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1 대한내시경복강경외과학회지 한상문 차선욱 1 김원우 전해명 1, 1 <Abstract> Totally Laparoscopic Distal Gastrectomy with D1+α Lymph Node Dissection Sang Moon Han, M.D., Seon Wook Cha, M.D. 1, Won Woo Kim, M.D., Hae Myung Jeon, M.D. 1 Department of Surgery, Kangnam CHA Hospital, College of Medicine, Pochon CHA University, 1 Department of Surgery, St. Mary s Hospital, College of Medicine, The Catholic University Purpose: The first totally laparoscopic gastrectomy was performed in To date, laparoscopic gastrectomy has been performed by a small number of surgeons around the world. The techniques of laparoscopic gastrectomy with perigastric lymph node dissection in early gastric cancer were reported in many laparoscopic surgery center, however most of them were hand-assisted laparoscopic gastrectomy or laparoscopy-assisted gastrectomy. Here, we have introduced the technique and initial results for totally laparoscopic gastrectomy with extra perigastric lymph node dissection for early gastric cancer. Methods: Five patients with early gastric cancer underwent totally laparoscopic gastrectomy with extra peri-gastric lymph node dissection. Reconstruction was performed with intracorporeally Billroth-II gastrojejunostomy or Roux-en-Y gastrojejunostomy using EEA (End to side anastomosis) or GIA stapler. Resected specimen was retrieved through 4 cm Pfannenstiel supra-pubic incision. Results: All laparoscopic gastrectomy technique on gastric cancer were performed successfully without conversion to open. Median dissected lymph node was 17 (range: 3 29), Operation time was 260 min. (range: ), and Median postoperative hospital days were 9 days (range: 7 12). There was no major complication. Conclusion: We need more cases to analysis the technique emphasis on minimizing the invasive procedure, on laparoscopic gastrectomy and intracorporeal reconstruction can be effective way of treating. The modified operative technique is recommended in early gastric cancer to increase the laparoscopic advantages., , Tel , Fax , wwk@cha.ac.kr. 116

117 Key words: Totally laparoscopic gastrectomy, Intracorporeal reconstruction, Roux-en-Y gastrojejunostomy, B-II gastrojejunostomy :, 서론.(1,2). (non-invasive treatment).(3-6) 1992 3 Kitano.(7),,.

2 117 Key words: Totally laparoscopic gastrectomy, Intracorporeal reconstruction, Roux-en-Y gastrojejunostomy, B-II gastrojejunostomy :, 서론.(1,2). (non-invasive treatment).(3-6) Kitano.(7),,.(4,8,9) 5 totally laparoscopic distal gastrectomy with D1+No.7 & No.8 lymph node dissection. 5 D1+ (Totally laparoscopic distal gastrectomy with D1+No.7 & No.8 lymph node dissection) 2 Roux-en-Y, 3 Billroth-II. 45 Reverse-Trendelenburg Lloyd-Davis position 20 (Fig. 1)., 1, 2. video monitor. 12 mmhg, mm (trocar) Fig. 2 6 (Port).. Scope scope. 4. Monitor 3. Patient -French position 대상및방법 2. Assistant, 2 cm, (9) Operator Fig. 1. Patient position for laparoscopic gastrectomy.

118 한상문 차선욱 김원우 전해명 3. Rt. midclavicle - 12 mm 2. Rt. flank 10 mm - liver retracter 4. Lt. midclavicle - 12 mm 5. Lt. flank 12 mm - drain insertion Roux-en-Y gastrojejunostomy Anastomosis 6.

번 결찰한 후 절단하고 주위 7번 림프절을 동시에 곽 청한다. 식도 위이행부(EG junction)를 확인하고 1번(우분문) 림프절 곽청을 시행한 후 EndoGIA 60 mm와 45 mm를 이용하여 병변으로부터 약 5 cm 상부에서 위를 절제한 다.

The anvil within the 18 Fr nasogastric tube.

3 118 한상문 차선욱 김원우 전해명 3. Rt. midclavicle - 12 mm 2. Rt. flank 10 mm - liver retracter 4. Lt. midclavicle - 12 mm 5. Lt. flank 12 mm - drain insertion Roux-en-Y gastrojejunostomy Anastomosis 6. Suprapubic pfannenstiel incision - retrieval of specimen Fig. 2. Location of the port site for laparoscopic gastrectomy. Fig. 4. Roux-en-Y Endo-to-side gastrojejunostomy. 번 결찰한 후 절단하고 주위 7번 림프절을 동시에 곽 청한다. 식도 위이행부(EG junction)를 확인하고 1번(우분문) 림프절 곽청을 시행한 후 EndoGIA 60 mm와 45 mm를 이용하여 병변으로부터 약 5 cm 상부에서 위를 절제한 다. 이때 떨어져 나온 위조직과 림프절은 Lapbag (Sejong med, Paju, Korea)에 넣어 위공장 문합술이 이루어 지는 동안 골반강 내에 잠시 위치하게 한다. 이후 저자 들은 위공장 문합과정에 방법을 달리하여 재건하였으 므로 수술 방법을 각각 따로 소개하기로 한다. Fig. 3. The anvil within the 18 Fr nasogastric tube. 1) Laparoscopic Roux-en-Y 위공장문합술 먼저 Treiz 인대에서 약 20 cm 하방 공장을 45 mm 3번 투관구를 통해 liver retractor를 넣어 수술 시야를 EndoGIA를 이용하여 절단하고 그 장간막은 Ultrasonic 확보한 후 주로 Ligasure (ValleyLab, Colorado. USA) 을 coagulation shear를 이용하여 장간막 혈관을 보존하면 이용하여 대망절개술을 시행하였다. 먼저 비장 하부를 서 무혈관 부위를 세로로 절개한다. 이어 Roux (distal 향해 대망을 절개한 후, 십이지장을 향해 절개하고 우 jejunum) limb을 횡행결장 앞으로 끌어올리면서 내강 위대망동정맥(Rt. gastroepiploic vessel)은 EndoClip을 으로 6번 투관구를 1 cm 가량 확장한 수술 절개창을 이용하여 두 번 결찰한 후 절단한다. 십이지장은 유문 통해 복강 내로 들어온 25 mm 자동단단문합기(EEA, (Pylorus)에서 1 cm 하방에서 endoscopic stapling de- United States Surgical Corporation, Norwalk, Connec- vice, 60 mm EndoGIA (Ethicon, Endo-Surgery, Cin- ticut)를 넣는다. 한편 EEA stapler anvil은 flip top을 꺾 cinnati, Ohio)를 이용하여 절단한다. 우위동정맥(Rt. 어 flipped anvil을 만들고, tip에 18 Fr nasogastric tube gastric artery)을 절단하여 각각 6번(유문하) 림프절과 (Nasogastric Sump Tube, Davol Inc., Cranston, Rhode 5번(유문상) 림프절을 곽청한다. 이때 총간동맥(Com- Island)를 끼워 결찰한다(Fig. 3). 이를 환자의 입을 통 mon hepatic artery) 주위의 8번 림프절을 곽청한다. 소 해 식도를 거쳐 남은 위(gastric pouch) 내에 위치하도 망을 따라 절개하면서 좌위동맥(Lt. gastric artery)을 찾 록 하고 Harmonic Scalpel을 이용하여 남은 위를 절개 아 EndoLoop (Sejong med, Paju, Korea)을 이용하여 두 하여 nasogastric tube만 anvil로부터 분리하고 투관구를

4 119 Table 1. Summary of cases No. S/A Site OP. PostoP. Macroscopic Size Histologic Pathologic Metastatic time HD depth (cm cm) type depth LN (min) (day) Reconstruction 1 F/66 Antrum Mucosa 1 1 Well diff. Mucosa 0/ Roux-en-Y 2 M/69 Antrum Mucosa Moderate diff. Submucosa 0/ Roux-en-Y 3 M/60 Antrum Submucosa 2 2 Poorly diff. Submucosa 0/ B-II 4 F/57 Antrum Mucosa Tubular adenoma Submucosa 0/ B-II 5 F/64 Antrum Submucosa 2 1 Well diff. Mucosa 0/ B-II LN=lymph node; HD=hospital day; Cx.=complication.. 25 mm EEA End to Side (Fig. 4) cm 45 mm EndoGIA Side to Side. Silk #2-0 intra-corporeal continuous running suture ( : ), Roux-en-Y. 9 ( : 7 12 ), ( : 3 29) (Table 1). Treiz 20 cm 60 mm EndoGIA End to Side. Silk #2-0 suture material continuous running suture. 100 cc Jackson-Pratt 3 6 Morrison s pouch. Lapbag 2 1 cm 3 4 cm (Pfannenstiel incision). 결과 5 totally laparoscopic distal gastrectomy with D1+ (No.7 & No.8) lymph node dissection., major complication 고찰 1992,, 1994.(3,7),.(10,11).,.(12) (1) (EUS) (2)..(5,6).

5 %.(13), 91.82% 85.8%.(14).(15) 2 cm.(16) (B-I or B-II), (wedge resection),.(3,17,18),(19),,(4) (B-I or B-II) (5) 1), 2) 3, 3) 4), 5), 6) (4). totally laparoscopic gastrectomy B-I B-II. 2 cm,, 5 totally laparoscopic gastrectomy. B-II, Roux-en-Y.(21,22), (N1 ) 7 ( ) 8 ( ).(4,9) D1+No.7 & No.8. Roux-en-Y B-II,. Endo GIA. totally laparoscopic gastrectomy,,,..,.(6,8,9) D2+,(8,20),,. 결론...

6 121 참고문헌 1) Liorens P. Gastric cancer mass survey in Cile. Semin surg Oncol 1991;7: ) Mastunoto Y, Yahai H, Tokiyama H, Nichiaki M, Higaki S, Okita K. Endoscopic ultrasonography for diagnosis of submucosal invasion in early gastric cancer. J Gastroenterol 2000;35: ) Kitano S, Iso Y, Moriyama M, Sugimachi K. Laparoscopic assisted Billroth I gastrectomy. Surg Laparosc Endosc 1994;2: ) Kitano S, Shimoda K, Miyahara M. Laparoscopic approches in the management of patients with early gastric carcinoma. Surg Laparosc Endosc 1995;5: ) Goh PM, Alponat A, Mak K, Kum CK. Early international result of laparoscopic gastrectomy. Surg Endosc 1997;11: ) Ohgami M, Otani Y, Kumai K, Kubota T. Curative laparoscopic surgery for early gastric cancer: five years experience. World J Surg 1999;23: ) Goh PM, Tekant Y, Isaac J. The technique of laparoscopic Billroth II gastrectomy. Surg Laparosc Endosc 1992;2: ) Goh PM, Khan AZ, So JB. Early experience with laparoscopic radical gastrectomy for advanced gastric cancer. Surg Laparosc Endosc 2001;11: ) Uyama I, Sugioka A, Fugita J, Komori Y. Completely laparoscopic extraperigastric lymph node dissection for gastric malignancies located in the middle or lower third of the stomach. Gastric cancer 1999;2: ) Goh PM, Kum CK. Laparoscopic Billroth II gastrectomy: a review. Surg Oncol 1993;2: ) Goh PM, Tekant Y, Kum CK, Isaac J, Ngoi SS. Totally intraabdominal laparoscopic Billroth II gastrectomy. Surg Endosc 1992;6: ) Breaux JR, Bringaze W, Chappuis C, Cohn I. Adenocarcinoma of the stomach: a review of 35 years and 1,710 cases. World J Surg 1990;14: ) Murakami T. Pathomorphological diagnosis. Definition and gross classification of early gastric cancer. Gann Monogr Cancer Res 1971;11: ) Ha TW, Kim IH, Sohn SS. Analysis of prognostic factors and outcome of early gastric cancer with and without lymph node metastasis. J Korean Surg Soc 2001;60: ) Takeshita K, Seki I, Tani M, Honda T, Saito N, Endo M. Rational lymphadenectomy for early gastric cancer with submucosal invasion: clinicopathological study. Surg Today 1998;28: ) Kitamura K, Yamaguchi T, Taniguchi H, Hagiwara A, Sawai K, Takahashi T. Analysis of lymph node metastasis in early gastric cancer: rationale of limited surgery. J Surg Oncol 1997;64: ) Anvari M, Park A. Laparoscopic assisted vagotomy and distal gastrectomy. Surg Endosc 1994;8: ) Lointer P, Leroux S, Ferrier C, Dapoigny M. A technique of laparoscopic gastrectomy and Billoth II gastrectomy. J Laparosc Surg 1993;3: ) Liorente J. Laparoscopic gastric resection of gastric leiomyoma. Surg Endosc 1994;8: ) Azagra JS, Georgen M, De Simone P. Minimally invasive surgery of gastric cancer. Surg Endosc 1999; 13: ) Kim WW, Gagner M, Biertho L, Waage A, Jacob B. Taking posterior rectus sheath laparoscopically to reinforcement the gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass. Obes Surg 2003;13: ) Kim WW, Gagner M, Kini S, et al. Laparoscopic versus Open Biliopancreatic Division with Duodenal Switch: a comparative study. J Gastrointest Surg 2003;7:552-7.

황지웅

황지웅 Comparison of Laparoscopy and Exploration in the Distal Pancreatectomy BACKGROUND: To determine the benefits of laparoscopic surgery compared with exploration, the clinical outcomes of open and laparoscopic