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1 J Korean Surg Soc 2009;77: DOI: 0.474/jkss 원 저 서혜부탈장에서전복막외복강경탈장교정술과개방적탈장교정술의비교분석 : 단일기관의초기경험 가톨릭대학교성빈센트병원, 서울성모병원외과 전강웅ㆍ정헌 ㆍ김성집ㆍ전경화ㆍ진형민ㆍ김준기 ㆍ박우배 The Comparative Analysis between Laparoscopic Total Extraperitoneal Repair and Open Tissue Repair: Initial Experience of a Single Institute Kang-Woong Jun, M.D., Hun Jung, M.D., Sung-Jeep Kim, M.D., Kyong-Hwa Jun, M.D., Hyung-Min Chin, M.D., Jun-Gi Kim, M.D., Woo-Bae Park, M.D. Department of Surgery, St. Vincent s Hospital, The Catholic University of Korea College of Medicine, Suwon, Seoul St. Mary s Hospital, Seoul, Korea Purpose: Laparoscopic herniorrhaphy has been recognized as one of the treatment options for inguinal hernia. This study compared the short-term results of two methods of repair: totally extraperitoneal (TEP) repair and open tissue based repair. Methods: A retrospective review was conducted on all patients who underwent laparoscopic TEP repair (LH, 05 cases) and open repair (OH, 57 cases) at our hospital between September 2007 and December Posterior wall repairs in open technique follow as McVay (25 cases) and Bassini (32 cases). Demographic data, operation time, perioperative complications, consumption of analgesics, and hospital stay were compared. Results: There was no significant difference in relation to patient characteristics; age, gender, BMI, medical and surgical history and hernia type. Also, there was no difference of operation time for both groups. Patients in the LH group consumed fewer analgesics (P=0.002). Intraoperative complications occurred more frequently in the LH group (P=0.036) but postoperative complications were similar. Hospital stay was shorter in LH (P<0.00). There was no difference of recurrence between LH group and OH group for 6 months. Conclusion: Laparoscopic TEP repair shows similar postoperative complications and recurrences and with less postoperative pain and hospital stay, compared with open tissue based hernia repair. However, further study with longer follow up data is necessary. (J Korean Surg Soc 2009;77: ) Key Words: Inguinal hernia, Laparoscopic herniorrhaphy, Open herniorrhaphy 중심단어 : 서혜부탈장, 복강경적탈장복원술, 개방적탈장복원술 서 론 책임저자 : 전경화, 경기도수원시팔달구지동 , 가톨릭대학교성빈센트병원외과 Tel: , Fax: dkkwkh@catholic.ac.kr 접수일 :2009 년 6 월 2 일, 게재승인일 :2009 년 7 월 3 일 서혜부탈장은외과의사가흔하게접하는질환중하나로 884년 Bassini에의해진정한의미의탈장교정술이시행되었으며, 그이후수술후재발률을낮추고합병증을감소시키기위한노력으로 McVay, Halsted, Shouldice 등에의해여러수술방법들이고안되어시행되었다.(,2) 그러나이 273
2 274 J Korean Surg Soc. Vol. 77, No. 4 러한수술방법들은근육이나근막을당겨서시행하는긴장성수술방법으로수술후통증이심하고, 상처의크기도비교적크며, 일상생활로의복귀에상당한시간을요했다. 이러한단점을보완하기위해 Lichtenstein 등 (3) 은 mesh를이용한무긴장성 (tension-free) 탈장교정술을시행하였으나, 상처의크기가기존술식과크게다르지않아미용적효과가크지않았다. 최근에는이러한단점을더욱보완한복강경탈장교정술이고안되어여러기관에서시행되고있다. 미국에서는연간약 770,000예의탈장교정술이시행되고있고이중약 0 5% 에서복강경탈장교정술이시행되고있으며,(4) 영국에서는연간약 05,000예의탈장교정술이시행되고있고이중약 4.% 에서복강경탈장교정술이시행되고있다.(5) 복강경탈장교정술은개방탈장교정술에비해수술후통증이적고, 일상생활로의복귀가빠르며, 미용적인면에서우수하고, 재발률도개방탈장교정술과비교했을때비슷하거나낮다는점에서주목을받고있다. 이러한장점에도불구하고전신마취의필요성, 복막외적관점에서서혜부해부학적구조의난해함, 수술수기습득의어려움, 개방탈장교정술에비해비싼비용등으로인해복강경탈장교정술이표준수술방법으로자리를잡는데아직한계가있다. 저자들은복강경을이용한전복막외 (totally extraperitoneal) 교정술의초기경험결과를기존의 mesh를사용하지않는고식적개방탈장교정술결과와비교고찰함으로써복강경탈장교정술의유용성및술기습득에필요한증례수 (learning curve) 를알아보고자하였다. 방법 2007년 9월부터 2008년 2월까지본원외과에서서혜부탈장으로진단하여수술을시행한환자 62명을대상으로하였다. 입원기록지와외래기록지를분석하여두군간에연령, 성별, 체질량지수 (body mass index), 탈장형태, 수술시간, 수술중및수술후합병증, 수술후재원기간, 진통제사용, 재발률등을후향적으로분석하였다. 복강경탈장교정술 (Laparoscopic Herniorrhapy, LH) 은제왕절개술과복강경하전립선암절제술의기왕력으로개방탈장교정술로전환을시행하였던 2예는제외하여 05예였고모두전복막외교정술을시행하였다. 개방탈장교정술 (Open Herniorrhapy, OH) 은 Bassini식교정술 32예와 McVay식교정술 25예, 총 57예를시행하였다. 통계분석은 Windows용 SPSS (version 2.0) 프로그램을사용하였고변수의비교는 chi-square test, one way ANOVA 등을이용하였다. 통계적의미는 P값이 0.05 이하를기준으로하였다. Table. Patient demographics Laparoscopic (n=05) Open (n=57) P-value Age (years) 54.9± ±8.5 Sex Male 93 (88.9%) 54 (94.7%) Female 2 (.%) 3 (5.3%) Body mass index (kg/m 2 ) 23.3± ±2.8 Medical history Yes 30 (29.0%) 23 (40%) No 75 (7.0%) 34 (59.6%) Hernia type Indirect 88 (82.2%) 49 (86%) Direct 0 (.2%) 8 (4%) Both 7 (6.6%) Hernia lesion Unilateral 02 (97.%) 57 (00%) Bilateral 3 (2.9%) 0 (0%) = not significant. 결 ) 대상군의임상양상 평균연령은 LH군 54.9세 ( 범위, 24 8), OH군 57.8세 ( 범위, 9 9) 로차이가없었고, 성별분포는 LH군에서남자 93예 (88.9%), 여자 2예 (.%), OH군에서남자 54예 (94.7%), 여자 3예 (5.3%) 로두군모두남성이많았다. 평균체질량지수는 LH군에서 23.3±2.8, OH군에서 23.2±2.8로두군간의차이가없었다. 과거력에서내과적질환이동반되어있는경우는 LH군에서 30예 (29%), OH군에서 23예 (40%) 였으며, 외과적수술을시행받았던경우는 LH군 25예 (4%), OH군 6예 (0%) 로 OH군에서동반된질환이더많았으며, 이중재발성탈장으로수술을시행한환자는 LH군 8예 (7%), OH군 4예 (7%) 였다. 탈장의형태는 LH군에서간접탈장 88예 (85.7%), 직접탈장 0예 (.2%), 혼합형이 7예 (6.6%, 이중양측성 3예가포함되었으며각각좌, 우탈장의형태가달랐음 ), OH군에서는간접탈장 49예 (89.0%), 직접탈장 8예 (.0%) 였으며혼합형은없었다. 또 LH군에서일측성은 02예 (97.%), 양측성 과
3 Kang-Woong Jun, et al:the Comparative Analysis between Laparoscopic Total Extraperitoneal Repair and Open Tissue Repair: Initial Experience of a Single Institute 275 Table 2. Clinical outcomes Laparoscopic (n=05) Open (n=57) P-value Operation time (min) 56.3± ±27.5 Administration of analgesics Yes 78 (75%) 47 (82.5%) No 27 (25%) 0 (7.5%) Frequency of analgesics use.5±.5 3.0± Duration of hospital stay (days).7±. 2.8± = not significant. Table 3. Perioperative complications Complications Laparoscopic (n=8) Open (n=6) P-value Fig. Learning curve of the laparoscopic herniorrhaphy. Intraoperative Peritoneum tearing Spermatic vessel injury Epigastric vessel injury Nerve injury Iliopubic vessel injury Postoperative Hematoma Urinary retention = not significant. 2 (%) (5.6%) 4 2 (.8) 5 (8.7%) 증은복막파열 5예, 하복벽동정맥손상 4예, 고환동정맥손상 예, 신경손상 예, 장골치골혈관 (iliopubic vessel) 손상이 예였으며이들은모두수술중처치가가능하였고, 이로인한개복으로의전환은없었다. 수술후합병증은혈종 (LH군 4예, OH군 예 ), 배뇨장애 (LH군 2예, OH군 4예 ) 로두군간에차이가없었다 (Table 3). 재발은 LH군에서 3예 (2.8%), OH군에서 예 (.7%) 로두군간차이가없었으며, 모두 McVay 탈장교정술로재수술하였다. 은 3예 (3%) 였고 OH군에서는 57예모두에서일측성이었다 (Table ). 2) 수술후임상경과수술시간은피부절개에서창상봉합까지의시간으로산정하였다. LH군은평균 56.3±24.분, OH군은평균 63.8± 27.5분으로두군간에차이는없었으며, 재원기간은 LH군평균.7±.일, OH군평균 2.8±.4일로 LH군에서유의하게짧았다 (P<0.00). 수술후통증은입원부터퇴원할때까지관찰하였고, 진통제는데메롤 (pethidine, Demerol R ) 과비스테로이드성항염제를사용하였다. 두군에서진통제를사용한경우는 LH군 78예 (75%), OH군 47예 (82.5%) 로차이가없었으며, 진통제사용빈도는 LH군평균.5±.5회, OH군평균 3.0±.8회로 LH군에서통계적으로유의하게낮았다 (P=0.002) (Table 2). 3) 합병증및재발수술중합병증은 LH군 2예 (.%), OH군 예 (.8%) 로 OH군에서유의하게낮았다 (P=0.036). 복강경수술중합병 4) 학습곡선 (Learning curve) 본연구에서는복강경탈장교정술을시행한환자를초기부터 0예씩나누어수술시간과의상관관계그래프를작성하였으며, 학습곡선이 30예가지나면서부터수술시간이 시간이내로안정화되기시작하였다 (Fig. ). 안정화되었던학습곡선이 80예에서수술시간이길어진것은감돈된음낭탈장및재발된양측성탈장수술을하였기때문이었다. 고찰 서혜부탈장은매우흔한질환으로, 유병률이남성에서 27%, 여성에서 3% 로보고되고있으며,(6) 세계적으로연간 2,000만예의서혜부탈장교정술이시행되고있다.(7) 서혜부탈장교정술은외과의사가흔하게시행하는수술중의하나로 884년 Bassini에의해진정한의미의탈장교정술이시행된이후여러수술방법이소개되면서발전하였으나,(,2) 최적의탈장교정술대한논의는아직도진행중이다.(8) 최근에는외과영역에서복강경수술에대한장점들이널리인정되면서복강경탈장교정술에대한관심이고조되어이
4 276 J Korean Surg Soc. Vol. 77, No. 4 미여러기관에서복강경탈장교정술이활발하게시행되고있다. 복강경탈장교정술은 982년 Ger(9) 에의해처음으로보고되었다. Ger 등은수술기왕력이있던서혜부탈장환자 2명을대상으로복강경하에금속클립 (metal clip) 을사용하여탈장교정술을시행하여 명이치료되었다고보고하였다.(9,0) 990년대초까지시행된복강경탈장교정술의재발률은약 25% 라고보고되어 (,2) 복강경탈장교정술시행에대한논란이많았으나이후수술술기의발전으로최근연구에서는복강경탈장교정술의재발률을 % 로낮게보고하고있다.(3) 복강경탈장교정술은 수술후통증이적고, 2 회복기간이빨라조기직장복귀가가능하며, 3 이전에박리하지않았던조직내에서시행되기때문에재발성탈장의교정이쉽고, 4 한번의시술로양측성탈장을교정할수있으며, 5 동시에진단적복강경을실시할수있고, 6 탈장낭의최고위결찰이가능하며, 7 미용효과가좋다는장점이부각되면서서혜부탈장교정술의표준술식으로서자리잡을수있을지에대한연구들이많이진행되고있다.(2,4,4-7) EU Hernia Trialist Collaboration(8) 의보고에따르면복강경탈장교정술과개방적탈장교정술을비교하는 20개의연구중 2개의연구에서복강경탈장교정술군의재원기간이더짧고 6개의연구에서는더길고, 2개의연구에서는비슷하였다. 국내보고에서 Youn 등 (5) 은복강경복원술군의수술후입원기간이개방탈장복원술군에비교하여통계학적으로유의한차이가없다고보고하였으나 Kim 등 (9) 은복강경군이 Lichtenstein, Bassini, McVay 탈장복원술군에비해입원기간이짧다고보고하였다. 본연구에서는복강경탈장교정술군의수술후입원기간이통계학적으로유의하게더짧은것으로나타났다. Wellwood 등 (20) 과 Stoker 등 (2) 은 visual analogue score (VAS) 를이용하여서혜부탈장수술후통증에대한비교를하였으며, 복강경탈장교정술군에서 VAS가더낮게나왔다고보고하였다. Papachristou 등 (22) 은탈장교정술후통증의비교를진통제투여횟수로비교하였으며진통제투여횟수가수술후 6시간까지는복강경탈장교정술군에서유의하게낮았다고보고하였다. 본연구에서는데메롤 (pethidine, Demerol R ) 과비스테로이드성항염제를사용하여수술후통증을조절하였으며진통제투여여부및투여빈도를측정하여두군간통증의비교를하였다. 진통제투여가필요한빈도는개방적술식과복강경술식사이에차 이가없었으나진통제투여횟수는복강경적탈장교정술군에서통계학적으로유의하게낮은것으로나타났다. Corbitt(23) 은복강경탈장교정술의합병증으로장골혈관의손상, 대퇴신경의손상으로인한감각이상과무감각, 다리근육의위축, 음낭혈종및부종, 드물게방광손상, 이산화탄소주입으로유발된피하기종등이있다고보고하였다. 본연구에서는합병증을수술중합병증과수술후합병증으로나눠서분류하였다. 복강경수술중합병증은대부분학습곡선에도달하기전의수술에서발생하였는데, 복막파열 5예, 하복벽동정맥손상 4예, 고환동정맥손상 예, 신경손상 예, 장골치골혈관 (iliopubic vessel) 손상 예로개방적술식에비해발생빈도가높았으나모두복강경적으로수술중처치가가능하여수술중합병증으로인한개방술식으로의전환은없었다. 수술후합병증은수술부위및음낭혈종, 배뇨장애로보존적치료로호전되었으며두군간에통계적으로유의성있는차이는없었다. Lowham 등 (24) 은복강경수술후재발의원인으로 주위조직의불충분한박리 (incomplete dissection), 2 후복벽결손부위에 mesh의부적절한겹침 (inadequate mesh overlap), 3 mesh의부적절한크기 (inadequately sized prosthesis), 4 mesh에발생한틈 (mesh slitting), 5 mesh의부적절한고정 (improper fixation) 등이있다고보고하였다. 본연구에서복강경수술후재발은 3예 (2.8%) 로모두학습곡선초기 (30 예 ) 에발생하였다. 그중 예는수술중탈장낭을소실 (missed hernia) 한경우로간접탈장형태로수술후 3일째에재발하였고, 나머지 2예는수술후 2개월과 5개월에직접탈장형태로재발하였는데주위조직의불충분한박리로인해 mesh에발생한틈을통해발생하거나후복벽결손부위에 mesh의부적적한겹침에의한것으로추정되며, 3예모두 McVay 법으로탈장교정술을시행하여현재까지재발소견을보이지않고있다. 본연구에서복강경탈장교정술후재발률은 2.8% 로비교적낮은재발률을보이고있으나추적기간이 6개월로짧아기존의탈장술식과의비교로결과차이를판정하기는어렵다. 서혜부탈장교정술후재발은주로수술후첫 5년내에발생하지만약 20% 에서는 5 20년후에도재발하는것으로알려져있기때문이다.(5) 본연구는향후증례수의보충과함께좀더계획적인추적관찰을통해결과에대한재평가가이루어져야할것이다. Neumayer 등 (25) 은 mesh를이용한복강경탈장수술과개방적탈장수술을비교하는무작위임상시험을시행하여
5 Kang-Woong Jun, et al:the Comparative Analysis between Laparoscopic Total Extraperitoneal Repair and Open Tissue Repair: Initial Experience of a Single Institute 277 복강경탈장수술이합병증의발생률이높고환자만족도가떨어진다고보고하였는데, 이것은개방적탈장교정술에비해복강경탈장교정술에덜익숙한수술자가포함되었고복강경탈장수술에사용되는기술을모니터하고표준화하는과정을생략한결과였기때문이었다. 학습곡선에도달할수록수술시간, 개복으로의전환, 합병증이감소되는데, 복강경탈장수술의기술적숙달을위해서 Bowne 등 (7) 은 30 50예가필요하다고하였고 Robert 등 (4) 은 예의넓은범주의증례수가필요하다고보고하였다. 본연구에서학습곡선은 30예에서안정화되다가감돈된탈장과양측성탈장이포함된 80예에서상승되는것을보여주었다. 이에저자들은복강경전복막외서혜부탈장수술의기술적습득을위해서는적어도 30예이상의증례수가필요하며고난이도의수술을위해서는좀더많은증례수가필요할것이라생각한다. 결 복강경을이용한전복막외교정술의초기경험결과를 mesh를사용하지않는고식적개방탈장교정술과비교한결과두군간에수술시간, 수술후합병증에있어통계학적으로유의한차이가없었다. 복강경군에서수술중합병증이많았으나대부분학습곡선에도달하기이전에발생하였고이로인한개복으로의전환은없었다. 복강경탈장교정술을받은경우진통제사용이유의하게감소하였고입원기간도짧게나타나서혜부탈장에서복강경하전복막외교정술은유용하고안전한수술방법으로사료된다. 두군간에재발률의차이를보이지는않았으나이는아직복강경탈장교정술의경험이 2년미만으로장기추적이이루어지지않은상태로좀더계획적인추적관찰을통한재평가가이루어져야한다고사료된다. 복강경전복막외서혜부탈장교정술을습득하기위한최소한의증례수가 30예로나타났으나감돈탈장, 재발성탈장등의난이한서혜부탈장의증례를해결하기위해서는좀더많은증례수가필요할수도있을것으로사료된다. 론 REFERENCES ) Bassini E. Nuovo metodo per la cura radicale hernia inguinale. Atti Conger Assoc Med 887;2:79. 2) Kim YH, Shin JH, Park JJ, Sohn BH, Yoo CH, Park YR, et al. A clinical review of the advantages of laparoscopic inguinal herniorrhaphy. J Korean Surg Soc 200;6: ) Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. The tension-free hernioplasty. Am J Surg 989;57: ) Fitzgibbons RJ Jr, Puri V. Laparoscopic inguinal hernia repair. Am Surg 2006;72: ) Sanjay P, Woodward A. A survey of inguinal hernia repair in Wales with special emphasis on laparoscopic repair. Hernia 2007;: ) Kingsnorth A, LeBlanc K. Hernias: inguinal and incisional. Lancet 2003;362: ) Bay-Nielsen M, Kehlet H, Strand L, Malmstrom J, Andersen FH, Wara P, et al. Quality assessment of 26,304 herniorrhaphies in Denmark: a prospective nationwide study. Lancet 200;358: ) Gould J. Laparoscopic versus open inguinal hernia repair. Surg Clin North Am 2008;88: ) Ger R. The management of certain abdominal herniae by intra-abdominal closure of the neck of the sac. Preliminary communication. Ann R Coll Surg Engl 982;64: ) Ger R, Monroe K, Duvivier R, Mishrick A. Management of indirect inguinal hernias by laparoscopic closure of the neck of the sac. Am J Surg 990;59: ) Fitzgibbons RJ Jr, Camps J, Cornet DA, Nguyen NX, Litke BS, Annibali R, et al. Laparoscopic inguinal herniorrhaphy. Results of a multicenter trial. Ann Surg 995;22:3-3. 2) Vogt DM, Curet MJ, Pitcher DE, Martin DT, Zucker KA. Preliminary results of a prospective randomized trial of laparoscopic onlay versus conventional inguinal herniorrhaphy. Am J Surg 995;69: ) Leibl BJ, Schmedt CG, Ulrich M, Kraft K, Bittner R. Laparoscopic hernia repair -- the facts, but no fashion. Langenbecks Arch Surg 999;384: ) Ger R, Mishrick A, Hurwitz J, Romero C, Oddsen R. Management of groin hernias by laparoscopy. World J Surg 993; 7: ) Youn SI, Kim BG, Cha SJ, Chang IT. The comparative analysis between laparoscopic inguinal herniorrhaphy and open inguinal herniorrhaphy. J Korean Surg Soc 2005;69: ) Kuhry E, van Veen RN, Langeveld HR, Steyerberg EW, Jeekel J, Bonjer HJ. Open or endoscopic total extraperitoneal inguinal hernia repair? A systematic review. Surg Endosc 2007;2:6-6. 7) Bowne WB, Morgenthal CB, Castro AE, Shah P, Ferzli GS. The role of endoscopic extraperitoneal herniorrhaphy: where do we stand in 2005? Surg Endosc 2007;2: ) EU Hernia Trialists Collaboration. Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized controlled trials. Br J Surg 2000;87: ) Kim JS, Jang HJ, Cho YP, Kim YH, Choi YB, Han MS. A comparing study of herniorrhaphies laparoscopy, lichtenstein and conventional repairs. J Korean Surg Soc 2002;63: ) Wellwood J, Sculpher MJ, Stoker D, Nicholls GJ, Geddes C,
6 278 J Korean Surg Soc. Vol. 77, No. 4 Whitehead A, et al. Randomised controlled trial of laparoscopic versus open mesh repair for inguinal hernia: outcome and cost. BMJ 998;37: ) Stoker DL, Spiegelhalter DJ, Singh R, Wellwood JM. Laparoscopic versus open inguinal hernia repair: randomised prospective trial. Lancet 994;343: ) Papachristou EA, Mitselou MF, Finokaliotis ND. Surgical outcome and hospital cost analyses of laparoscopic and open tension-free hernia repair. Hernia 2002;6: ) Corbitt JD Jr. Transabdominal preperitoneal herniorrhaphy. Surg Laparosc Endosc 993;3: ) Lowham AS, Filipi CJ, Fitzgibbons RJ Jr, Stoppa R, Wantz GE, Felix EL, et al. Mechanisms of hernia recurrence after preperitoneal mesh repair. Traditional and laparoscopic. Ann Surg 997;225: ) Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R Jr, Dunlop D, Gibbs J, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 2004;350:
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