Elderly indirect inguinal hernia

　　How is an elderly indirect inguinal hernia caused? The following is a brief description:

　　First, Etiology

　　1. Degenerative changes in abdominal muscles

　　Under normal circumstances, the free edges of the internal oblique and transversus abdominis muscles have a sphincter-like action on the internal ring and inguinal canal, and when they contract, the interval between the internal ring and the inguinal canal is reduced, which can enhance the resistance of the abdominal wall. In the elderly, due to the degenerative changes in the muscles, that is, the number of collagen fibers degenerating is more than that synthesized, these muscles become weaker in contraction, which becomes the pathological basis of senile indirect inguinal hernia.

　　2. Concurrent diseases with increased intraperitoneal pressure

　　Increased intraperitoneal pressure is an important triggering factor for hernias, and conditions such as benign prostatic hyperplasia, chronic constipation, and chronic bronchitis are prone to cause long-term increased intraperitoneal pressure, further promoting the occurrence and development of elderly inguinal hernias.

　　Second, Pathogenesis

　　Although the peritoneal processus vaginalis in the elderly has closed, there is still a funnel-shaped defect or a larger internal ring at the peritoneal orifice, and there is no muscle protection in the inguinal area, and the spermatic cord passes through, forming a weak area. Normally, the free edge of the internal oblique and transversus abdominis muscles has a sphincter-like action on the internal ring and inguinal canal. When these muscles contract, their free edges, including the rectus abdominis, converge towards the inguinal ligament. The intervertebral ligament and the internal ring are pulled upward and outward, thereby reducing the interval between the internal ring and the inguinal canal, enhancing the resistance of the abdominal wall, and preventing the formation of a hernia. Due to aging and degenerative changes in the tissues, the abdominal wall muscles become weak and the transversalis fascia more fragile in the elderly. The transversalis aponeurosis and internal oblique muscle are difficult to converge with the inguinal ligament, the occlusion mechanism fails, and the resistance of this area to intraperitoneal pressure is weakened. In addition, elderly people commonly have diseases that increase intraperitoneal pressure, and when intraperitoneal pressure suddenly increases, these muscles lose their defensive function, the internal ring relaxes, and abdominal viscera take advantage of this to push the peritoneum outward at the internal ring, forming an indirect inguinal hernia.

　　After the elderly develop an indirect inguinal hernia, due to the stiffness of the ligaments and the hardening of the blood vessels, the probability of incisional and strangulated hernias increases, and the occurrence time is earlier than that of younger individuals, making intestinal necrosis and toxic shock more likely.

　　1. Intestinal incarceration

　　Under normal circumstances, the contents of the hernia (usually the intestine) can be pushed into the hernia sac under the action of abdominal cavity pressure and can be returned to the abdominal cavity by itself (or by external force). When various reasons (such as friction, adhesion, etc.) cause the reversible contents of the hernia to suddenly be unable to be returned, and the local mass to increase, it indicates that intestinal incarceration has occurred, which is called incarcerated hernia at this time. After intestinal incarceration, the main clinical manifestations are those of intestinal obstruction.

　　2. Intestinal strangulation

　　If the incarcerated hernia persists and is not treated in a timely manner, the contents of the hernia (mainly the intestine) may experience circulatory disorders, leading to intestinal obstruction, intestinal necrosis, and even intestinal perforation, resulting in strangulated hernia.

　　Compared with adult inguinal hernia, senile inguinal hernia has the following characteristics:

　　1. The clinical symptoms are not obvious

　　In the absence of incarceration, the clinical symptoms of senile inguinal hernia are often not obvious, just a reversible mass in the inguinal region. Some patients have minor symptoms such as local descent and acid胀 discomfort without attracting attention, so the course of the disease is often long, reaching several years or even several tens of years. Some patients only seek medical attention for the first time when incarceration occurs, even leading to intestinal obstruction, peritonitis, and other conditions.

　　2. Prone to incarceration and strangulation

　　Due to the long course and repeated herniation of senile inguinal hernia, the neck of the hernia sac is subjected to long-term friction and surface damage, resulting in adhesion with the contents of the hernia and inability to be returned, causing a large hernia mass to settle in the scrotum. Since the neck of the hernia sac is the narrowest part of the hernia sac, the oblique hernia is prone to incarceration and strangulation.

　　3. The incidence of sliding hernia is high

　　The incidence of sliding hernia in senile inguinal hernia is higher than that in other age groups. In clinical practice, for elderly males with a long history, large scrotal-type hernias often show refractory symptoms and very few cases of incarceration, which should raise the suspicion of sliding hernia.

　　4. The incidence of giant oblique hernia is high

　　The elderly have relatively small physical activity, and the course of the hernia is relatively long. The hernia mouth and sac are large, often forming giant oblique hernia. Once a giant oblique hernia is formed, the chance of incarceration is actually less than that of the young and strong.

　　5. Often accompanied by other diseases

　　In addition to the general signs inherent in inguinal hernia, the elderly often have signs such as atrophy of abdominal muscles, decreased abdominal wall tension, chronic anorectal diseases, benign prostatic hyperplasia, chronic respiratory diseases, cardiovascular diseases, and so on. Attention should be paid to examination.

　　How to prevent senile inguinal hernia? The following is a brief introduction:

　　1. Change bad living habits

　　1. Quit smoking

　　Smoking can not only cause chronic cough and increase intraperitoneal pressure, but also inhibit the synthesis of collagen fibers and promote the degenerative change of abdominal muscles, which is one of the important triggering factors of senile inguinal hernia. Therefore, the elderly are best not to smoke or reduce the amount of smoking.

　　2. Maintain smooth defecation

　　Constipation is one of the important causes of increased abdominal pressure, therefore, maintaining smooth defecation 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 defecating at regular times.

　　2. Actively prevent and treat

　　Actively prevent and treat diseases that increase intra-abdominal pressure, such as chronic bronchitis, emphysema, and benign prostatic hyperplasia.

　　What examinations should be done for elderly inguinal hernias? A brief description is as follows:

　　1. Hernia angiography

　　Ultrasound can diagnose early inguinal hernias and is the best method for differential diagnosis for patients with abdominal pain of unknown cause in the inguinal region. Before surgery, it can accurately diagnose the type and number of hernias to assist in the selection of surgical methods, effectively reducing the occurrence of residual hernias. After surgery, hernia angiography can diagnose recurrent inguinal hernias and can accurately differentiate between residual hernias, new hernias, or true recurrent hernias, providing a more objective basis for effective surgical treatment.

　　2. Ultrasound examination

　　Color Doppler can detect the bilateral subcutaneous inguinal arteries in patients with inguinal hernias and determine whether the patient has an indirect or direct hernia based on whether the hernia sac neck and hernia sac are located on the medial or lateral side of the subcutaneous inguinal artery. It can also observe the blood supply and blood flow velocity of the hernia contents to understand whether there is strangulation or necrosis.

　　3. Standing X-ray film

　　In incarcerated inguinal hernias, CT scans show intestinal distension, stepped gas-liquid levels, and signs of intestinal obstruction, which are helpful for accurate diagnosis.

　　4. CT scan

　　For inguinal hernias, intermuscular hernias, femoral hernias, and obturator hernias, diagnosis and differentiation are of great value.

　　The following is a brief description of the dietary principles for elderly inguinal hernias:

　　1. Constipation is one of the important causes of increased abdominal pressure. Therefore, maintaining smooth bowel movements is an effective method for preventing inguinal hernias. The elderly should eat more vegetables and fruits, drink water in moderation, and develop the habit of regular bowel movements.

　　2. Quit smoking. Smoking not only causes chronic cough, leading to increased intra-abdominal pressure, but also inhibits the synthesis of collagen fibers, promoting degenerative changes in the abdominal muscles, which is one of the important predisposing factors for elderly inguinal hernias. Therefore, it is best for the elderly to quit smoking and drinking.

　　3. Avoid greasy foods, and do not eat overly salty or spicy foods.

　　The following is a brief description of the treatment methods for elderly inguinal hernias:

　　1. Treatment

　　There are two methods of treatment for elderly inguinal hernias: wearing a hernia belt and surgical repair. Surgical repair is the ideal method for cure, while the hernia belt is only used when surgery is contraindicated, the patient does not want surgery, or surgery cannot be performed temporarily.

　　1. Hernia belt treatment

　　It is suitable for the elderly, weak, or those who have been sick for a short time or cannot undergo surgery due to other serious illnesses. The patient must lie flat when wearing the hernia belt to ensure that the hernia contents are completely reduced. Therefore, the hernia belt is not suitable for irreducible hernias.

　　The hernia belt should be properly sized for use (the hernia cap must be slightly larger than the hernia ring) to press against the top of the hernia ring, preventing the hernia mass from protruding outward. The patient should wear the hernia belt during the day and remove it when sleeping. After long-term use of the hernia belt, the neck of the hernia sac becomes thick and tough due to repeated friction, and adhesions are likely to occur between the hernia contents and the inner wall of the hernia sac, leading to a reducible hernia. Therefore, when the hernia belt is not effective in controlling the hernia contents from protruding, surgical treatment should be considered promptly.

　　2. Surgical treatment

　　The surgical principles of elderly inguinal hernias are generally the same as those of young people, mainly high ligation and excision of the hernia sac, closure of the internal ring, and repair of the weak abdominal wall. The surgical methods and evaluations of elderly inguinal hernias should fully consider their special anatomical and pathological changes and the systemic organ function diseases associated with them. The overall condition of elderly patients should be correctly evaluated before surgery, the overall nutritional status of elderly patients should be improved, and their immune resistance to diseases should be enhanced. At the same time, attention should be paid to the control and treatment of some senile diseases that increase intraperitoneal pressure, such as chronic cough, difficulty in urination, refractory constipation, ascites, etc., in order to reduce the risk of surgery and postoperative complications. For some elderly patients, the hernia-internal intestinal tract may contain feces, and sometimes symptoms of intestinal obstruction may occur, known as hernia feces retention. After the defecation is promoted by massage and enema, consideration can be given to elective surgery.

　　3. Management of several special elderly inguinal hernias

　　(1)滑动性腹股沟疝：Commonly seen in elderly patients with a longer history, most of them descend to the scrotum, and the hernia mass is large. Due to the easy occurrence of adhesions during the sliding process, it often becomes a refractory hernia. The pathological feature is that the tissue connected to the hernia sac contains the main blood vessels supplying the prolapsed organ, and after injury and transection, it can cause it to lose vitality, which should be paid attention to during surgery. For elderly patients with giant hernias, if a longer segment of the intestinal loop is involved, intraperitoneal repair surgery should be adopted to avoid causing intussusception obstruction of the intestinal loops or affecting their blood supply.

　　(2) Giant inguinal hernia: In elderly patients, the abdominal wall muscles, tendons, and ligaments atrophy and degenerate, resulting in reduced tension and a longer course of disease. The internal ring is significantly enlarged, and a large amount of intra-abdominal contents (such as small intestine, colon, etc.) may sometimes prolapse into the hernia sac, forming a giant hernia. For the repair of such giant hernias, some suggest adopting a whole-piece repair method. That is, after the entire hernia sac is freed from the scrotum, it is returned to the abdominal cavity as a whole along with its hernia contents, and the peritoneal defect at the internal ring is repaired using the bottom of the hernia sac without the need to remove the hernia sac or separate the adherent hernia contents. Since the adhesions between the intestinal loops do not necessarily equal to the occurrence of obstruction, it is often futile and sometimes even harmful to forcibly separate the adhesions before surgery when there are no symptoms of intestinal obstruction in the patient. Sometimes, it may even cause massive hemorrhage or intestinal tract injury and other complications, even the risk of adhesive intestinal obstruction after surgery. For patients with obvious defects in the abdominal wall, artificial repair materials should be used to strengthen them, and surgery is the most appropriate. It is strictly forbidden to强行 suture the adjacent tissues together under excessive tension, otherwise it is bound to cause immediate or future tearing of the tendons and ligaments, resulting in new defects and leading to the recurrence of hernia. The following matters should be noted: ①Before surgery, patients should be advised to lie flat for one week, with the buttocks elevated while lying flat, which is conducive to the complete or partial spontaneous regression of the hernia contents. ②After the entire hernia sac and hernia contents are returned to the abdominal cavity as a whole, the excess peritoneum does not need to be removed, and inverted folding suture can be used.

　　(3) Coexisting Hernia: Although elderly patients are more common with inguinal indirect hernia, due to the weakness of Hesselbach triangle, the incidence of direct hernia is relatively high, and there is a possibility of coexisting inguinal direct hernia and indirect hernia. The literature reports that the coexistence rate is 4%. To avoid missing coexisting hernia, after transversely cutting the hernial sac, it is necessary to routinely insert the index finger into the abdominal cavity from the hernial ring to determine the relationship between the hernial ring and the inferior epigastric artery, palpate the strength of Hesselbach triangle, whether there is fascial defect and hidden extraperitoneal bulge. If coexisting hernia is confirmed, after returning the direct hernia sac, the proximal sac of the transversely cut indirect hernia can be further separated inward to merge the two hernial sacs into one, and then perform high ligation.

　　(4) Recurrent Hernia: When performing reoperation for recurrent hernia, it is necessary to emphasize several issues: ① The routine treatment method for high ligation of the hernial sac is to suture and tie it through the hernial sac, but the purse-string suture is not suitable for elderly recurrent patients because the internal ring orifice of elderly recurrent hernia is large, and the purse-string suture is difficult to tighten and is prone to tear the peritoneum. It can be sutured with an overlapping mattress suture to close the neck of the hernial sac, making the large opening of the hernial sac smaller, and finally sutured and tied. ② Below the closed hernial sac, suture the inferior margin of the internal oblique muscle with the transversalis fascia 2 to 3 times to strengthen the internal ring orifice. ③ For patients with severe tissue defects in the inguinal region and difficult to repair, it is advisable to solve the surgical problems from the perspectives of biomechanics and physiology, and it is better to choose tension-free hernia repair surgery.

　　Second, Prognosis

　　The most important factors that need to be controlled in elderly patients after surgery are pain, heart failure, and infection, especially pulmonary infection, which poses the greatest threat to elderly patients after surgery. Not only is it easy to cause the recurrence of hernia, but it can also lead to death. Prevention is more important than treatment, so elderly patients after surgery should be encouraged to get out of bed early or adopt a semi-sitting position. The method of lying flat due to fear of recurrence after surgery is not advisable. Choosing appropriate antibiotics, strengthening deep breathing exercises and back tapping to remove sputum, proper warming, and other measures can help elderly patients safely through the postoperative period.