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1 J Korean Surg Soc 2010;79: DOI: /jkss 원 저 대퇴탈장에서의전복막외복강경탈장교정술 성균관대학교의과대학강북삼성병원외과학교실 백진희ㆍ박용래ㆍ손병호 Totally Extraperitoneal (TEP) Approach for Femoral Hernia Jin Hee Paik, M.D., Yong Lai Park, M.D., Byung Ho Son, M.D. Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea Purpose: The aims of this study were to evaluate the efficacy of laparoscopic totally extraperitoneal (TEP) repair of femoral hernia. Methods: Eight patients who underwent laparoscopic TEP repair for femoral hernia between 2008 and 2010 were reviewed retrospectively. In total, 256 adult patients underwent inguinal or femoral hernia repair; TEP was performed in 224 patients. The preoperative diagnosis, clinical symptom, operative finding, postoperative complications, chronic pain, and recurrence were analyzed. Results: The incidence of femoral hernia was 8 (3.1%) in the present study. The female to male ratio was 3:1 (6 females and 2 males). Seven patients were preoperatively misdiagnosed with inguinal hernia using ultrasonography. Computed tomography (CT) was performed in three patients, and femoral hernia was diagnosed in two patients. Two patients had synchronous femoral hernia with direct or indirect inguinal hernia. One patient has previously undergone ipsilateral inguinal hernia repair. In all patients, the hernia sac was irreducible by gas insufflation. Seven patients had lipoma-like soft tissue in hernia sac. Peritoneal tears developed in three patients. There was one postoperative complication: chronic discomfort due to seroma. There was no recurrence during median 6.5 months (range 2 26). Conclusion: Laparoscopic TEP repair is safe and effective therapeutic option for repair of femoral hernia. CT images are the most valuable type for the evaluation of the femoral hernia. (J Korean Surg Soc 2010;79: ) Key Words: Computed tomography, Femoral hernia, Laparoscopic surgery, Totally extraperitoneal (TEP) repair 중심단어 : 전산화단층촬영, 대퇴탈장, 복강경수술, 복막외교정술 서 대퇴탈장은대퇴관을통해탈장이생긴것으로, 전방으로는엉덩두덩관 (ilio-pubic tract), 후방으로는 Cooper인대, 외측으로는대퇴정맥, 내측으로는엉덩두덩관과 Cooper인 책임저자 : 손병호, 서울시종로구평동 , 성균관대학교강북삼성병원외과 Tel: , Fax: byunghomd.son@samsung.com 접수일 :2010 년 4 월 15 일, 게재승인일 :2010 년 8 월 9 일 론 대의합류지점 ( 갈고리인대, lacunar ligament) 을경계로하고있다 (Fig. 1).(1) 대퇴탈장은발견당시크기가작지만탈장낭의형성부위인대퇴관이대퇴정맥, 갈고리인대, 골반뼈등단단한조직으로이루어져주위조직의부종에의해쉽사리내용물을압박할수있어감돈의발생률이높다.(2) 대퇴탈장에대한수술적방법에도많은변화가있어왔다. 과거부터사용해오던자가조직봉합 (tissue repair) 방법으로 McVay 술식,(3) Lockwood 술식 (4) 이있으며 McVay 술식에서는수술후봉합면의긴장, 서혜탈장의유인, 복벽박리로인한수술후불편감등의단점이있고 Lockwood 술식에서는빗살근막 (pectineus fascia) 의연약함, 봉합선의긴장과함 393

394 J Korean Surg Soc. Vol. 79, No. 5 Fig. 1. (A) The schematic drawing of relevant anatomy of right femoral hernia.(1) (B) Laparoscpic view of right groin area. 께재발률이높은단점이있다.

2 394 J Korean Surg Soc. Vol. 79, No. 5 Fig. 1. (A) The schematic drawing of relevant anatomy of right femoral hernia.(1) (B) Laparoscpic view of right groin area. 께재발률이높은단점이있다. 각종인공보형물을이용한무긴장성교정술 (5) 도시행되고있으며최근에는복강경을이용한술식인 transabdominal preperitoneal (TAPP) 술식,(6) totally extraperitoneal (TEP) 술식 (7) 및 intraperitoneal onlay mesh (IPOM) 술식 (8) 등도시행하고있다. TAPP 술식은복강내접근으로인한합병증이발생하고 IPOM 술식은복강내장기와접촉함으로써발생하는유착형성, 장루관형성, 감염, 패혈증등의위험이있다. 이에반해 TEP 술식은 mesh가이동 (migration) 할위험성이있지만재발률이낮고 ( %) 수술후통증이유의하게적은장점이있는술식이다.(9) 국내에서는대퇴탈장에서 TEP 술식후그결과에대한보고가없어이에본원에서는 TEP 술식을통한탈장교정술도중대퇴탈장으로진단된 8예의수술전검사소견, 수술중소견, 수술후추적관찰자료를분석하여이술식의안정성및유용성에대하여알아보고자본연구를시행하였다. 방법 1) 대상및방법 2008년 1월부터 2010년 3월까지본원에서서혜부탈장교정술을시행받은 256명의환자들중출혈경향이있거나경제적이유로개방탈장교정술을시행한경우를제외하고복강경 TEP 술식으로수술받은 224명중에서대퇴탈장으로확진된 8명의환자들을대상으로하였다. 환자들의임상양상, 영상의학적진단방법, 수술전진단여부, 수술소견, 만성통증등의수술후합병증및재발에대하여수술녹화영상, 수술기록지, 검사결과및외래기록지와전화면담등을통한후향적연구를시행하였다. 또한, 수술전시행한영상학적진단의유용성에대해분석하였다. 2) 수술방법수술은전신마취후배꼽아래에수직으로 1.5 cm 가량절개선을넣고탈장이있는방향의앞쪽배곧은근집 (anterior rectus sheath) 을노출시킨후앞쪽배곧은근집에절개선을넣은후배곧은근뒷면을따라복막전공간 (preperitoneal space) 을박리하였다. 이때수술공간을만들기위해고무풍선이부착된투관침을 (Spacemaker R Autosuture, Norwalk, CT, USA) 복막전공간에넣고수술공간을확보하였다. 카메라를삽입후치골결합 (symphysis pubis) 의중앙선에서상방에 5 mm 투관침을넣고, 배꼽아래투관침과치골결합상방의투관침사이에 5 mm 투관침하나를추가로삽입하였다. Cooper 인대, 하배벽혈관 (inferior epigastric vessels) 과대퇴혈관을확인한후직접탈장유무와대퇴탈장을관찰하고 Bogros 공간박리를시행하여간접탈장유무를확인하였다. 그물막은폴리에스터그물막 (Parietex R, Sofradim, Formans, France) 을사용하였으며 2 4개의 Tacker R (Autosuture, Norwalk, CT, USA) 및 Tissel R (Baxter AG, Wien, Austria) 을사용하여고정하였다. 이후가스가빠지는것을보면서카메라를제거하고 CO 2 가스가빠지면투관침을제거하고수술을마쳤다. 결과 1) 임상양상 총 8예중남녀비는 6예에서여자, 2예에서남자였고평균연령대는남자 57세 (53 61), 여자 58.3세 (48 68) 로두군간의차이는없었다. 동반질환으로는여자 6예중 1예에서고혈압, 1예에서는우측서혜탈장으로수술받은기왕력이있었고남자 2예중 1예에서과거에완치판정받은결핵이있었다 (Table 1). 주증상으로는서혜부종괴가남자 2예,

groin mass Sono: Rt. inguinal hernia Absent 3 F 68 Lt Lt. groin mass Sono: Lt. inguinal hernia Hypertension 4 F 53 Rt Rt. groin mass Sono: Rt. inguinal hernia Absent 5 M 61 Lt Lt. groin mass Sono: Lt. inguinal hernia Pulmonary Tb CT: both inguinal hernia 6 F 54 Rt Rt.

3 Jin Hee Paik, et al:totally Extraperitoneal (TEP) Approach for Femoral Hernia 395 Table 1. Clinical characteristics of patients Cases Gender Age (yr) Site Symptom Radiologic diagnosis Comorbidity 1 F 64 Lt Leg numbness Sono*: Lt. inguinal hernia Absent CT : Lt. femoral hernia 2 M 53 Rt Rt. groin mass Sono: Rt. inguinal hernia Absent 3 F 68 Lt Lt. groin mass Sono: Lt. inguinal hernia Hypertension 4 F 53 Rt Rt. groin mass Sono: Rt. inguinal hernia Absent 5 M 61 Lt Lt. groin mass Sono: Lt. inguinal hernia Pulmonary Tb CT: both inguinal hernia 6 F 54 Rt Rt. groin mass Sono: Rt. inguinal hernia Absent 7 F 48 Rt Rt. groin mass CT: Rt. femoral hernia Absent 8 F 63 Lt Lt. groin mass Sono: Lt. inguinal hernia Absent *Sono = ultrasonography; CT = computed tomography; Tb = tuberculosis. Fig. 2. The ultrasonographic finding of right femoral hernia. The Doppler image shows the femoral hernial sac nearby the femoral vessel. 여자 2 예, 다리저림이여자 4 예였다. 2) 진단 수술전이학적검사로는동반탈장이있던남자 2예및여자 6예에서두덩뼈결절 (pubic tubercle) 의하측방에서탈장낭을촉지하여대퇴탈장으로진단하였다. 이학적검사에서대퇴탈장이의심될경우수술당시반대측탈장여부도확인하였다. 영상의학적검사는이학적검사에서대퇴탈장이의심되는경우에시행하였는데초음파를시행한경우는남자 2예, 여자 5예였고전산화단층촬영술을시행한경우는남자 1예, 여자 2예였다 (Table 1). 초음파결과로는 7예모두에서서혜탈장으로진단했으며 (Fig. 2) 전산화단층촬영술에서는 2예에서대퇴탈장으로진단하였다 (Fig. 3). Fig. 3. The CT finding of left femoral hernia. There are typical findings of femoral hernia: venous compression and localized hernial sac in femoral area (arrow). 3) 수술소견 탈장의위치는우측이 4예 ( 남자 1예, 여자 3예 ), 좌측이 4예 ( 남자 1예, 여자 3예 ) 였고반대쪽간접서혜탈장이동반된예가남자 1예, 같은쪽직접서혜탈장이동반된예가남자 1예, 이전서혜탈장으로수술을했던곳과같은쪽에서대퇴탈장이발생한예가여자 1예있었다. 대퇴탈장의특성상 8예전부가감돈이되어있었고탈장낭의내용물에지방종같은것이포함된경우는 7예였다. 탈장결손부로복막또는복막전조직 (preperitoneal structure) 의유착이동반된경우는 7예였다. 탈장낭을복원할때 3예에서복막이찢어져 2예에서는 Ligamax Endoscopic clip (Johhn & John K.K., Tokyo, Japan) 을이용해결찰을시행하였고 1예에서는 Endoknot R (Ethicon, Cincinnati, OH, USA) 을이용하여연속봉합하였다 (Table 2).

4 396 J Korean Surg Soc. Vol. 79, No. 5 Table 2. Operative findings Cases CH* RAGI HC ATAAW PTDR TMD Contralateral indirect + + +, clipping Ipsilateral direct Recurrent + + +, clipping , suture 8 + *CH = coexisting hernia; RAGI = reduction after gas insufflations; HC = hernia content (associated lipoma like lesion); ATAAW = adhesion to anterior abdominal wall; PTDR = peritoneal tearing during reduction and its treatment; TMD = taking mesh down the Cooper s ligament. Table 3. Clinical outcomes of laparoscopic TEP* repair for femoral hernia Cases Pain (acute/chronic) Wound problem Seroma Recurrence 1 +/ 2 +/ 3 +/ 4 +/ 5 +/ 6 +/ + 7 +/ 8 +/ *TEP = totally extraperitoneal. 4) 수술후경과 추적관찰 ( 범위 2 26개월, median 8.6개월 ) 결과수술후심각한통증은없었고상처에문제가발생한예는없었으며여자 1예에서장액종 (seroma) 에의한불편감을호소하였다 (Table 3). 재발및만성통증은없었다. 고 대퇴륜은외측으로는대퇴정맥 (femoral vein), 위로는서혜인대 (inguinal ligament), 내측으로는갈고리인대 (lacunar ligament), 뒤로는치골인대 (pectineal ligament) 로경계를이루며, 대퇴탈장은탈장낭이대퇴륜을통해서혜인대하방에있는대퇴관으로나온것이다.(10) Naude 등,(11) Mjåland 등 (12) 의연구에의하면대퇴탈장은남자보다여성에빈발하며 (1:2 2.5) Yoo 등 (13) 의국내보고에서도여자에게호발하는것으로보고하였다. 이는비교적넓은골반을가진 찰 여성의해부학적특징으로상대적으로대퇴륜이넓은이유에서기인한다. 본연구에서도남녀비는 1대 4로여성에서호발하는것으로나타나다른연구결과와일치하였다. Mikkelsen 등 (14) 은대퇴탈장은서혜탈장이약 5 20% 에서동반된다고하였다. 또한서혜탈장의수술과거력이있는환자에서대퇴탈장이많이보고된다고하였으며, 이러한이유로는서혜탈장수술시이미동반되어있던대퇴탈장을간과하였거나서혜탈장수술시과도한주위조직박리로대퇴륜을느슨하게한경우, 서혜탈장수술로인해대퇴륜막이과도하게당겨져대퇴륜이확장되기때문이다.(15) 대퇴탈장은서혜탈장과오인되는경우가많기때문에수술전에정확히진단하기가어렵고 (16) 대퇴륜의좁은해부학적특징때문에뚜렷한탈장의돌출증후가없어도교액이나감돈이다른복벽탈장보다흔하여응급수술을받게될가능성이높아진다.(17) 대퇴탈장이있는남자의경우 50% 에서, 여자의경우 10% 에서서혜탈장을동반하는것으로알려져있다.(18) 본연구에서는 2예의남자환자에서동측직접탈장과반대측간접탈장을각 1예씩동반하였고이전에서혜탈장으로수술받은경우가여자환자에서 1예있었다. 즉서혜탈장수술시대퇴탈장을놓치기쉽고, 대퇴탈장은다른서혜탈장을동반하는경우가있을수있어서개방성탈장교정술 (open hernia repair) 을시행할때염두에두고있어야할것으로사료된다. 수술전영상학적검사는주로초음파를이용하는데본연구에서는 7예의대퇴탈장환자에서초음파를시행한결과모두대퇴탈장을서혜탈장으로진단하였다. 이는초음파검사가시술자의주관적인검사라는점과서혜부의복잡한해부학적구조가서혜탈장과대퇴탈장을감별하는데정확성이떨어지는원인이라하겠다.(19) 따라서초음파검

Jin Hee Paik, et al:totally Extraperitoneal (TEP) Approach for Femoral Hernia 397 Fig. 4. Laparoscopic view of right femoral hernia. The lipoma-like mass observed in femoral area defect.

5 Jin Hee Paik, et al:totally Extraperitoneal (TEP) Approach for Femoral Hernia 397 Fig. 4. Laparoscopic view of right femoral hernia. The lipoma-like mass observed in femoral area defect. 사를할때는이학적검사소견과의비교가반드시필요할것으로판단된다. 한편전산화단층촬영은대퇴탈장과서혜탈장을구분하는기준으로삼을수있는탈장낭 (hernia sac) 과치골결절 (pubic tubercle) 과의위치적관계및대퇴정맥 (femoral vein) 의압박여부를관찰하기쉬우며 (20) 특히 multidetector-row computed tomography를통한수술전진단은대퇴탈장의진단에중요한구조물인, 서혜인대와하배벽동맥을구분하는데큰도움이되는데본연구에서도전산화단층촬영에서대퇴정맥측면으로대퇴탈장낭이있는경우를관찰하기용이하여수술전의영상학적진단에는초음파보다전산화단층촬영이더효과적이었다. 대퇴탈장의수술방법으로는과거에는 McVay 술식을주로이용하다가각종인공보형물을이용한무긴장성술식이보편화되는듯하였으나상처의크기가기존수술법과다르지않아미용적효과를크게보지못하는단점이부각되면서최근에는복강경을이용한탈장교정술이대두되었다. 복강경술식으로는복강경을복강내로접근하는방식인 TAPP 술식, 복직근의후면을통해복막전공간에보형물을넣는 TEP 술식, 복막을절개하여복막전공간을박리할필요없이바로복막에인공보형물을자동봉합기, 압정, 봉합사등을이용해부착하여복벽을강화하는방법인 IPOM 술식이있는데본원에서는 TEP 술식을이용하였다. 수술소견에대하여대퇴탈장의해부학적양태에대하여기술된경우는없었다. 본연구에서는수술을녹화한영상을토대로이에대한분석을시행한바 8예의 TEP 수술에있어서복막전지방 (preperitoneal fat) 이지방종 (lipoma) 같은형태로관찰되는경우가대부분이었다 (Fig. 4). 이러한탈장 결손부에대한복막전지방의유착은비교적단단하여초기에시행한 3예에서탈장낭복원도중복막이찢어졌다. 이후탈장낭복원을탈장결손부의뒤쪽에서시도하여복막이찢어지지않아탈장낭복원은탈장결손부의뒤쪽에서시행하는것이좀더용이한접근방식일것으로사료된다. 본연구에서는 8예전예에서재발이나만성통증은없었으나여자 1예에서장액종이발생하였는데이를방지하기위한추후방법에관하여고찰이필요할것으로사료된다. 그물망은 Tacker R 및 Tissel R 을사용하여고정하였는데 Lovisetto 등 (21) 의연구와마찬가지로 Tissel이수술후불편감을감소시키는데역할을했을것으로사료된다. 대퇴탈장은다른탈장과의동반가능성, 탈장의뒤쪽결손부로의접근과탈장낭교정의용이함, 수술후불편감및재발, 그리고미용적인측면등을고려해봤을때 TEP 술식이좋은수술방법이될것으로생각한다. 결 저자들은 8예의환자에서복강경 TEP 술식으로대퇴탈장의수술을시도하였다. 수술후합병증및재발에대하여향후더많은증례와장기간의추적관찰기간이필요하겠으나대퇴탈장에대한치료방법으로복강경 TEP 술식은안전하고효과적인수술방법이라고여겨진다. 또한수술전영상학적검사로는초음파보다전산화단층촬영술이더유의하다고사료된다. 론 REFERENCES 1) Ramshaw B. Surgical anatomy of the inguinal region and abdominal wall: clinical application of the total extraperitoneal approach for laparoscopic inguinal hernia repair. In: Soper NJ, editor. Problems in General Surgery. Abdominal Hernias. Vol. 19. Philadelphia: Lippincott Williams & Wilkins; p ) Amid PK, Shulman AG, Lichtenstein IL. The femoral canal: the key to femoral herniorrhaphy. Int Surg 1990;75: ) McVay CB, Savage LE. Etiology of femoral hernia. Ann Surg 1961;154: ) Rahaman QM, Goswami B, Gumta MK, Samanta S, Mukhopadhyay S, Chattopadhyay M. Bilateral femoral hernia in male--a case report. J Indian Med Assoc 2005;103:237, 42. 5) Lichtenstein IL. Herniorrhaphy. A personal experience with 6,321 cases. Am J Surg 1987;153: ) Bátorfi J. The treatment of inguinofemoral hernias with lapa-

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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