Indirect inguinal hernia in the elderly
Introduction
Introduction to the elderly inguinal hernia The elderly inguinal hernia (obliqueinguinalherniainoldman) belongs to acquired sputum and is one of the common diseases in the elderly. The disease gradually develops with age, and the incarceration of a few oblique hernias can cause acute intestinal obstruction, which is extremely harmful. China has a large population of aging, not only the incidence of senile sputum is higher than that of western countries, but also the high recurrence rate caused by traditional hernia repair is also very prominent. The majority of inguinal hernia in China is the most common slanting sputum. Therefore, exploring the elderly The treatment of inguinal hernia is a hot issue of current surgery. basic knowledge The proportion of illness: the incidence rate is about 0.003% - 0.006% Susceptible people: the elderly Mode of infection: non-infectious Complications: shock
Cause
The cause of the elderly inguinal hernia
(1) Causes of the disease
Degenerative disease of abdominal muscles (30%):
Under normal circumstances, the free edge of the oblique and transverse abdominis muscles have a sphincter effect on the inner ring and the inguinal canal. When the contraction occurs, the gap between the inner ring and the groin area is reduced, which can enhance the resistance of the abdominal wall. In the elderly, due to the degenerative lesions of the muscles, that is, the amount of collagen fibers degraded more than the synthesis, the contractile force of these muscles is weakened, which becomes the pathological basis of the senile inguinal hernia.
Increased intra-abdominal pressure (42%):
Increased intra-abdominal pressure is an important predisposing factor for sputum, and prolonged intra-abdominal pressure caused by prostatic hypertrophy, chronic constipation and chronic bronchitis further promotes the occurrence and development of inguinal hernia in the elderly.
(two) pathogenesis
Although the peritoneal sheath of the elderly has been locked, there is still a funnel-shaped defect or a large inner ring at the peritoneal orifice, and there is no muscle protection in the groin area, and there is a fine cord passing through, forming a weak zone, under normal circumstances. The free edge of the abdominal oblique muscle and the transverse abdominis muscle has a sphincter effect on the inner ring and the inguinal canal. When these muscles contract, the free edge includes the rectus abdominis muscles that are close to the inguinal ligament, the concave ligament and the inner ring together. It is pulled outwards, which narrows the gap between the inner ring and the groin area, strengthens the resistance of the abdominal wall, prevents the formation of sputum, and the degenerative lesions occur in the elderly due to aging, making the abdominal muscles weak and the transverse transverse fascia more fragile. The tendon arch and the oblique internal oblique muscle are difficult to close with the inguinal ligament, and the incision mechanism is invalid, which causes the resistance to intra-abdominal pressure in this area to be weakened. In addition, the elderly group is more common in diseases with increased intra-abdominal pressure, when the intra-abdominal pressure increases rapidly. When these muscles lose their defense function, the inner ring is slack, and the abdominal organs take the peritoneum outward at the inner ring to form the inguinal hernia.
As the main component of the transverse fascia, collagen plays a decisive role in maintaining the tensile strength of the transverse fascia. It has been confirmed that the abdominal transverse fascia elastic fibers are broken in the abdominal paralysis patients, and the collagen staining shows that the collagen structure is sparse and separated. It can be seen that the ability of the transverse fascia to resist the elevation of physiological or pathological intra-abdominal pressure depends on the composition and strength of the collagen fibers involved, while the content of the transverse fascia collagen in the inguinal region decreases with age. The body is obviously negatively correlated. As the age increases, the metabolism of the body slows down, and the rate of renewal of the gel in the tissue slows down and ages, which is easily destroyed, resulting in a decrease in the content. At the same time, the proliferation of fibroblasts is suppressed, and the number is also reduced. Significantly reduced, this degenerative tissue change is related to the imbalance of protease and anti-protease ratio in serum and the lack of antitrypsin. In addition, long-term smoking in the elderly, harmful substances in tobacco such as free radicals enter the blood circulation, It disrupts the protease and anti-protease system, thereby destroying the elastin and collagen of the transverse fascia.
Prevention
Elderly inguinal hernia prevention
1. Change bad habits and cultivate a healthy lifestyle.
(1) Smoking cessation: smoking can not only cause chronic cough, leading to increased intra-abdominal pressure, but also inhibit the synthesis of collagen fibers and promote the degeneration of abdominal muscles. It is one of the important predisposing factors for the elderly inguinal hernia, so the elderly are best. Do not smoke or reduce the amount of smoking.
(2) Keeping the stool smooth: constipation is one of the important reasons for the increase of abdominal pressure. Therefore, keeping the stool unobstructed is an effective way to prevent inguinal hernia. The elderly should eat more vegetables, fruits, quantitative drinking water, and develop the habit of regular bowel movements. .
2. Actively prevent and treat diseases that promote increased intra-abdominal pressure, such as chronic bronchitis, emphysema, and enlarged prostate.
Complication
Complications of the elderly inguinal hernia Complications
In the elderly, after inguinal hernia, because of the toughness of the ligament, hardening of the arteries, the incidence of incarceration and strangulation increases, and the time of emergence is earlier, and intestinal necrosis and toxic shock are prone to occur.
Symptom
Elderly inguinal hernia symptoms Common symptoms Inguinal pain constipation Painless scrotal mass groin or closed hole swelling bloating lower abdominal pain nausea involves pain
Compared with adult inguinal hernia, the elderly inguinal hernia has the following characteristics:
1. The clinical symptoms are not obvious: the clinical symptoms of the inguinal hernia in the elderly are not obvious in the absence of incarceration, only the reversible mass in the inguinal region, some patients have partial symptoms such as partial fall and soreness and discomfort without paying attention. Therefore, the course of the disease is long, up to several years or even 10 years, and some patients have incarcerated, even intestinal obstruction, peritonitis and other conditions before the first visit.
2. Incarceration and strangulation are easy to occur: the elderly inguinal hernia is caused by long course of disease and repeated sputum, so that the neck of the sac is long-term subjected to friction and surface damage, so that the contents of the sputum are stuck and cannot be reconciled, resulting in a large sputum block. Settled in the scrotum, because the neck of the sac is the narrowest part of the sac, it is easy to incarcerate and narrow.
3. The incidence of slippery sputum is high: the incidence of snoring in the inguinal hernia is higher than that of other age groups. In clinical practice, older men have a longer history and a large scrotal hernia, which is often difficult to re-exhibit. It is rare for incarcerators to suspect the possibility of slippery.
4. The incidence of giant scorpion is high: the elderly have relatively small physical activity, and the sputum has a relatively long course of disease. The sputum and sac are larger, often forming a giant slanting scorpion. The chances of winning are less than those of young adults.
5. Many other diseases: In addition to the intrinsic signs of the inguinal hernia, the elderly are often accompanied by abdominal muscle atrophy, abdominal wall tension, chronic anorectal disease, prostatic hypertrophy, chronic respiratory disease, cardiovascular disease and other signs, should Pay attention to the inspection.
Examine
Examination of the elderly inguinal hernia
1. Herniography can diagnose early inguinal hernia and is the best differential diagnosis for patients with unexplained inguinal pain. Before surgery, it can accurately diagnose the type and number of hernias to assist with surgical methods. Selection, effectively reduce the occurrence of residual sputum, postoperative sputum angiography, can not only diagnose recurrent inguinal hernia, but also accurately leave the remaining sputum, new sputum or true recurrent sputum, providing more effective surgical treatment For an objective basis.
2. B-ultrasound color Doppler can detect the bilateral inferior epigastric artery in patients with inguinal hernia, and determine whether the patient is straight or oblique according to the medial or lateral side of the inferior epigastric artery and the hernia sac; The blood supply of the object, the blood flow velocity, to understand whether there is strangulation and necrosis.
3. Standing X-ray film shows flatulence in the incarcerated inguinal hernia, stepped gas-liquid equal intestinal obstruction signs, help to confirm the diagnosis.
4. CT scan is of great value for the diagnosis and differential diagnosis of inguinal hernia and abdominal wall hernia, femoral hernia and obturator hernia.
Diagnosis
Diagnosis and identification of elderly inguinal hernia
Diagnostic criteria
1. Life history and medical history Inquire about the patient's history of smoking and chronic constipation in detail, understand the time, size, reversibility, softness and elasticity of the tumor, whether it is accompanied by pain or gastrointestinal symptoms, pay attention to whether there is any abdomen Chronic diseases with increased internal pressure, such as chronic bronchitis, emphysema, and enlarged prostate.
2. Clinical manifestations The patient has a lump that appears when standing, walking or coughing, and disappears after lying down; the mass increases with age, and there is a heavy fall or waist discomfort when the mass appears (caused by pulling the mesentery). If the patient has a cough or force, he or she can be covered with an expansive impulse; if the contents are small intestine, the lumps may still have a "squeaky" sound; after the tumor disappears, for the male patient, the examiner can use the index finger. The tip is inserted into the outer ring from the upper part of the scrotum along the spermatic cord. It can be found that the outer ring is wider and wider than the normal contralateral side. If the fingertip enters the inguinal canal and the patient has a cough, the fingertip has a sense of impulse, and the thumb is tight outside the abdominal wall. Press the inner ring, let the patient stand coughing, such as the inguinal hernia, that is, no lump, but if the patient coughs, the lump can still appear, the abdominal muscles shrink, and the abdominal wall tension is reduced.
3. Auxiliary examination can help to identify the sputum part; CT scan can help the identification of inguinal hernia and abdominal wall, femoral hernia, obturator hernia, etc.; color Doppler can observe the blood supply of sputum content, Blood flow velocity to understand the presence or absence of strangulation and necrosis.
Differential diagnosis
1. Testicular hydrocele: The mass is all in the scrotum, and the upper boundary of the mass can be extracted. The hand can be squeezed or lying down, and the light transmission test is positive. The testicular fluid can not be smashed. In the liquid, and the inguinal hernia can be found in the testicles behind the mass.
2. Varicocele: The large varicocele is very similar to the oblique sputum. More than 95% of the former occurs on the left side, because the left internal spermatic vein enters the left renal vein at a right angle, resulting in poor blood return. The right internal spermatic vein enters the inferior vena cava to form an obtuse angle. The oblique sac is more common on the right side. The varicocele palpation is a sputum-like sensation. The light transmission test is negative. There is no typical cough impulse, unlike when the sputum is returned. Sudden retreat.
3. Axillary cold abscess: The mass is often large, and the position is mostly in the lateral axillary fossa of the groin. The edge is unclear, but the texture is soft and fluctuating, and there is tuberculosis in the lumbar or ankle joint.
4. The lymph nodes in the groin area, the identification of lipoma or other tumors and the oblique hernia, especially the incarcerated sputum, are sometimes difficult. However, the above lumps become larger and larger, gradually proliferate, and cannot move or return at the beginning, and will not There are symptoms of intestinal obstruction.
