다중검출기전산화단층촬영 (MDCT) 에서보이는복벽탈장의다양한영상소견 1 김신영 신형철 김상원 김일영 김영통 복벽탈장은흔하게볼수있는질환으로합병증이잘동반되고대부분수술적치료가필요하기때문에정확한진단을위해서세밀한영상학적검사가필수적이다. 근래도입된다중전산화단층촬영술은복벽의구조, 정확한탈장의종류, 그리고조기합병증을진단하는데효과적이다. 이에저자들은다중검출기전산화단층촬영술을이용한복벽탈장의다양한영상학적소견에대해알아보고자한다. 복벽탈장은비교적흔한질환으로서대부분이학적검사를통해진단할수있지만, 비만, 복통등이동반되면정확한진단이쉽지않고감돈, 폐색등과같은합병증이생겼을때는응급수술을요하기때문에영상학적검사가필수적이다. 과거에는단순촬영이나바륨조영술을이용해진단했지만, 현재는전산화단층촬영술이중요한역할을차지하고있다. 전산화단층촬영술을시행하면탈장의모양, 내용물과주변구조물과의관계를잘알수있으며, 근래에도입된다중검출기전산화단층촬영술 (multi-detector row CT, 이하 MDCT) 은전통적인전산화단층촬영술에비해걸리는시간이더짧고, 복강내장기를잘볼수있어감돈, 폐색과같은합병증을조기에발견할수있다는장점이있다. 또한다면상재구성영상 (multiplanar reformation image) 을이용하면정확한탈장의종류, 위치, 크기, 그리고이와관련된복벽의구조를알수있다 (1, 2). 이에저자들은 MDCT와다면상재구성영상을이용한복벽의해부학적구조와이와관련된다양한복벽탈장의영상학적소견에대해알아보고자한다. (hypogastric hernia), 요부탈장 (lumbar hernia), 반월선상탈장 (spigelian hernia) 등으로, 서혜부탈장은직, 간접서혜탈장과대퇴탈장으로그리고골반부탈장은폐쇄공탈장 (obturator hernia), 좌골탈장 (sciatic hernia), 회음탈장 (perineal hernia) 으로각각세분화된다. 이를분류하는데탈장의위치와복벽의해부학적구조를아는것이중요하다 (1, 2). 전복벽은피부, 피하지방, 표층근막, 한개또는그이상의근육층, 심층근막, 전복막지방층 (properitoneal fat), 복막으로이루어져있다. 복직근 (rectus abdominis muscle) 은백선 (linea alba) 의양쪽에있는데검상돌기 (xyphoid process) 복벽탈장의종류와복벽의해부학적구조 복벽탈장은크게복측탈장 (ventral hernia), 서혜부탈장 (inguinal hernia), 골반부탈장 (pelvic hernia) 그외절개부탈장 (incisional hernia), 장루주위탈장 (parastomal hernia), 리트레씨탈장 (Littre s hernia), 리처씨탈장 (Richter s hernia) 등으로나누어진다. 복측탈장은다시제대탈장 (umbilical hernia), 제주위탈장 (paraumbilical hernia), 상복벽탈장 (epigastric hernia), 하복벽탈장 1 순천향대학교천안병원영상의학과이논문은 2009 년 3 월 1 일접수하여 2009 년 4 월 11 일에채택되었음. 57 Fig. 1. Coronal volume- rendered image shows anatomic location of ventral hernias. 1. Epigastric hernia 2. Spigelian hernia 3. Umbilical & Paraumbilical hernia
김신영외 : 다중검출기전산화단층촬영 (MDCT) 에서보이는복벽탈장의다양한영상소견 에서부터치골결합 (symphysis pubis) 까지이어져있다. 복직근은 3개의측벽근의건막에의해둘러싸여있는데 3개의측벽근초가모두복직근의후방으로주행하는배꼽하방에서와달리배꼽상방에서는내측근 (internal oblique muscle) 과복횡근 (transverse abdominis muscle) 은복직근초의후방으로주행하지않는다. 측벽근은외측근, 내측근, 복횡근으로이루어져있으며반월선 (linea semilunaris) 에의해복직근과분리되어있다 (3). 복측탈장 복측탈장은중앙부결손을통한제대탈장, 제주위탈장, 상복벽탈장, 하복벽탈장, 후부결손을통한요부탈장과측부결손에의한반월선상탈장등으로나누어진다 (Fig. 1). 제대탈장은가장흔한복측탈장으로서대부분탯줄결찰후복벽이완전히막히지않아발생하는선천적탈장이며후천적제대탈장은뚱뚱하거나다산경험이있는여성에서잘발생하고작은제륜 (umbilical ring) 을통해발생하기때문에폐색과같은합병증이잘생긴다 (1, 4) (Fig. 2, ). 제주위탈장은배꼽주변의백선 (linea alba) 의결손을통해생기는것으 Fig. 3. 76-year-old woman with hepatocellular carcinoma. xial MDCT scan shows an epigastric hernia containing transverse colon and omental fat (arrow). Note a midline defect in anterior abdominal wall (arrowhead). Fig. 2. 79-year-old woman with fever and chills.. xial MDCT scan obtained through umbilicus shows umbilical hernia sac containing omental fat (arrow).. Sagittal reformatted image shows a defect in the abdominal wall (arrowhead) with protrusion of herniated sac into subcutaneous tissue. 58
로복직근이분리되어생기기도한다 (1). 상복벽탈장은상대적으로덜흔하며배꼽과검상돌기 (xyphoid process) 사이의백선을통해생기고전복막지방층, 혈관, 드물게내장을포함한다 (1, 2) (Fig. 3). 위험요소로는임신, 복수, 비만등이있으며위궤양이나담낭질환때와유사 한상복부통증이동반된다 (5). 하복벽탈장은배꼽하방에서발생하는것으로종종감돈이나폐색을일으킨다 (2). 요부탈장은장골뼈이식등의수술이나외상에의해생기며내장, 후복막지방, 신장등이탈장될수있다 (Fig. 4, ). 요 Fig. 4. 74-year-old man with palpable mass on right flank.. xial MDCT scan shows superior lumbar hernia with protrusion of ascending colon (arrow).. Coronal reformatted image reveals herniated ascending colon through superior lumbar triangle (arrowhead). Fig. 5. 69-year-old woman with endometrial cancer.. xial MDCT scan shows protrusion of small bowel (arrow) through a defect in right lateral abdominal wall.. Coronal volume-rendered image depicts hernia sac containing small bowel loops through linea semilunaris (arrowhead). 59
김신영외 : 다중검출기전산화단층촬영 (MDCT) 에서보이는복벽탈장의다양한영상소견 부탈장은상요부삼각지 (Grynflett-Lesshaft triangle) 와하요부삼각지 (Petit-triangle) 의두구역을통해생긴다. 상요부삼각지는앞쪽으로는내측근, 위쪽으로는 12번째늑골, 뒤쪽으로는척추거근 (erector spinal muscle) 으로이루어지며하요부삼각지는앞쪽으로는외측근, 아래쪽으로는장골능 (iliac crest), 뒤쪽으로는광배근 (latissimus dorsi muscle) 으로둘러싸여있다 (1, 2). 복부좌상은요부탈장을일으키는드문경우로, 복부좌상을받으면복강내압력이갑자기올라가근육이약한곳의복벽결손이생기는데특히상, 하요부삼각지는모두해부학적으로취약한곳이기때문에탈장이생길수있다. 이런경우내장이나장간막의손상이동반될수있기때문에개복술의적응증이된다 (6). 반월선상탈장은복측탈장의약 2% 를차지하며복직근초와외측근, 복횡근의건막이융합되어생기는반월선의결손으로생기고반월선은 9번째늑연골에서치골결합까지이어져있다 (4, 7) (Fig. 5, ). 겹의복횡근건막으로이루어진구조물로서서혜인대의 1 cm 상방, 하복벽혈관 (inferior epigastric vessel) 의외측에위치한다 (5). 서혜부탈장은직접서혜탈장, 간접서혜탈장그리고대퇴탈장으로나누어진다 (Fig. 6). 직접서혜탈장은여자보다남자에서흔하며소아에서는고환과같이주행하는복막이폐색 (obliteration) 되지않아생기는데반해성인에서는복횡근막의선천적약화로말미암아생긴다 (Fig. 7, ). 간접서혜탈장은복벽탈장중에서가장흔한것으로수술적치료를받은복벽탈장의약 66% 를차지한다 (Fig. 8, ). 직접서혜탈장 서혜부탈장 서혜관 (inguinal canal) 은전복벽하방을주행하는약 4 cm 정도의짧고가는관으로서외측근, 내측근, 복횡근의건막으로덮여있다. 서혜관의전방은외측근과내측근의건막으로, 후방은복횡근막으로이루어져있으며상방은내측근과복횡근으로, 하방은서혜인대의상부표면으로이루어져있다. 서혜관에는천부서혜륜 (superficial inguinal ring) 과심부서혜륜 (deep inguinal ring) 의 2개의출구가있는데, 천부서혜륜은외측근건초에있는삼각형모양의구조물이고심부서혜륜은 2 Fig. 6. Coronal reformatted image shows inguinal hernias correlated with anatomy of abdominal wall. Direct inguinal hernia (arrowhead) through inguinal triangle, indirect inguinal hernia (arrow) through inguinal canal and femoral hernia (arrowheads) through femoral canal. Fig. 7. 81-year-old man with palpable mass in both inguinal areas.. xial MDCT scan shows bilateral direct inguinal hernias containing small bowel (arrows) medial to inferior epigastric vessel (arrowhead).. Coronal reformatted image shows abdominal wall defect more clearly (arrows). 60
Fig. 8. 83-year-old man with vomiting, nausea and palpable mass in right inguinal area.. xial MDCT scan shows right indirect inguinal hernia containing mesenteric fat (arrow).. Sagittal reformatted image shows more well delineation of precise hernia shape (arrow). Fig. 9. 77-year-old woman with unreductable mass in left inguinal area.. xial MDCT scan shows left femoral hernia (arrow) medial to femoral vessels (arrowhead).. Sagittal reformatted image shows an abdominal wall defect (arrowhead) with herniation of small bowel loop (arrow). 은탈장낭이하복벽혈관의안쪽을따라주행하며반대로간접서혜탈장은하복벽혈관의바깥쪽에있는것이중요한감별점이다 (2, 5). 또한, 직접서혜탈장이서혜관의뒤쪽벽인 Hesselbach triangle이라는공간을통해주행하는데반해간접서혜탈장은남자에서는정삭 (spermatic cord) 을따라심부서혜륜에서천부서혜륜까지주행하며여자에서는원형인대 (round ligament) 를따라대음순 (labia majora) 까지이르게된다 (4, 5, 7). Hesselbach triangle은외측으로는하복벽동맥, 하방으로는서혜인대그리고내측으로는복직근초의외측을따라경계가이루어진다. 대퇴탈장은대퇴정맥의안쪽의비어있는공간과서혜인대의뒤쪽으로경계지어지는약 2 cm 길이의대퇴관 (femoral canal) 을통해발생하며여자에서흔하고주로오른쪽에발생한다 (1) (Fig. 9, ). 대퇴관은좁고단단하게부착되어있기때문에대퇴탈장에서는감돈이잘생긴다 (4). 서혜탈장과대퇴탈장을구분하는데있어해부학적 Fig. 10. 72-year-old woman with left femoral hernia. 인위치외에도 MDCT를이용한방법들이제시되고있다. 첫 xial MDCT scan shows femoral hernia with localized sac (arrowhead) and venous compression (arrow). 째, 대퇴관이좁아서서혜탈장에비해대퇴정맥이탈장낭에의해압박받기쉽다는것이며 (Fig. 10) 둘째, 치골결절 (pubic tubercle) 을기준점으로삼아서혜탈장인경우에는탈장낭이 61
김신영외 : 다중검출기전산화단층촬영 (MDCT) 에서보이는복벽탈장의다양한영상소견 Fig. 11. Comparison between the femoral and inguinal hernia.. xial MDCT scan in a patient with femoral hernia on which orthogonal lines are drawn through the pubic tubercle. The orthogonal lines identify this hernia as femoral as it lies in the posterolateral quadrant.. xial MDCT scan in a patient with an indirect inguinal hernia. The orthogonal lines show this hernia to be inguinal as it lies anterior to a transverse line through the pubic tubercle and as it crosses medial to the pubic tubercle. 통해소장, 요관, 대망혹은소망이탈장되고탈장낭은치골근 (pectineal muscle) 과외폐쇄근 (external obturator muscle) 사이또는폐쇄막 (obturator membrane) 층사이로주행한다. 좌골탈장은대혹은소좌골공 (greater or lesser sciatic foramen) 을통해발생하며내부에는대부분소장과요관이포함된다 (Fig. 12). 회음탈장은요생식격막 (urogenital diaphragm), 항문거근 (levator ani muscle), 미골근육 (coccygeal muscle) 의약화로인해생기며항문과대음순주변에생긴다 (1, 2, 7). 리처씨탈장 (Richter s hernia) 리처씨탈장은복벽의작은결손을통해장간막의반대편내장벽만돌출되는것으로 partial enterocele, Lavater s Fig. 12. Coronal volume- rendered image shows anatomic location of pelvic hernias. 혼동되는경우가있으나멕켈씨게실 (Meckel s diverticulum) hernia, nippled hernia 등여러가지이름으로불린다. 가끔 1. Sciatic hernia 의탈장인리트레씨탈장 (Littre s hernia) 과는완전히다르 2. Obturator hernia 다. 복강경수술후발생하는탈장의약반수를차지하며탈장된조직은급격히괴사되나내강은유지된다 (2, 10) (Fig. 치골결절의안쪽까지튀어나오는데반해대퇴탈장인경우에 13-C). 는탈장낭이치골결절의바깥쪽에국한된다. 다시말해치골결절을지나는평행선과수직선을그어공간을 4등분하게되면, 복벽절개부탈장서혜탈장은앞쪽중앙에, 대퇴탈장은뒤쪽측면에위치하며 (Fig. 11, ), 직접서혜탈장보다간접서혜탈장인경우탈장복벽절개부탈장은복부수술후에생기는합병증의하나로낭이더안쪽에위치한다 (8, 9). 약 0.5-13.9% 에서발생하나대동맥수술후에는약 41% 의발생률이보고되어있다. 대개수술후 1달이내에발생하나 5 년동안무증상인경우도있다. 위험인자로는비만, 고령, 복수골반부탈장등이있다 (1, 2) (Fig. 14, ). 골반부탈장은여성에서많이발생하며골반저근육 (pelvic floor muscle) 의선척적인약화로인해생긴다. 폐쇄공탈장은나이많은여성에서잘생기며폐쇄공 (obturator foramen) 을 62
Fig. 13. 80-year-old man with pain on left inguinal area.,. xial MDCT scan show dilatation of small bowel (arrow) with herniation of antimesenteric wall of small bowel (arrowhead). C. Intraoperative finding shows focal necrosis of antimesenteric border of small bowel loop (arrow). C Fig. 14. 76-year-old woman with history of adhesiolysis.. xial MDCT scans show defect in mid-abdomen (arrow).. Sagittal reformatted image shows incisional hernia containing small bowel (arrow). 63
김신영외 : 다중검출기전산화단층촬영 (MDCT) 에서보이는복벽탈장의다양한영상소견 Fig. 15. 70-year-old woman with abdominal pain and previous debulking operation with colostomy for ovarian cancer and carcinomatosis peritonei.. xial MDCT scan shows parastomal herniation of colon adjacent to the colostomy stoma (arrow).. Sagittal reformatted image also shows herniation of colon into subcutaneous fat layer (arrow). 장루주위탈장 장루주위탈장은복벽절개부탈장의일종으로장루 (stoma) 에인접해서생기며비만, 영양실조, 기침등에의해잘발생한다. 임상적진단이어려워전산화단층촬영술로탈장된내장을확인하는것이유용하다 (1, 2) (Fig. 15, ). 리트레씨탈장 (Littre s hernia) 리트레씨탈장은서혜부탈장의일종으로멕켈씨게실이탈장낭에포함되어있는것을말하며지속성제장관막관탈장 (persistent omphalomesenteric duct hernia) 이라고도부른다 (1, 2). 참고문헌 1. guirre D, Santosa C, Casola G, Sirlin C. bdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics 2005;25:1501-1520 2. guirre D, Casola G, Sirlin C. bdominal wall hernias: MDCT findings. JR m J Roentgenol 2004;183:681-690 3. Gore RM, Levine MS. Textbook of gastrointestinal radiology. 2nd ed. Philadelphia: Saunders, 2000:2010-2013 4. Harrison L, Keesling C, Martin NL, Lee KR, Wetzel LH. bdominal wall hernias: review of herniography and correlation with cross-sectional imaging. Radiographics 1995;15:315-332 5. hosale PR, Patnana M, Viswanathan C, Szklaruk J. The inguinal canal: anatomy and imaging features of common and uncommon masses. Radiographics 2008;28:819-835 6. Killeen KL, Girard S, DeMeo JH, Shanmuganathan K, Mirvis SE. Using CT to diagnose traumatic lumbar hernia. JR m J Roentgenol 2000;174:1413-1415 7. Miller P, Mezwa DG, Feczko PJ, Jafri ZH, Madrazo L. Imaging of abdominal wall hernias. Radiographics 1995;15:333-347 8. Cherian PT, Parnell P. The diagnosis and classification of inguinal and femoral hernia on multisection spiral CT. Clin Radiol 2008;63:184-192 9. Suzuki S, Furui S, Okinaga K, Sakamoto T, Murata J, Furukawa, et al. Differentiation of femoral versus inguinal hernia: CT findings. JR m J Roentgenol 2007;189:w78-w83 10. Skandalakis PN, Zoras O, Skandalakis JE, Mirilas P. Richter hernia: surgical anatomy and technique of repair. m J Surg 2006;72: 180-184 64
J Korean Soc Radiol 2009;61:57-65 bdominal Wall Hernias: Various Imaging Features Correlated with the natomy of bdominal Wall at MDCT 1 Shin Young Kim, M.D., Hyeong Cheol Shin, M.D., Sang Won Kim, M.D., Il Young Kim, M.D., Young Tong Kim, M.D. 1 Department of Radiology, Soonchunhyang University Cheonan Hospital bdominal wall hernias are a common condition. However, they may develop acute complications and require surgical correction in most cases. Hence, the correct radiological examination is requisite for an accurate diagnosis. multi-detector row CT (MDCT) provides an accurate identification of the anatomy of the abdominal wall, precise hernia type, and helps in the detection of early signs of complication. We report various imaging features of abdominal wall hernias via a MDCT. Index words : Hernia, abdominal Tomography, X-ray computed ddress reprint requests to : Hyeong Cheol Shin, M.D., Department of Radiology, Soonchunhyang University Cheonan Hospital, 23-20 ongmyung-dong, Cheonan, Chungnam 330-721, Korea. Tel. 82-41-570-3515 Fax. 82-41-579-9026 E-mail: hcshin@schca.ac.kr 65