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1 대한내시경복강경외과학회지 Vol. 2. No. 2, 2009 원저 단일술자가시행한복강경담낭절제술 62 예에대한임상적고찰 왈레스기념침례병원외과 박하경ㆍ이윤식ㆍ박진현 62 Cases of Laparoscopic Cholecystectomy by a Single Surgeon Ha Kyoung Park, M.D., Yun Sik Lee, M.D., Jin Hyun Park, M.D. Department of Surgery, Wallace Memorial Baptist Hospital, Busan, Korea Purpose: Laparoscopic cholecystectomy (LC) has been the treatment of choice for acute and chronic disease of the gallbladder. We have performed 62 cases of LC from January to April This study aims to clinically analyze 62 cases of LC that were performed by a single surgeon over a 7 year period and to evaluate the effectiveness and safety of laparoscopic treatment for gallbladder disease. Methods: From January to April , 62 patients underwent LC at the Department of Surgery by a single surgeon. We retrospectively analyzed the patients ages, gender distribution and chief complaints, the operation times, the duration of hospitalization, the conversion rate to open cholecystectomy and the causes, the diagnostic methods and the postoperative complications through a review of the patients charts. Results: The mean age was 46 years and the ratio of males to females was :.4. The most common chief complaint was right upper quadrant pain (52.97%). The mean operative time was minutes and the duration of hospitalization was 5.2 days and the duration of postoperative hospitalization was 3.86 days. The conversion rate was 3.29% and the most common cause of conversion was anatomic uncertainty due to inflammatory adhesion. Abdominal sonography was the most common diagnostic method and this was performed in 73.27% of the patients. The postoperative complication rate was.93%. Conclusion: LC has become the gold standard for the treatment of benign gallbladder diseases. We think that LC is effective and safe, and even at a secondary care hospital, if the surgeon has accumulated operative experience and improved operative skill. Key words: Laparoscopic cholecystectomy, Cholecystitis, Single surgeon 중심단어 : 복강경담낭절제술, 담낭염, 단일술자 서 론 대상및방법 987년프랑스외과의사 Mouret 에의해도입된복강경담낭절제술은창상의크기가작은미용적인효과뿐만아니라, 창상에대한견인이없기때문에수술후환자의고통이적고, 개복담낭절제술에비해입원기간이짧고, 일상으로복귀가빨라경제적, 시간적으로효율적인장점이있어 2 오늘날양성담낭질환에대한표준술식으로자리잡고있다. 본연구에서는 200년 월 2일부터 2008년 4월 30일까지단일술자가시행한복강경담낭절제술 62예를문헌고찰과함께보고하는바이다. 통신저자 : 박진현, 부산시금정구남산동 우편번호 : 왈레스기념침례병원외과 Tel: , Fax: jhpark@wmbh.co.kr 200년 월 2일부터 2008년 4월 30일까지왈레스기념침레병원외과에서단일술자가시행한연속적인복강경담낭절제술 642예가운데개복담낭절제술로전환된 2예를제외한 62예를대상으로연령및성별, 과거수술력과병력, 주증상과병력기간, 수술시간및입원기간, 개복술로의전환율및그원인, 방사선학적검사및병리조직학적진단, 합병증발생률에대해의무기록을통하여후향적으로조사하였다. 본원은전공의수련병원으로수술팀은한명의외과의와 2명의전공의또는 명의전공의와전문간호사로구성된 3명으로, 수술은모두한명의외과의에의해 4공식으로시행되었다. 마취후모든환자에게도뇨관과비위관을삽입하고, 수술직후비위관은즉시제거하였고, 도뇨관제거는환자의상태에따라예외를두었으며, 배액관은심한염증, 출혈염려가있을경우제한적으로사용하였다. 02

2 박하경외 2 인 : 단일술자가시행한복강경담낭절제술 62 예에대한임상적고찰 03 결과 ) 연령및성별분포환자의평균연령은 46세였고, 30대에서 60대사이가전체환자의 82.77% 였으며 (Table ), 남녀성비는남자 258예 (4.50%), 여자 363예 (58.50%) 로 :.4였다. 2) 과거수술력및병력과거복부수술력은총 5예 (8.52%) 있었다. 그중복강경담낭절제술에영향을미칠수있는상부복부수술력으로는십이지장궤양 3예, 장폐색 3예, 장천공 2예, 총상 예등으로총 9예 (.45%) 가있었다 (Table 2). 동반질환은고혈압, 당뇨, 총담관담석, 호흡기계질환, B형간염, C형간염, 심장질환등이있었다 (Table 3). 총담관담석이동반된경우는 ERCP를통해총담관담석을제거하고복강경담낭 절제술을시행하였다. 3) 주증상과수술전진단명및병력기간주증상은복통이 40예 (64.56%) 였고, 이중우상복부통증이 329예 (52.97%) 로가장많았고, 위주위통증이 52예 (8.37%), 전반적인복통이 20예 (3.22%) 로나타났다. 위주위불편감을호소한경우가 8예 (2.90%), 등또는옆구리통증이 6예 (2.58%), 소화불량이 5예 (2.42%) 있었다. 황달 8예 (.29%), 가슴통증 3예 (0.48%), 고열과오한 8예 (.29%), 오심 2예 (0.32%) 로조사되었다. 그러나증상을호소하지않는경우도 68예 (27.05%) 있었다 (Table 4). 수술전진단으로는담석증 497예 (80.03%), 담낭염 405예 (65.22%), 담낭용종및종양 79예 (2.72%) 였다 (Table 5). 병력기간은 주일이내 84예 (29.6%), 주일에서 개월이내 63예 (26.2%), 개월에서 6개월이내 77예 (2.4%), 6개월에서 2개월이내 32예 (5.2%), 년이상 65예 (26.6%) 였다 (Fig. ). Table. Age distribution Age (years) No. of patients (%) Table 3. Associated diseases Associated disease No. of patients (%) (6.28) 9 (9.6) 36 (2.90) 46 (23.5) 3 (8.20) 59 (9.50) 7 (.3) 62 (00) Hypertension Diabetic Mellitus Common bile duct stones Respiratory diseases Hepatitis type B, hepatitis type C Heart disease Nephropathy Acute pancreatitis Cerebral infarction Liver cirrhosis Toxic hepatitis Miscellary 92 (4.8) 52 (8.37) 34 (5.47) 25 (4.02) 9 (3.05) 3 (2.09) 8 (.28) 6 (0.96) 3 (0.48) 24 (3.86) Table 2. Previous history of operations Previous history of operations No. of patients Table 4. Chief complaint Upper abdomen Duodenal ulcer Miscellany Intestinal obstruction Bowel perforation Exploration laparotomy due to gun shot Lower abdomen Appendectomy Hysterectomy Cesarean section Ectopic pregnancy Laparoscopic tubal ligation Uterine myomectomy Chief complaint No. of patients (%) Abdominal pain Right upper quardrant pain Epigastric pain Diffuse abdominal pain Epigastric discomfort Back or flank pain Dyspepsia Jaundice Chest pain Fever or chilling Nausea No symptom 40 (64.56) 329 (52.97) 52 (8.37) 20 (3.22) 8 (2.90) 6 (2.58) 5 (2.42) 8 (.29) 3 (0.48) 8 (.29) 68 (27.05)

3 04 대한내시경복강경외과학회지제 2 권제 2 호 2009 Table 5. Preoperative diagnosis Preoperative diagnosis No. of patients(%) Table 6. Duration of hospitalization Days No. of patients (%) Cholelithiasis Cholecystitis Polyp and adenoma 497 (80.03%) 405 (65.27%) 79 (2.72%) < Mean: (74.40) 36 (2.90) 8 (2.90) 3 (0.48) Table 7. Causes of conversion Causes of conversion No. of patients Anatomic uncertainty Inflammatory adhesion Perforation with abscess Arterial bleeding Extrahepatic bile duct injury Suspicious gallbladder cancer Fig.. Period of symptoms. Table 8. Diagnostic methods Methods No. of patients (%) USG CT MRCP ERCP 455 (73.27) 95 (3.40) 20 (3.22) 22 (9.64) 5) 개복술로의전환율 Fig. 2. Operative times. 4) 수술시간및입원기간수술시간은마취기록지를참고하여, 마취도입부터마취종료까지시간으로산정하였다. 수술시간은평균 분이었고, 60분이내 33예 (50.40%), 60분에서 90분 20예 (33.82%), 9분에서 20분 77예 (2.40%), 2분에서 80분 8예 (2.90%), 80분이상소요된경우가 3예 (0.48%) 로나타났다 (Fig. 2). 수술전검사기간, 수술과수술후입원기간까지포함된평균재원기간은대부분의환자에서 6일이내였으며, 평균 5.2일이었다 (Table 6). 수술후입원기간은평균 3.86일이였다. 수술중개복술로전환된경우는총 642예중 2예로 3.27% 였다. 원인은심한염증성유착 (5예) 및농양을동반한담낭천공 (3예) 등해부학적불명확으로인한경우가총 8예 (2.80%) 로가장많았고, 담낭동맥출혈, 담관손상, 담낭암의심등이각각 예씩있었다 (Table 7). 복강경담낭절제술중총담관이손상된 예는즉시개복술로전환하여루와이간공장문합술 (Roux-en-Y Hepaticojejunostomy) 를시행하였다. 수술중담낭암이의심되어동결절편검사를시행한 예는 T3 병기로개복술로전환하여확대담낭절제술을시행하였다. 6) 방사선학적검사및병리조직학적진단수술전방사선학적검사로는초음파를이용한경우가총 455예 (73.27%) 로가장많았고, CT는 95예 (3.40%), MRCP 는 20예 (3.22%), ERCP는 22예 (9.64%) 이용하였다 (Table 8). 복강경담낭절제술후조직검사결과 62예중담석을가

4 박하경외 2 인 : 단일술자가시행한복강경담낭절제술 62 예에대한임상적고찰 05 Table 9. Pathologic diagnosis Pathologic diagnosis No. of patients Table 0. Postoperative complications Postoperative complications No. of patients (%) Cholelithiasis Cholecystitis Chronic cholecystitis Acute cholecystitis Acute gangrenous Empyema Xanthogranulomatous Eosinophilic Follicular Polyp Adenoma Adenomatous hyperplasia Malignancy Adenocarcinoma Papillary carcinoma Autolysis 진경우는 56예있었고, 담낭염이 429예, 용종은 4예있었다. 담낭암은총 6예로, 선암 5예와유두상암 예가있었다 (Table 9). 선암중 ptis 병기 예는외래통원하며경과를관찰중이다. ptb 병기 3예중 예는추가수술을권고하였으나환자가고령이라는이유로거부하였고, 예는타병원으로전원되었으며, 예는외래통원하면서항암제복용중이다. pt2 병기 예는타병원으로전원되었다. 7) 수술후합병증 복강경담낭절제술이후합병증은총 62예중 2예 (.93%) 로조사되었는데, 그종류로는담관손상 2예 (0.32%), 담즙유출 4예 (0.64%), 혈복강 예 (0.6%), 창상감염 5예 (0.8%) 가있었다 (Table 0). 담관손상 2예중 예는술후담관협착정도가심하여루와이간공장문합술을시행하였고, 예는한시적인경피경간담즙배액술 (Percutaneous transhepatic billiary drainage) 을시행한후담관협착부위에스텐트를삽입하였다. 담즙유출 4예는초음파유도하에배액관을삽입하여배액시키고항생제치료하였다. 혈복강 예는개복해서지혈및복강세척을하였다. 복강경담낭절제술을시행한 62예에서는사망한환자가없었으나, 개복술로전환한 2예중 예에서복강내농양으로인한패혈증으로사망하였다. 고 990년대초우리나라에도입된복강경담낭절제술은축적된경험과수술장비의발달로술기능력이향상되면서, 점차그적응증이확대되었고, 수술시간과입원기간이 찰 Bile duct injury Bile leakage Hemoperitoneum Death Wound infection Hematoma Infection Seroma 4 (0.64) 0 (0.00) 5 (0.8) 2 (.93) 단축되고, 개복술로의전환율과합병증이감소되면서보다안전하고효과적인양성담낭질환에대한표준술식으로오늘날자리잡고있다. 3 공식, 3공식, 4공식, 4공식양손견인술 (Two-handed surgeon assistant retract) 등 3 여러방법중본원단일술자는견인이용이한 4공식으로시행하였다. 기존보고에서복강경담낭절제술을시행받았던환자중에복부수술과거력이있었던경우를 6.8% 로보고하였는데, 4 본연구에서는복부수술과거력을가진경우가 5 예 (8.52%) 로더많았지만안전하게복강경담낭절제술을시행하였다. 그러나, 그중복강경담낭절제술에영향을미칠수있는십이지장궤양, 장폐색, 장천공, 총상등은총 9예 (.45%) 로낮게나타났는데, 이는수술적응증선택에있어서복강경담낭절제술실패율을낮추기위해, 과거상복부수술력을가진환자는제외시켰기때문으로사료된다. Jae 등 5 은수술전에증상을호소하지않는환자를 20.7% 로보고하였으나본조사에서는증상을호소하지않는경우가 27.05% 로높게나타났다. 이는최근건강검진을통해우연히알게되었거나, 다른질환으로검사중우연히발견된경우가상대적으로많았기때문으로생각된다. 무증상담석증은증상발현빈도나합병증병발빈도가매우드물어예방적인담낭절제술은필요하지않다고하나, 거대담석, 석회화담낭등과같은경우무증상담석증이라도담낭암가능성을배제하기위해수술적절제가필요하다. 6 본연구에서는담석갯수가지속적으로증가한경우, 담석크기가커진경우, 과거담낭염으로내과적항생제치료를시행한과거력이있었던경우, 환자가강력히수술을원한경우등에도수술을시행하였다. 환자가수술전에호소하는주증상은복통으로 64.56% 에서나타났고, 이중우상복부통증이 52.97% 로가장많았다. 복강경담낭절제술의수술시간은국내의경우 Jung 등 7 의보고에의하면평균 56.3분이소요되었으나, 본연구의경우평균 67.37분이소요되었다. 타보고에서는제투관침을삽관하는시간을시작시간으로하여투관침제거후

5 06 대한내시경복강경외과학회지제 2 권제 2 호 2009 창상봉합완료시간까지를수술시간으로측정하였고, 본원에서는마취도입부터마취종료까지의시간을수술시간으로산정하였기때문에마취시간까지도포함되어있어서, 이를감안하면유사한결과로평가될수있을것으로사료된다. Park과 Shin 4 은단일술자에의해시행된복강경담낭절제술,000예에서평균수술시간은 57.0분이었고, 전반기 500예는 69.7분, 후반기 500예의경우 45.2분으로단축되었다고보고하였다. 수술시간에대한산정기준의차이를무시하더라도, 본원의 62예에대한결과가,000예중전반기 500예의결과와비슷한것으로보아향후경험의축적으로수술시간을더욱단축시킬수있으리라기대한다. Jung 등 7 은수술후평균입원기간을 3.7일로보고하였고, 본연구에서수술후평균입원기간은 3.86일로유사하게나타났다. 수술전검사기간이포함된평균입원기간을 Chung 등 8 은 4.±2.0일이라고보고하였으며, 일이라는국내보고 4,9- 도있었다. 본연구에서는평균입원기간이 5.2일로나타났는데, 이는병원사정에따라서수술전검사기간의차이가많을것으로사료된다. 현재미국, 영국, 홍콩에서는 70세이하, American Society of Anesthesiologist Risk Classification I or II 경우입원을하지않고, 당일수술후마취회복을위한수시간뒤에당일퇴원해서통원치료하여도큰위험이나불편감이없었다는보고도있었다. 2-4 이와비교하여국내환자의경우개개인의상태, 병원사정, 의료보험문제등여러차이가있겠지만, 수술후불안감및경구약제로조절가능한통증조절도주사제에의지하려는심리, 회복을위한요양까지도수술병원에서해결하려는풍조, 사보험을청구하기위해입원및입원기간연장을요구하는국내환자의식이개선된다면입원기간단축에도움이될것으로생각한다. Jung 등 7 은개복술로의전환율을 8.6% 로보고하였고, Chung 등 8 은 0.9% 로보고하였다. 본연구에서는 642예중개복술로전환된경우가 2예 (3.27%) 였고, 원인으로급성및괴사성염증으로인한해부학적유착 5예와천공성농양으로복강경수술진행이어려운경우가 3예로조사되었다. 타보고에비해급성및괴사성담낭염비율이다르고, 이로인해복강경수술진행이어려운경우개복술전환을선택할수도있지만, 환자의상태가안정적일경우수술시간이더소요되더라도복강경으로수술을마무리하려는시도와단일술자의경험적숙련도증가등으로전환율이낮게나타난것으로사료된다. 복강경담낭절제술에서개복술로전환하는요인에대해 Friede 등 5 은해부학적으로담낭관, 담관, 담낭동맥등의확인이어려운경우와담관및장관손상등수술중에합병증발생과환자의비만, 기복강형성의실패, 담낭암, 담관암등의예상치못한병변의발견등을들었다. 또한, Oh 등 6 은수술시간지연으로개복수술전환이이뤄진다고도 보고했다. 본연구에서도담낭관, 담도, 담낭동맥등이해부학적으로확인이어려운경우와담관손상, 예기치못한출혈과담낭암이원인으로작용하였다. 기존의보고에서복강경담낭절제술중우연히발견된담낭암의빈도는약 % 로보고되고있는데, 7,8 본연구에서도 0.96% 로유사하게나타났다. ptb 병기의경우 3 5% 에서림프절전이가보고되었기때문에재수술의대상이될수있다. 9-2 본원의경우 ptb 병기를가진 3예중 예는추가수술을권고하였으나환자가고령이라는이유로거부하였고, 예는타병원으로전원되었으며, 예는외래통원하면서항암제복용중이다. 복강경담낭절제술은기존의개복담낭절제술보다수술중담도손상의합병증이더높은것으로보고되고있다. 22 Fisher 23 는세계적으로가장노련한외과의들조차도복강경담낭절제술중담관손상합병증이 % 정도생길수있기때문에환자에게그가능성에대해충분한정보를제공할필요가있다고하였다. 본연구에도담관손상은 642예중 3예 (0.46%) 로유사한결과를보였다. Wolf 등 24 의보고에따르면담관손상, 담즙유출, 재수술이나수혈을필요로하는출혈, 사망등주요합병증은복강경담낭절제술시행중개복술로전환한경우 (5.9%) 에서개복담낭절제술을시행한경우 (4.4%) 보다더높다고보고했다. 본연구에서복강경담낭절제술시행중개복술로전환한경우주요합병증은총담관손상 예, 담낭동맥출혈 예, 사망 예로총 3예였다. 복강경담낭절제술이후발견된담관손상은 2예, 담즙유출은 4예, 혈복강 예로총 7예가조사되어, 복강경으로시도된담낭절제술 642예중에서는주요합병증이총 0예 (.56%) 로낮게나타났다. Ahn 등 25 은 500 예의복강경담낭절제술에서수술후합병증 3예 (2.6%) 와수술중합병증 예 (2.2%) 로총합병증은 24예 (4.8%) 로발생하였다고한다. 본연구에서주요합병증과기타합병증까지포함된총합병증은복강경담낭절제술이후 62예중 2예 (.93%) 였고, 수술중발생한합병증으로개복술로전환된경우와개복전환수술후합병증까지모두포함한복강경으로시도된담낭절제술 642예의총합병증은 5예 (2.34%) 로낮게나타났다. 이는숙련된술자가경험이축척된다면복강경담낭절제술합병증발생을감소시킬수있을것으로사료된다. 결 복강경담낭절제술은양성담낭질환치료의표준술식이다. 기존보고와비교하여재원기간, 개복술로의전환율및수술후합병증이큰차이를보이지않으므로, 외과의사가술기를충분히숙달하고경험을축적하여, 복강경담낭절제술의적응증을신중하게선택한다면중소병원에서도효과적이고안전하게사용할수있는표준술식임을확인하였다. 론

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노영남

노영남 Purpose: Delayed massive hemorrhages from pseudoaneurysm rupture of the peripancreatic large arteries, after pancreaticoduodenectomy, are fatal. We reviewed the clinical course and outcome of bleeding