Journal of Minimally Invasive Surgery Original Article Vol. 15. No. 4, 212 단일통로복강경충수절제술후합병증발생의위험인자 동국대학교의과대학일산병원외과학교실 이희성ㆍ백용해ㆍ한인웅ㆍ최원용ㆍ곽범석ㆍ박영진ㆍ오민구ㆍ김홍용 What Are the Risk Factors for Complication in Transumbilical Single-Port Appendectomy? Hee Sung Lee, M.D., Yong Hae Baik, M.D., In Woong Han, M.D., Won Yong Choi, M.D., Beom Seok Kwak, M.D., Young Jin Park, M.D., Min Gu Oh, M.D., Hong Yong Kim, M.D. Department of Surgery, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea Purpose: Along with the development of minimally invasive surgery, laparoscopic surgery has recently been adopted worldwide. In cases of laparoscopic appendectomy, single port appendectomy is increasingly being adopted due to its cosmetic advantages and reduced pain. This study was conducted to evaluate the risk factors associated with post-operative complications in single port appendectomy. Methods: Forty-nine consecutive patients who underwent transumbilical single port appendectomy (TUSPLA) were enrolled in this study. We reviewed the initial WBC count, hscrp, position of the appendix, and intra operative findings and then analyzed the data by univariate and multivariate analysis. Results: Complications were observed in five of the 49 patients (1.2%). Specifically, wound complications were observed in three patients (6.1%), and periappendiceal fluid collection occurred in two patients (4.1%). Univariate analysis revealed a retrocecal type appendix (p=.46) and overweight (BMI 23, p=.34) as risk factors significantly correlated with the occurrence of complications. Conversely, retrocecal type appendix (p=.121) and overweight (BMI 23, p=.329) were not significantly correlated with complications upon multivariate analysis. Conclusion: For patients with a high risk of postoperative complications, including those with retrocecal appendix undergoing TUSPLA and obese patients, sufficient informed consent is necessary, and intensive monitoring for the incidence of complications must be considered postoperatively. However, further studies enrolling larger groups of patients should be conducted to confirm these findings. Key words: Single-port, Laparoscopic appendectomy, Complications 서 최소침습수술의발달에따라복강경수술은외과학분야에서널리시행되고있다. 외과영역에서응급수술을요하는가장흔한질환인급성충수염의경우, 1983년 Semm 1 에의해복강경충수절제술 (Laparoscopic appendectomy) 이처음소개되었고급성충수염의수술적치료방법으로널리시행되고있다. 1년전부터시행되고있던기존의개복충수절제술에비해통증의경감, 짧은재원기간및빠른회복, 유착이적은장점으로인해시행빈도가늘어, 현재는 Received August 26, 212, Revised 1st, October 14, 212; 2nd, October 2, 212, Accepted October 21, 212 Corresponding author:yong Hae Baik Department of Surgery, Dongguk University Ilsan Hospital, 814, Siksa-dong, Ilsandong-gu, Goyang 41-773, Korea Tel:+82-31-961-7264, Fax:+82-31-961-7144 E-mail:Whitedrag@naver.com This article is related with subject posted in 212 International Congress of the Korean Society of Endoscopic & Laparoscopic Surgeons. http://dx.doi.org/1.762/jmis.212.15.4.138 론 복강경충수절제술이급성충수염환자에대해서보편적인치료방법으로받아들여지고있다. 2-5 또한수술중복강내장기들을관찰할수있어다른질환에대한감별진단이가능하고, 충수돌기위치의변이 (variation) 가있는경우에도충수를찾기쉬우며복강내세척이필요한경우에보다철저한세척이가능하다는장점이있다. 6 복강경충수절제술은현재 3개의통로를이용한수술이일반적인방법이다. 한편, 최소침습수술이보다적은숫자의통로를통한수술방법을모색하게되었고기구및술기의발달에힘입어 2개의통로를이용한수술방법을거쳐수술부위의상처를최소화하기위해하나의절개창만을이용한단일통로복강경충수절제술 (Single-port laparoscopic surgery) 이새로운수술방법으로소개되었다. 기존의복강경충수절제술에비하여단일통로복강경충수절제술 (Single-port laparoscopic appendectomy, SLA) 의시행은여러가지장점이보고되고있고, 기존수술방법에비해최소침습수술의개념에부합하는바그시행횟수가늘어가고있다. 여러장점에도불구하고, 수술후합병증의발생은재원기간의증가및의료비용의상승, 환자의삶의질저하등 This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Hee Sung Lee et al.: What Are the Risk Factors for Complication in Transumbilical Single-Port Appendectomy? 139 을초래하여단일통로복강경충수절제술의여러장점을경감시키게된다. 따라서이러한합병증을유발하는데수술전어떠한요인이기여하는지를알아보고, 이러한위험인자가있는환자에서는기존의 3개의통로를이용한복강경수술의시행을고려하거나단일통로복강경수술중이라도기존수술방식으로의전환을고려함으로써단일통로복강경충수절제술을시행받은환자에서의장점을최대한살리고자이연구를계획하였다. 대상및방법 1) 연구방법본연구는동국대학교일산병원에서단일통로복강경충수절제술을처음시행한 21년 3월부터 211년 12월까지총 22개월의기간을대상으로하였다. 동기간동안충수염으로수술받은환자는 431명 ( 개복충수절제술 123명, 복강경충수절제술 38명 ) 으로이중단일통로복강경충수절제술을시행받은 5명이었다. 수술중심한유착으로인하여기존의 3개를통로를이용한복강경충수절제술로전환했던 1예는본연구에서제외하였다. 총 49명환자의충수돌기염의진단은환자의현병력과이학적검사, 혈액검사, CT 소견을조합하여진단하였다. 단일통로복강경충수절제술의수술대상은기존의개복수술, 3개의통로를이용한복강경충수절제술, 단일통로복강경충수절제술의장단점을환자및보호자에게설명후환자의선택에따라수술방법을결정하였다. 복강경수술을원하였던환자중복부수술의기왕력과복막염의병력이있을때는단일통로복강경충수절제술대상에서제외하였고, 이들환자는기존의복강경충수절제술이나개복수술을시행하였다. 전체 49명의환자중남자는 24명, 여자는 25명이였으며, 평균연령은 24.9세였다. 합병증발생의위험인자를알아보기위하여수술을시행받은환자의성별, 나이, 비만도, 응급실내원시백혈구수치와체온, CT상에서충수의위치및염증정도, 수술중관찰된주위장기와의유착유무, 수술중특이소견을의무기록을토대로후향적으로조사하였다. 소아와성인의합병증발생차이를보기위하여 16세미만을소아로정의 ( 본원소아과진료기준 ) 하여조사하였고, 비만도는체질량지수 (Body Mass Index, BMI) 를기준으로 23 kg/m 2 이상 ( 과체중, 대한비만학회기준 ) 과미만으로구분하였다. 발열은겨드랑이체온이 37.5 o C 이상 (http://en.wikipedia.org) 으로정의하였으며, 백혈구수치는 1,/μl ( 정상백혈구 : 4, 1,/μl, 본원진단검사의학과기준 ) 이상을백혈구증가증 (leukocytosis) 로정의하였다. 충수의위치는수술전시행한 CT 소견을기준으로막창자뒤충수 (Retrocecal type appendix) 와그외의위치로구분하였고, 염증정도는수술후병리소견에따라화농성 (Suppurative), 괴사성 (Gangrenous), 천공성 (Perforated) 으로분류하였다. 본연구에서합병증은수술후발생한장마비, 배꼽상처부위염증의발생, 술후발생한복강내액체저류나농양형성으로정의하였다. 합병증발생에대한통계분석은단변량분석과다변량분석으로확인하였다. 두군의평균차이를보기위하여 t-test를이용하였으며, χ-square test와 logistic 회귀분석을이용하여합병증위험인자에대한단변량분석과다변량분석을시행하였고, p value는.5 이하를유의한수준으로정의하였다. 2) 수술방법모든환자의수술은단일술자 ( 복강경충수절제술 1예이상시행 ) 에의해진행되었고, 환자를앙와위 (Supine position) 로위치시키고전신마취후에, 집도의와제 1조수가환자의좌측에서수술을진행하였다. 먼저단일포트는수술용장갑 (No.6) 의검지, 중지, 약지부위를잘라서 12 mm 투관침하나와 2개의 5 mm 투관침을 Silk 1-를이용하여고정한다음상처견인기 (Wound retractor, Alexis R, Applied Medical, CA, USA) 와결합시켜서사용하였다. 배꼽에 15 mm에서 18 mm 가량수직으로절개창을만들어, 배꼽아래쪽복막에다른구조가끼이지않은것을확인한다음상처견인기를삽입하였다. 복강경수술중복압은 12 mmhg를기본으로하였고필요에따라 14 mmhg까지증감하였다. 복강경수술기구는경성기구 (rigid instrument) 를사용하였으며, 3도기울기의 5 mm 경성카메라 (Olympus R, Japan) 를이용하여시야를확보하였다 (Fig. 1). 박리기 (dissector) 를이용하여충수간막을분리하여충수동맥을확인후 15 mm 클립과리가슈어 (Ligasure R ) 를이용하여결찰및절단하였고, 충수기시부에서 2 mm 떨어진부위에서 Surgi-tiel R (Tyco Healthcare, USA) 루프를이용하여이중결찰하였다. 충수 Fig. 1. Single-port via umbilicus.
14 Journal of Minimally Invasive Surgery Vol. 15. No. 4, 212 는카메라의시야가확보된상태에서장갑의 3번째손가락부위를이용하여복강밖으로제거하였다. 수술소견에따라서삼출물의배액이필요하다고생각될때는배액관 (Jackson-Pratt drain) 을추가적으로우하복부에삽입하였다. 상처견인기및장갑을제거한후배꼽의복막과백색선을 Vicryl R 1- ( 소아의경우 Vicryl R 2-) 을이용하여봉합하였다. 피부봉합은하지않은채로거즈볼을이용하여압박드레싱시행후수술을마쳤다. 환자에게는수술전후로 2세대 Cephalosporin (Cefminox sodium) 을정맥을통해투여하였고, 수술소견상충수의천공이있는경우에는 Metronidazole을추가해서투여하였다. Table 1. Patient characteristics Predictor Age (yr) Sex M F BMI* Fever ( 37.5 o C) CBC ( 1,) OP time (min) Hospital day (day) *Body mass index. 결 단일통로복강경충수절제술을받은총 49명의환자중, 술후합병증이있었던환자는 5명 (1.2%) 으로, 배꼽부위염증이 3명 (6.1%), 수술부위농양이 2명 (4.1%) 이었다. 환자의평균나이는정상환자 ( patient group, N) 군이 27.1±14.8세, 합병증이발생하였던환자 (Complicated patient group, C) 군이 31.6±15.5세로통계적으로유의한차이가없었다. 환자의비만도는정상군이 21.4±2.9 kg/m 2 였고, 합병증군이 26.1±3.1 kg/m 2 로합병증군이정상군에비해서비만도가더높게나타났다 (p=.1). 발열이있었던환자는 3명으로, 모두정상군에서나타났지만통계적의미는없었다. 정상군중에서백혈구증가증이있었던환자는 36명 (81.8%), 합병증군에서는 3명 (6%) 으로두군의차이는없었다 (p=.251). 수술시간은합병증군이 8±15.4분으로정상군59.9±2.1분에비해의미있게길었다 (p=.1). 환자의재원기간은합병증군이 9±4.4일로합병증이발생하지않은군 (5±1.2) 에비하여 4일이상길었다 (Table 1). 합병증발생과관련된인자에대한단변량분석에서는, 연령에따른 ( 소아 1명 [6.7%], 성인 4명 [11.8%]) 합병증발생 No. patients (n) p value (44) Complication (5) 27.1±14.6 과 22 (5%) 22 (5%) 21.4±2.9 3 (6.9%) 36 (81.8%) 59.9±2.1 5±1.2 31.6±15.6 2 (4%) 3 (6%) 26.1±3.1 3 (6%) 8±15.4 9±4.4.518.672.1.156.251.1.35 의차이는없었고 (p=.587), 성별은남자환자 2명 (8.3%), 여자환자 3명 (11.4%) 에서합병증이발생하여두군의차이는없었다 (p=.672). 환자의체질량지수상비만도가 23 미만인환자중 1명 (8.3%) 에서합병증이발생한것에비해비만도 23 이상인환자에서는 4명 (21.1%) 의합병증이발생하여, 통계적으로유의한소견을보였다 (p=.34). 환자의내원당시의백혈구수치를바탕으로한분류에서는, 정상백혈구수치를보인 2명 (18.2%) 에서합병증이발생하였고, 백혈구증가증이있었던환자중 3명 (7.7%) 에서합병증이발생하여이는통계적으로유의성은없었다 (p=.251). 충수의위치에따른합병증발생빈도는막창자뒤충수형환자중 4명 (26.7%), 기타위치에충수가있었던환자중 1명 (2.9%) 에서합병증이발생하여두군이유의한소견을보였다 (p=.11). 충수의염증정도에따른합병증발생은각군에서유의한차이를보이지않았다 (p=.581). 수술중주위장기와의유착으로인해주위조직으로부터박리가필요했던환자는 5명이었다. 3명은대망과충수간막과의유착이있 Table 2. Predictors for development of complication in single port appendectomy, univariate analysis Predictor Age (yr) <16 16 Sex M F BMI (kg/m 2 ) <23 23 Initial WBC counts Leukocytosis* Initial body temperature Fever Location of appendix Retro-cecal Others Appendicitis finding Suppurative Gangrenous Perforated Intra op-adhesion- Adhesion No. patients (%) Complication (-) 14 (93.3) 31 (88.2) 22 (91.7) 22 (88) 3 (96.8) 15 (78.9) 9 (81.8) 36 (92.3) 41 (89.1) 3 (1) 11 (73.3) 34 (97.1) 37 (88.1) 4 4 2 (4.) 42 (95.5) Complication (+) 1 (6.7) 4 (11.8) 2 (8.3) 3 (12) 1 (3.2) 4 (21.1) 2 (18.2) 3 (7.7) 5 (1.9) 4 (26.7) 1 (2.9) 5 (11.9) 3 (6.) 2 (4.5) *WBC counts 1,/ul, Body temperature 37.5 o C. p value.587.672.34.251.547.11.581.1
Hee Sung Lee et al.: What Are the Risk Factors for Complication in Transumbilical Single-Port Appendectomy? 141 Table 3. Significant predictors for development of complication in single port appendectomy, multivariate analysis Predictor Odds ratio 95% CI p value BMI <23 23 Location of appendix Retro-cecal Others* Intra op-adhesion- Adhesion (+) 1.423.83 2.559.19-3.3.25-8.12.778-214.82.271.585.74 *Retroilealtype, Pelvic type, Anterocecal type. 었고, 2명은원위부회장과맹장과충수가유착이있었던경우이다. 이중 3명 (6%) 에서합병증이발생하였고 2명은대망과충수간막의유착이있었던환자였고, 1명은원위부회장및맹장과의유착이있었던환자로, 유착이없었던군에서합병증이발생한 2명 (4.5%) 에비하여통계적으로유의한소견을나타내었다 (p=.1)(table 2). 상기결과를토대로한다변량분석에서는 BMI가 23 이상인경우에서 BMI 23 미만인경우보다 1.4배로합병증발생의위험이증가하였으나통계적유의성은없었고 (p=.271), 충수돌기위치에따른분석에서도막창자뒤충수형인환자의경우가그외의충수형인환자의경우에비해약 2% 가량의합병증발생위험성이높았으나역시통계적인유의성은없었다 (p=.585). 단변량분석에서수술후합병증발생에가장유의한인자로나타났던수술중주위조직과의유착이있는경우가다변량분석에서합병증발생의위험도가 2.5배가량증가하는추세를보였으나 (p=.74) p value.5 이하를유의한기준으로하였을때그의미를상실하였다 (Table 3). 합병증이발생한환자중, 배꼽염증이있었던 3명은반복적인상처소독과추가적인경구항생제사용으로호전되었고, 복강내농양이형성된환자 2명중 1명의경우정상퇴원후복통이발생하여 CT 검사를시행후맹장주위로액체저류가확인하고재입원하여항생제정맥투여후호전되었다. 다른 1명은술후 7일째발열및복통으로재입원하였고, CT상발견된복강내농양으로항생제치료및경피적배액관삽입술 (Percutaneous drainage) 후호전되었다 (Fig. 2). 고찰최소침습수술 (Minimal Invasive Surgery) 에대한관심의증가와더불어수술후반흔을줄이기위한연구가다방면으로활발히진행되고있는상황이다. 24년 Kalloo 7 에의 Fig. 2. Post operative peritoneal abscess. 해처음소개된 Natural orifice transluminal endoscopic surgery (NOTES) 는질, 방광, 구강, 직장등인체의자연개구부를통한수술부위로접근하는수술방법이며현재충수절제술분야에서도 NOTES를이용한여러가지수술방법이시도되고있다. 내시경으로위를통과하여수술하는방법과여성환자의질을통해수술하는방법, S상결장을통한접근방법등이소개되고있지만, 8-1 특수장비의필요성, 불충분한시야, 봉합부위의불안정성과기복 (pneumoperitoneum) 의문제점, 긴수술시간그리고비용-효과측면에서의부적합성등의단점으로아직은실험적단계인수술법으로받아들여지고있으며 11-13 이를해결하기위한추가적인연구가진행되고있는상황이다. 이에반해단일통로충수절제술은 NOTES에비교하여안전하고, 기존의기구를이용하여수술가능하며, 단일통로를통한수술이어려운경우에는추가적인투관침을설치하거나기존의수술로전환할수있어환자에게적용가능성이높은수술방법이다. 14 복강경충수절제술분야에서기존의술식은 3개의분리된투관침을삼각모양으로 (1개의 12 mm port, 두개의 5 mm port) 삽입하여수술하는방법인반면에최소침습수술의개념을극대화하기위한시도로보다적은개수의투관침을이용한수술술기가소개되고있고, 15,16 이러한관점에서, 두개의투관침을이용한복강경충수절제술을거쳐, 최근에는배꼽을통한단일통로복강경충수절제술로발전하고있다. 기존의복강경충수절제술과단일통로복강경충수절제술을비교하는연구들이소개되고있고, Kim 등 17 에의하면두군에서술후통증을비교하였을때, 시각통증척도 (Visuasl analogue scale, VAS) 를기준으로수술후첫 24시간의통증이단일통로복강경충수절제술을받은환자군에서조금더높게보고되었으나통계적유의성은없었다. 위연구에서는단일통로복강경충수절제술후수술통증
142 Journal of Minimally Invasive Surgery Vol. 15. No. 4, 212 이많은경향을보인이유로기존복경경수술에비해큰배꼽절개창을원인으로생각하고있다. Cervini 등 18 에의하면이같은통증을해결하기위한방법으로수술부위에수술을끝내기전배꼽부위에국소마취제를투여하거나, 횡행근의신경을차단하는방법 (Transversus abdominis plane (TAP) block) 을시도해볼수있다하였다. 19,2 또한복강경수술시에기복을만들기위해사용되는이산화탄소와수술중발생한연기가술후통증을유발하는중요한인자로알려져있는데단일통로복강경수술에서는수술후이가스의제거가불완전하여통증이기존술식보다큰것으로판단된다. 이를해결하기위한방법으로단일통로를만들때이용하는수술용장갑에 3방향카테터를이용하여가스를제거하는방법이소개되고있고, 21 이는술후통증경감에도움이될것으로생각된다. 하지만많은논문에서는단일통로복강경충수절제술에서수술후통증이기존복강경수술에비하여높지않다고보고되고있다. 14,22 한편몇몇연구에서는단일통로복강경충수절제술의수술시간이기존의복강경충수절제술에비해더긴것이문제점으로지적되고있으나, 17,23 술자가일정한학습곡선을지나고나면수술시간은기존의복강경수술시간에비해큰차이가없거나, 24 더짧아진다고서술하고있다. 25,26 본원의경험으로는기존의복강경수술의평균수술시간 (62.8분) 27 에비하여단일통로충수절제술의평균시간 (72.7 분 ) 이길었으나, 합병증이있는경우를제외하면큰차이가없었고, 단일통로수술의경우시행횟수가늘어감에따라수술시간이짧아지는것을확인할수있었다. 단일통로복강경수술은기존의복강경수술을안전하게시행하고있던술자에게는쉽게적용가능한수술이며, 21 미용적인측면에서환자의만족감을높일수있는수술방법이다. 단일통로복강경수술이가지고있는여러가지장점에도불구하고술후합병증의발생은재원기간의증가로인한의료비의상승과환자의만족도저하로이어져그장점을반감시킨다. 본연구에서는충수의위치가맹장뒤에있었던경우와환자의체질량지수가 23 kg/m 2 이상이었던경우, 그리고수술중유착이있었던환자에서합병증발생이높은것으로나타났고, 이는본원에서수술시에연성기구를사용하지않았기때문에충수가맹장후면에위치한경우접근이쉽지않았고, 과체중인경우충수간막조직의두께가상대적으로두꺼워이의처리가기존의 3개의투관침을이용한복강경수술에비하여어려운것이원인으로생각된다. 유착이있는경우도기구간의거리가좁고각도가제한되어, 자유로운기구의조작에어려움이있어조직박리에시간이더소요되고이러한요소들이합병증의발생을높일것으로추정된다. 단일통로복강경충수절제술은한곳의통로를통해서카메라와수술기구를조작해야한다는제한을가지고있는수술이다. 이러한태생적인특징때문에카메라와수술기 구간, 수술기구와수술기구간, 그리고체외에서술자의양손의충돌로인해움직임이제한된다. 이는결과적으로수술의난이도를높이게되며이러한제약은술자의학습곡선 (learning curve) 를지나면서어느정도는극복이가능하나 3개의통로를이용한복강경충수절제술에비하면여전히단일통로복강경충수절제술의단점으로지적되고있다. 이러한단점을보완하기위한방법으로 Kim 등 28 은투관침의높이를다르게하여술자의양손의충돌을줄이고, 연성카메라 (flexible scope) 와연성기구를사용함으로써제한된움직임을조금이나마경감시켜보다정교한조작을가능하게하였다. 본원에서의경험상, 연성기구의사용은수술중다소간의도움이될수있으나, 연성카메라의사용은고정되지않는연성카메라의끝부분에수술기구의끝이충돌하여시야가잦은변경을유발하여도움이되지는못하였다. Kim 등 28 은만약단일포트를이용한수술의진행이어려울것으로생각되는경우에환자의안전과최적의수술을위하여우하복부에추가적인투관침을삽입후수술하는것을추천하였다. 이경우수술과정에서기구의제한적움직임을경감시켜, 좀더정교한조작을가능하게하였고, 배액관삽입시우하복부의투관침삽입부위를이용하여불필요한침습적인술기를줄일수있었다. 28,29 위방법은단일통로충수절제술을시행하던중, 3개의통로를이용한충수절제술로의전환을고려할때선택할수있는또다른방법으로생각된다. 본연구의한계는본원에서처음단일통로복강경충수절제술을시작한사례부터포함하여분석하였기때문에학습곡선을지나지않은많은사례가포함되어 3개의통로를이용하는복강경충수절제술과의직접적인장단점의비교는어렵다. 또한환자의사례가많지않아본연구만으로단일통로복강경충수절제술의적응증을정하는것은어려운일이다. 하지만처음으로단일통로복강경충수절제술을준비하는술자에게수술의적응이되는환자를선별함에있어조금이나마도움을주고자하는의도로연구가이루어졌고, 추후에복막염이나과거복부수술의기왕력이있는환자를대상으로도수술을시행하여결과비교시보다현실적으로적용할수있는결과가얻어질것으로생각된다. 결론단일통로복강경충수절제술은 3개의통로를이용한기존의복강경하충수절제술에비해덜침습적인술기로받아들여지고있으나이수술후합병증의발생은재원기간의연장및환자가겪는고통의증가로인해단일통로복강경충수절제술의장점을반감시키게된다. 따라서단일통로복강경충수절제술을시행받는환자중후맹장형충
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