Incisional Hernia

　　An abdominal organ that protrudes through the obturator canal into the inguinal triangle is called an obturator hernia. The contents of an obturator hernia are mainly small intestine. The contents that can be embedded in the obturator canal include part of the intestinal wall or the entire bowel. The contents can also include the bladder, ovary, fallopian tube, appendix, colon, and Meckel's diverticulum. The causes of the disease are mainly due to the following factors:

　　1. Local weakness

　　The obturator canal provides a potential pathway for the occurrence of obturator hernias, but it is not necessarily a hernia. Only when local tissues are weak, such as when the obturator externus muscle ruptures and moves caudally or when the obturator membrane is abnormally thin, can a hernia possibly form under the action of intraperitoneal pressure. The hernia sac can directly protrude through the ruptured obturator externus muscle or can protrude above the obturator externus muscle, along with the obturator nerve and blood vessels, passing through the obturator orifice, or it can protrude below the obturator externus muscle.

　　2. Degeneration of pelvic floor tissues

　　This hernia is more common in elderly patients, most often occurring in people aged 70 to 80. Larrieu et al. reported an average age of onset of 67 years, which may be related to the physiological changes of aging, such as the relaxation of the pelvic fascia and the atrophy of pelvic floor muscles.

　　3. Wide obturator canal

　　Obturator hernias are more common in female patients. This is related to the physiological characteristics of wider and straighter obturator canals in women. Due to multiple pregnancies and increased intraperitoneal pressure, women may also have overly relaxed and wide perineum.

　　4. Emaciation

　　Diseases such as multiple illnesses, weakness, malnutrition, emaciation, and any consumptive diseases can cause the obturator orifice to lose the pad of extraperitoneal fat tissue, making the peritoneum above it prone to indentation and forming a hernia sac.

　　5. Increased intraperitoneal pressure

　　Diseases that increase intraperitoneal pressure, such as chronic bronchitis, long-term coughing, and habitual constipation, can all lead to increased intraperitoneal pressure.

　　Obturator hernias often occur in the elderly. Due to the delayed pain response in elderly patients, herniated contents may become strangulated, leading to symptoms such as strangulated intestinal obstruction, diffuse peritonitis, and toxic shock. Delayed treatment can lead to bowel necrosis, perforation, thigh abscess, and fistula. According to statistics by foreign scholars, the incidence of bowel necrosis and perforation reaches 50%, with a mortality rate of 13% to 40%; in China, the incidence of bowel necrosis and perforation is as high as 80%, with a mortality rate of 12% to 75%.

　　Obturator hernia is prone to incarceration, intestinal necrosis, and intestinal perforation. Manual reduction is more dangerous than for other types of hernia, and surgery is the only effective treatment method. Once diagnosed or suspected to be caused by intestinal obstruction due to this disease, surgical treatment should be chosen. To prevent the occurrence of this disease, attention should be paid to the following points:

　　① Maintain an optimistic and pleasant mood

　　Long-term appearance of mental tension, anxiety, irritability, depression, and other emotions can lead to imbalance in the excitation and inhibition processes of the cerebral cortex, so it is necessary to maintain a cheerful mood.

　　② Moderation in life

　　Pay attention to rest and work-life balance; maintaining an optimistic, positive, and upward attitude towards life is very helpful in preventing diseases. Follow a regular routine for meals and daily life, avoid overexertion, maintain a cheerful mood, and develop good living habits.

　　③ Rational diet

　　It is recommended to consume more high-fiber foods and fresh vegetables and fruits. A balanced diet including proteins, sugars, fats, vitamins, trace elements, and dietary fibers is essential. Mix meat and vegetables, diversify food varieties, and give full play to the complementary effects of nutrients in foods, which is also very helpful in preventing this disease.

　　Obturator hernia is prone to incarceration, intestinal necrosis, and intestinal perforation. Manipulative reduction is more dangerous than for other types of hernias, and surgery is the only effective treatment method. Generally, patients can eat liquid or soft food 6-12 hours after surgery, and common food can be eaten the next day. Patients undergoing surgery need to eat high-protein, high-vitamin, low-fat foods during the recovery period, and eat more vegetables and fruits. Avoid stimulants, especially smoking.

　　Obturator hernia is prone to incarceration, intestinal necrosis, and intestinal perforation. Manipulative reduction is more dangerous than for other types of hernias, and surgery is the only effective treatment method. Once diagnosed or suspected to be caused by intestinal obstruction due to this disease, surgical treatment should be chosen. There are many surgical approaches, some advocate making a longitudinal incision below the inguinal ligament on the surface of the mass, separate the adductor longus and pubic muscle inward and outward, and expose the hernia sac. Milligan advocates the inguinal incision, cutting the posterior wall of the inguinal canal to expose the obturator canal. Some also advocate the suprapubic approach, that is, the Cheathe-Henry approach, making a transverse incision along the pubis, transversely cutting the anterior sheath of the rectus abdominis, separating the rectus abdominis outward, and pushing the peritoneum upward, retracting the bladder, and directly exposing the obturator canal. However, since most obturator hernias are difficult to diagnose before surgery, and it is also difficult to understand the vitality of the intestinal segment and further treatment methods according to the above two approaches, most scholars advocate the abdominal approach.

　　1. Abdominal approach surgery

　　The advantages of abdominal incision include:有利于急性肠梗阻的确诊、判断肠管生机及做出相应处理；易于暴露左右闭孔管口；做修补时能妥善保护好闭孔神经与血管。

　　Key points of surgery: Make a median or lateral median incision in the lower abdomen, pull the small intestine to the upper abdomen, which helps to expose the orifices and clamped intestinal tubes of various abdominal hernias. If it is confirmed to be an incarcerated obturator hernia, expose the obturator orifice and gently dilate the narrow ring with a curved hemostat or finger to facilitate the return of the intestinal loop. Generally, the clamped intestinal tubes can be returned after dilating the narrow ring. If the return is still difficult, it is necessary to use a sharp knife to incise a little of the fibrous ring of the obturator canal orifice along the groove probe; incise from the inside of the hernia sac inward and downward to avoid the obturator vessels and nerves. If necessary, an additional longitudinal incision can be made on the surface of the obturator body below the inguinal ligament of the thigh root at the same time, gently push the hernia mass upward from the bottom of the hernia sac to aid in reduction. After reduction, carefully check the vitality of the intestinal tube. Small localized necrosis can be buried and sutured; small area of sheet-like necrosis can be trimmed locally before sutured; when there is large area of sheet-like necrosis, enterectomy should be performed and sutured after antibiotics.

　　2. Retroperitoneal Extraperitoneal (Cheathe-Henry Approach) Surgery

　　Make a transverse incision above the pubic bone, cut the anterior sheath of the rectus abdominis in the same direction, and pull the bilateral rectus abdominis (mainly the affected side) outward. Push the peritoneum medially, pull the bladder downward, free the hernia sac and its contents from the obturator canal, and handle them properly.

　　3. Transobturator Approach Surgery (incision at the root of the thigh below the inguinal ligament)

　　The patient lies on his back, the buttocks are elevated, the thighs are slightly flexed and adducted to relax the adductor muscles. Make a longitudinal incision below the inguinal ligament between the adductor longus and the adductor magnus on the medial aspect of the thigh, or make a vertical incision at the convex part of the hernia mass. Incise the fascia lata, expose the adductor longus, and pull it medially; pull the pubic muscle laterally, and if necessary, partially detach it from the pubic attachment, then the hernia sac can be exposed. Incise the bottom of the hernia sac, carefully examine the contents, and if there is intestinal necrosis, switch to laparotomy. If there is no intestinal necrosis, return the intestine to the peritoneal cavity. The treatment of the hernia sac is the same as above. Suture the pubic muscle and the relative periosteum several times to repair the obturator canal. Suture the wound without drainage.

　　4. Transinguinal Approach Surgery

　　The incision approach is similar to the transinguinal surgery for inguinal or femoral hernia. Cut the aponeurosis of the external oblique muscle along the fiber direction until the outer ring of the inguinal canal, then pull the round ligament (or spermatic cord) and the conjoint tendon inward and upward, cut the posterior wall tissue of the inguinal canal to the peritoneum, push the peritoneum medially, expose the obturator foramen extraperitoneally, and expose the hernia sac. Free the hernia sac and its contents from the obturator canal, cut the hernia sac, check the vitality of the intestine, and if the condition is good, return it to the peritoneal cavity. If there is necrosis, the intestine should be resected through the abdomen. Suture the neck of the hernia and excise the hernia sac. Suture the obturator canal with thick silk thread in an interrupted manner and suture the wound.

　　The disadvantages of the transinguinal approach include a narrow surgical field, poor exposure, difficult anatomy, or the need for an additional incision when there is intestinal necrosis.

　　5. Laparoscopic Inguinal Hernia Repair Surgery

　　Haith (1998) reviewed 8 cases of laparoscopic inguinal hernia repair reported in the literature, and performed a repair operation with a patch on a 35-year-old female patient with a history of a closed inguinal hernia under laparoscopy, achieving good therapeutic effects.