Direct inguinal hernia

　　Firstly, etiology

　　Inguinal hernia, like indirect inguinal hernia, occurs in the inguinal region, and their occurrence and development are closely related in anatomy and physiology. It is currently believed that anatomical defects, intrinsic obstruction of the occlusion mechanism, and changes in the collagen structure of the tissue are possible causes of inguinal hernia. In addition, it is also related to factors such as the increase in age, lack of exercise, obesity, multiple pregnancies, long-term bed rest leading to weight loss and a decline in health level, and the use of too low and too long transverse incisions or abdominal 'cosmetic surgery' incisions, which cut off the inferior fibers of the transversalis fascia arch and the sensory or motor nerves in the inguinal region, leading to muscle atrophy.

　　Secondly, pathogenesis

　　1. Anatomical factors:The inguinal canal exists in the inguinal region, through which the testis and spermatic cord pass. Behind it, there is a vascular cavity and femoral sheath for the lower limb blood vessels. The upper and posterior sides of the medial side of the inguinal ligament form a weak area of the abdominal wall, and it has the following characteristics: the external oblique muscle layer is a tendinous structure, and even lacks a tendinous layer at the superficial ring; the arcuate inferior margin of the internal oblique and transversus abdominis muscles and the medial half of the inguinal ligament form a gap to accommodate the spermatic cord (uterine round ligament) and its inner and middle tunicae, thus lacking protection. If the inferior margins of the two muscles cannot reach the superior margin of the spermatic cord and its tunicae, the weakness becomes more obvious. Anson believes that well-developed muscles can prevent inguinal hernias in only 26%, 62% of one muscle is underdeveloped or cannot reach the superior margin of the spermatic cord, and 12% both cannot provide support; the attachment point of the internal oblique muscle is high, and 36.8% of the gaps are not closed when it contracts, which may be the direct cause of inguinal hernia formation; the inferior margins of the internal oblique and transversus abdominis muscles vary in development. If both the inferior margins of the left and right muscles terminate in front of the rectus abdominis, the inguinal triangle on the lateral side of the rectus abdominis is only protected by the transversalis fascia; although the transversalis fascia and fascia are attached to the pubic tubercle ligament to become the posterior wall of the inguinal canal, the transversalis fascia can also thicken in the inguinal region, but these structures are not as strong as muscles and tendons, and the transversalis fascia layer constitutes the deep inguinal ring. In front of the deep ring, there is protection from the internal oblique muscle, and the posterior side of the superficial ring is entirely tendinous or fascial components, making the protection weaker.

　　2. Acquired factors:The strength of the abdominal wall and the pressure acting on it are the fundamental factors for the occurrence of hernia. A weak abdominal wall cannot prevent the formation of a hernia. In addition to structural factors of the abdomen, it is also related to nutritional status, physical labor, pregnancy, rapid weight loss, and even heredity.

　　（1）Increased intraperitoneal pressure: Any disease that causes an increase in intraperitoneal pressure has the potential to trigger an inguinal hernia, including obesity, chronic bronchitis, benign prostatic hyperplasia, constipation, ascites, pregnancy, etc.

　　（2）Abdominal trauma: Direct外伤 to the abdominal wall is related to the occurrence of hernia. This may be due to the fact that trauma can weaken the strength of the abdominal wall structure, although animal experiments do not fully support this point, abdominal trauma can exacerbate the hernia.

　　（3）Age: There is an absolute relationship between the occurrence of inguinal hernia and age. This may be due to the increased incidence of certain diseases that increase intraperitoneal pressure with age, such as a decrease in abdominal fat tissue, metabolic disorder of abdominal collagen tissue, and thinning of various normal tissue structures in the inguinal region, which can also promote the occurrence and development of inguinal hernia.

　　（4）Inguinal canal wall muscle defense function weakened or lost: The anatomical defects in the inguinal region can be compensated for by the defense action produced by the contraction of the internal oblique and transversus abdominis muscles. Firstly, it is the sphincter action, that is, when the abdominal wall moves or the abdominal pressure increases, the contraction of the internal oblique and transversus abdominis muscles tightens the inguinal ligament and pulls it upward and outward, locking the internal ring to resist the increased abdominal pressure. The second is the occlusive function. Normally, the internal oblique and transversus abdominis muscles form an upward arch at the superior part of the inguinal canal, with a distance of 0.5 to 2.0 cm from the corresponding inguinal ligament. The contraction of the muscles flattens the arch towards the inguinal ligament, and approaches the iliopectineal ligament and inguinal ligament, occluding the gap, strengthening the posterior wall of the inguinal canal, and compensating for the weak spots of the transversalis fascia. These functions are crucial in preventing the occurrence of inguinal hernia. If the inguinal ligament, iliopectineal ligament, and the internal oblique and transversus abdominis muscles do not form a complete arch due to relaxation, underdevelopment, and various causes of muscle atrophy and reduced contraction strength, it can lead to weakened or lost sphincter and occlusive actions.

　　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 the intraperitoneal pressure and can be spontaneously (or with external force) retracted back into the intraperitoneal cavity. When various reasons (such as friction, adhesion, etc.) cause the contents of a reducible hernia to suddenly become irreducible, and the local mass increases, it indicates that intestinal incarceration has occurred, which is called an incarcerated hernia at this time. After intestinal incarceration, the main clinical manifestations are those of intestinal obstruction.

　　: 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 Increased pulse rate, rapid breathing, and elevated white blood cell count, indicating shock. ③ Peritoneal irritation signs (local tenderness, rebound pain, muscle tension, etc.). ④ Intestinal sounds change from hyperactive to hypoactive or absent, and a

　　1, A hemispherical, reducible mass appears above the pubic tubercle, which appears when standing and disappears when lying flat; it does not require manual reduction, rarely incarcerates (due to the wide hernia sac neck), and is more common in the elderly, rarely occurs in women and children.

　　2, The base of the mass is wide, and it is rare to fall into the scrotum.

　　3, After the mass is reduced, press the internal ring.

　　4, The direct hernia triangle can be palpated for obvious defects in the abdominal wall.

　　5, If part of the bladder wall constitutes part of the sliding hernia, bladder irritation symptoms may occur.

　　Firstly, change bad living habits and cultivate a healthy lifestyle

　　1, Quit smoking:Smoking not only causes chronic cough, leading to increased intra-abdominal pressure, but also inhibits the synthesis of collagen fibers and promotes the degeneration of the abdominal muscles, which is one of the important factors that trigger inguinal hernia in the elderly. Therefore, the elderly should not smoke or reduce the amount of smoking.

　　2, Keep the bowels regular:Constipation is one of the important reasons for 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 fixed amount, and develop the habit of defecating at a fixed time, etc.

　　Secondly, actively prevent and treat

　　Diseases that increase intra-abdominal pressure, such as chronic bronchitis, emphysema, and benign prostatic hyperplasia, etc.

　　1, Gastrointestinal contrast or barium enema examination:It can detect the shadow of the intestinal loop in the inguinal region, especially in sliding hernia.

　　2, Intravenous pyelography and cystography: Observe whether the hernia involves the urinary and reproductive systems, such as the relationship between the sliding hernia and the bladder.

　　3, Hernia angiography: In 1967, Ducharme injected contrast agent into the peritoneal cavity to observe whether there was any protrusion of the peritoneum, also known as peritoneal angiography. This method is helpful for detecting certain small and initial hernias in the inguinal region or certain rare hernias, such as perineal hernia and obturator hernia, especially when there is a suspicion of recurrence after inguinal hernia repair, this method can be used to confirm it.

　　4, CT: It can observe the location, shape, size of the hernia sac, and contents. When the bladder is filled with contrast agent, it can observe whether the sliding hernia involves the bladder.

　　5, Ultrasound examination: This method is ideal for the diagnosis of hernia, as it can detect small hernias, especially in obese patients, and can clearly show the shape of the inguinal hernia, the surrounding adjacent relationships, the size of the hernia sac and contents, etc. It can dynamically observe these during certain body positions or deep breathing, and can differentiate from inguinal lymphadenopathy, hydrocele, lipoma, hematoma, and other conditions.

　　6, Laparoscopy: In recent years, laparoscopy can be used for both the diagnosis and treatment of inguinal hernia, with satisfactory results.

　　Therapeutic diet for inguinal hernia:

　　1, Pork 120 grams, root of Paulownia tree, Momordica cochinchinensis root, and Xanthium sibiricum seeds each 10 grams. Take as a decoction, once a day.

　　2. 15 grams of fennel, 4 grams of salt, 2 duck eggs with green peel. Fry fennel and salt together and grind it into powder, mix it with the duck eggs beaten in a bowl, fry it into an omelette in the oil, take it with warm rice wine before going to bed every night, and take it every 4 days as a course of treatment.

　　3. 50 grams of Eucommia ulmoides seed, fried with salt and ground into powder, add 25 grams of black sesame, take 9 grams each time, twice a day.

　　4. Take 20 grams of garlic skin, boil it in water, and take it several times a day. Garlic skin is the skin attached to the garlic meat, about 1000 grams of garlic can peel off 20 grams of skin.

　　(The above information is for reference only, please consult a doctor for details)

　　I. Treatment

　　1. The treatment principle of inguinal direct hernia is the same as that of indirect hernia:

　　① Elderly or weak patients with serious diseases of other organs who cannot tolerate surgery can use hernia belt conservative treatment;

　　② Herniorrhaphy;

　　③ Hernioplasty;

　　④ Supportive symptomatic treatment.

　　2. Hernia Repair Surgery:Modern surgical technology requires hernia repair surgery to meet five basic requirements, namely: mild postoperative pain, short recovery time, low recurrence rate of hernia, few surgical complications, and the ability to prevent the recurrence of inguinal floor under the primary hernia area.

　　3. Surgical Plan:The choice of surgical plan should be based on the patient's condition and the type of hernia. The Chinese Medical Association, the Society of Surgery, the Group of Hernia and Abdominal Wall Surgery suggests in the 'Treatment Plan for Groin Hernia, Femoral Hernia, and Abdominal Wall Incision Hernia (Draft)':

　　Type I: high ligation of the hernia sac and internal ring repair surgery; flat patch tension-free hernia repair surgery (Lichtenstein surgery) can also be adopted.

　　Type II: tension-free hernia repair surgery with hernia ring filling; tension-free hernia repair surgery with flat patch; if there is a lack of artificial repair material, Basssini, McVay, Halsted, and Shouldice surgeries can also be used, and try to add tissue tension reduction steps.

　　Type III: tension-free hernia repair surgery with hernia ring filling; tension-free hernia repair surgery with flat patch; huge patch reinforcement of visceral sac surgery (Stoppa surgery); when there is no artificial repair material, consider using autologous material and pay attention to reduce tension.

　　Type IV: tension-free hernia repair surgery with hernia ring filling; huge patch reinforcement of visceral sac surgery.

　　II. Prognosis

　　Most surgeries are cured, but there is a recurrence rate of 4% to 10%.