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1 대한외과학회지 : 제76권제3호 Vol. 76, No. 3, March, 2009 원 저 대퇴탈장수술전후의진단일치율과진단의정확도에영향을미치는요인 원광대학교의과대학외과학교실 유호길ㆍ이광만ㆍ최운정 The Diagnostic Concordance of Femoral Hernia and the Factors Influencing Diagnosis Ho-gil Yoo, M.D., Kwang-man Lee, M.D., Un-jong Choi, M.D. Department of Surgery, Wonkwang University School of Medicine, Iksan, Korea Purpose: Misdiagnosis is frequent in femoral hernia as inguinal hernia. The aims of this study were to examine the diagnostic concordance and to define the factors having influence on the correct diagnosis of femoral hernia. Methods: Thirty-two patients who underwent femoral hernia operations were analyzed retrospectively. Results: The mean age of the study subjects was 65.8±15.5 (36 97) and the female to male ratio was 5.4:1. The mean body mass index (BMI) was 19.8 kg/m 2 ( kg/m 2 ). Twelve patients (37.5%) showed preand post-operative diagnostic concordance and 20 patients (62.5%) did not. Among the 20 misdiagnosed cases, 16 cases were misdiagnosed as inguinal hernia, 2 cases as lipoma, and 1 case as lymphadenopathy. The factors related to the correct diagnosis of femoral hernias were associated with groin mass (96.9%, 31/32: 23 painless and 8 painful), size fluctuation of mass (cyclic wax and wane pattern) (84.4%, 27/32), long duration of mass (over 1 month) (75.0%, 24/32), femoral venous compression CT findings (63.6%, 14/22), and positive ultrasonographic findings (42.1%, 8/19). Emergency operation was done in 12 cases (37.5%). Incarceration was found in 23 cases (71.9%) and most of the incarcerated organs were omental fat (11 cases) and small bowel (10 cases). Bowel resection was done in 4 cases and 2 patients combined inguinal hernia. Conclusion: Through the careful taking of medical history and physical examination, physicians can achieve the correct diagnosis and can also decrease the frequency of emergency operations and their related complications. (J Korean Surg Soc 2009;76: ) Key Words: Femoral hernia, Diagnosis, Misdiagnosis, Computed tomography 중심단어 : 대퇴탈장, 진단, 오진, 컴퓨터단층촬영 서 대퇴탈장은대퇴관을통해탈장낭이나온것으로, 나이 책임저자 : 최운정, 전북익산시신용동 , 원광대학교의과대학외과학교실 Tel: , Fax: docjong@wonkwang.ac.kr 접수일 :2008 년 9 월 26 일, 게재승인일 :2008 년 11 월 20 일본논문은 2007 년대한외과학회추계학술대회에서구연하였음. 본논문은 2007 년도원광대학교의교비지원에의해서수행됨. 론 가증가할수록발생빈도가증가하며, 마른여성에호발하는것으로알려져있다. 복벽탈장의 80% 정도가서혜탈장이며, 5% 정도가대퇴탈장이다.(1) 대퇴탈장은수술전진단율이낮아흔히서혜탈장, 서혜부림프절종대, 지방종, 대퇴동맥동맥류, 음낭수종, 요근농양등으로오진되기쉬우며, 정확한진단이수술중에이루어지는경우가흔하다 (Fig. 1). 대퇴탈장은수술전정확히진단하여선택수술을하는경우보다장폐색이나장괴사등의합병증으로응급수술을하게되는빈도가서혜탈장보다 3배정도많으며, 이에따른사망률이높은것으로 179
2 180 J Korean Surg Soc. Vol. 76, No. 3 Fig. 1. Diagram of misdiagnosed cases of femoral hernias. 알려져있다.(2-5) 이에저자들은대퇴탈장의수술전후진단의일치율과대퇴탈장의정확한진단에영향을미치는인자들을알아보고자본연구를시행하였다. 방법 1) 대상 1988년 1월부터 2007년 10월까지원광대학교의과대학병원에서수술을통해대퇴탈장으로확진된 32명의환자들을대상으로하였다. 2) 방법환자들의임상정보, 주증상, 진단방법, 감돈및교액여부, 수술전진단여부, 응급수술시행여부, 탈장낭의크기및내용물, 수술소견, 교정방법등을후향적으로비교조사하였으며, 미진한기록및경과추적관찰은전화를통한추가조사도시행하였다. 저체중은체질량지수가 18.5 kg/m 2 이하인경우로하였으며, 대퇴탈장수술전후진단의일치율과진단의정확도에미치는요인으로서 32명의환자들이가지고있던여러임상정보중진단적가치가있는소견들을분석하였고, 초음파검사와컴퓨터단층촬영등보조적인진단방법의유용성을알아보았다. 또한환자들을 10년을기준으로과거 10년 (1988년 1997년) 과최근 10년 (1998년 2007년) 으로나누어시기별특성이있는지조사하였다. 수술은환자의전신상태와마취위험도를판단하여, 전신마취, 척추마취, 부분마취하에시행하였다. 응급실에내원하여당일 12시간이내에수술이시행되었던경우와주로외래방문및입원후정규수술계획에따른경우를분류하여응급수술과선택수술로구분하였으며, 수술도중 감돈및교액유무를조사하였고, 탈장낭의크기, 내용물등도조사하였다. 수술방법은외복사근막 (external oblique aponeurosis) 의절개여부에따라고식적서혜부접근법 (inguinal approach) 과서혜인대하방의대퇴탈장낭에직접접근하는대퇴접근 (crural approach) 으로구분하였고, 대퇴낭은대부분절개후내용물을확인하고낭의목부위에서고위결찰후절제하였다. 넓혀진대퇴륜을교정하는방법에따라자가조직봉합 (tissue repair) 과인공막삽입 (prosthetic mesh) 사용여부를조사하였다. 최근에는부분마취하에인공막삽입수술을도입하여피부절개부위에국소마취제를주사하고이후근막과복막을중심으로단계적으로국소마취제를주사하면서수술을진행하였다. 대퇴접근수술에사용되는 PHS R 메쉬의 onlay는대퇴륜에맞도록재단하여사용하였고, Perfix R 메쉬의안쪽조각 (inner petals) 은짧게자른후바깥인공막을대퇴륜에고정하였다 (Fig. 2). 3) 분석및통계처리 SPSS 13.0을이용하여불연속변수의빈도는 Chi-square법으로, 연속변수의평균은 student t-test법으로분석하였다. 결과 1) 환자의임상적특성 (Table 1) 대상환자들의평균나이는 65.8±15.5세 (36 97세) 였으며, 여자가 27예남자가 5예로 5.4:1로여자에서더많이발생하였다. 체질량지수 (body mass index) 는평균 19.8±2.9 kg/m 2 ( ) 였으며, 이중 BMI 18.5 kg/m 2 이하의저체중을보인환자는 12예 (37.5%) 였다. 수술전환자들이호소하는주증상은서혜부종괴가 20예 ( 무통성종괴 15예, 통증성종괴 5예 ) 로가장많았으며, 복부통증이 12예였다. 또
3 Ho-gil Yoo, et al The Diagnostic Concordance of Femoral Hernia and the Factors Influencing Diagnosis 181 Fig. 2. Crural approach of femoral hernia using Perfix (A) and PHS (B). 한 서혜탈장이 동반되었던 경우가 2예로서 모두 직접탈장 Table 1. Patient demographics Demographics No. (%) Age (mean±s.d.)(years)(range) 65.8±15.5 (36 97) Gender Female 27 (84.3) Male 5 (15.7) ±2.9 ( ) BMI (mean±s.d.)(kg/m )(range) Low body weight (BMI 18.5 kg/m2) 12 (37.5) Site of hernia Right 16 (50.0) Left 16 (50.0) Chief complaint Localized Painless mass 15 (46.8) Painful mass 5 (15.6) Generalized Abdominal pain 12 (37.5) Recurred femoral hernia 1 (3.1) Combined inguinal hernia 2* (6.2) Previous hernia operation 2 (6.2) BMI = body mass index. *Combined inguinal hernias were all di rect forms. The cases of previous hernia operation were all indrect forms. 이었으며, 이전에 서혜 간접탈장으로 수술하였던 과거력을 가진 환자도 2명이었다. 2) 수술 소견 및 방법(Table 2) 응급수술로 시행된 경우는 12예(37.5%)와 정규 수술로 시행된 경우는 20예(62.5%)로서, 전신마취 하 12예, 척추마 취 하 8예, 부분마취 하 12예에서 시행하였다. 평균 대퇴탈 장낭의 크기는 4.1±1.3 cm였고, 수술 시야에서 복강 내 장기 가 감돈된 경우는 23예였으며, 감돈된 장기는 주로 장막 지 방(11예)과 소장(10예)이었고, 그 중 4예에서는 장 괴사가 있어 장 절제를 시행하였다. 수술 방법으로는 자가조직 탈 장교정술이 14예, 인공막 메쉬 삽입이 18예(PHS 10예, Perfix 6예, mesh patch 2예)였다. 수술 후 일부 환자에서 수술 창에 장액종(seroma)이 발생하였으며, 1명의 환자에서 만성 허혈성 장협착으로 장 절제술을 추가 시행하였다. 사 망한 예는 1명으로 패혈증이 원인이었으며, 최소 1년 이상 추적관찰 되었던 31명에서 조사된 추적 관찰 기간(65.7± 37.7 months) 동안 대퇴탈장이 재발된 경우는 없었다.
4 182 J Korean Surg Soc. Vol. 76, No. 3 Table 2. Operations findings Characteristics No. (%) Schedule Elective 20 (62.5) Emergency 12 (37.5) Anesthesia Local 12 (37.5) Spinal 8 (25.0) General 12 (37.5) Sac size (mean±s.d.)(cm)(range) 4.1±1.3 ( ) Incarceration Yes 23* (71.8) (Omental fat 11, small bowel 10, colon 2) No 9 (28.2) Approach Inguinal 13 (40.6) (McVay 12, mesh patch 1) Crural 19 (59.4) (PHS R 10, Perfix R 6, tissue suture 2, mesh patch 1) *In 4 cases, bowel resection was performed, 2 cases combined with inguinal hernias. Table 3. Diagnostic concordance and missed diagnosis Assessment No. (%) Diagnostic concordance 12 (37.5) Missed diagnosis 20 (62.5) Inguinal hernia 16 (80.0) Lipoma 2 (10.0) Lymph node enlargement 1 (5.0) No recognition of femoral lesion 1* (5.0) *One case was accidentally found during intestinal resection due to intestinal necrosis. 3) 진단의정확도에영향을미치는요인 (Table 3, 4, 5) 대퇴탈장수술전후진단의일치율은 37.5% (12예) 였으며, 오진된경우는 20예로서서혜탈장으로진단된환자가가장많았고 (16예, 80.0%), 그외대퇴지방종, 서혜부림프절종대로진단된경우가각각 2예, 1예였으며, 장괴사로수술도중발견된경우도 1예있었다 (Table 3). 진단일치를보였던환자군과오진을보였던환자군의비교에서는여러임상정보와신체검사소견, 탈장의양상, 보조적진단방법중통계적으로유의한소견은컴퓨터단층촬영수행여부였다 (Table 4). 하지만, 대퇴탈장으로확진된본연구의대상환자들이보였던진단적가치가있는특성들의비교에 Table 4. Comparison between diagnostic and misdiagnostic femoral hernias Characteristics Diagnostic Misdiagnostic group group P-value (n=12) (n=20) No. (%) No. (%) Age (mean±s.d.)(years) 64.4± ± * BMI (mean±s.d.)(kg/m 2 ) 19.6± ± * Ratio of gender (female/male) 9/3 18/ Site of hernia (right/left) 6/6 10/ Existence of groin mass 11 (91.7) 20 (100) Size of sac (mean±s.d.)(cm) 4.3± ± * Fluctuation of size 11 (91.7) 16 (80.0) Long history of symptoms 9 (75.0) 15 (75.0) (more than one month) Performance of 8 (66.7) 11 (55.0) ultrasonography Performance of CT 11 (91.7) 11 (55.0) Schedule of emergency 4 (33.3) 7 (35.0) Periods (remote/recent 10 yr) 4/8 6/ BMI = body mass index. *Student t-test, Chi-square. Table 5. Factors related to the diagnostic accuracy of femoral hernia Factors Ratio (%) Existence of groin mass 31/32 (96.9) Size fluctuation 27/32 (84.4) Long duration of symptom 24/32 (75.0) (more than one month) Positive sonographic finding (n=19) 8/19 (42.1) Computed tomographic finding (n=22) Positive venous compression 14/22 (63.6) Localized sac in femoral ring 11/22 (50.0) 서는초음파검사와컴퓨터단층촬영은대퇴탈장의정확한진단에큰도움을주지못했고, 대퇴종괴와함께비교적긴증상발현의병력과대퇴종괴의크기증감이반복되는경우는진단에유의한가치가있었다 (Table 5, Fig. 3). 4) 시기별분석 (Table 6) 최근 10년 (1998년 2007년) 과그이전과거 10년동안의시기별분석에서는환자발생이 22예와 10예로서대퇴탈장수술건수가 2배증가하였으나, 두군간환자의나이, 성별, 환자체질량지수, 수술전진단정확도, 응급수술빈도등에서는차이를보이지않았다.
5 Ho-gil Yoo, et al:the Diagnostic Concordance of Femoral Hernia and the Factors Influencing Diagnosis 183 Fig. 3. Cases are confirmed as a femoral hernia. There are no typical findings of femoral hernia which are venous compression and localized sac in femoral ring on CT image (arrows). Table 6. Remote 10 years ago vs. recent 10 years ago Characteristics Remote Recent 10 years 10 years (n=10) (n=22) No. (%) No. (%) P-value Age (mean±s.d.)(years) 61.6± ± * Gender (female/male) 9/1 18/ BMI (mean±s.d.)(kg/m 2 ) 19.0± ± * Incarceration 7 (70.0) 16 (72.7) Emergency operation 2 (20.0) 9 (40.9) Diagnostic concordance 4 (40.0) 8 (36.3) BMI = body mass index. *Student t-test, Chi-square. 고 대퇴륜은외측으로는대퇴정맥, 위로는서혜인대, 내측으로는열공인대 (lacunar ligament), 뒤로는치골인대 (pectineal ligament) 로경계를이루며, 대퇴탈장은탈장낭이대퇴륜을통해서혜인대하방에있는대퇴관으로나온것이다.(6,7) 이러한대퇴탈장에대한국내보고를보면, 대퇴탈장의분석에대한단독연구는없으며, 대부분증례보고들이다. 이는외국의보고를보더라도연구대상수가 50예정도인것을보면, 대퇴탈장의발생빈도가극소수임을알수있다.(2-5) 대퇴탈장의발생빈도는성인탈장의 5% 미만이라고하나, 최근고령인구가급증함을고려할때발생빈도가 찰 증가할것으로예상되어고령의노인에대한섬세한진찰이요구된다. 단일기관의보고이지만본연구에서는최근 10년동안대퇴탈장의수술빈도가 2배로증가하였다 (Table 6). 대퇴탈장의발생위치는서혜탈장과비슷하게주로우측에호발하는것으로알려져있으나,(1-5) 본연구에서는우측과좌측의빈도가동일하였다. 남자보다여성에빈발하며이는비교적넓은골반을갖은여성의해부학적특징으로상대적으로대퇴륜이넓은이유에서기인한다. 본연구에서도남녀비는 1 대 5.4로여성에서호발하였으며, 최근에는고령의환자중남자환자 4예를경험하였다. 대퇴탈장진단시서혜탈장이동반될가능성이있으며, 보고자마다다르지만약 5 20% 에서동반된다고하였다.(8) 또한서혜탈장의수술과거력이있는환자에서대퇴탈장이많이보고된다고하였으며, 이러한상관관계의이유로는서혜탈장수술시이미동반되어있던대퇴탈장을간과했을때와서혜탈장수술시과도한주위조직박리로대퇴륜을느슨하게한경우, 서혜탈장수술로인해대퇴륜막이과도게당겨져대퇴륜이확장되기때문이다.(8,9) 본연구에서도 2명의환자에서동시에서혜탈장을가지고있었으며, 이전에서혜탈장의수술기왕력을가진경우도 2명이있었다. 대퇴탈장은무증상일때는촉지하기가쉽지않으며, 종괴가있어도서혜탈장과오인되는경우가많기때문에수
6 184 J Korean Surg Soc. Vol. 76, No. 3 술전에정확히진단하기가어렵고,(3,10,11) 대퇴륜의좁은해부학적특징때문에뚜렷한탈장의돌출증후가없어도교액이나감돈이다른복벽탈장보다흔하여응급수술을받게될가능성이높아진다. 응급대퇴탈장수술은 1970, 80 년대는 30% 의이환율과 10% 의사망률로복벽탈장중에서가장예후가좋지않았으며, 교액이동반되고고령환자일수록예후가나쁘다고알려져있다.(12,13) 본연구에서도대퇴탈장낭내에복부장기가감돈된예는 23예였으나, 과반수가장간막지방의감돈으로복부통증이나장폐색이없어선택수술을시행하였고, 장이감돈된 12예에서는장폐색증상으로응급수술을시행하였다. 장관이감돈된 12 명중 4명에서장절제를하였으며, 그중 1명은수술후패혈증으로사망하였다. 수술전정확한진단은초음파검사가도움이되는것으로알려져있다.(14,15) 하지만 Zhang 등 (16) 과 Bradley 등 (17) 은컬러도플러초음파검사가서혜부탈장의존재여부를판단하는데도움을줄수있으나간접탈장과직접탈장의구분, 서혜탈장과대퇴탈장간의감별진단에약 45% 정확도로서감별진단에있어초음파검사의한계성을지적하였다. 본연구에서도 32명의환자중 19명에서수술전초음파검사를시행하였으나초음파검사를통한진단은 8명 (42.1%) 으로정확한진단에큰영향을미치지못하였다. 이러한초음파검사는시술자의주관적인검사라는점과서혜부의복잡한해부학적구조로인해탈장유무를진단하는데에는유용하나서혜탈장과대퇴탈장을감별하는데낮은정확성을보여, 컴퓨터단층촬영의필요성이대두되었다. 임상적으로진단이확실하지않고, 장합병증이의심될경우컴퓨터단층촬영이가장좋은영상진단방법으로여겨져왔다. 하지만이또한서혜부탈장의진단은비교적쉽게할수있으나탈장형태의감별진단은불확실하다고보고하고있다.(18-20) 반면에 Delabrousse 등 (18) 은치골결절 (pubic tubercle) 을기준점으로하여 X축과 Y축으로가상의선을그어 X축의뒤쪽에탈장낭이있는경우서혜탈장과감별이가능하다고하였다. Cherian과 Parnell(21) 은다면나선컴퓨터단층촬영 (multisectioned spiral computed tomography) 을이용한고해상의관상면과시상면영상 (high resolution coronal and sagittal image) 을통한연구에서관상면재건영상이대퇴삼각부 (femoral triangle) 를해부학적으로정확히관찰할수있어, 치골결절을기준으로사용하는것은의미가없다고하였고, 서혜인대, 대퇴정맥, 대퇴장내전근 (adductor longus femoris) 으로이뤄지는영상학적대퇴삼각부 (radiological femoral triangle) 에탈장낭이있을경우서혜탈장과감별이가능하다고하였다. Suzuki 등 (22) 에의하면탈장낭이치골결절외측으로만위치되어있고, 대퇴정맥의압박 (compression) 이보이면서혜탈장과감별하는데도움이된다고하였으나이는대퇴탈장의크기가비교적큰경우나진행된경우이며, 또촬영하는간격 (slice) 에따라다르므로영상을분석하는데주의를필요로한다. 본연구에서수술전진단은신체검사에서명확히대퇴탈장의소견이보인경우는초음파검사나컴퓨터단층촬영을하지않았고, 장괴사등의응급증상이선행되었을때는보조적검사를추가하기보다는응급수술로대퇴탈장을확진하였다. 수술전진단이애매할때초음파검사를먼저시행하였고초음파검사를할수없거나초음파검사시행후에도진단이어려울땐컴퓨터단층촬영을시행하였다. 따라서보조진단검사의정확도를평가하기에는한계가있으나, 수술전컴퓨터단층촬영을시행한 22명중에서대퇴탈장의중요한소견이라고하는탈장낭의대퇴륜내위치소견은 11명 (50.0%), 대퇴정맥압박소견은 14명 (63.6%) 에서만보여컴퓨터단층촬영이서혜탈장과감별진단에있어서큰도움을주지는못하는것으로나타났다 (Fig. 3). 대퇴탈장의크기가작은경우나앙와위에서탈장낭의내용물이환납된경우, 컴퓨터단층촬영시환자의자세, 복압유지상태등여러요인으로인해실제로는초음파검사와컴퓨터단층촬영검사는대퇴탈장의정확한진단에는한계가있었다. 대퇴탈장에서환자자신은물론의료진도병변을인지하지못하는경우가있다 (Fig. 1). Naude 등 (3) 의보고에의하면, 환자들은평균에 1.4회이상의진료방문횟수를보이나, 탈장낭의크기가작은경우는하복부의불편감과함께가벼운하부쏠림증상만있어병변의위치를간과하기쉽다고하였다. 본연구에서는환자가호소하는주증상으로서서혜부종괴를주소로내원한환자가 20명이었으며, 주증상이복부통증을보인환자는 12명이었다. 신체검사에서서혜부종괴가 31명있었으며, 27명은종괴크기의증감변화가있었고, 24명은 1달이상지속되는종괴를가지고있었다. 대퇴탈장과서혜탈장간에감별진단의혼동에대하여 Alimoglu 등 (23) 은지방을싸고있는 Scarpa씨근막이서혜부와대퇴부를연속적으로덮고있기때문에탈장낭이서혜인대상방으로이동하는경향이있어탈장낭이서혜부에존재할수있기때문에서혜탈장혹은지방종, 림프절종대등으로오진되기쉽다고설명하였다.
7 Ho-gil Yoo, et al:the Diagnostic Concordance of Femoral Hernia and the Factors Influencing Diagnosis 185 Fig. 4. Emergency operation was done due to severe bowel obstruction of right femoral hernia. Unfortunately, he had got femoral hernia 4 months ago (arrow). 수술방법으로과거에는자가조직교정술인 Mcvay씨수술을주로하였으나, 최근에는서혜부탈장수술에서메쉬삽입이보편화됨에따라선택수술에서발견되는대퇴탈장도대퇴부접근만을통해인공막을삽입고정하는방법이각광을받고있다.(23) 본연구자들도최근 10년동안에대퇴접근수술을많이시행하였고제품화된 PHS R 와 Perfix R 메쉬를대퇴륜에간단히고정하는방법으로서무긴장교정술이라는점과수술후통증도감소된다는점때문에사용하였다. 수술후의합병증은재발과대퇴정맥혈전증등이보고되고있으나본저자들은경험하지않았다. 따라서대퇴탈장의크기가작은경우, 본연구의 Fig. 4의증례와같이초기에는환자가호소하는자각증상이경미하므로자세한문진과복부진찰시허리띠이하의서혜부까지도철저히검사하여수술전빠르고정확한진단을통해교액이나감돈을줄여야수술후합병증및사망률을감소시킬수있을것으로생각한다. 결론 대퇴탈장은비교적마르고여성인고령노인에서발생하였으며, 최근고령인구의증가로그발생이증가함을알수있었다. 본연구에서는대퇴탈장의수술전후진단일치율은 37.5% 였고, 수술전정확한진단을위해서는초음파검사나컴퓨터전산촬영등방사선검사에의존하기보다는수술전자세한문진과신체검사가진단의정확도를높일수있으며, 특히서혜인대이하부위에서발견되는종괴에대해서는항상대퇴탈장의가능성을고려해야응급수술및 합병증의빈도를줄일수있을것으로생각한다. REFERENCES 1) Richards AT, Quinn TH, Fitzgibbons RJ. Abdominal wall hernias. In: Greenfield LJ, editor. Surgery: Scientific Principles and Practice. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; p ) Kemler MA, Oostvogel HJ. Femoral hernia: is a conservative policy justified? Eur J Surg 1997;163: ) Naude GP, Ocon S, Bongard F. Femoral hernia: the dire consequences of a missed diagnosis. Am J Emerg Med 1997;15: ) Nilsson H, Stylianidis G, Haapamaki M, Nilsson E, Nordin P. Mortality after groin hernia surgery. Ann Surg 2007;245: ) Brittenden J, Heys SD, Eremin O. Femoral hernia: mortality and morbidity following elective and emergency surgery. J R Coll Surg Edinb 1991;36: ) Sandblom G, Haapaniemi S, Nilsson E. Femoral hernias: a register analysis of 588 repairs. Hernia 1999;3: ) Buchin P, Steinau G, Ophoff K, Dreuw B, Truong S, Schumpelick V. Femoral hernia in childhood: evaluation of sonography as a diagnostic aid. Hernia 1999;3: ) Mikkelsen T, Bay-Nielsen M, Kehlet H. Risk of femoral hernia after inguinal herniorrhaphy. Br J Surg 2002;89: ) Bendavid R. Femoral hernias: primary versus recurrence. Int Surg 1989;74: ) Rhind JR. Lateral femoral hernia. J R Coll Surg Edinb 1971; 16: ) Ponka JL, Brush BE. Problem of femoral hernia. Arch Surg 1971;102: ) Quill DS, Devlin HB, Plant JA, Denham KR, McNay RA,
8 186 J Korean Surg Soc. Vol. 76, No. 3 Morris D. Surgical operation rates: a twelve year experience in Stockton on Tees. Ann R Coll Surg Engl 1983;65: ) Malek S, Torella F, Edwards PR. Emergency repair of groin herniae: outcome and implications for elective surgery waiting times. Int J Clin Pract 2004;58: ) Chen KC, Chu CC, Chou TY, Wu CJ. Ultrasonography for inguinal hernias in boys. J Pediatr Surg 1998;33: ) Chou TY, Chu CC, Diau GY, Wu CJ, Gueng MK. Inguinal hernia in children: US versus exploratory surgery and intraoperative contralateral laparoscopy. Radiology 1996;201: ) Zhang GQ, Sugiyama M, Hagi H, Urata T, Shimamori N, Atomi Y. Groin hernias in adults: value of color Doppler sonography in their classification. J Clin Ultrasound 2001;29: ) Bradley M, Morgan D, Pentlow B, Roe A. The groin hernia - an ultrasound diagnosis? Ann R Coll Surg Engl 2003;85: ) Delabrousse E, Denue PO, Aubry S, Sarlieve P, Mantion GA, Kastler BA. The pubic tubercle: a CT landmark in groin hernia. Abdom Imaging 2007;32: ) Ianora AA, Midiri M, Vinci R, Rotondo A, Angelelli G. Abdominal wall hernias: imaging with spiral CT. Eur Radiol 2000;10: ) Zarvan NP, Lee FT Jr, Yandow DR, Unger JS. Abdominal hernias: CT findings. AJR Am J Roentgenol 1995;164: ) Cherian PT, Parnell AP. The diagnosis and classification of inguinal and femoral hernia on multisection spiral CT. Clin Radiol 2008;63: )Suzuki S, Furui S, Okinaga K, Sakamoto T, Murata J, Furukawa A, et al. Differentiation of femoral versus inguinal hernia: CT findings. AJR Am J Roentgenol 2007;189:W ) Alimoglu O, Kaya B, Okan I, Dasiran F, Guzey D, Bas G, et al. Femoral hernia: a review of 83 cases. Hernia 2006;10: 70-3.
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