SUTI (Single Umbilical Tangential Incision) Laparoscopic TEP Inguinal Hernia Repair 25 TAPP) 과전복막접근하탈장수술 (laparoscopic totally extraperitoneal inguina

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ORIGINAL ARTICLE pissn 2234-778X eissn 2234-5248 J Minim Invasive Surg 2015;18(1):24-29 Journal of Minimally Invasive Surgery 단일공배꼽접면절개 (SUTI) 를통한복강경전복막서혜탈장교정술 임명훈, 설지영 충남대학교의학전문대학원외과학교실 SUTI (Single

1 ORIGINAL ARTICLE pissn X eissn J Minim Invasive Surg 2015;18(1):24-29 Journal of Minimally Invasive Surgery 단일공배꼽접면절개 (SUTI) 를통한복강경전복막서혜탈장교정술 임명훈, 설지영 충남대학교의학전문대학원외과학교실 SUTI (Single Umbilical Tangential Incision) Laparoscopic TEP Inguinal Hernia Repair Myung-Hoon Lim, M.D., Ji-Young Sul, M.D., Ph.D. Department of Surgery, Chungnam National University School of Medicine, Daejeon, Korea Purpose: Single port laparoscopic inguinal hernia repair has been performed to further reduce port related morbidities and to improve the cosmetic outcome. However, the cosmetic result of single port laparoscopic totally extraperitoneal inguinal hernia repair (TEP) has not been superior to that of transabdominal preperitoneal hernia repair (TAPP). The aim of this study is to introduce and assess the Single Umbilical Tangential Incision (SUTI) for Lap-TEP repair. Methods: Forty one hernia repairs of 34 patients were performed using SUTI-TEP method. SUTI was made all along the inferolateral skin of the umbilical pit and a vertical incision of less than one centimeter was made in the supra- or infraumbilical skin if needed; the total length of the incision was 2~2.5 cm. SILS TM port and conventional instruments were used for the procedure. Results: All procedures were completed without conversion to the conventional TEP procedure. Mean operation time was 73 minutes for unilateral primary hernia, 119 minutes for bilateral primary hernia, 88.5 minutes for unilateral recurrent hernia, and 120 minutes for bilateral recurrent hernia. There were two cases of wound seroma and four cases of urinary retention postoperatively. Other significant complications were not noted. There was no recurrence of hernia during the follow-up period of one to 24 months. At routine follow-up visit at three months postoperative, the scar was barely visible and overall level of patient satisfaction was very high. Conclusion: The SUTI-TEP inguinal hernia repair is safe and shows superior cosmetic results. Further studies are required in order to assess the long-term outcome. Received September 23, 2014 Revised 1st October 10, nd October 19, 2014 Accepted October 23, 2014 Corresponding author Ji-Young Sul Department of Surgery, Chungnam National University School of Medicine, 33, Munhwa-ro, Jung-gu, Daejeon , Korea Tel: Fax: jysul@cnu.ac.kr Keywords: Single incision, Single port, Laparoscopic totally extraperitoneal repair, Inguinal hernia This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright 2015 The Journal of Minimally Invasive Surgery. All rights reserved. 서론 단일공 (single port) 을통한복강경수술이가능하고, 그수술의결과가기존의복강경수술과마찬가지로안전하다면, 단일공수술의가장큰장점은바로미용적인면이다. 단일공복 강경수술은주로배꼽이라는자연공 (natural orifice) 을통해서이루어져수술후반흔이가려지는무절개효과 (incisionless effect) 를보인다. 1 복강경서혜부탈장교정술은경복강복막전층탈장교정술 (laparoscopic Transabdominal Pre-peritoneal hernia repair, Journal of Minimally Invasive Surgery Vol.18, No.1,

SUTI (Single Umbilical Tangential Incision) Laparoscopic TEP Inguinal Hernia Repair 25 TAPP) 과전복막접근하탈장수술 (laparoscopic totally extraperitoneal

최근복강경전복막탈장교정술인 TEP 에도단일공수술이많이보고되고있으나주로절개방법이배꼽하방 (infraumbilical) 또는배꼽을통한 (transumbilial) 절개를사용하는데, 3,4 infraumbilical incision

5 이에저자는단일공 TEP 탈장교정술시행시배꼽절개선을약간변형한단일공배꼽접면절개 (Single Umbilical Tangential Incision, SUTI) 를소개하고, 이방법의가능성및안정성에대하여알아보고자하였다.

수술은기존 TEP 수술에경험이풍부한단일외과의에의하여시행되었으며, 수술전충분한고지에의거한동의를한환자에게시행되었다.

subcutaneousfat Perforators Inferior epigastric artery and vein Fig. 1. Single Umbilical Tangential Incision.

2 SUTI (Single Umbilical Tangential Incision) Laparoscopic TEP Inguinal Hernia Repair 25 TAPP) 과전복막접근하탈장수술 (laparoscopic totally extraperitoneal inguinal hernia repair, TEP) 로이루어지는데, 2 단일공복강경탈장교정술에서는배꼽을통한전복막접근이힘든 TEP 보다는배꼽을통한수술이가능한 TAPP 가미용의효과가높아 TAPP 방법위주로시행되었다. 최근복강경전복막탈장교정술인 TEP 에도단일공수술이많이보고되고있으나주로절개방법이배꼽하방 (infraumbilical) 또는배꼽을통한 (transumbilial) 절개를사용하는데, 3,4 infraumbilical incision 의경우절개선이배꼽의자연주름에가려지지않을수있어미용의효과가경감되고, transumbilical incision 의경우그단어자체만으로는어떻게배꼽을통하여전복막공간으로접근을했는지에대한정보가결여되어있다. 5 이에저자는단일공 TEP 탈장교정술시행시배꼽절개선을약간변형한단일공배꼽접면절개 (Single Umbilical Tangential Incision, SUTI) 를소개하고, 이방법의가능성및안정성에대하여알아보고자하였다. 대상및방법 2013 년 5월부터 2014 년 2월까지충남대학교병원외과에서서혜부탈장으로진단받고 SUTI-TEP 으로수술을시행받은환자 41 명을대상으로하였다. 수술은기존 TEP 수술에경험이풍부한단일외과의에의하여시행되었으며, 수술전충분한고지에의거한동의를한환자에게시행되었다. SUTI 배꼽접면절개방법접면절개는배꼽와 (umbilical pit) 의가운데가아니라배꼽와의측면 ( 서혜탈장위치의동측 ) 피부에말그대로접면절개를가한후복직근의전복직근초에도달하는것을의미하며, 나머지는기존의복강경전복막수술과동일하다 (Fig. 1). 배꼽모양에따라 (Fig. 2), 오메가모양을시계방향 90도혹은반시계방향 90도로돌린 rotated omega (Ω) incision 을사용 Single umbilical tangential incision (SUTI) Rectus muscle Skin and subcutaneousfat Perforators Inferior epigastric artery and vein Fig. 1. Single Umbilical Tangential Incision. The tangential skin incision was performed at the hidden lateral surface of the umbilical crater. After making the incision, the dissection was done up the rectus sheath by using blunt dissection. Horizontal Vertical T-shaped A B C Oval Hooded vertical D E (What is an attractive umbilical shape? Retrieved from %2b0ceIZ6Sdw%3d%3d) Fig. 2. The shapes of the umbilicus. The umbilicus can have varying position, shapes, depths, and lengths and they influence the overall shape of the incision.

26 Myung-Hoon Lim and Ji-Young Sul 하거나 (dotless) question mark incision 을배꼽모양에따라달리선택하였다

단일공복강경수술후상처부위의통증을완화하기위하여절개를가하기전배꼽주변의피부에국소마취제인 0.5% bupivacaine 이나 0.75% ropivacaine 을주입하였다.

사용기구는기존의 conventional straight, regular (33 cm) or long length (45 cm) graspers, 30 o 5 mm

아래튀어나온부분을잘라낸후사용하였다 (Fig. 4). SUTI-TEP 수술의효용성평가 수술방법및사용기구수술은기존복강경전복막서혜탈장교정술방법과다르지않다.

를이용한통증의정도, 수술합병증, 병원재원기간, 만성통증의유무, 재발의유무등을사용하여평가하였다. A B C or or or or or Fig. 3.

(A) 90 degree clockwise rotated or counterclockwise rotated omega incision.

(C) If possible, all the incision should lie inside the umbilical crater, but can be

3 26 Myung-Hoon Lim and Ji-Young Sul 하거나 (dotless) question mark incision 을배꼽모양에따라달리선택하였다 (Fig. 3). 절개선의길이는약 2.5 cm로하고, 배꼽모양에따라모든절개선이배꼽에들어가지못하는경우절개선을배꼽중앙선상방이나하방, 혹은상하양쪽으로연장하여사용하였다. 단일공복강경수술후상처부위의통증을완화하기위하여절개를가하기전배꼽주변의피부에국소마취제인 0.5% bupivacaine 이나 0.75% ropivacaine 을주입하였다. 갈수있게하였다. 사용기구는기존의 conventional straight, regular (33 cm) or long length (45 cm) graspers, 30 o 5 mm long (45 cm) telescope 를사용하였으며, SILS TM port (Covidien, Norwalk, Connecticut, USA) 아래튀어나온부분을잘라낸후사용하였다 (Fig. 4). SUTI-TEP 수술의효용성평가 수술방법및사용기구수술은기존복강경전복막서혜탈장교정술방법과다르지않다. 6 환자의수술체위중양팔을벌리지않고환자의몸옆에붙임으로써수술중외과의가환자의가슴쪽으로최대한올라 수술의가능성과안전성은수술시간, 다른수술로의전환여부, 수술직후 VAS 를이용한통증의정도, 수술합병증, 병원재원기간, 만성통증의유무, 재발의유무등을사용하여평가하였다. A B C or or or or or Fig. 3. A variety of incision options according to the umbilical shapes. (A) 90 degree clockwise rotated or counterclockwise rotated omega incision. (B) Reversed, inverted, inverted and reversed (dotless) question mark incision. (C) If possible, all the incision should lie inside the umbilical crater, but can be extended a little bit more superiorly or inferiorly. This technique resulted in minimal scarring. A B Fig. 4. SILS TM port preparation for SUTI- TEP. The bottom portion of SILS TM port was cutted. Journal of Minimally Invasive Surgery Vol. 18. No. 1, 2015

4 SUTI (Single Umbilical Tangential Incision) Laparoscopic TEP Inguinal Hernia Repair 27 결과환자분포 (Table 1) 34명의환자에서 41 예의단일공복강경전복막탈장교정술을시행하였다. 남녀의비는 5.8:1 로남자에서많았으며, 단측탈장 27예, 양측탈장 7예, 원발성탈장 31 예, 재발성탈장 3예였고, 이중탈장의유형으로는간접탈장이 31 예, 직접탈장 6예, 판탈롱탈장 3예, 대퇴탈장 1예였다. 수술결과 (Table 2) SUTI-TEP 의수술시간은원발성단측탈장 73분, 양측탈장 119 분, 재발성단측탈장 88.5 분, 양측성인경우 120 분이었다. 수술직후통증을 VAS 로측정한결과 SILS TM port 의하연을제거하지않고원래모양대로쓰면서국소마취제를쓰지않은경우통증의정도가심해서평균 7.5 점을보인반면, cutted SILS TM port 를사용하고국소마취제를사용한경우평균 3.04 로나타났다. 수술직후합병증은상처장액종 2예로간단하게외래에서치료되었으며, 4명의환자에서수술직후소변저류가있었으나다음날호전되어퇴원하였다. SUTI-TEP 중기존의다공수술이나개복수술로전환한경우는없었으며, 최장 24개월동안의추적조사에서도만성통증을호소하거나, 재발된경우가발견되지않았다. 환자들의만족도는매우높았다 (Fig. 5). 고찰 단일공수술인 Single port or single incision TEP 은보통배꼽하방인 infraumbilical or 배꼽을통한 transumbilical incision Table 1. Patient demographics SUTI-TEP (41 hernias/34 patients) Age (ranges) 60.5 (27~81) Gender (M : F) 29 : 5 BMI (kg/m 2 ) (ranges) (20.7~29.17) Hernia side (Rt : Lt : Bilateral) 20 : 7 : 7 Hernia types Primary : Recurrent 31 : 3 Unilateral : Bilateral 27 : 7 Indirect : Direct : Pantaloon : Femoral 36 : 6 : 3 : 1 으로많이시행되어왔다. 3,4 그러나 infraumbilical incision 의 경우상대적으로큰반흔 (scar) 이남아단일공복강경수술의 장점인미용적인면을추구할수없고, transumbilical 이라는 단어는실상 umbilicus 를뚫고복강내로들어간것인지, 단지 배꼽의피부를경유했다는것인지, 혹은배꼽중어느부위에 절개를가한것인지의여부는알수가없다. 5 따라서저자는이모든문제를해결하고자단일공수술시배 꼽절개를변형한접면절개인 SUTI 를사용하여단일공전복막 서혜탈장수술을시행하였다. 배꼽의모양은크게 hooded oval or T-shape, oval, horizontal, vertical, hooded vertical 등 5 가지로나뉜다 (Fig. 2). 7 SUTI 의장 점은개개인의배꼽모양에따라절개모양을다양화하여, 변 형선택하여가함으로써, 배꼽주름내에대부분의절개가위치 하므로, infraumbilical incision 처럼수술직후절개의전길이 가보이지않아미용면에서매우유리하다는점이다. 복직근의 6 pack 을나타내는건교차 (tendinous intersection) 는사람마다매우다양해서보통 1~4 개정도존재하며배꼽상 방에주로존재한다. 8 따라서 SUTI-TEP 시행과정에서배꼽상 방으로절개가가해지고복직근의뒤를통해전복막공간으로 접근할때건교차에의하여접근이힘들가능성을예상할수 있다. 그러나다행히복직근건교차는근육의전층이아닌중 간깊이의근육만이포함되며, 특히복직근전초에밀접히붙어 있고, 복직근후초와는거의유착등이없어배꼽상방의절개 로도아무런문제없이복직근과복직근후초를통하여전복막 Table 2. Operative data Operation Time (min, (ranges)) SUTI-TEP Primary unilateral : bilateral 73.6 (63~111) : 119 (84~176) Recurrent unilateral : bilateral 88.5 (82~95) : 120 Hospital Stay (days) 1 VAS (visual Analog Scale) Immediate postoperative period Conventional SILS 7.5 Cutted SILS+local anesthetic 3.04 Postoperative follow-up Immediate postoperative complications 1~24 months Wound seroma 2 Postoperative urinary retention 4 Chronic pain 0 Recurrence 0 Conversion to open or conventional TEP 0

28 Myung-Hoon Lim and Ji-Young Sul A B C D Fig. 5. Umbilcus and wound results at 3 months postoperatively. 강에접근할수있으므로, 저자의접면절개방법사용에는문제가없다.

첫째, 환자의수술체위로양쪽팔을환자의몸에붙이는것 ; 둘째, 환자의가슴쪽에위치하는외과의의 high up position; 셋째, 배꼽의접면절개 ; 넷째, 수술직전장시간작용하는국소마취제의절개부위주입, 그리고마지막으로 cutted SILS TM port 이다.

복강경수술의장점이절개가적어통증이적은것도포함되는데, 절개는작은데통증이심하다면이는또다른논란을야기할수있다. 따라서저자는두가지방법을사용하여수술후통증을경감하였는데, 수술절개부위의국소마취제주입후수술하는것과 cuttted SILS 이다.

SILS TM port 의 dimension 은위아래넓은부분이 50 mm, 길이 50 mm, waist 부분 27 mm로길이가 길고, 위아래가넓어서위아래닿는부분이눌림으로인한통증이야기될수있을것으로생각하고, SILS TM port 의아래튀어나온부분을잘라낸후사용하였다.

5 28 Myung-Hoon Lim and Ji-Young Sul A B C D Fig. 5. Umbilcus and wound results at 3 months postoperatively. 강에접근할수있으므로, 저자의접면절개방법사용에는문제가없다. SUTI-TEP 서혜탈장교정술이성공하려면 5가지요소가매우중요하다. 첫째, 환자의수술체위로양쪽팔을환자의몸에붙이는것 ; 둘째, 환자의가슴쪽에위치하는외과의의 high up position; 셋째, 배꼽의접면절개 ; 넷째, 수술직전장시간작용하는국소마취제의절개부위주입, 그리고마지막으로 cutted SILS TM port 이다. 환자의몸에팔을붙이고외과의가환자의가슴쪽에위치하여수술하면단일공수술시발생하는수술포지션에따른부담이줄어인체공학적으로좀더편한수술을하게된다. 단일공복강경수술을하는경우, 수술직후절개가들어갔던배꼽부위에심한통증을호소하는경우가있다. 복강경수술의장점이절개가적어통증이적은것도포함되는데, 절개는작은데통증이심하다면이는또다른논란을야기할수있다. 따라서저자는두가지방법을사용하여수술후통증을경감하였는데, 수술절개부위의국소마취제주입후수술하는것과 cuttted SILS 이다. 수술절개부위의국소마취제주입만으로는수술후통증감소가많지않았는데아마도 SILS TM port 의모양때문인것으로사료된다. SILS TM port 의 dimension 은위아래넓은부분이 50 mm, 길이 50 mm, waist 부분 27 mm로길이가 길고, 위아래가넓어서위아래닿는부분이눌림으로인한통증이야기될수있을것으로생각하고, SILS TM port 의아래튀어나온부분을잘라낸후사용하였다. 잘라낸후사용한또다른이유는 SILS TM port 크기가절개선이나 SILS TM port 가삽입되는복직근과복직근후초사이의공간보다커서수술시삽입이힘들었기때문이다. 아래쪽 bottom portion 을잘라내어사용한후통증의감소를경험하였다. 따라서국소마취제주입은 port entry site 에대한통증감소를목적으로하며, cutted SILS TM port 는 entry site 와 3~4 cm 떨어진부위의통증감소를목적으로한다. 본연구에서도 SILS TM port 만을사용해서수술했던경우통증이심했던반면, 장시간작용국소마취제와 cutted SILS TM port 를사용했던경우통증이매우줄어서, 이두가지요소가환자의수술직후통증을많이경감시키는역할을하여, 미용적인면에서나통증면에서 SUTI-TEP 에대한환자의만족도를더욱높이는역할을하였다. SUTI-TEP 수술결과원발성단측성서혜부탈장의경우수술시간은약 70분, 양측탈장 119 분정도소요되었다. 시간은좀더걸렸지만, 다른수술로의전환이나심한합병증등은없었다. SUTI-TEP 수술시간기존의복강경전복막탈장교정술에비하여약 10~30 분정도의시간이더소요되었는데, 6 이 Journal of Minimally Invasive Surgery Vol. 18. No. 1, 2015

6 SUTI (Single Umbilical Tangential Incision) Laparoscopic TEP Inguinal Hernia Repair 29 는절개선이들어가는피부에국소마취주입및 SILS TM port cutting 등수술기구에대한준비시간 ( 약 10~15 분 ) 뿐아니라피부절개및봉합시기존절개방법보다더미용적으로봉합하는데대한시간소요 ( 약 10~20 분 ) 를감안해야한다 (data not shown). 만일이를감안하면단일공수술이시간이더걸리는것은사실이지만실제전복막강내에서의수술시간의차이가아주크지는않다. 또한단일공 TEP 수술에대한다른저자의결과와크게다르지않다. 9 SUTI-TEP 수술후재원기간은하루로기존의복강경전복막탈장교정술과저자나다른저자의경험과크게다르지않았다. 6,9,10 짧게는 1개월, 길게는 24개월의추적조사에서도재발인만성서혜통증등은한예도없었고, 절개부위에대한환자의만족도는매우높았다. 비교적짧은추적조사기간이었지만 SUTI-TEP 서혜탈장교정술은기존의복강경전복막탈장교정술과비교하여수술후합병증이나재발률의차이가없이안전하고수술이가능하며, 미용적인면에서도매우우수하였다. 단일공수술인 SUTI-TEP 이기술적으로, 인체공학적으로아직은많은노력이필요하지만, 그결과와환자의만족도를볼때지속적으로추구해볼만한가치가있다고하겠다. REFERENCES 1) Chamberlain RS, Sakpal SV. A comprehensive review of singleincision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) techniques for cholecystectomy. J Gastrointest Surg 2009;13: ) Gong K, Zhang N, Lu Y, et al. Comparison of the open tensionfree mesh-plug, transabdominal preperitoneal (TAPP), and totally extraperitoneal (TEP) laparoscopic techniques for primary unilateral inguinal hernia repair: a prospective randomized controlled trial. Surg Endosc 2011;25: ) He K, Chen H, Ding R, Hua R, Yao Q. Single incision laparoscopic totally extraperitoneal inguinal hernia repair. Hernia 2011;15: ) Fuentes MB, Goel R, Lee-Ong AC, et al. Single-port endolaparoscopic surgery (SPES) for totally extraperitoneal inguinal hernia: a critical appraisal of the chopstick repair. Hernia 2013;17: ) Dowden RV. Transumbilical breast augmentation is safe and effective. Semin Plast Surg 2008;22: ) Choi YH, Sul JY. Long-term Outcomes of Laparoscopic Totally Extraperitoneal Inguinal Herniorrhaphy. J Minim Invasive Surg 2012;15: ) Cavale N, Butler PE. The ideal female umbilicus? Plast Reconstr Surg 2008;121:356e-357e. 8) Meenakshi S, Manjunath KY. The tendinous intersections of rectus abdominis muscle. J MGIMS 2008;13: ) Wijerathne S, Agarwal N, Ramzy A, Lomanto D. A prospective randomized controlled trial to compare single-port endo-laparoscopic surgery versus conventional TEP inguinal hernia repair. [published online ahead of print Jun 6, 2014]. Surg Endosc; DOI /s ) Kim Z, Cho SW, Kim YJ, et al. Laparoscopic Totally Extraperitoneal Herniorrhaphy: Is it Feasible for Recurrent Inguinal Hernias? J Korean Soc Endosc Laparosc Surg 2009;12:

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