자궁절제술의종류및방법 현재여성에서시행되는수술중가장많은빈도를보이는수술중의하나가자궁절제술이다. 1813년 Conrad Langenbeck에의해최초로질식자궁절제술이성공적으로시행되고, 1853년 Walter Burnham에의해최초로성공적인복식아전자궁절제술 (subtotal hysterectomy) 이시행된이래 1,2) 각종복강경수술기구와기술의발달로 1989년에는 Reich 등에의해복강경을이용한자궁절제술이최초로시행되었다. 3) 이후복강경하질식자궁절제술 (laparoscopically assisted vaginal hysterectomy, LAVH), 복강경하전자궁절제술 (total laparoscopic hysterectomy, TLH), 복강경하아전자궁절제술 (subtotal laparoscopic hysterectomy), Semm식자궁절제술 (classic intrafascial Semm hysterectomy, CISH) 등의다양한수술기법이소개되어이전에개복수술을필요로했던질환의대부분이복강경수술로대체되고있으며수술기구와술기의발전으로복강경수술의범위가더넓어질것으로기대되고있다. 최근에는로봇-보조자궁절제술 (robot-assisted laparoscopic hysterectomy) 이시행되었고 (2002년), 4) 단일공법복강경하전자궁절제술 (SPA-TLH) 또한소개되었다 (2008년). 5) 자궁절제술의종류와방법은다음과같다. 1. 자궁절제술의종류 1) 질식자궁절제술 2) 복식자궁절제술 3) 복강경을이용한자궁절제술 4) 로봇-보조자궁절제술 5) hand-assisted laparoscopy (HAL) 6) 소개복술 (mini-laparotomy) 7) 단일공법복강경하자궁절제술 8) transvaginal NOTES 2. 복강경을이용한자궁절제술의분류 <Reich 의분류, 2007> 6) 1) Diagnostic laparoscopy with vaginal hysterectomy 2) Laparoscopic-assisted vaginal hysterectomy 3) Laparoscopic hysterectomy 4) Total laparoscopic hysterectomy 5) Laparoscopic supracervical hysterectomy including classical interstitial Semm hysterectomy 6) Vaginal hysterectomy with laparoscopic vault suspension or laparoscopic pelvic reconstruction
7) Laparoscopic hysterectomy with lymphadenectomy 8) Laparoscopic hysterectomy with lymphadenectomy and omentectomy 9) Laparoscopic radical hysterectomy with lymphadenectomy 상기분류외에도 Nezhat 등 (1995), Garry 등 (1994), Munro and Parker (1993) 의분류가 있음. 3. 복강경하질식자궁절제술 (LAVH) 의방법 1) 전신마취하에쇄석위에서자궁거상기를삽입후배꼽에 verres needle로복강을천자하여이산화탄소를주입 2) 배꼽에복강경을넣고복강을살핀후에하복부에투관침을삽입 3) 난소인대및난관, 원인대를절단하거나자궁부속기를절제하는경우에는자궁관사이막 (mesosalpinx) 과누두골반인대 (infundibulopelvic ligament) 절단 4) 광인대를자르고방광을박리 5) 다음은질식단계로자궁경부를절개하고복강으로진입한뒤에자궁천골인대와기인대, 자궁혈관을각각자르고결찰 6) 자궁을제거한후에복막과질원개부를자궁천골인대에고정 7) 다시복강경을이용하여지혈여부및요관주행확인 4. 복강경하전자궁절제술 (TLH) 의방법 1) 자궁조작기 (± 질튜브 ) 삽입 2) 포트설치및복강내관찰 3) 난소인대 / 골반누두인대절단및원인대절단 4) 기인대절단 (± 요관 / 자궁혈관박리 ) 5) 방광박리 6) 질벽절개 (± 자궁천골인대절단 ) 7) 자궁세절 8) 자궁제거 9) 질원개 (vaginal vault) 및골반복막봉합 (pelvic peritonealization) 으로나눈다. 5. Classic intrafascial Semm hysterectomy (CISH) 의방법 1) 난소의제거유무에따라원인대 (round ligament) 와난소인대혹은골반누두인대 (infundibulopelvic ligament) 를절단 2) 광인대 (broad ligament) 의앞면과뒷면을박리하고, 방광박리 3) 자궁협부부위까지박리되면 CISH loop를이용하여자궁천골인대 (uterosacral ligament) 와자궁경-체부연결부위에거치
4) 다음질식수술과정으로자궁거상기를제거하고, 자궁경부를 tenaculum으로잡은후 CURT set (Calibrated Uterine Resection Tool) 의 guide rod로자궁내강을통과한후 morcellator를이용하여편평원주상피결합부를포함한내자궁경상피절제를시행 5) 다시복강경수술로 CISH loop를단단히결찰 6) 자궁경-체부결찰 2cm 상방을절단 7) 복막봉합 (pelvic peritonealization) 9) SEMM set (serrated edged macro-morcellator) 를이용하여절제된자궁체부를분쇄하여제거 6. Hand-assisted laparoscopy 의방법 1) After induction of general endotracheal anesthesia, the patient is placed in a dorsal lithotomy position. 2) A uterine manipulator is placed in the uterus. 3) A 6- to 8-cm Pfannenstiel incision is made 2 cm above the pubis symphysis and carried down to the subcutaneous tissues. The fascia is opened by use of monopolar electrosurgery. The muscles are split in the midline, and the peritoneum is entered bluntly. Hand-assisted access is established. 3) Depending on the uterine size and surgeon's preference, a primary 5- or 10-mm port can be placed in the upper abdomen with guidance of the hand inside the abdomen, followed by insufflation 4) The laparoscope is inserted next, and the abdominal cavity is evaluated. 5) Two or three additional 5-mm ports are placed under direct visualization. 7. 단일공법복강경하자궁절제술의방법 NOTES (Natural Orifice Translumenal Endoscopic Surgery, 자연개구부내시경수술 ) 는신속한회복, 좋은미용효과등의장점이있으나, 기술적인어려움과합병증발생위험으로아직은임상적으로널리이용되지못하고있다. 이에비해배꼽부위에하나의절개만시행하여복강경으로수술하는단일공법복강경수술은 NOTES의장점을가지고있으면서도 NOTES의단점을어느정도극복할수있어최근크게각광을받고있다. 1) 장점 1 배꼽외에는수술상처가없으며배꼽의상처또한배꼽의주름으로가려져거의찾아볼수없게된다. 2 수술후통증이적으며회복이빠르다. 3 일반복강경수술을시행할때보다배꼽의구멍이크기때문에배꼽을통하여절제된조직을꺼내기가쉽다. 4 피하기종 (subcutaneous emphysema) 을예방할수있다.
5 홈메이드포트를이용하여수술을시행할경우상처견인기의양끝테두리를조임에따라압박효과에의해배꼽절개부위의출혈을멈추게한다. 구멍을확장하는효과도있어수술조작을용이하게한다. 또한수술비용을절감할수있다. 6 부인과수술의경우에는일반복강경수술처럼자궁을절제한후질을통하여절제된조직을복강밖으로꺼낼수있다. 7 단일공법복강경수술은일반적인복강경기구에의해서도시행될수있으며언제나단일공법에서다공법 (multi-port) 복강경수술로의전환이가능하다. 2) 단점단일공법복강경수술의가장큰단점은모든기구들이가까이있어기구간의충돌이빈번하여일반적인복강경수술에비해수술이어렵다는것이다. 기구들을제한된범위로만움직일수있고, 수술자와내시경을조작하는수술보조자간의협동이잘되어야한다. 기구축의빈번한엇갈림에도적응하여야한다. 이러한조작의어려움으로일반복강경수술에비해시행초기에수술시간이더걸리게된다. 3) Procedures 환자는전신마취후쇄석위 (lithotomy position) 를취한다. 이때환자의팔은옆으로벌리지않고몸에붙여수술자및수술보조자의행동반경을되도록크게한다. 우리나라에서많이쓰이는홈메이드포트를이용하는경우수술장갑의손가락부위를필요한만큼가위로잘라투관침 (troca) 을끼운후가스가새지않게결찰한다. 수술중발생하는연기를좀더빨리제거하기위해서는수술장갑의투관침이부착되지않은나머지손가락부위를자르고켈리겸자 (Kelly forceps) 등의수술기구로닫아놓는다. Three-way catheter를사용할수도있다. 수술자와수술보조자의손가락으로배꼽의좌우양측복벽을잡아서들어올린후배꼽을몸의장축방향으로절개한다. 일부절개된배꼽의피부를앨리스겸자 (Allis forceps) 로잡은다음높이들어올려배꼽의경계를넘지않은한도로배꼽의피부절개를확장한다. 근막절개술 (fasciotomy) 을시행하여복강내로의통로를만든다. 상처견인기를배꼽의통로에끼워넣고미리만들어진수술장갑을상처견인기의바깥쪽테두리에끼워감아완전한포트를구성한다. 복강경수술에필요한 CO2 가스는수술장갑에부착된투관침을통하여불어넣는다. 환자의상부를낮추어시야확보에좋은자세를만들고배꼽의포트에내시경및 2개의수술기구를동시에삽입하여수술을진행한다. 내시경은일직선으로곧은 5 mm의 0도또는 30도내시경을사용하고, 최근개발된자유롭게구부러지는내시경을사용할수도있다. 수술기구또한일반적으로많이사용되는일직선의구부러지지않는 5~10 mm 복강경수술기구들을사용할수있으며구부러지는기구들또한사용할수있다. 수술자는환자의좌측이나우측에서서 2개의삽입된수술기구를양손으로조작한다. 제1 수술보조자는수술자의반대편에서서내시경을조작하고제2 수술보조자는환자의양측다리중간에서서자궁거상기를조작한다.
4) Morcellation 방법및전동식조직세절기 (electromechanical morcellator) 의사용절제된조직을질이아닌복벽을통하여꺼낼때배꼽의포트로직접꺼내거나내시경백에넣어꺼내는데조직이큰경우배꼽을통해수술칼로작게절단하여꺼낸다. 세절해서꺼낼경우조직이복강내로흩어지는것을막기위해되도록내시경백에넣은후세절하여꺼내는것을권장한다. 일반복강경수술에이용하는전동식조직세절기를단일공법복강경수술에서도이용할수있다. 8. Transvaginal NOTES 에의한자궁절제술의방법 7) 1) Under general anesthesia with endotracheal intubation, patients were placed in the Trendelenburg position with legs bandaged and supported in the stirrups. 2) A 12F Foley catheter was inserted. The operation began as in conventional vaginal surgery, with resection of the vaginal wall around the cervix and creating a 3-cm posterior colpotomy through the posterior fornix of the vagina. 3) Then the uterosacral ligaments were dissected, and the uterine vessels were sealed and cut up to the level of the isthmus. 4) The vaginal port was then established by inserting the inner rim of a small Alexis wound retractor (Applied Medical Resources Corp., Rancho Santa Margarita, CA) around the cervix and fixing it from behind the colpotomy wound (Fig. 5A), and the outer rim of the wound retractor outside of the vagina was draped with the disposable surgical glove of which 3 fingers were fixed with 10- or 5-mm cannulas. 5) 5-mm 30-degree endoscope or a 10-mm conventional endoscope as the visual medium. 6) A laparoscopic single-tooth tenaculum to manipulate the uterus. All other necessary instruments were ordinary straight ones as used in conventional laparoscopy. References 1. Langenbeck CJM. Geschichte einer von mir glucklich verichteten extirpation der ganger gebarrmutter. Bibliotyh Chir Opth Hanover 1817;1:557-62. 2. Burnham W. Extirpation of the uterus and ovaries for sarcomatous disease. Nelson s Am Lancet 1853;7:147-51. 3. Reich H, DeCaprio J, McGlynn F. Laparoscopic hysterectomy. J Gynecol Surg 1989;5:213-6. 4. Diaz-Arrastia C, Jurnalov C, Gomez G, Townsend C Jr. Laparoscopic hysterectomy using a computer-enhanced surgical robot. Surg Endosc 2002; 16:1271-3. 5. Kim YW. Single port (one port) total laparoscopic hysterectomy (TLH) and laparoscopically assisted vaginal hysterectomy (LAVH): initial experience in Korea. Video presented at the 94th Annual Congress of the Korean Society of Obstetrics and Gynecology; September 26-27,2008; Seoul, Korea. 6. Reich H. Total laparoscopic hysterectomy: indications, techniques and outcomes. Curr Opin Obstet Gynecol. 2007 Aug;19(4):337-44. 7. Lee CL, Wu KY, Su H, Wu PJ, Han CM, Yen CF. Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (NOTES): a series of 137 patients. J Minim Invasive Gynecol 2014:21:818-24.