒊䜔 Q䠃A 䛾୍䛴䛸䛧䛶グ㍕䛥䜜䜛 ሙྜ䜒䛒䛳䛯䚹䛣䜜䜙䛾㛵㐃ᩥ᭩䛾ྡ⛠䛿䚸 䛂䜺䜲䝗䝷䜲䞁䛃9 ௳䚸䛂ᇶ‽䛃7 ௳䚸䛂ᣦ㔪䛃4 ௳䚸 䛂䛭䛾௚䛃2 ௳䚸䛰䛳䛯䠄㈨ᩱ 15 ῧཧ↷䠅䚹

䠎䠅ᾏእ䜺䜲䝗䝷䜲䞁䛾ㄪᰝ⤖ᯝ 䠄1䠅⡿ᅜ䜺䜲䝗䝷䜲䞁䛾ㄪᰝ≧ἣ

⡿ᅜ AHRQ 䛜㐠Ⴀ䛧䚸ྛᅜ䛾デ⒪䜺䜲䝗

䝷 䜲 䞁 䜢 ཰ ㍕ 䛩 䜛 National Guideline Clearinghouse(NGC)䛾䜴䜵䝤䝃䜲䝖䛻䛚䛔 䛶䚸䛂Surgery䛃䛸䛔䛖 䜹䝔䝂䝸䞊䜢ㄪᰝ䛧䛯 䛸䛣䜝䚸390 ௳䠄2004䡚2016 ᖺⓎ⾜䠅䛾䜺䜲 䝗䝷䜲䞁䛜☜ㄆ䛷䛝䚸䛭䛾䛖䛱䚸NGC 䛾ᥖ

㍕ᇶ‽䈜䛻ྜ⮴䛩䜛䜺䜲䝗䝷䜲䞁䛿 76 ௳

76

䠄2011 䡚2016 ᖺⓎ⾜䠅䛷䛒䛳䛯䠄㈨ᩱ 16䠅䚹 䛣䜜䜙 76 ௳䛾ᩥ⊩䛾䛖䛱䚸䝍䜲䝖䝹䛛䜙 2 ௳ 䛜ヱᙜᩥ⊩䛸䛧䛶ೃ⿵䛻ᣲ䛢䜙䜜䛯䛜䚸ᮏ

ᩥෆᐜ䜢☜ㄆ䛧䛯⤖ᯝ䚸㧗㞴ᗘ᪂つ་⒪

ᢏ⾡䛻㛵㐃䛩䜛ᩥ⊩䛿ぢᙜ䛯䜙䛺䛛䛳䛯䚹

ୖグ䛾䝕䞊䝍䝧䞊䝇᳨⣴䛷䛿䚸⡿ᅜ䛻䛚 䛡䜛㧗㞴ᗘ་⒪ᢏ⾡䛻㛵㐃䛩䜛䜺䜲䝗䝷䜲 䞁䜢☜ㄆ䛷䛝䛺䛛䛳䛯䛜䚸ศᢸ◊✲⪅䠄Ἑ 㔝䠅䛜䝅䞁䜺䝫䞊䝹ᅾఫ᫬䛻౑⏝䛧䛶䛔䛯 㧗㞴ᗘ᪂つ་⒪ᢏ⾡䛻㛵䛩䜛ᣦ㔪䞉䜺䜲䝗 䝷䜲䞁䛸䛧䛶䚸䛂A Consensus document on Robotic Surgery䛃䛻䛿䚸⾡⪅䛾せ௳䜔⑓㝔 䛸䛧䛶䛾་⒪Ᏻ඲యไ➼䛾㧗㞴ᗘ་⒪ᢏ

⾡䛻㛵㐃䛩䜛グ㍕䛜ྵ䜎䜜䛶䛔䛯䠄㈨ᩱ

16 ཧ↷䠅䚹

䠄䠎䠅ⱥᅜ䜺䜲䝗䝷䜲䞁ㄪᰝ≧ἣ

䐟 ⱥᅜ䛜㐠Ⴀ䛧䚸デ⒪䜺䜲䝗䝷䜲䞁䜢䛿䛨 䜑䛸䛩䜛䜺䜲䝎䞁䝇඲⯡䜢཰㍕䛩䜛 NICE 䛾䜴䜵䝤䝃䜲䝖ୖ䛻䛚䛔䛶䚸ᡭ⾡䜔᳨ᰝ➼

䛾ᡭᢏ䛻㛵䛩䜛䜺䜲䝎䞁䝇䜢ᥖ ㍕ 䛩 䜛 䛂 Technology appraisal guidance 䛃 䛚 䜘 䜃 䛂Medical technologies guidance䛃䛾䜹䝔 䝂䝸䞊ෆ䜢ㄪᰝ䛧䛯䛸䛣䜝䚸䛭䜜䛮䜜 188

௳䚸 28 ௳䠄䛸䜒䛻 2011䡚2016 ᖺⓎ⾜䠅 䛾䜺䜲䝎䞁䝇䛜☜ㄆ䛷䛝䛯䚹䛣䜜䜙䛾ᩥ⊩

䛾䝍䜲䝖䝹䛛䜙㧗㞴ᗘ᪂つ་⒪ᢏ⾡䛻㛵 㐃䛩䜛ᩥ⊩䛿ぢᙜ䛯䜙䛺䛛䛳䛯䚹

䐠 ୖグ䛾 NICE 䛾䜴䜵䝤䝃䜲䝖ୖ඲⯡䛻 䛚䛔䛶䚸௨ୗ䛻♧䛩 Key Words 䛻䛶 ෌ ᗘㄪᰝ䜢⾜䛳䛯䛸䛣䜝䚸8 ௳䛾ᩥ⊩䛜☜ㄆ 䛷䛝䛯䚹䛣䜜䜙 8 ௳䛾ᮏᩥෆᐜ䛛䚸 䛂Laparoscopic repair of abdominal aortic Aneurysm 䛃䚸䛂 Laparoscopic

retroperitoneal lymph nodedissection for testicular cancer䛃䛾 2 ௳䛜ヱᙜᩥ⊩䛸䛧 䛶☜ㄆ䛷䛝䛯䚹 ෆᐜ䛿ⷧ䛔䜒䛾䛾䠄1 䝨

䞊䝆䛾䜏䠅䚸䛂ᢏ⾡ⓗ䛻㞴䛷䛒䜛䛣䛸䜢

Inform 䛩䜛䛣䛸䛃䛂䝕䞊䝍䝧䞊䝇䛻Ⓩ㘓䛩

䜛䛣䛸䛃䛂㞟Ꮫⓗ䝏䞊䝮䛷⾜䛖䛣䛸䛃䛾䜺䜲䝎 䞁䝇䛜 ♧䛥䜜䛶䛔䛯䠄㈨ᩱ 17 ཧ↷䠅䚹

䠄Key Words䠅

Surgeon credentialing Training

guidelines Privileging qualified surgeons Minimal requirements for granting privileging surgeons Technically demanding surgery

䠄䠏䠅䛭䛾௚

ⱥ⡿௨እ䛾ᾏእ䛾≧ἣ䜒ᢕᥱ䛩䜛䛯䜑䚸 䝅䞁䜺䝫䞊䝹ᅜ❧኱Ꮫእ⛉ᩍᤵ 2 ྡ䜘䜚䚸 ᮏ௳䛻㛵䛩䜛⪺䛝ྲྀ䜚㠃ㄯㄪᰝ䜢⾜䛳䛯

⤖ᯝ䚸䝅䞁䜺䝫䞊䝹䛻䛚䛔䛶䛿䚸ᅜ䛜ᐃ䜑 䛯⤫୍ⓗ䛺䝹䞊䝹䛿䛺䛔䛜䚸⑓㝔⊂⮬䛾

ྲྀ䜚Ỵ䜑䛸䛧䛶䚸㧗㞴ᗘ᪂つ་⒪ᢏ⾡䛾ᥦ ౪䛻䛒䛯䛳䛶䚸஦๓ᑂᰝ䜢⾜䛳䛶䛔䜛䛣䛸 䛜䜟䛛䛳䛯䠄㈨ᩱ 18 ཧ↷䠅䚹

䠠䠊⪃ᐹ

ᅜෆ䜺䜲䝗䝷䜲䞁➼䛾ㄪᰝ⤖ᯝ䛻䜘䜚䚸㧗㞴 ᗘ་⒪ᢏ⾡䛾㛵㐃ᩥ᭩䛻䛿䚸䛂䜺䜲䝗䝷䜲䞁䛃 䛾䜋䛛䚸䛂ᐇ᪋ᇶ‽䛃䚸䛂ᥦゝ䛃䛸䛔䛳䛯ྡ⛠

䛾ᩥ᭩䜒䛒䜚䚸䜎䛯䚸Ꮫ఍ဨ㝈ᐃ䛷බ㛤䛥䜜 䛶䛔䜛ᩥ᭩䜒䛒䛳䛯䚹㧗㞴ᗘ᪂つ་⒪ᢏ⾡

䛾ᑟධ䛻䛒䛯䛳䛶䚸≉ᐃᶵ⬟⑓㝔➼䛿䚸䜺 䜲䝗䝷䜲䞁䛸䛔䛖ྡ⛠䛾䜏䛺䜙䛪䚸ᐇ᪋ᇶ‽䚸 ᥦゝ䛸䛔䛳䛯䚸㛵ಀᏛ఍䛜Ⓨฟ䛩䜛㧗㞴ᗘ ᪂つ་⒪ᢏ⾡䛾㛵㐃ᩥ᭩䛻ᇶ䛵䛝ホ౯䛩 䜛䛣䛸䛜ồ䜑䜙䜜䜛䚹䜎䛯䚸㛵ಀᏛ఍䛿䚸⟇ᐃ 䛧䛯㛵㐃ᩥ᭩䛻䛴䛔䛶䚸⑓㝔ཪ䛿Ꮫ఍ဨ䛛 䜙䛾䜰䜽䝉䝅䝡䜱䝸䝔䜱䛾ྥୖ䜢ᅗ䜛䛸䛸䜒䛻䚸

ྛ㛵㐃ᩥ᭩䛾୰䛷䚸ᑟධ䛻䛒䛯䛳䛶䛾ホ౯ 㡯┠䛸䛺䛳䛶䛔䜛㛵㐃グ㍕䛻䛴䛔䛶䜟䛛䜚 䜔䛩䛟᝟ሗⓎಙ䛩䜛䛣䛸䛜ᮃ䜎䛧䛔䚹

௒ᅇ䚸⡿ᅜ䞉ⱥᅜ䛾デ⒪䜺䜲䝗䝷䜲䞁䝕䞊䝍 䝧䞊䝇᳨⣴䛻䜘䜚䚸䜹䝔䝂䝸䞊᳨⣴ཬ䜃 Key

77

Word ᳨⣴䜢䛧䛯䛸䛣䜝䚸㧗㞴ᗘ᪂つ་⒪ᢏ

⾡䛻㛵䛩䜛ᣦ㔪䞉䜺䜲䝗䝷䜲䞁䛿 2 ௳䛧䛛ヱ ᙜ䛧䛺䛛䛳䛯䚹௚᪉䚸⡿ᅜᏛ఍䛾䝽䞊䜻䞁䜾 䜾 䝹 䞊 䝥 䛜 స ᡂ 䛧 䛶 䛔 䜛 䛂 A Consensus document on Robotic Surgery䛃䛿㧗㞴ᗘ᪂ つ་⒪ᢏ⾡䛾㛵㐃ᩥ᭩䛻ヱᙜ䛩䜛䛣䛸䛛䜙䚸 ᾏእ䛻䛚䛔䛶䜒䚸ಶูᏛ఍䛾ฟ䛧䛶䛔䜛㧗 㞴ᗘ᪂つ་⒪ᢏ⾡䛾㛵㐃ᩥ᭩䛜䚸බⓗᶵ 㛵䛜㐠Ⴀ䛩䜛デ⒪䜺䜲䝗䝷䜲䞁䛾䝕䞊䝍䝧䞊 䝇᳨⣴䛷䛿☜ㄆ䛷䛝䛪䚸ಶูᏛ఍䛾䝩䞊䝮 䝨䞊䝆➼䛻ᥖ㍕䛥䜜䛶䛔䜛ྍ⬟ᛶ䛿㧗䛔䚹

☜ㄆ䛥䜜䛯ᾏእ䜺䜲䝗䝷䜲䞁➼䛾ᑡᩘ౛䛷䛿䚸 䛂⾡⪅䛾せ௳䛃䚸䛂ᣦᑟయไ䛃䚸䛂䛭䛾䜋䛛་

⒪Ᏻ඲䛻㛵䛩䜛஦㡯䛃䚸䛂⑓㝔䛻䜘䜛஦๓ᑂ ᰝ䛃➼䛾グ㍕䛜ㄆ䜑䜙䜜䛶䛚䜚䚸ᾏእ䛻䛚䛔 䛶䜒䚸≉ᐃ䛾་⒪⾜Ⅽ䛻䛚䛔䛶䛿䚸Ꮫ఍䜔

⑓㝔䜢୰ᚰ䛸䛧䛶䚸㧗㞴ᗘ་⒪ᢏ⾡䛾ᥦ౪ 䛻䛒䛯䛳䛶䛿䚸୍ᐃ䛾┘ᰝ䝅䝇䝔䝮䜔᮲௳

䛾୰䛷⾜䜟䜜䛶䛔䜛䜒䛾䛸⪃䛘䜙䜜䛯䚹 䜎䛯䚸䝅䞁䜺䝫䞊䝹኱Ꮫ䛾እ⛉ᩍᤵ䛛䜙䛾

⪺䛝ྲྀ䜚ㄪᰝ䛻䜘䜚䚸ᾏእ䛻䛚䛔䛶䚸ᨻᗓ䝺 䝧䝹䛷㧗㞴ᗘ᪂つ་⒪ᢏ⾡䛻㛵䛩䜛ᑟධ 䝥䝻䝉䝇䛻䛴䛔䛶䚸⤫୍ⓗ䛺䝹䞊䝹䜢ㄢ䛧䛶 䛔䜛஦ᐇ䛿☜ㄆ䛷䛝䛺䛛䛳䛯䚹

௒ᅇ䚸ᅜෆእ䛾㧗㞴ᗘ་⒪ᢏ⾡䛻㛵䛩䜛 䜺䜲䝗䝷䜲䞁䜢ᩚ⌮䛩䜛䛣䛸䛻䜘䜚䚸௒ᚋ䜒་

⒪ᢏ⾡䛾㐍ᒎ䛻క䛔᪂䛯䛻Ꮫ఍䛷స䜙䜜䜛 㧗㞴ᗘ་⒪ᢏ⾡䜺䜲䝗䝷䜲䞁䛾㉁䛾ྥୖ䛻

㈨䛩䜛▱ぢ䜢ᚓ䜛䛣䛸䛜䛷䛝䛯䚹

䠡䠊⤖ㄽ

ᮏศᢸ◊✲⌜䛾ㄪᰝ⤖ᯝ䛻䜘䜚䚸ᅜෆእ䛾 㧗㞴ᗘ᪂つ་⒪ᢏ⾡䛻㛵䛩䜛䜺䜲䝗䝷䜲䞁

➼䛾ᐇែ䛜ᢕᥱ䛷䛝䛯䚹ᅜෆ䛾㧗㞴ᗘ་⒪

ᢏ⾡䛾㛵㐃ᩥ᭩䛻䛿䚸䛂䜺䜲䝗䝷䜲䞁䛃䛾䜋䛛䚸 䛂ᐇ᪋ᇶ‽䛃䚸䛂ᥦゝ䛃䛸䛔䛳䛯ྡ⛠䛾ᩥ᭩䜒 䛒䜚䚸䜎䛯䚸Ꮫ఍ဨ㝈ᐃ䛷බ㛤䛥䜜䛶䛔䜛ᩥ

᭩䜒䛒䛳䛯䚹ᾏእ䜺䜲䝗䝷䜲䞁䛾ㄪᰝ䛻䜘䜚䚸

≉ᐃ䛾་⒪ᢏ⾡䠄౛䛘䜀䝻䝪䝑䝖ᡭ⾡䠅䛻㛵 䛩䜛㛵㐃ᩥ᭩䛻䛴䛔䛶䚸⡿ᅜ䛷䛿Ꮫ఍䝺䝧

䝹䛷ᥦၐ䛩䜛ᣦ㔪䚸ⱥᅜ䛷䛿ᅜ❧ಖ೺་⒪

◊✲ᡤ䛜⟇ᐃ䛩䜛䜺䜲䝎䞁䝇䛜ᑡᩘ౛☜ㄆ 䛥䜜䛯䚹䜎䛯䚸ᮏศᢸ◊✲⌜䛜ㄪᰝ䛧䛯㝈䜚䚸 ᾏእ䛾⌧≧䛸䛧䛶䚸㧗㞴ᗘ᪂つ་⒪ᢏ⾡䛾 ᑟධ䛩䜛䛻䛒䛯䛳䛶ᨻᗓ䝺䝧䝹䛷ᐃ䜑䜛ໟ ᣓⓗ䛺ᣦ㔪䛿☜ㄆ䛷䛝䛺䛛䛳䛯䚹

௨ୖ䜢㋃䜎䛘䜛䛸䚸ᡃ䛜ᅜ䛻䛚䛔䛶㧗㞴ᗘ

་⒪᪂つ་⒪ᢏ⾡䛾ᑟධ䛻㛵䛩䜛䚸ᨻᗓ䝺 䝧䝹䛷䛾⤫୍ⓗ䛺䝹䞊䝹䜢ᐃ䜑䛯䛣䛸䛿䚸

኱ኚ᭷ព⩏䛷䛒䜚㠉᪂ⓗ䛺ྲྀ⤌䛸ゝ䛘䜛䚹㛵 㐃Ꮫ఍䜢୰ᚰ䛻䛥䜙䛻඘ᐇ䛧䛯㧗㞴ᗘ᪂つ

་⒪ᢏ⾡䛻㛵㐃䛩䜛䜺䜲䝗䝷䜲䞁➼䛾ᩚഛ ཬ䜃࿘▱䜢ᅗ䛳䛶䛔䛝䚸䜎䛯䚸་⒪ᶵ㛵䛻䛚 䛔䛶䛣䜜䜙䛾ไᗘ䜢㐺ṇ䛻㐠⏝䛩䜛䛣䛸䛻䜘 䜚䚸᪥ᮏ䛾་⒪䛾ྥୖ䛻ᐤ୚䛩䜛䛣䛸䛜ᮇᚅ 䛥䜜䜛䚹

䠢䠊◊✲Ⓨ⾲

ㅮ₇Ⓨ⾲䠖䛺䛧 ㄽᩥⓎ⾲䠖䛺䛧 Ꮫ఍Ⓨ⾲䠖䛺䛧

▱ⓗ㈈⏘ᶒ䛾ฟ㢪䞉Ⓩ㘓≧ἣ䠄ணᐃ䜢ྵ

䜐䚹䠅

1. ≉チྲྀᚓ䠖䛺䛧 2. ᐇ⏝᪂᱌Ⓩ㘓䠖䛺䛧 3.䛭䛾௚䠖≉䛻䛺䛧

78

߶ೋౕҫྏٗढ़Ͷؖ࿊ͤ Ζࠅ಼Ϊ ΢χϧ΢ϱ౵Ͷͯ͏ͱ͹௒ࠬ݃Վ

஭ʥԾى͹ชॽͺɼʰ߶ೋౕҫྏٗढ़ͶؖͤΖخຌద͵ߡ͓๏ʱΝࡨఈͤΖܨҤͲफॄ͠Ηͪؖ࿊ชॽͲ͍ΕɼຌΪ΢χϧ΢ϱ͹ଲেҫྏٗढ़͖ͫΔͳ͏ͮͱɼ߶ೋౕҫྏٗढ़Ͷ֚౲ͤΖΚ͜Ͳͺ͵͏ɽ 㻺㼛䜺䜲䝗䝷䜲䞁ྡᏛ఍⾡⪅䛾せ௳ᣦᑟయไ䛭䛾௚་⒪Ᏻ඲ 䛻㛵䛩䜛஦㡯㻵㻯䛻㛵䛩䜛 ஦㡯 㻝ෆど㙾ୗእ⛉ᡭ⾡᪋⾜䛻䛒䛯䛳䛶䛾䜺䜲䝗䝷䜲䞁᪥ᮏෆど㙾እ⛉Ꮫ఍ʕʕʷʷ 㻞ෆど㙾ᡭ⾡ᨭ᥼䝻䝪䝑䝖ᡭ⾡ᑟධ䛻㛵䛩䜛ᥦゝ᪥ᮏෆど㙾እ⛉Ꮫ఍ʕʕʕʷ 㻟᪂་⒪ᶵჾ䛻㛵䛩䜛ぢゎ㻔㻞㻜㻝㻞㻚㻝㻞㻚㻜㻢᭦᪂㻕᪥ᮏෆど㙾እ⛉Ꮫ఍ʖʷʷʷ 㻠᪥ᮏෆど㙾እ⛉Ꮫ఍䠄㻶㻿㻱㻿䠅䛾ෆど㙾ᡭ⾡ᨭ᥼䝻䝪䝑䝖ᑟධ᮲௳䛾㑂Ᏺႏ㉳᪥ᮏෆど㙾እ⛉Ꮫ఍ʖʷʷʷ 㻡⤒⓶ⓗ⤒⟶ⓗ⬻⾑ᰦᅇ཰ᶵჾ㻌㻌㐺ṇ౑⏝ᣦ㔪➨㻞∧䞉ᐇ᪋ᇶ‽᪥ᮏ⬻༞୰Ꮫ఍䚸᪥ᮏ⬻⚄⤒እ⛉Ꮫ఍䚸᪥ᮏ⬻⚄⤒⾑⟶ෆ἞⒪Ꮫ఍ʕʷʕʷ 㻢㢌⵹ෆື⬦䝇䝔䞁䝖䠄ື⬦◳໬⑕⏝䠅䚷㐺ṇ౑⏝ᣦ㔪䠄㻞㻜㻝㻟ᖺ㻝㻞᭶∧䠅᪥ᮏ⬻༞୰Ꮫ఍䚸᪥ᮏ⬻⚄⤒እ⛉Ꮫ఍䚸᪥ᮏ⬻⚄⤒⾑⟶ෆ἞⒪Ꮫ఍ʕʷʕʷ 㻣㢌⵹ෆື⬦䝇䝔䞁䝖䠄⬻ື⬦⒗἞⒪⏝㻲㼘㼛㼣㻌㻰㼕㼢㼑㼞㼠㼑㼞㻕㻌㐺ṇ౑⏝ᣦ㔪➨㻞∧䠄㻞㻜㻝㻡ᖺ㻠᭶∧䠅䞉ᐇ ᪋ᇶ‽᪥ᮏ⬻༞୰Ꮫ఍䚸᪥ᮏ⬻⚄⤒እ⛉Ꮫ఍䚸᪥ᮏ⬻⚄⤒⾑⟶ෆ἞⒪Ꮫ఍ʕʷʕʷ 㻤⬻⚄⤒㡿ᇦ་⒪ᶵჾ䛂䜶䞁䝪䝇䝣䜱䜰䛃ཬ䜃䛂䜈䝟䝇䝣䜱䜰䛃䛾㐺ṇ౑⏝䛻ಀ䜛యไ➼䛾せ௳᪥ᮏ⬻⚄⤒⾑⟶ෆ἞⒪Ꮫ఍䚸᪥ᮏ⬻⚄⤒እ⛉Ꮫ఍䚸᪥ᮏ䜲䞁䝍䞊䝧䞁䝅䝵䝘䝹䝷䝆䜸䝻䝆䞊䠄㻵㼂㻾䠅Ꮫ఍ʕʕʷʷ 㻥⤒䜹䝔䞊䝔䝹ⓗ኱ື⬦ᘚ⨨᥮⾡ᐇ᪋᪋タᇶ‽⤒䜹䝔䞊䝔䝹ⓗ኱ື⬦ᘚ⨨᥮⾡㛵㐃Ꮫ఍༠㆟఍ʕʕʕʷ 㻝㻜䝠䝖䠄⮬ᕫ䠅㦵᱁➽⏤᮶⣽⬊䝅䞊䝖౑⏝䛾᪋タᇶ‽䛚䜘䜃ᐇ᪋་ᇶ‽䝠䝖䠄⮬ᕫ䠅㦵᱁➽⏤᮶⣽⬊䝅䞊䝖㛵㐃Ꮫ఍༠㆟఍ʕʷʕʷ 㻝㻝᳜㎸ᆺ⿵ຓேᕤᚰ⮚ㄆᐃ᪋タ䞉་ᖌ᭦᪂ᇶ‽⿵ຓேᕤᚰ⮚἞⒪㛵㐃Ꮫ఍༠㆟఍ʕʕʕʖ 㻝㻞ᚰ⮚⛣᳜ᐇ᪋᪋タㄆᐃᇶ‽ᚰ⮚⛣᳜㛵㐃Ꮫ఍༠㆟఍ʕʕʕʕ 㻝㻟⬚㒊኱ື⬦⒗䝇䝔䞁䝖䜾䝷䝣䝖ᐇ᪋ᇶ‽᪥ᮏ䝇䝔䞁䝖䜾䝷䝣䝖ᐇ᪋ᇶ‽⟶⌮ጤဨ఍ʕʕʕʖ 㻝㻠㻠Ꮫ఍఍ဨ䜈䛾ὀពႏ㉳䠄ᖹᡂ㻞㻢ᖺ㻝㻝᭶㻝㻣᪥䠅᪥ᮏෆど㙾እ⛉Ꮫ఍䚸᪥ᮏ⫢⫹⮅እ⛉Ꮫ఍䚸᪥ᮏᾘ໬ჾእ⛉Ꮫ఍䚸᪥ᮏእ⛉Ꮫ఍ʖʷʷʕ 㻝㻡䛶䜣䛛䜣䛻ᑐ䛩䜛㏞㉮⚄⤒่⃭⒪ἲ䛾ᐇ᪋䜺䜲䝗䝷䜲䞁᪥ᮏ䛶䜣䛛䜣Ꮫ఍ʕʕʷʷ 㻝㻢䛶䜣䛛䜣እ⛉䛾㐺ᛂ䛻㛵䛩䜛ᣦ㔪᪥ᮏ䛶䜣䛛䜣Ꮫ఍ʖʷʷʷ 㻝㻣ෆഃഃ㢌ⴥ䛶䜣䛛䜣䛾デ᩿䛸ᡭ⾡㐺ᛂ䛻㛵䛩䜛䜺䜲䝗䝷䜲䞁᪥ᮏ䛶䜣䛛䜣Ꮫ఍ʖʷʷʷ 㻝㻤᪂⓶㉁䛶䜣䛛䜣䛾እ⛉἞⒪䜺䜲䝗䝷䜲䞁᪥ᮏ䛶䜣䛛䜣Ꮫ఍ʖʷʷʷ 㻝㻥⬻⭘⒆デ⒪䜺䜲䝗䝷䜲䞁๓ᩥ㻞㻜㻝㻡∧᪥ᮏ⬻⭘⒆Ꮫ఍ʖʷʷʷ 㻞㻜⬻⭘⒆デ⒪䜺䜲䝗䝷䜲䞁䠖୰ᯡ⚄⤒⣔ཎⓎᝏᛶ䝸䞁䝟⭘᪥ᮏ⬻⭘⒆Ꮫ఍ʖʷʷʷ 㻞㻝Ἢᒀჾ⭡⭍㙾ᡭ⾡䜺䜲䝗䝷䜲䞁㻞㻜㻝㻠ᖺ∧᪥ᮏἪᒀჾෆど㙾Ꮫ఍ʷʷʷ 㻞㻞Ἢᒀჾ⛉㡿ᇦ䛻䛚䛡䜛㻌㼐㼍㻌㼂㼕㼚㼏㼕㻌ᨭ᥼ᡭ⾡䜢⾜䛖䛻ᙜ䛯䛳䛶䛾䜺䜲䝗䝷䜲䞁᪥ᮏἪᒀჾ⛉Ꮫ఍㻌᪥ᮏἪᒀჾෆど㙾Ꮫ఍ʕʕʕʕ 㻞㻟፬ே⛉ᝏᛶ⭘⒆䛻ᑐ䛩䜛䝻䝪䝑䝖ᨭ᥼ୗᡭ⾡䛻㛵䛩䜛ᣦ㔪᪥ᮏ⏘⛉፬ே⛉Ꮫ఍ʕʕʕʕ 㻞㻠ຍ㱋㯤ᩬኚᛶ⑕䛻ᑐ䛩䜛ග⥺ຊᏛⓗ⒪ἲ䛾䜺䜲䝗䝷䜲䞁᪥ᮏ║⛉Ꮫ఍ʕʕ 㻞㻡ⓑෆ㞀ᡭ⾡ే⏝║ෆ䝗䝺䞊䞁౑⏝せ௳➼ᇶ‽᪥ᮏ║⛉Ꮫ఍ʕʷ 㻞㻢ᒅᢡ▹ṇᡭ⾡䛾䜺䜲䝗䝷䜲䞁᪥ᮏ║⛉Ꮫ఍ʕʕ 㻞㻣Ỉᬗయ㻌ᣑᙇ䝸䞁䜾౑⏝䜺䜲䝗䝷䜲䞁᪥ᮏ║⛉Ꮫ఍ʕʕ 㻞㻤⏘፬ே⛉ෆど㙾ᡭ⾡䜺䜲䝗䝷䜲䞁᪥ᮏ⏘፬ே⛉Ꮫ఍ʕʕʕ 㻞㻥ぬ㓰ୗ⬻ᡭ⾡᪋タㄆᐃไᗘ㻌ᣦ㔪᪥ᮏ⬻⚄⤒እ⛉Ꮫ఍ʕʷʕʷ 㻟㻜యእᚠ⎔䛻䜘䜛᪂⏕ඣᛴᛶ⾑ᾮί໬⒪ἲ䜺䜲䝗䝷䜲䞁᪥ᮏᑠඣ⛉Ꮫ఍ʕ 㻟㻝ඛኳᛶ䛚䜘䜃ᑠඣᮇⓎ⑕ᚰ⑌ᝈ䛻ᑐ䛩䜛䜹䝔䞊䝔䝹἞⒪䛾㐺ᛂ䜺䜲䝗䝷䜲䞁᪥ᮏᑠඣ⛉Ꮫ఍ʕʷ 㻟㻞ඛኳᛶᚰ⑌ᝈ䚸ᚰ⮚኱⾑⟶䛾ᵓ㐀ⓗ⑌ᝈ䠄㼟㼠㼞㼡㼏㼠㼡㼞㼍㼘㻌㼔㼑㼍㼞㼠㻌㼐㼕㼟㼑㼍㼟㼑䠅䛻ᑐ䛩䜛䜹䝔䞊䝔䝹἞ ⒪䛾䜺䜲䝗䝷䜲䞁᪥ᮏᑠඣ⛉Ꮫ఍ʕʕʕ ˠ৏ى͹Ϊ΢χϧ΢ϱͺɼ೧݆̑ݳࡑͶͱ:HE৏Ͷͱޮ֋͠Ηͱ͏ͪΪ΢χϧ΢ϱ

ˠʰढ़ं͹གྷ݇ʱɼʰࢨ಍ର੏ʱɼʰͨ͹ଠҫྏ҈સͶؖͤΖߡ͓๏ʱͶͯ͏ͱͺɼ޲ਫ਼࿓ಉ঴ಝพݜڂൟʤᅵౖൟʥʰ߶ೋౕ৿وҫྏٗढ़͹಍೘Ͷ౲ͪͮͱ͹خຌద͵ߡ͓๏ʱ͹ىࡎͶ૮౲ͤΖ΍͹͹༙ໃͲ൓இ͢ͱ ͏Ζɽ

㈨ᩱ

79

㻺㼍㼠㼕㼛㼚㼍㼘㻌㻳㼡㼕㼐㼑㼘㼕㼚㼑㻌㻯㼘㼑㼍㼞㼕㼚㼓㼔㼛㼡㼟㼑䛻䛚䛡䜛እ⛉㛵㐃䛾デ⒪䜺䜲䝗䝷䜲䞁

䠄ᥖ㍕ᇶ‽䛻ྜ⮴䛩䜛䜒䛾䛾䜏䠅

㻺㼛 㻼㼡㼎㼘㼕㼟㼔

㼅㼑㼍㼞 㼀㼕㼠㼘㼑㻌㼛㼒㻌㻯㻼㻳

㻝 㻞㻜㻝㻢㻚㻟

㻼㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㼟㻌㼒㼛㼞㻌㼠㼔㼑㻌㼜㼞㼑㼢㼑㼚㼠㼕㼛㼚㻘㻌㼐㼑㼠㼑㼏㼠㼕㼛㼚㻘㻌㼍㼚㼐㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼞㼑㼟㼜㼕㼞㼍㼠㼛㼞㼥㻌㼐㼑㼜㼞㼑㼟㼟㼕㼛㼚 㼍㼟㼟㼛㼏㼕㼍㼠㼑㼐㻌㼣㼕㼠㼔㻌㼚㼑㼡㼞㼍㼤㼕㼍㼘㻌㼛㼜㼕㼛㼕㼐㻌㼍㼐㼙㼕㼚㼕㼟㼠㼞㼍㼠㼕㼛㼚㻦㻌㼍㼚㻌㼡㼜㼐㼍㼠㼑㼐㻌㼞㼑㼜㼛㼞㼠㻌㼎㼥㻌㼠㼔㼑㻌㻭㼙㼑㼞㼕㼏㼍㼚㻌㻿㼛㼏㼕㼑㼠㼥㻌㼛㼒 㻭㼚㼑㼟㼠㼔㼑㼟㼕㼛㼘㼛㼓㼕㼟㼠㼟㻌㼀㼍㼟㼗㻌㻲㼛㼞㼏㼑㻌㼛㼚㻌㻺㼑㼡㼞㼍㼤㼕㼍㼘㻌㻻㼜㼕㼛㼕㼐㼟㻌㼍㼚㼐㻌㼠㼔㼑㻌㻭㼙㼑㼞㼕㼏㼍㼚㻌㻿㼛㼏㼕㼑㼠㼥㻌㼛㼒㻌㻾㼑㼓㼕㼛㼚㼍㼘 㻭㼚㼑㼟㼠㼔㼑㼟㼕㼍㻌㼍㼚㼐㻌㻼㼍㼕㼚㻌㻹㼑㼐㼕㼏㼕㼚㼑㻚

㻞 㻞㻜㻝㻢㻚㻟 㻳㼡㼕㼐㼑㼘㼕㼚㼑㻌㼒㼛㼞㻌㼜㼞㼑㼢㼑㼚㼠㼕㼛㼚㻌㼛㼒㻌㼞㼑㼠㼍㼕㼚㼑㼐㻌㼟㼡㼞㼓㼕㼏㼍㼘㻌㼕㼠㼑㼙㼟㻚

㻟 㻞㻜㻝㻢㻚㻝 㻳㼡㼕㼐㼑㼘㼕㼚㼑㻌㼒㼛㼞㻌㼏㼍㼞㼑㻌㼛㼒㻌㼠㼔㼑㻌㼜㼍㼠㼕㼑㼚㼠㻌㼞㼑㼏㼑㼕㼢㼕㼚㼓㻌㼙㼛㼐㼑㼞㼍㼠㼑㻌㼟㼑㼐㼍㼠㼕㼛㼚㻛㼍㼚㼍㼘㼓㼑㼟㼕㼍㻚 㻠 㻞㻜㻝㻡㻚㻝㻝 㻮㼘㼛㼛㼐㻌㼠㼞㼍㼚㼟㼒㼡㼟㼕㼛㼚㻚

㻡 㻞㻜㻝㻡㻚㻝㻝 㻳㼡㼕㼐㼑㼘㼕㼚㼑㻌㼒㼛㼞㻌㼜㼞㼑㼢㼑㼚㼠㼕㼛㼚㻌㼛㼒㻌㼡㼚㼜㼘㼍㼚㼚㼑㼐㻌㼜㼍㼠㼕㼑㼚㼠㻌㼔㼥㼜㼛㼠㼔㼑㼞㼙㼕㼍㻚 㻢 㻞㻜㻝㻡㻚㻥

㻼㼞㼛㼜㼔㼥㼘㼍㼤㼕㼟㻌㼍㼓㼍㼕㼚㼟㼠㻌㼕㼚㼒㼑㼏㼠㼕㼢㼑㻌㼑㼚㼐㼛㼏㼍㼞㼐㼕㼠㼕㼟㻦㻌㼍㼚㼠㼕㼙㼕㼏㼞㼛㼎㼕㼍㼘㻌㼜㼞㼛㼜㼔㼥㼘㼍㼤㼕㼟㻌㼍㼓㼍㼕㼚㼟㼠㻌㼕㼚㼒㼑㼏㼠㼕㼢㼑㻌㼑㼚㼐㼛㼏㼍㼞㼐㼕㼠㼕㼟 㼕㼚㻌㼍㼐㼡㼘㼠㼟㻌㼍㼚㼐㻌㼏㼔㼕㼘㼐㼞㼑㼚㻌㼡㼚㼐㼑㼞㼓㼛㼕㼚㼓㻌㼕㼚㼠㼑㼞㼢㼑㼚㼠㼕㼛㼚㼍㼘

㼜㼞㼛㼏㼑㼐㼡㼞㼑㼟㻚

㻣 㻞㻜㻝㻡㻚㻤 㼀㼞㼑㼍㼠㼙㼑㼚㼠㻌㼛㼒㻌㻯㼡㼟㼔㼕㼚㼓㻓㼟㻌㼟㼥㼚㼐㼞㼛㼙㼑㻦㻌㼍㼚㻌㻱㼚㼐㼛㼏㼞㼕㼚㼑㻌㻿㼛㼏㼕㼑㼠㼥㻌㼏㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻚 㻤 㻞㻜㻝㻡㻚㻣 㻱㼢㼑㼞㼛㼘㼕㼙㼡㼟㻌㼒㼛㼞㻌㼜㼞㼑㼢㼑㼚㼠㼕㼚㼓㻌㼛㼞㼓㼍㼚㻌㼞㼑㼖㼑㼏㼠㼕㼛㼚㻌㼕㼚㻌㼘㼕㼢㼑㼞㻌㼠㼞㼍㼚㼟㼜㼘㼍㼚㼠㼍㼠㼕㼛㼚㻚

㻥 㻞㻜㻝㻡㻚㻣 㻹㼑㼞㼗㼑㼘㻌㼏㼑㼘㼘㻌㼏㼍㼞㼏㼕㼚㼛㼙㼍㻚

㻝㻜 㻞㻜㻝㻡㻚㻢 㻸㼛㼣㼑㼞㻌㼡㼞㼕㼚㼍㼞㼥㻌㼠㼞㼍㼏㼠㻌㼟㼥㼙㼜㼠㼛㼙㼟㻌㼕㼚㻌㼙㼑㼚㻦㻌㼍㼟㼟㼑㼟㼟㼙㼑㼚㼠㻌㼍㼚㼐㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻚 㻝㻝 㻞㻜㻝㻡㻚㻢 㼂㼑㼚㼛㼡㼟㻌㼠㼔㼞㼛㼙㼎㼛㼑㼙㼎㼛㼘㼕㼟㼙㻌㼕㼚㻌㼍㼐㼡㼘㼠㼟㻌㼍㼐㼙㼕㼠㼠㼑㼐㻌㼠㼛㻌㼔㼛㼟㼜㼕㼠㼍㼘㻦㻌㼞㼑㼐㼡㼏㼕㼚㼓㻌㼠㼔㼑㻌㼞㼕㼟㼗㻚 㻝㻞 㻞㻜㻝㻡㻚㻟

㻿㼛㼏㼕㼑㼠㼥㻌㼒㼛㼞㻌㼂㼍㼟㼏㼡㼘㼍㼞㻌㻿㼡㼞㼓㼑㼞㼥㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㼟㻌㼒㼛㼞㻌㼍㼠㼔㼑㼞㼛㼟㼏㼘㼑㼞㼛㼠㼕㼏㻌㼛㼏㼏㼘㼡㼟㼕㼢㼑㻌㼐㼕㼟㼑㼍㼟㼑㻌㼛㼒㻌㼠㼔㼑㻌㼘㼛㼣㼑㼞 㼑㼤㼠㼞㼑㼙㼕㼠㼕㼑㼟㻦㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼍㼟㼥㼙㼜㼠㼛㼙㼍㼠㼕㼏

㼐㼕㼟㼑㼍㼟㼑㻌㼍㼚㼐㻌㼏㼘㼍㼡㼐㼕㼏㼍㼠㼕㼛㼚㻚

㻝㻟 㻞㻜㻝㻡㻚㻞 㻮㼘㼍㼐㼐㼑㼞㻌㼏㼍㼚㼏㼑㼞㻦㻌㼐㼕㼍㼓㼚㼛㼟㼕㼟㻌㼍㼚㼐㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻚

㻝㻠 㻞㻜㻝㻡㻚㻞 㻼㼘㼍㼠㼑㼘㼑㼠㻌㼠㼞㼍㼚㼟㼒㼡㼟㼕㼛㼚㻦㻌㼍㻌㼏㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻌㼒㼞㼛㼙㻌㼠㼔㼑㻌㻭㻭㻮㻮㻚 㻝㻡 㻞㻜㻝㻡㻚㻞

㻼㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㼟㻌㼒㼛㼞㻌㼜㼑㼞㼕㼛㼜㼑㼞㼍㼠㼕㼢㼑㻌㼎㼘㼛㼛㼐㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻦㻌㼍㼚㻌㼡㼜㼐㼍㼠㼑㼐㻌㼞㼑㼜㼛㼞㼠㻌㼎㼥㻌㼠㼔㼑㻌㻭㼙㼑㼞㼕㼏㼍㼚 㻿㼛㼏㼕㼑㼠㼥㻌㼛㼒㻌㻭㼚㼑㼟㼠㼔㼑㼟㼕㼛㼘㼛㼓㼕㼟㼠㼟㻌㼀㼍㼟㼗㻌㻲㼛㼞㼏㼑㻌㼛㼚

㻼㼑㼞㼕㼛㼜㼑㼞㼍㼠㼕㼢㼑㻌㻮㼘㼛㼛㼐㻌㻹㼍㼚㼍㼓㼑㼙㼑㼚㼠㻚

㻝㻢 㻞㻜㻝㻡㻚㻝 㻳㼍㼟㼠㼞㼛㻙㼛㼑㼟㼛㼜㼔㼍㼓㼑㼍㼘㻌㼞㼑㼒㼘㼡㼤㻌㼐㼕㼟㼑㼍㼟㼑㻦㻌㼞㼑㼏㼛㼓㼚㼕㼠㼕㼛㼚㻘㻌㼐㼕㼍㼓㼚㼛㼟㼕㼟㻌㼍㼚㼐㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼕㼚㻌㼏㼔㼕㼘㼐㼞㼑㼚㻌㼍㼚㼐㻌㼥㼛㼡㼚㼓 㼜㼑㼛㼜㼘㼑㻚

㻝㻣 㻞㻜㻝㻡㻚㻠 㻼㼑㼥㼞㼛㼚㼕㼑㻓㼟㻌㼐㼕㼟㼑㼍㼟㼑㻦㻌㻭㼁㻭㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻚

㻝㻤 㻞㻜㻝㻠 㻳㼡㼕㼐㼑㼘㼕㼚㼑㻌㼒㼛㼞㻌㼍㼡㼠㼛㼘㼛㼓㼛㼡㼟㻌㼠㼕㼟㼟㼡㼑㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻚

㻝㻥 㻞㻜㻝㻡 㻭㻯㻾㻌㻭㼜㼜㼞㼛㼜㼞㼕㼍㼠㼑㼚㼑㼟㼟㻌㻯㼞㼕㼠㼑㼞㼕㼍㼹㻌㼞㼍㼐㼕㼛㼘㼛㼓㼕㼏㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼔㼑㼜㼍㼠㼕㼏㻌㼙㼍㼘㼕㼓㼚㼍㼚㼏㼥㻚

㻞㻜 㻞㻜㻝㻡㻚㻝 㻭㼙㼑㼞㼕㼏㼍㼚㻌㻳㼑㼞㼕㼍㼠㼞㼕㼏㼟㻌㻿㼛㼏㼕㼑㼠㼥㻌㼍㼎㼟㼠㼞㼍㼏㼠㼑㼐㻌㼏㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻌㼒㼛㼞㻌㼜㼛㼟㼠㼛㼜㼑㼞㼍㼠㼕㼢㼑㻌㼐㼑㼘㼕㼞㼕㼡㼙㻌㼕㼚 㼛㼘㼐㼑㼞㻌㼍㼐㼡㼘㼠㼟㻚

㻞㻝 㻞㻜㻝㻡 㻭㻯㻾㻌㻭㼜㼜㼞㼛㼜㼞㼕㼍㼠㼑㼚㼑㼟㼟㻌㻯㼞㼕㼠㼑㼞㼕㼍㼹㻌㼞㼛㼡㼠㼕㼚㼑㻌㼏㼔㼑㼟㼠㻌㼞㼍㼐㼕㼛㼓㼞㼍㼜㼔㼥㻚

㻞㻞 㻞㻜㻝㻠㻚㻝㻞 㻵㼚㼠㼞㼍㼜㼍㼞㼠㼡㼙㻌㼏㼍㼞㼑㻦㻌㼏㼍㼞㼑㻌㼛㼒㻌㼔㼑㼍㼘㼠㼔㼥㻌㼣㼛㼙㼑㼚㻌㼍㼚㼐㻌㼠㼔㼑㼕㼞㻌㼎㼍㼎㼕㼑㼟㻌㼐㼡㼞㼕㼚㼓㻌㼏㼔㼕㼘㼐㼎㼕㼞㼠㼔㻚 㻞㻟 㻞㻜㻝㻠㻚㻝㻝 㻭㼏㼞㼛㼙㼑㼓㼍㼘㼥㻦㻌㼍㼚㻌㻱㼚㼐㼛㼏㼞㼕㼚㼑㻌㻿㼛㼏㼕㼑㼠㼥㻌㼏㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻚

㻞㻠 㻞㻜㻝㻠㻚㻝㻝

㻞㻡 㻞㻜㻝㻠 㻳㼡㼕㼐㼑㼘㼕㼚㼑㻌㼒㼛㼞㻌㼜㼞㼑㼛㼜㼑㼞㼍㼠㼕㼢㼑㻌㼜㼍㼠㼕㼑㼚㼠㻌㼟㼗㼕㼚㻌㼍㼚㼠㼕㼟㼑㼜㼟㼕㼟㻚 㻞㻢 㻞㻜㻝㻠㻚㻥 㻻㼜㼠㼕㼙㼍㼘㻌㼟㼥㼟㼠㼑㼙㼕㼏㻌㼠㼔㼑㼞㼍㼜㼥㻌㼒㼛㼞㻌㼑㼍㼞㼘㼥㻌㼒㼑㼙㼍㼘㼑㻌㼎㼞㼑㼍㼟㼠㻌㼏㼍㼚㼏㼑㼞㻚 㻞㻣 㻞㻜㻝㻠㻚㻥 㻸㼛㼏㼛㼞㼑㼓㼕㼛㼚㼍㼘㻌㼠㼔㼑㼞㼍㼜㼥㻌㼛㼒㻌㼘㼛㼏㼍㼘㼘㼥㻌㼍㼐㼢㼍㼚㼏㼑㼐㻌㼎㼞㼑㼍㼟㼠㻌㼏㼍㼚㼏㼑㼞㻌㻔㻸㻭㻮㻯㻕㻚 㻞㻤 㻞㻜㻝㻠㻚㻥

㻰㼥㼟㼜㼑㼜㼟㼕㼍㻌㼍㼚㼐㻌㼓㼍㼟㼠㼞㼛㻙㼛㼑㼟㼛㼜㼔㼍㼓㼑㼍㼘㻌㼞㼑㼒㼘㼡㼤㻌㼐㼕㼟㼑㼍㼟㼑㻚㻌㻵㼚㼢㼑㼟㼠㼕㼓㼍㼠㼕㼛㼚㻌㼍㼚㼐㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼐㼥㼟㼜㼑㼜㼟㼕㼍㻘 㼟㼥㼙㼜㼠㼛㼙㼟㻌㼟㼡㼓㼓㼑㼟㼠㼕㼢㼑㻌㼛㼒㻌㼓㼍㼟㼠㼞㼛㻙㼛㼑㼟㼛㼜㼔㼍㼓㼑㼍㼘㻌㼞㼑㼒㼘㼡㼤

㼐㼕㼟㼑㼍㼟㼑㻘㻌㼛㼞㻌㼎㼛㼠㼔㻚

㻞㻥 㻞㻜㻝㻠㻚㻥 㻰㼞㼡㼓㻌㼍㼘㼘㼑㼞㼓㼥㻦㻌㼐㼕㼍㼓㼚㼛㼟㼕㼟㻌㼍㼚㼐㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼐㼞㼡㼓㻌㼍㼘㼘㼑㼞㼓㼥㻌㼕㼚㻌㼍㼐㼡㼘㼠㼟㻘㻌㼏㼔㼕㼘㼐㼞㼑㼚㻌㼍㼚㼐㻌㼥㼛㼡㼚㼓㻌㼜㼑㼛㼜㼘㼑㻚 㻟㻜 㻞㻜㻝㻠㻚㻤 㻹㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼢㼑㼚㼛㼡㼟㻌㼘㼑㼓㻌㼡㼘㼏㼑㼞㼟㻦㻌㼏㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㼟㻌㼛㼒㻌㼠㼔㼑㻌㻿㼛㼏㼕㼑㼠㼥㻌㼒㼛㼞㻌㼂㼍㼟㼏㼡㼘㼍㼞㻌㻿㼡㼞㼓㼑㼞㼥

㼍㼚㼐㻌㼠㼔㼑㻌㻭㼙㼑㼞㼕㼏㼍㼚㻌㼂㼑㼚㼛㼡㼟㻌㻲㼛㼞㼡㼙㻚 㻟㻝 㻞㻜㻝㻠㻚㻣

㻿㼥㼟㼠㼑㼙㼕㼏㻌㼠㼔㼑㼞㼍㼜㼥㻌㼒㼛㼞㻌㼜㼍㼠㼕㼑㼚㼠㼟㻌㼣㼕㼠㼔㻌㼍㼐㼢㼍㼚㼏㼑㼐㻌㼔㼡㼙㼍㼚㻌㼑㼜㼕㼐㼑㼞㼙㼍㼘㻌㼓㼞㼛㼣㼠㼔㻌㼒㼍㼏㼠㼛㼞㻌㼞㼑㼏㼑㼜㼠㼛㼞㻌㻞㻙㼜㼛㼟㼕㼠㼕㼢㼑 㼎㼞㼑㼍㼟㼠㻌㼏㼍㼚㼏㼑㼞㻦㻌㻭㼙㼑㼞㼕㼏㼍㼚㻌㻿㼛㼏㼕㼑㼠㼥㻌㼛㼒㻌㻯㼘㼕㼚㼕㼏㼍㼘

㻻㼚㼏㼛㼘㼛㼓㼥㻌㼏㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻚

㻟㻞 㻞㻜㻝㻠㻚㻣

㻞㻜㻝㻟㻌㻭㻴㻭㻛㻭㻯㻯㻛㼀㻻㻿㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻌㼒㼛㼞㻌㼠㼔㼑㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼛㼢㼑㼞㼣㼑㼕㼓㼔㼠㻌㼍㼚㼐㻌㼛㼎㼑㼟㼕㼠㼥㻌㼕㼚㻌㼍㼐㼡㼘㼠㼟㻦㻌㼍㻌㼞㼑㼜㼛㼞㼠 㼛㼒㻌㼠㼔㼑㻌㻭㼙㼑㼞㼕㼏㼍㼚㻌㻯㼛㼘㼘㼑㼓㼑㻌㼛㼒

㻯㼍㼞㼐㼕㼛㼘㼛㼓㼥㻛㻭㼙㼑㼞㼕㼏㼍㼚㻌㻴㼑㼍㼞㼠㻌㻭㼟㼟㼛㼏㼕㼍㼠㼕㼛㼚㻌㼀㼍㼟㼗㻌㻲㼛㼞㼏㼑㻌㼛㼚㻌㻼㼞㼍㼏㼠㼕㼏㼑㻌㻳㼡㼕㼐㼑㼘㼕㼚㼑㼟㻌㼍㼚㼐㻌㼀㼔㼑㻌㻻㼎㼑㼟㼕㼠㼥 㻿㼛㼏㼕㼑㼠㼥㻚

㻟㻟 㻞㻜㻝㻠㻚㻢 㻼㼔㼑㼛㼏㼔㼞㼛㼙㼛㼏㼥㼠㼛㼙㼍㻌㼍㼚㼐㻌㼜㼍㼞㼍㼓㼍㼚㼓㼘㼕㼛㼙㼍㻦㻌㼍㼚㻌㻱㼚㼐㼛㼏㼞㼕㼚㼑㻌㻿㼛㼏㼕㼑㼠㼥㻌㼏㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻚 㻟㻠 㻞㻜㻝㻠㻚㻢 㻳㼡㼕㼐㼑㼘㼕㼚㼑㼟㻌㼒㼛㼞㻌㼘㼍㼜㼍㼞㼛㼟㼏㼛㼜㼕㼏㻌㼜㼑㼞㼕㼠㼛㼚㼑㼍㼘㻌㼐㼕㼍㼘㼥㼟㼕㼟㻌㼍㼏㼏㼑㼟㼟㻌㼟㼡㼞㼓㼑㼞㼥㻚

㻟㻡 㻞㻜㻝㻠㻚㻢 㻹㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼜㼞㼕㼙㼍㼞㼥㻌㼏㼡㼠㼍㼚㼑㼛㼡㼟㻌㼟㼝㼡㼍㼙㼛㼡㼟㻌㼏㼑㼘㼘㻌㼏㼍㼞㼏㼕㼚㼛㼙㼍㻚㻌㻭㻌㼚㼍㼠㼕㼛㼚㼍㼘㻌㼏㼘㼕㼚㼕㼏㼍㼘㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻚 㻟㻢 㻞㻜㻝㻠㻚㻢

㼀㼕㼙㼕㼚㼓㻌㼍㼚㼐㻌㼠㼥㼜㼑㻌㼛㼒㻌㼟㼡㼞㼓㼕㼏㼍㼘㻌㼠㼞㼑㼍㼠㼙㼑㼚㼠㻌㼛㼒㻌㻯㼘㼛㼟㼠㼞㼕㼐㼕㼡㼙㻌㼐㼕㼒㼒㼕㼏㼕㼘㼑㻙㼍㼟㼟㼛㼏㼕㼍㼠㼑㼐㻌㼐㼕㼟㼑㼍㼟㼑㻦㻌㼍㻌㼜㼞㼍㼏㼠㼕㼏㼑 㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻌㼒㼞㼛㼙㻌㼠㼔㼑㻌㻱㼍㼟㼠㼑㼞㼚㻌㻭㼟㼟㼛㼏㼕㼍㼠㼕㼛㼚

㼒㼛㼞㻌㼠㼔㼑㻌㻿㼡㼞㼓㼑㼞㼥㻌㼛㼒㻌㼀㼞㼍㼡㼙㼍㻚

㻟㻣 㻞㻜㻝㻠㻚㻡 㻿㼑㼚㼠㼕㼚㼑㼘㻌㼘㼥㼙㼜㼔㻌㼚㼛㼐㼑㻌㼎㼕㼛㼜㼟㼥㻌㼒㼛㼞㻌㼜㼍㼠㼕㼑㼚㼠㼟㻌㼣㼕㼠㼔㻌㼑㼍㼞㼘㼥㻙㼟㼠㼍㼓㼑㻌㼎㼞㼑㼍㼟㼠㻌㼏㼍㼚㼏㼑㼞㻦㻌㻭㼙㼑㼞㼕㼏㼍㼚㻌㻿㼛㼏㼕㼑㼠㼥㻌㼛㼒 㻯㼘㼕㼚㼕㼏㼍㼘㻌㻻㼚㼏㼛㼘㼛㼓㼥㻌㼏㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻌㼡㼜㼐㼍㼠㼑㻚

㻟㻤 㻞㻜㻝㻠㻚㻠 㻯㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻌㼛㼚㻌㼐㼕㼍㼓㼚㼛㼟㼕㼟㻌㼍㼚㼐㻌㼠㼞㼑㼍㼠㼙㼑㼚㼠㻌㼛㼒㻌㼔㼥㼜㼛㼚㼍㼠㼞㼍㼑㼙㼕㼍㻚 㻟㻥 㻞㻜㻝㻠㻚㻠 㻼㼞㼑㼟㼟㼡㼞㼑㻌㼡㼘㼏㼑㼞㼟㻦㻌㼜㼞㼑㼢㼑㼚㼠㼕㼛㼚㻌㼍㼚㼐㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼜㼞㼑㼟㼟㼡㼞㼑㻌㼡㼘㼏㼑㼞㼟㻚 㻠㻜 㻞㻜㻝㻠㻚㻟 㻹㼑㼐㼕㼏㼍㼘㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼗㼕㼐㼚㼑㼥㻌㼟㼠㼛㼚㼑㼟㻦㻌㻭㼁㻭㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻚

㈨ᩱ

80

㻺㼍㼠㼕㼛㼚㼍㼘㻌㻳㼡㼕㼐㼑㼘㼕㼚㼑㻌㻯㼘㼑㼍㼞㼕㼚㼓㼔㼛㼡㼟㼑䛻䛚䛡䜛እ⛉㛵㐃䛾デ⒪䜺䜲䝗䝷䜲䞁

䠄ᥖ㍕ᇶ‽䛻ྜ⮴䛩䜛䜒䛾䛾䜏䠅 㻠㻝 㻞㻜㻝㻠㻚㻞 㻯㼑㼞㼢㼕㼏㼍㼘㻌㼟㼜㼕㼚㼑㻌㼕㼚㼖㼡㼞㼥㻌㼙㼑㼐㼕㼏㼍㼘㻌㼠㼞㼑㼍㼠㼙㼑㼚㼠㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㼟㻚

㻠㻞 㻞㻜㻝㻠㻚㻞 㻸㼛㼣㻌㼎㼍㼏㼗㻌㼜㼍㼕㼚㻌㼙㼑㼐㼕㼏㼍㼘㻌㼠㼞㼑㼍㼠㼙㼑㼚㼠㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㼟㻚

㻠㻟 㻞㻜㻝㻠㻚㻞 㼀㼛㼠㼍㼘㻌㼔㼕㼜㻌㼞㼑㼜㼘㼍㼏㼑㼙㼑㼚㼠㻌㼍㼚㼐㻌㼞㼑㼟㼡㼞㼒㼍㼏㼕㼚㼓㻌㼍㼞㼠㼔㼞㼛㼜㼘㼍㼟㼠㼥㻌㼒㼛㼞㻌㼑㼚㼐㻙㼟㼠㼍㼓㼑㻌㼍㼞㼠㼔㼞㼕㼠㼕㼟㻌㼛㼒㻌㼠㼔㼑㻌㼔㼕㼜㻌㻔㼞㼑㼢㼕㼑㼣㻌㼛㼒 㼠㼑㼏㼔㼚㼛㼘㼛㼓㼥㻌㼍㼜㼜㼞㼍㼕㼟㼍㼘㻌㼓㼡㼕㼐㼍㼚㼏㼑㻌㻞㻌㼍㼚㼐㻌㻠㻠㻕㻚

㻠㻠 㻞㻜㻝㻠 㻳㼡㼕㼐㼑㼘㼕㼚㼑㻌㼒㼛㼞㻌㼏㼍㼞㼑㻌㼛㼒㻌㼠㼔㼑㻌㼜㼍㼠㼕㼑㼚㼠㻌㼞㼑㼏㼑㼕㼢㼕㼚㼓㻌㼘㼛㼏㼍㼘㻌㼍㼚㼑㼟㼠㼔㼑㼟㼕㼍㻚

㻠㻡 㻞㻜㻝㻠 㻵㼚㼠㼑㼞㼢㼑㼚㼠㼕㼛㼚㼟㻌㼒㼛㼞㻌㼜㼞㼑㼢㼑㼚㼠㼕㼛㼚㻌㼍㼚㼐㻌㼠㼞㼑㼍㼠㼙㼑㼚㼠㻌㼛㼒㻌㼜㼞㼑㼟㼟㼡㼞㼑㻌㼡㼘㼏㼑㼞㼟㻚㻌㻵㼚㻦㻌㻼㼞㼑㼢㼑㼚㼠㼕㼛㼚㻌㼍㼚㼐㻌㼠㼞㼑㼍㼠㼙㼑㼚㼠㻌㼛㼒 㼜㼞㼑㼟㼟㼡㼞㼑㻌㼡㼘㼏㼑㼞㼟㻦㻌㼏㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻚

㻠㻢 㻞㻜㻝㻠 㻭㼐㼡㼘㼠㻌㼣㼑㼕㼓㼔㼠㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼑㼢㼕㼐㼑㼚㼏㼑㻙㼎㼍㼟㼑㼐㻌㼚㼡㼠㼞㼕㼠㼕㼛㼚㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑

㻠㻣 㻞㻜㻝㻠 㼂㻭㻛㻰㼛㻰㻌㼏㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻌㼒㼛㼞㻌㼠㼔㼑㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼡㼜㼜㼑㼞㻌㼑㼤㼠㼞㼑㼙㼕㼠㼥㻌㼍㼙㼜㼡㼠㼍㼠㼕㼛㼚 㼞㼑㼔㼍㼎㼕㼘㼕㼠㼍㼠㼕㼛㼚㻚

㻠㻤 㻞㻜㻝㻠 㻭㻯㻾㻌㻭㼜㼜㼞㼛㼜㼞㼕㼍㼠㼑㼚㼑㼟㼟㻌㻯㼞㼕㼠㼑㼞㼕㼍㼹㻌㼍㼓㼓㼞㼑㼟㼟㼕㼢㼑㻌㼚㼛㼚㼙㼑㼘㼍㼚㼛㼙㼍㼠㼛㼡㼟㻌㼟㼗㼕㼚㻌㼏㼍㼚㼏㼑㼞㻌㼛㼒㻌㼠㼔㼑㻌㼔㼑㼍㼐㻌㼍㼚㼐㻌㼚㼑㼏㼗㻚 㻠㻥 㻞㻜㻝㻠 㻭㻯㻾㻌㻭㼜㼜㼞㼛㼜㼞㼕㼍㼠㼑㼚㼑㼟㼟㻌㻯㼞㼕㼠㼑㼞㼕㼍㼹㻌㼎㼘㼡㼚㼠㻌㼏㼔㼑㼟㼠㻌㼠㼞㼍㼡㼙㼍㻌䇶㻌㼟㼡㼟㼜㼑㼏㼠㼑㼐㻌㼍㼛㼞㼠㼕㼏㻌㼕㼚㼖㼡㼞㼥㻚

㻡㻜 㻞㻜㻝㻠 㼀㼞㼑㼍㼠㼙㼑㼚㼠㻌㼛㼒㻌㼜㼞㼑㼟㼟㼡㼞㼑㻌㼡㼘㼏㼑㼞㼟㻚㻌㻵㼚㻦㻌㻼㼞㼑㼢㼑㼚㼠㼕㼛㼚㻌㼍㼚㼐㻌㼠㼞㼑㼍㼠㼙㼑㼚㼠㻌㼛㼒㻌㼜㼞㼑㼟㼟㼡㼞㼑㻌㼡㼘㼏㼑㼞㼟㻦㻌㼏㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑 㼓㼡㼕㼐㼑㼘㼕㼚㼑㻚

㻡㻝 㻞㻜㻝㻠 㻮㼘㼛㼛㼐㻌㼠㼞㼍㼚㼟㼒㼡㼟㼕㼛㼚㻌㼕㼚㻌㼠㼔㼑㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼟㼕㼏㼗㼘㼑㻌㼏㼑㼘㼘㻌㼐㼕㼟㼑㼍㼟㼑㻚㻌㻵㼚㻦㻌㻱㼢㼕㼐㼑㼚㼏㼑㻙㼎㼍㼟㼑㼐㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒 㼟㼕㼏㼗㼘㼑㻌㼏㼑㼘㼘㻌㼐㼕㼟㼑㼍㼟㼑㻚

㻡㻞 㻞㻜㻝㻠 㻭㻯㻾㻌㻭㼜㼜㼞㼛㼜㼞㼕㼍㼠㼑㼚㼑㼟㼟㻌㻯㼞㼕㼠㼑㼞㼕㼍㼹㻌㼞㼍㼐㼕㼛㼘㼛㼓㼕㼏㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼘㼛㼣㼑㼞㻌㼓㼍㼟㼠㼞㼛㼕㼚㼠㼑㼟㼠㼕㼚㼍㼘㻌㼠㼞㼍㼏㼠㻌㼎㼘㼑㼑㼐㼕㼚㼓 㻡㻟 㻞㻜㻝㻠 㻿㼜㼑㼏㼕㼍㼘㻌㼜㼛㼜㼡㼘㼍㼠㼕㼛㼚㼟㻚㻌㻵㼚㻦㻌㻼㼞㼑㼢㼑㼚㼠㼕㼛㼚㻌㼍㼚㼐㻌㼠㼞㼑㼍㼠㼙㼑㼚㼠㻌㼛㼒㻌㼜㼞㼑㼟㼟㼡㼞㼑㻌㼡㼘㼏㼑㼞㼟㻦㻌㼏㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻚 㻡㻠 㻞㻜㻝㻠 㻭㻯㻾㻌㻭㼜㼜㼞㼛㼜㼞㼕㼍㼠㼑㼚㼑㼟㼟㻌㻯㼞㼕㼠㼑㼞㼕㼍㼹㻌㼞㼑㼟㼑㼏㼠㼍㼎㼘㼑㻌㼟㼠㼛㼙㼍㼏㼔㻌㼏㼍㼚㼏㼑㼞㻚

㻡㻡 㻞㻜㻝㻠 㻳㼡㼕㼐㼑㼘㼕㼚㼑㻌㼒㼛㼞㻌㼟㼡㼞㼓㼕㼏㼍㼘㻌㼍㼠㼠㼕㼞㼑㻚

㻡㻢 㻞㻜㻝㻠 㻹㼍㼚㼍㼓㼕㼚㼓㻌㼍㼏㼡㼠㼑㻌㼏㼛㼙㼜㼘㼕㼏㼍㼠㼕㼛㼚㼟㻌㼛㼒㻌㼟㼕㼏㼗㼘㼑㻌㼏㼑㼘㼘㻌㼐㼕㼟㼑㼍㼟㼑㻚㻌㻵㼚㻦㻌㻱㼢㼕㼐㼑㼚㼏㼑㻙㼎㼍㼟㼑㼐㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼟㼕㼏㼗㼘㼑㻌㼏㼑㼘㼘 㼐㼕㼟㼑㼍㼟㼑㻚

㻡㻣 㻞㻜㻝㻠 㻭㻯㻾㻌㻭㼜㼜㼞㼛㼜㼞㼕㼍㼠㼑㼚㼑㼟㼟㻌㻯㼞㼕㼠㼑㼞㼕㼍㼹㻌㼞㼍㼐㼕㼛㼘㼛㼓㼕㼏㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼕㼚㼒㼑㼏㼠㼑㼐㻌㼒㼘㼡㼕㼐㻌㼏㼛㼘㼘㼑㼏㼠㼕㼛㼚㼟㻚 㻡㻤 㻞㻜㻝㻠 㻭㻯㻾㻌㻭㼜㼜㼞㼛㼜㼞㼕㼍㼠㼑㼚㼑㼟㼟㻌㻯㼞㼕㼠㼑㼞㼕㼍㼹㻌㼐㼡㼏㼠㼍㼘㻌㼏㼍㼞㼏㼕㼚㼛㼙㼍㻌㼕㼚㻌㼟㼕㼠㼡㻚

㻡㻥 㻞㻜㻝㻠 㻳㼡㼕㼐㼑㼘㼕㼚㼑㻌㼒㼛㼞㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼣㼛㼡㼚㼐㼟㻌㼕㼚㻌㼜㼍㼠㼕㼑㼚㼠㼟㻌㼣㼕㼠㼔㻌㼘㼛㼣㼑㼞㻙㼑㼤㼠㼞㼑㼙㼕㼠㼥㻌㼍㼞㼠㼑㼞㼕㼍㼘㻌㼐㼕㼟㼑㼍㼟㼑㻚 㻢㻜 㻞㻜㻝㻠 㼂㻭㻛㻰㼛㻰㻌㼏㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻌㼒㼛㼞㻌㼟㼏㼞㼑㼑㼚㼕㼚㼓㻌㼍㼚㼐㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼛㼢㼑㼞㼣㼑㼕㼓㼔㼠㻌㼍㼚㼐㻌㼛㼎㼑㼟㼕㼠㼥 㻢㻝 㻞㻜㻝㻟 㻹㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼛㼎㼟㼠㼞㼡㼏㼠㼕㼢㼑㻌㼟㼘㼑㼑㼜㻌㼍㼜㼚㼑㼍㻌㼕㼚㻌㼍㼐㼡㼘㼠㼟㻦㻌㼍㻌㼏㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻌㼒㼞㼛㼙㻌㼠㼔㼑㻌㻭㼙㼑㼞㼕㼏㼍㼚

㻯㼛㼘㼘㼑㼓㼑㻌㼛㼒㻌㻼㼔㼥㼟㼕㼏㼕㼍㼚㼟㻚

㻢㻞 㻞㻜㻝㻟㻚㻤 㻵㼚㼠㼞㼍㼛㼜㼑㼞㼍㼠㼕㼢㼑㻌㼠㼑㼟㼠㼟㻌㻔㻾㻰㻙㻝㻜㻜㼕㻌㻻㻿㻺㻭㻌㼟㼥㼟㼠㼑㼙㻌㼍㼚㼐㻌㻹㼑㼠㼍㼟㼕㼚㻌㼠㼑㼟㼠㻕㻌㼒㼛㼞㻌㼐㼑㼠㼑㼏㼠㼕㼚㼓㻌㼟㼑㼚㼠㼕㼚㼑㼘㻌㼘㼥㼙㼜㼔㻌㼚㼛㼐㼑 㼙㼑㼠㼍㼟㼠㼍㼟㼑㼟㻌㼕㼚㻌㼎㼞㼑㼍㼟㼠㻌㼏㼍㼚㼏㼑㼞㻚

㻢㻟 㻞㻜㻝㻟㻚㻡

㻿㼡㼙㼙㼍㼞㼥㻌㼛㼒㻌㼑㼢㼕㼐㼑㼚㼏㼑㻙㼎㼍㼟㼑㼐㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻦㻌㼜㼑㼞㼕㼜㼞㼛㼏㼑㼐㼡㼞㼍㼘㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼍㼚㼠㼕㼠㼔㼞㼛㼙㼎㼛㼠㼕㼏㻌㼙㼑㼐㼕㼏㼍㼠㼕㼛㼚㼟 㼕㼚㻌㼜㼍㼠㼕㼑㼚㼠㼟㻌㼣㼕㼠㼔㻌㼕㼟㼏㼔㼑㼙㼕㼏㻌㼏㼑㼞㼑㼎㼞㼛㼢㼍㼟㼏㼡㼘㼍㼞㻌㼐㼕㼟㼑㼍㼟㼑㻚㻌㻾㼑㼜㼛㼞㼠㻌㼛㼒㻌㼠㼔㼑㻌㻳㼡㼕㼐㼑㼘㼕㼚㼑㻌㻰㼑㼢㼑㼘㼛㼜㼙㼑㼚㼠

㻿㼡㼎㼏㼛㼙㼙㼕㼠㼠㼑㼑㻌㼛㼒㻌㼠㼔㼑㻌㻭㼙㼑㼞㼕㼏㼍㼚㻌㻭㼏㼍㼐㼑㼙㼥㻌㼛㼒㻌㻺㼑㼡㼞㼛㼘㼛㼓㼥㻚

㻢㻠 㻞㻜㻝㻟 㻯㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻌㼛㼚㻌㼠㼔㼑㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼕㼚㼢㼍㼟㼕㼢㼑㻌㼙㼑㼚㼕㼚㼓㼛㼏㼛㼏㼏㼍㼘㻌㼐㼕㼟㼑㼍㼟㼑㻚

㻢㻡 㻞㻜㻝㻟㻚㻝 㻯㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㼟㻌㼒㼛㼞㻌㼠㼔㼑㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼛㼢㼑㼞㼣㼑㼕㼓㼔㼠㻌㼍㼚㼐㻌㼛㼎㼑㼟㼕㼠㼥㻌㼕㼚㻌㼍㼐㼡㼘㼠㼟㻘㻌㼍㼐㼛㼘㼑㼟㼏㼑㼚㼠㼟 㼍㼚㼐㻌㼏㼔㼕㼘㼐㼞㼑㼚㻌㼕㼚㻌㻭㼡㼟㼠㼞㼍㼘㼕㼍㻚

㻢㻢 㻞㻜㻝㻟 㻯㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㼟㻌㼒㼛㼞㻌㼠㼔㼑㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼞㼛㼠㼍㼠㼛㼞㻌㼏㼡㼒㼒㻌㼟㼥㼚㼐㼞㼛㼙㼑㻌㼕㼚㻌㼠㼔㼑㻌㼣㼛㼞㼗㼜㼘㼍㼏㼑㻚 㻢㻣 㻞㻜㻝㻞㻚㻝㻝 㻰㼑㼜㼠㼔㻌㼛㼒㻌㼍㼚㼍㼑㼟㼠㼔㼑㼟㼕㼍㻌㼙㼛㼚㼕㼠㼛㼞㼟㻌䇵㻌㻮㼕㼟㼜㼑㼏㼠㼞㼍㼘㻌㻵㼚㼐㼑㼤㻌㻔㻮㻵㻿㻕㻘㻌㻱㻙㻱㼚㼠㼞㼛㼜㼥㻌㼍㼚㼐㻌㻺㼍㼞㼏㼛㼠㼞㼑㼚㼐㻙㻯㼛㼙㼜㼍㼏㼠㻌㻹㻚 㻢㻤 㻞㻜㻝㻞㻚㻤 㻿㼛㼚㼛㼂㼡㼑㻌㻔㼟㼡㼘㼜㼔㼡㼞㻌㼔㼑㼤㼍㼒㼘㼡㼛㼞㼕㼐㼑㻌㼙㼕㼏㼞㼛㼎㼡㼎㼎㼘㼑㼟㻕㻌䇵㻌㼏㼛㼚㼠㼞㼍㼟㼠㻌㼍㼓㼑㼚㼠㻌㼒㼛㼞㻌㼏㼛㼚㼠㼞㼍㼟㼠㻙㼑㼚㼔㼍㼚㼏㼑㼐㻌㼡㼘㼠㼞㼍㼟㼛㼡㼚㼐

㼕㼙㼍㼓㼕㼚㼓㻌㼛㼒㻌㼠㼔㼑㻌㼘㼕㼢㼑㼞㻚

㻢㻥 㻞㻜㻝㻞㻚㻣 㻾㼑㼐㻌㼎㼘㼛㼛㼐㻌㼏㼑㼘㼘㻌㼠㼞㼍㼚㼟㼒㼡㼟㼕㼛㼚㻦㻌㼍㻌㼏㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㻌㼒㼞㼛㼙㻌㼠㼔㼑㻌㻭㻭㻮㻮㻚 㻣㻜 㻞㻜㻝㻞㻚㻡

㻱㼍㼞㼘㼥㻌㼠㼔㼞㼛㼙㼎㼡㼟㻌㼞㼑㼙㼛㼢㼍㼘㻌㼟㼠㼞㼍㼠㼑㼓㼕㼑㼟㻌㼒㼛㼞㻌㼍㼏㼡㼠㼑㻌㼐㼑㼑㼜㻌㼢㼑㼚㼛㼡㼟㻌㼠㼔㼞㼛㼙㼎㼛㼟㼕㼟㻦㻌㼏㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㼟 㼒㼛㼞㻌㼠㼔㼑㻌㻿㼛㼏㼕㼑㼠㼥㻌㼒㼛㼞㻌㼂㼍㼟㼏㼡㼘㼍㼞㻌㻿㼡㼞㼓㼑㼞㼥㻌㼍㼚㼐㻌㼠㼔㼑

㻭㼙㼑㼞㼕㼏㼍㼚㻌㼂㼑㼚㼛㼡㼟㻌㻲㼛㼞㼡㼙㻚

㻣㻝 㻞㻜㻝㻞 㻼㼍㼠㼕㼑㼚㼠㻌㼎㼘㼛㼛㼐㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㼟㻦㻌㼙㼛㼐㼡㼘㼑㻌㻠㻌㻙㻌㼏㼞㼕㼠㼕㼏㼍㼘㻌㼏㼍㼞㼑㻚 㻣㻞 㻞㻜㻝㻞 㻼㼍㼠㼕㼑㼚㼠㻌㼎㼘㼛㼛㼐㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㼟㻦㻌㼙㼛㼐㼡㼘㼑㻌㻞㻌㻙㻌㼜㼑㼞㼕㼛㼜㼑㼞㼍㼠㼕㼢㼑㻚

㻣㻟 㻞㻜㻝㻝㻚㻥 㼁㼜㼐㼍㼠㼑㼐㻌㻿㼛㼏㼕㼑㼠㼥㻌㼒㼛㼞㻌㼂㼍㼟㼏㼡㼘㼍㼞㻌㻿㼡㼞㼓㼑㼞㼥㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㼟㻌㼒㼛㼞㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼛㼒㻌㼑㼤㼠㼞㼍㼏㼞㼍㼚㼕㼍㼘㻌㼏㼍㼞㼛㼠㼕㼐㻌㼐㼕㼟㼑㼍㼟㼑㻚 㻣㻠 㻞㻜㻝㻝㻚㻡

㼀㼔㼑㻌㼏㼍㼞㼑㻌㼛㼒㻌㼜㼍㼠㼕㼑㼚㼠㼟㻌㼣㼕㼠㼔㻌㼢㼍㼞㼕㼏㼛㼟㼑㻌㼢㼑㼕㼚㼟㻌㼍㼚㼐㻌㼍㼟㼟㼛㼏㼕㼍㼠㼑㼐㻌㼏㼔㼞㼛㼚㼕㼏㻌㼢㼑㼚㼛㼡㼟㻌㼐㼕㼟㼑㼍㼟㼑㼟㻦㻌㼏㼘㼕㼚㼕㼏㼍㼘㻌㼜㼞㼍㼏㼠㼕㼏㼑 㼓㼡㼕㼐㼑㼘㼕㼚㼑㼟㻌㼛㼒㻌㼠㼔㼑㻌㻿㼛㼏㼕㼑㼠㼥㻌㼒㼛㼞㻌㼂㼍㼟㼏㼡㼘㼍㼞㻌㻿㼡㼞㼓㼑㼞㼥㻌㼍㼚㼐

㼠㼔㼑㻌㻭㼙㼑㼞㼕㼏㼍㼚㻌㼂㼑㼚㼛㼡㼟㻌㻲㼛㼞㼡㼙㻚

㻣㻡 㻞㻜㻝㻝 㻼㼍㼠㼕㼑㼚㼠㻌㼎㼘㼛㼛㼐㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼓㼡㼕㼐㼑㼘㼕㼚㼑㼟㻦㻌㼙㼛㼐㼡㼘㼑㻌㻝㻌㻙㻌㼏㼞㼕㼠㼕㼏㼍㼘㻌㼎㼘㼑㼑㼐㼕㼚㼓㻛㼙㼍㼟㼟㼕㼢㼑㻌㼠㼞㼍㼚㼟㼒㼡㼟㼕㼛㼚㻚 㻣㻢 㻞㻜㻝㻝 㻳㼡㼕㼐㼑㼘㼕㼚㼑㻌㼒㼛㼞㻌㼜㼞㼛㼏㼑㼟㼟㼕㼚㼓㻌㼒㼘㼑㼤㼕㼎㼘㼑㻌㼑㼚㼐㼛㼟㼏㼛㼜㼑㼟㻚

81

ῧ௜㈨ᩱձ

A Consensus Document on Robotic Surgery

Prepared by the SAGES-MIRA Robotic Surgery Consensus Group

㸦Surg Endosc. 2008 Feb;22(2):313-25ࠊhttp://.sages.org㸧

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) The Minimally Invasive Robotic Association (MIRA)

ᮏࢥࣥࢭࣥࢧࢫࡣ24࣮࣌ࢪ࡟ࢃࡓࡾࠊࣟ࣎ࢵࢺᡭ⾡ࡢ㐺ᛂࠊࣜࢫࢡࠊࢥࢫࢺ࣋

ࢿࣇ࢕ࢵࢺࠊ⾡⪅ࡢ㈨᱁ㄆᐃ࡜ࢺ࣮ࣞࢽࣥࢢ࡟ࡘࡁࠊ㏙࡭ࡽࢀ࡚࠸ࡿࠋ

㈨᱁ㄆᐃ࡟ࡘ࠸࡚㸦࿴ヂࡋ࡚せⅬࢆᢤ⢋㸧

1. ⾡⪅ࡢ㈨᱁ㄆᐃࡣࠊಶࠎࡢ་⒪᪋タ࠶ࡿ࠸ࡣ⑓㝔࡛ࡢ≉ูጤဨ఍࡛ᑂ㆟ࡉ

ࢀࡿࠋྛ Unit 㛗ࡣࠊࣟ࣎ࢵࢺᡭ⾡ࢆ㛤ጞࡍࡿ࡟࠶ࡓࡾࠊࡇࡢ≉ูጤဨ఍࡟⾡

⪅ࡢ㈨᱁ㄆᐃࢆ⏦ㄳࡍࡿࠋࡇࡢ≉ูጤဨ఍ࡣࠊ⑓㝔࠾ࡼࡧ㐺ษ࡞ᨻᗓᶵ㛵 ࡢㄆᐃࡀᚲせ࡛࠶ࡿࠋ

2. ⾡⪅ࡣࠊእ⛉ࣞࢪࢹࣥࢺࣉࣟࢢ࣒ࣛ⤊஢ࠊヱᙜ⑌ᝈศ㔝ࡢᑓ㛛་ࡢྲྀᚓࡀ ᚲせ

3. ⾡⪅ࡣ ヱᙜ⑌ᝈศ㔝࡛༑ศ࡞ᡭ⾡⤒㦂ࡀ࠶ࡾࠊⰋዲ࡞ᡂ⦼࡛࠶ࡿᚲせࡀ

࠶ࡿ㸦Unit㛗ࡢᢎㄆࡀᚲせ㸧

4. ึᅇࢣ࣮ࢫ࡛ࡣࠊࡑࡢᢏ⾡ࡢExpertࡢReview࠶ࡿ࠸ࡣAssistࡀᚲせ࡛࠶ࡿ

㸦ExpertࡢㄆᐃࡣࠊUnit㛗࠾ࡼࡧ≉ูጤဨ఍ࡢㄆᐃ㸧ࠋ 5. ヱᙜᡭ⾡ࡣࠊᑓ௵໬ࡋࡓデ⒪ࢳ࣮࣒ࢆᙧᡂࡍࡿᚲせࡀ࠶ࡿ

6. ࣟ࣎ࢵࢺᡭ⾡㛤ጞᚋࡣࠊ㐺ᛂ࡞ᮇ㛫ࠊ㐺ᙜ࡞⑕౛ᩘࡲ࡛ࡣࠊᡭ⾡ࡢෆᐜ࡜

⤖ᯝ࡟ࡘ࠸࡚Monitorࡀᚲせ࡛࠶ࡿࠋᮇ㛫࡜⑕౛ᩘࡣ≉ูጤဨ఍ࡀỴᐃࠋ 7. ⾡⪅ࡢ㈨᱁ㄆᐃࡣࠊ୍ᐃᮇ㛫࡛᭦᪂ࡍࡿᚲせࡀ࠶ࡾࠊࡇࢀ࡟ࡣࠊヱᙜᢏ⾡

ࡢ⤖ᯝࡢホ౯࡜ࠊ㛵㐃Ꮫ఍࡬ࡢฟᖍ࡞࡝ࡢ⩏ົࢆࡩࡃࡳࠊࡇࢀࡽࡢ⤖ᯝ࡟

ࡼࡗ࡚ࡣࠊ㈨᱁ㄆᐃࢆ๤ዣࡍࡿࡇ࡜ࡶྍ⬟࡛࠶ࡿ㸦≉ูጤဨ఍ࡢ㈐௵㸧

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ᅜእࡢ㧗㞴ᗘ་⒪ᢏ⾡࡟㛵㐃ࡍࡿ࢞࢖ࢻࣛ࢖ࣥࡢ஦౛

࠙㈨ᩱࠚ ^㈨ᩱ

82

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Laparoscopic repair of abdominal aortic aneurysm Interventional procedure guidance

ΉPublished: 22 August 2007! nice.org.uk/guidance/ipg229Ί

ᮏ࢞࢖ࢲࣥࢫࡣ࣮࣌ࢪ࡟ࢃࡓࡾࠊ⭡⭍㙾ୗࡢ⭡㒊኱ື⬦⒗ಟ᚟⾡࡟ࡘ࠸

࡚ࠊࡑࡢ㐺ᛂࠊᐇ᪋ࡢせ௳ࠊᢏ⾡ࡢᴫせࠊࣜࢫࢡࠊ࣋ࢿࣇ࢕ࢵࢺࡀ㏙࡭ࡽࢀ࡚

࠸ࡿࠋ

ᐇ᪋ࡢせ௳࡟ࡘ࠸࡚㸦࿴ヂࡋ࡚せⅬࢆᢤ⢋㸧

1. ᮏ⾡ᘧࡣࠊ≉ูࡢ┘ᰝࢩࢫࢸ࣒ୗ࠶ࡿ࠸ࡣ⮫ᗋヨ㦂࡜ࡋ࡚ᐇ᪋ࡍ࡭ࡁ࡛

࠶ࡿࠋ

2. ᐇ᪋࡟࠶ࡓࡾࠊ The clinical governance leads in their Trusts ࡟ሗ࿌ࠋ

3. ᮏ⾡ᘧࡣࠊ⾡ᘧ࡟㛵ࡍࡿ≉ูࡢICࡀᚲせ࡛࠶ࡾࠊ௚ࡢᡭ⾡⾡ᘧࡢ࿊♧ࠊ 㛤⭡⾡࡬ࡢ⛣⾜ࡢྍ⬟ᛶ࡞࡝ࡢㄝ᫂ࡀᚲせࠋ

4. ᮏ⾡ᘧ࡟㛵ࡍࡿ᝟ሗࢆ National Vascular Database ࡬ࡢⓏ㘓ࡀᚲ㡲ࠋ

5. ᝈ⪅ࡢ㐺ᛂࡣࠊᮏศ㔝࡟⢭㏻ࡋࡓ㞟Ꮫⓗࢳุ࣮࣒࡛᩿ࡍࡿᚲせࡀ࠶ࡿࠋ

6. ᮏ⾡ᘧࡣࠊ⾑⟶እ⛉࡟⢭㏻ࡋࠊ࠿ࡘࠊ㧗ᗘ࡞⭡⭍㙾ᡭ⾡ࡢࢺ࣮ࣞࢽࣥࢢ

ࢆཷࡅࡓእ⛉་ࡀᐇ᪋ࡍࡿࡇ࡜ࠋ

83

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Laparoscopic retroperitoneal lymph node dissection for testicular cancer Interventional procedure guidance

(Published: 22 March 2006 nice.org.uk/guidance/ipg158)

ᮏ࢞࢖ࢲࣥࢫࡣ࣮࣌ࢪ࡟ࢃࡓࡾࠊ⢭ᕢ࢞ࣥ࡟ᑐࡍࡿ⭡⭍㙾ୗᚋ⭡⭷ࣜࣥࣃ

⠇㒌Ύ⾡࡟ࡘ࠸࡚ࠊࡑࡢ㐺ᛂࠊ⾡⪅ࡢせ௳ࠊᢏ⾡ࡢᴫせࠊࣜࢫࢡࠊ࣋ࢿࣇ࢕ࢵ

ࢺࡀ㏙࡭ࡽࢀ࡚࠸ࡿࠋ

ᐇ᪋ࡢせ௳࡟ࡘ࠸࡚㸦࿴ヂࡋ࡚せⅬࢆᢤ⢋㸧

ᮏ⾡ᘧࡣࠊ≉ูࡢ┘ᰝࢩࢫࢸ࣒ୗ࠶ࡿ࠸ࡣ⮫ᗋヨ㦂࡜ࡋ࡚ᐇ᪋ࡍ࡭ࡁ

࡛࠶ࡿࠋ

ᐇ᪋࡟࠶ࡓࡾࠊThe clinical governance leads in their Trusts࡟ሗ࿌

ᮏ⾡ᘧࡣࠊ⾡ᘧ࡟㛵ࡍࡿ≉ูࡢ IC ࡀᚲせ࡛࠶ࡾࠊ㔜⠜࡞ྜే⑕ࡢྍ⬟

ᛶ࡞࡝ࡢㄝ᫂ࡀᚲせ

ᮏ⾡ᘧࡢ⤖ᯝࡢ┘ᰝࠊホ౯ࡀᚲ㡲

⾡⪅ࡣࠊヱᙜศ㔝ࡢ㛤⭡⾡ࠊ࠾ࡼࡧ⭡⭍㙾ୗᡭ⾡ࡢ༑ศ࡞⤒㦂ࡀᚲせ

࡛࠶ࡾࠊᐇ᪋࡟࠶ࡓࡗ࡚ࡣ㞟Ꮫⓗࢳ࣮࣒ᵓᡂࡀᚲせࠋ

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