하인두 악성신생물 등 상병에 후두 전적출 및 하인두 부분적출술(자125-1× 100%)과 동시 산정된 기관개창술(자134가-기타× 50%)에 대하여

청구내역 (여/68세)

○ 상병명 : 상세불명의 하인두 악성 신생물, 상세불명의 림프절의 속발성 및 상세불명의 악성신생물, 상세불명의 심장성 부정맥, 삼킴 곤란 등

○ 처치 및 수술 자125-1 후두전적출 및 하인두부분적출술 1*1 자16사 피판작성술-유리피판술[피부 또는 근육](기타) 1*1 자211 경부림프절청소술(편측, 보존적)-산정지침(7)에서 정한 수술과 동시 수술 1*1 자455 갑상선수술[낭종, 선종, 갑상선기능항진등](갑상선엽전절제술)-편측[제2수술] 1*1 자134가(3) 기관 또는 기관지협착증수술(경부접근)-기타(티-튜브삽관, 기관 개창 등)[제2수술] 1*1

진료내역

[수술기록지]

○ 수술명 : Total Laryngectomy and Partial Hypopharyngectomy

- Reconstruction of Pharynx with microvascular free flaps

- Radical neck dissection(RND), unilateral

- Other partial thyoidectomy

- tracheal fenestration (Total laryngectomy: partial pharyngectomy: RND(R), Lt ALT free flap reconstruction)

○ 수술 전 진단명 : malignant tumor hypopharynx

○ 수술 후 진단명 : lymph node of metastasis

- malignant tumor of hypopharynx

○ 수술 방법 및 소견 Under general via orotracheal intubation, routine skin preparation and draping were done in supine position with neck hyperextension. Following marking with surgipen, U-shaped incision was made. An apron flap was elevated excluding platysma muscle up to the level of the hyoid bone, and sutured to the drapes. Inferior skin flap was undermined.

The dissection was carried up along the anterior border of the trapezius muscle. The lower end of the SCM muscle was transected and dissected, exposing the internal jugular vein. The strap muscles were removed and the anterior belly of the diagastric was transected. The hypoglossal nerve was also identified and preserved. Metastatic lymph nodes above the anterior border of the SCM(level Ⅱ, Ⅲ) muscle were removed. The greater auricular nerve was sacrified.

The median raphe was identified between the two sternohyoid muscles at the level of the thyroid isthmus and cleaved by blunt dissection. Dissection was continued at the midline to the thyroid cartilage and the trachea. The two sternothyroid muscles were separated at the midline, exposing the thyroid isthmus. The thyroid gland was bisected at the isthmus and the resected margins of the right and left thyroid gland were suture-ligated with vicryl. Right upper pole of thyroid was partial removed and suture-ligated with vicryl. The left thyroid gland was clear and remained. At the posterior border of the SCM, the spinal accessory nerve was sacrified. The carotid artery sheath was opened but no injury.

The dissection was carried up along the anterior border of the trapezius muscle. The upper end of the SCM muscle was transected and dissected from levator muscle, exposing the internal jugular vein. The omohyoid muscle was identified on each side and transected. The sternothyroid muscles were also transected. The suprahyoid muscles were dissected from the body of the hyoid was cut from the point of its origin on the hyoid bone. Dissection was continued laterally along the superior surface of the hyoid bone. The lesser horns of the hyoid bone were transected and the greater horn was grasped with and Allis clamp and the tip of the hyoid bone was carefully dissected free. The superior surface of the hyoid bone was dissected and the superior horn of the thyroid cartilage was grasped at its base with an Allis clamp and pulled forward. The superior horn was dissected along its along axis. Inferior constrictor muscles were dissected from the lateral border to the thyroid cartilage. The trachea was resected. The pharynx was entered in the midline at the level of the epiglottic tip, and incision was continued inferiorly with including cervical esophagus. The larynx was finally detached from the esophagus.

The anterolateral thigh free flap was obtained by plastic surgeon. Then the vessel anastomosis was done with cervical artery and subclavian and external vein by plastic surgeon. The ALT free flap was sutured with pharynx and cervical esophagus mucosa with vicryl. After irrigation with betadine solution and meticulous bleeding control, inferior flap was sutured to the tracheal opening. Tracheal fenestration was performed. One Hemovac was inserted. The apron flap was approximated to the neighbouring skin as layer by layer. A light dressing was applied. Intraoperatively bleeding was minimal and immediated postoperative vital signs were stable. There was no sign of dyspnea.

참고

○ 건강보험 행위 급여·비급여 목록표 및 급여 상대가치점수 제9장 처치 및 수술료 산정지침 (보건복지부 고시 제2010-235호, 2010.1.1. 시행)

○ 대한이비인후과학. 이비인후과학 두경부학 Ⅱ. 일조각. 2009. p1709~1710

○ Flint: Cummings Otolaryngology: Head & Neck Surgery, 5th ed.

심의내용

동 건은 하인두 악성신생물 등의 상병으로 total laryngectomy and partial hypopharyngectomy, tracheal fenestration 등을 시행하고 「자125-1 후두 전적출 및 하인두 부분적출술× 100%」와 동시에 「자134가(3) 기관 또는 기관지협착증수술(경부접근)-기타× 50%」를 별도 청구한 사례로, 후두전적출술시 시행하는 기관개창술(tracheal fenestration)은 후두전적출술 시에 동일 피부절개 하에 부수적으로 동시에 실시하는 일련의 과정이므로 「자134가(3) 기관 또는 기관지협착증수술(경부접근)-기타 × 50%」는 별도 인정하지 아니함.

[2011.10.10. 진료심사평가위원회]