Inguinal hernia

　　Inguinal hernia is mainly caused by two aspects, the patency or closure of the processus vaginalis is one of the important conditions for the occurrence of hernia, which is caused by congenital factors. Because there is an anatomical defect in the inguinal region, it is caused by acquired factors. Next, let's explain in detail.

　　Firstly, congenital factors

　　In the early embryonic stage, the testicle is located on both sides of the spine, corresponding to the 2nd-3rd lumbar vertebrae, and gradually moves downwards between the transversus abdominis fascia and the peritoneum on the posterior abdominal wall. At 3 months of embryonic development, the testicle moves to the iliac fossa, approaches the inguinal canal ring at 7 months, and enters the inguinal canal at about a month before birth, generally descending into the scrotum before birth. If the testicle remains on the posterior abdominal wall or in the inguinal area after birth, it is called cryptorchidism.

　　During the descent of the testicle, a part of the peritoneum that is close to the front of the testicle follows the testicle through the inguinal canal and descends into the scrotum, thus forming the processus vaginalis that connects the abdominal cavity. During normal development, soon after birth, except for the part surrounding the testicle, which forms the固有鞘膜, the rest of the parts atrophy, close, and leave a very thin fibrous cord or disappear. If this processus vaginalis remains open and unclosed, still connected to the abdominal cavity, it forms a congenital hernia sac. According to the principle of hydrostatic pressure in physics, the weakest point bears the greatest pressure, also known as 'focal pressure'. Therefore, when the abdominal pressure increases or the abdominal wall muscles relax due to certain factors, it is easy to form congenital indirect inguinal hernia.

　　If only the lower segment of the processus vaginalis is closed and the upper segment remains open, it can also trigger congenital indirect hernia. Since the descent speed of the right testicle is slower than that of the left, the processus vaginalis remains unclosed for a longer time, so the opportunity to trigger congenital indirect hernia is more on the right side. It can be seen that the opening or closure of the processus vaginalis is one of the important conditions for the occurrence of hernia, so Russel once片面地 believed that 'without peritoneal sac, there is no hernia'.

　　Secondly, acquired factors

　　The pathogenesis of acquired indirect hernia is completely different, as it is caused by an anatomical defect in the inguinal canal area. Since the processus vaginalis has closed, a new hernia sac is formed through the inguinal canal. Firstly, the inguinal canal area was originally a vulnerable part of the abdominal wall without muscle protection, with the spermatic cord passing through. If the inferior margin of the transversus abdominis fascia arch and the internal oblique muscle is high or underdeveloped, it can further weaken the resistance in this area. Secondly, the failure of the protective mechanism in physiology. Normally, there are two physiological defense functions:

　　Firstly, the sphincter action of the transversus abdominis and the internal oblique muscles on the inguinal ring. When the transversus abdominis and the transversus abdominis fascia contract, the fascia thickens to form an interiliac ligament, which is pulled upwards and outward along with the inguinal ring. Thus, the inguinal ring within the deep surface of the internal oblique muscle is closed, preventing the formation of the hernia sac.

　　The opening and closing action of the transversus abdominis fascia arch. During normal rest, the transversus abdominis fascia arch (or the conjoint tendon) bulges upwards, but when the abdominal muscles are stimulated and the transversus abdominis and internal oblique muscles become tense, the transversus abdominis fascia arch can be flattened and brought closer to the inguinal ligament, closing the inguinal ring to prevent the occurrence of hernia. If the transversus abdominis fascia or the transversus abdominis muscle is underdeveloped, the muscle is relaxed. If the lower margin of the arch separates from the inguinal ligament, it is more likely to trigger an acquired indirect hernia. Clinically, acquired indirect hernia is more common than congenital ones.

　　老年、体衰、肥胖、腹肌缺乏锻炼等情况常使腹壁肌力减退而诱发腹股沟斜疝。胶原代谢异常与腹外疝发病有很密切的关系。

　　Old age, physical weakness, obesity, lack of exercise of the abdominal muscles, and other conditions often lead to weakened abdominal wall muscle strength and trigger inguinal indirect hernia. Abnormal collagen metabolism has a very close relationship with the occurrence of extraperitoneal hernia.

　　Recurrent or persistent inguinal indirect hernia can lead to intestinal incarceration and strangulation. The following will give a detailed introduction:

　　1. Intestinal incarceration

　　Under normal circumstances, the contents of the hernia (usually the intestine) can be pushed into the hernia sac under the pressure of abdominal cavity pressure and can be spontaneously (or by external force) pushed back into the abdominal cavity. When various factors (such as friction, adhesion, etc.) cause the contents of a reducible hernia to suddenly not be reducible, and the local mass increases, it indicates that intestinal incarceration has occurred. At this time, it is called an incarcerated hernia, and the main clinical manifestations after intestinal incarceration are those of intestinal obstruction.

　　2. Intestinal strangulation

　　If an incarcerated hernia persists and is not treated promptly, the contents of the hernia (mainly the intestine) may experience circulatory disturbances, leading to intestinal obstruction, necrosis, and even perforation, resulting in strangulated hernia. The clinical manifestations of intestinal strangulation include:

　　① Sudden, persistent, and severe abdominal pain.

　　② Tachycardia, rapid breathing, increased white blood cell count, and other signs of shock.

　　② Peritoneal irritation signs (local tenderness, rebound pain, muscle tension, etc.).

　　④ Intestinal sounds change from hyperactive to hypoactive or absent, and 'water passing through the ear' sound can be heard.

　　⑤ Hematemesis (or blood-tinged fluid), hematochezia.

　　⑥ There is a marked swelling, bulging, and mass in the abdomen.

　　⑦ X-ray examination shows an isolated dilated and protruding small intestine or intestinal segment within the abdomen, with widened intestinal spaces, elevation, and abdominal effusion.

　　⑧ Puncture of the abdominal cavity can draw out hemorrhagic fluid.

　　Inguinal indirect hernia is a symptom where abdominal contents protrude through the peritoneal薄弱area of the inguinal region. Indirect hernia is the most common type of extraperitoneal hernia, with clinical symptoms including:

　　1. Easy-reducible hernia manifests as a reducible mass in the inguinal region, appearing when standing or carrying heavy loads. The mass can be pushed back into the abdominal cavity when lying flat and resting or by hand.

　　2. The mass is soft,呈带蒂“梨形”，reaching the scrotum or the labia majora.

　　3. During physical examination, by inserting a finger into the external ring of the inguinal canal, an enlarged external ring orifice can be detected, with a sense of impact during coughing. When the internal ring orifice is pressed with the finger, and the patient stands up and coughs, the hernia does not appear.

　　4. In patients with irreducible indirect inguinal hernia, the hernia does not disappear even when lying flat.

　　5. Incarcerated hernia is characterized by a sudden enlargement of the mass, becoming tense and hard, accompanied by marked pain, and cannot be pushed back into the abdominal cavity. If the incarcerated content is the intestine, it may present with signs of mechanical intestinal obstruction.

　　6、绞窄性疝的临床症状多较严重。绞窄时间长者，由于疝内容物发生感染，侵及周围组织，引起疝外被盖组织的急性炎症。

　　6. The clinical symptoms of strangulated hernia are usually more severe. The longer the strangulation time, the more likely the hernia contents will become infected, invade the surrounding tissues, and cause acute inflammation of the extraperitoneal covering tissues.

　　7. Local swelling and pain, recurrent inguinal hernias with local swelling and pain, in addition to the mass in the inguinal area, usually have no special symptoms, occasionally feel local swelling and pain, even causing upper abdominal or umbilical pain. Unremitting inguinal hernias are manifested as varying degrees of acid and sagging sensation. These symptoms occur with the appearance of the mass and alleviate with the disappearance of the mass.

　　How to prevent indirect inguinal hernia

　　Most hernias cannot be prevented, but it is possible to reduce the recurrence of hernias. The following suggestions can help reduce the recurrence of hernias:

　　1. Change bad living habits and cultivate a healthy lifestyle.

　　1) Quit smoking: Smoking not only can cause chronic cough, leading to increased abdominal pressure, but also can inhibit the synthesis of collagen fibers and promote the degeneration of abdominal muscles, which is one of the important predisposing factors for elderly inguinal hernia. Therefore, the elderly are best not to smoke or reduce the amount of smoking.

　　2) Eat more high-fiber foods to keep the bowels regular. Constipation is one of the important causes of increased abdominal pressure, so keeping the bowels regular is an effective method to prevent inguinal hernia. The elderly should eat more vegetables and fruits, drink water in a quantitative manner, and develop the habit of regular defecation.

　　3) Avoid lifting, pushing, or pulling heavy objects.

　　The diagnosis of indirect inguinal hernia is generally made through physical examination, routine laboratory tests, and the inguinal external ring shock test. The following will give a detailed introduction:

　　I. Physical examination

　　The inguinal external ring shock test is an auxiliary examination method used to check whether the abdominal inguinal position is normal. After the hernia mass is retracted into the abdominal cavity, the tip of the finger can be extended into the external ring through the scrotal skin, and it can be found that the external ring is expanded. Generally, the size of the external ring has little clinical significance, but when the external ring is expanded, the tip of the finger can follow it into the inguinal canal, check and understand the condition of the internal ring and the posterior wall of the inguinal canal, which has guiding significance for proposing appropriate surgical methods. Some concealed indirect hernias can be established through this test, but this examination method causes extremely uncomfortable feelings to the patient, and it is not necessary to implement it routinely for those with clear diagnosis.

　　II. Auxiliary examination

　　1. Ultrasound examination

　　Color Doppler ultrasound can detect the bilateral inguinal arteries of patients with inguinal hernia and determine whether the patient has an indirect hernia or an indirect hernia based on whether the sac neck and sac are located on the inside or outside of the inguinal artery below the abdominal wall; it can also observe the blood supply of the hernia contents, blood flow velocity, to understand whether there is strangulation and necrosis.

　　2. Other examinations

　　For patients with indirect inguinal hernia with pain, it is necessary to check blood routine and C-reactive protein at the same time to clarify whether there is infection. For patients with other diseases such as lung and abdominal diseases but unclear diagnosis, the examination plan can include examination frames such as electrocardiogram, liver function test, blood creatinine, blood urea nitrogen (BUN), and ultrasonic examination of gastrointestinal diseases.

　　Indirect inguinal hernia is the protrusion of abdominal contents through the weak area of the inguinal canal and is unrelated to diet, normal diet is enough. If symptoms are severe or complications occur, then surgical treatment is needed. Pay special attention to the diet of patients with indirect inguinal hernia after surgery:

　　1. Generally, patients can start with liquid food such as congee, thin lotus root powder, vegetable juice, fruit juice, etc., 6 to 12 hours after surgery, and soft food or common food such as soft rice, noodles, egg cake, chopped and cooked vegetables and meat the next day, focusing on nutritious, easy-to-digest, light diet.

　　2. In terms of diet, eat more nutritious foods and more coarse fiber foods, such as chives, celery, cabbage, coarse grains, beans, bamboo shoots, various fruits, etc.

　　3. Keep the bowels smooth, and you can use jellyfish, bitter melon, sweet potatoes, etc.

　　4. After surgery, avoid foods that can cause intestinal distension, such as milk, soy milk, eggs, etc.

　　5. Avoid smoking, alcohol, greasy, fried, moldy, and preserved foods.

　　6. Abstain from spicy foods such as garlic and mustard.

　　Indirect inguinal hernia can be seen as a recurrent pedunculated 'pear-shaped' mass in the inguinal area, which can be reduced into the peritoneal cavity. After the mass is reduced, the mass does not appear again after pressing the internal ring and increasing abdominal pressure. Intraoperatively, it is confirmed that the hernial sac is located on the lateral side of the subcutaneous artery of the abdominal wall. The principles of treatment and medication are:

　　Principles of Treatment

　　1. Conservative treatment.

　　2. High ligation of the hernial sac.

　　3. Herniorrhaphy.

　　4. Hernioplasty.

　　5. Supportive symptomatic treatment.

　　Principles of Drug Use

　　For elective surgery of indirect inguinal hernia, antibiotics can generally be omitted.

　　For patients with incarcerated or strangulated hernia, or hernia without incarceration or strangulation but with infection in the respiratory or urinary system, medication including medication frame 'A' and 'B' is required.

　　For patients with complications or weakened constitution after strangulated hernia operation, in addition to the application of 'A' and 'B' after operation, new special drugs and supportive symptomatic treatment can also be considered.