Indirect inguinal hernia in adults
Introduction
Introduction to adult inguinal hernia Inguinal hernia (adultinguinalhernia) is different from indirect inguinal hernia. Adult inguinal hernia (adultinguinal hernia) is formed after the peritoneal sheath has been completely occluded due to weak inner ring, and the hernia sac enters the inguinal canal. The weak point on the wall, rather than within the spermatic cord, is the acquired sputum, so it is also called the acquired inguinal hernia. Adult inguinal hernia is sometimes difficult to distinguish from direct hernia, especially in cases with long history and large pupils. basic knowledge Sickness ratio: 0.1% Susceptible people: no specific population Mode of infection: non-infectious Complications: constipation, intestinal obstruction, bloating
Cause
Causes of adult inguinal hernia
(1) Causes of the disease
1. Defects in the anatomical structure of the inguinal canal: it is the basis of the onset of adult inguinal hernia.
2. acquired acquired damage and loss of muscle physiological defense function in the inguinal canal: it is one of the basis of adult inguinal hernia.
In addition, when the transverse fascia and the transverse abdominis contract, the intercondylar ligament and the inner ring are pulled outward together, thereby closing the inguinal canal in the deep part of the intra-abdominal oblique muscle, preventing the formation of the hernia sac, for various reasons. When the sphincter of the transverse abdominis muscle and the internal oblique muscle to the inner ring is weakened or lost, it can also lead to the occurrence of acquired inguinal hernia.
3. Increased intra-abdominal pressure: increased intra-abdominal pressure is one of the important factors to promote the occurrence of various abdominal hernias. Under normal circumstances, the visceral sag into the lower abdomen and pelvic cavity when the person is erect, and the pressure on the abdominal wall of the groin area is increased when lying flat. 3 times, has the role of promoting the formation of inguinal hernia, in some physiological and pathological conditions (heavy physical labor, chronic constipation, cirrhosis ascites, chronic bronchitis, emphysema, etc.), abdominal pressure increased and persisted, bound to It is necessary to destroy the anatomical structure and physiological defense function of the inguinal region. At the same time, the intra-abdominal hypertension can cause the internal organs to directly break through the inner ring and enter the inguinal canal to form the inguinal hernia.
4. Biological abnormalities: Biological abnormalities are the auxiliary factors leading to the occurrence of inguinal hernia. Clinical practice has confirmed that some inguinal anatomical defects and long-term intra-abdominal pressure increase do not occur inguinal hernia, on the contrary Many people who have neither congenital anatomical defects nor increased intra-abdominal pressure for light physical labor or mental work can also suffer from inguinal hernia. Obviously, it is difficult to fully clarify the groin with congenital anatomical defects and long-term intra-abdominal pressure. The pathogenesis of the scorpion.
(two) pathogenesis
Although the adult peritoneal sheath is already locked, the inguinal canal is a weak muscle wall without muscle protection. Due to the passage of the spermatic cord or uterine round ligament, an inguinal canal with a spiral stepped structure is formed, and the tube is There is no truly intact wall; the inferior border of the inferior oblique muscle of the inguinal canal and the arcuate arch of the ventral transverse arch have a certain distance from the inguinal ligament of the inguinal canal, generally 0.5 to 2.0 cm wide. 15% of people are above 2.0cm), with an average of 0.7cm, making the inguinal canal a weakened abdominal wall without abdominal muscle protection, especially the inner ring, the inner mouth of the inguinal canal, when the spermatic cord or uterine round ligament passes through An incompletely structured rupture formed on the transverse fascia is an important weakness of the lower abdominal wall. When the viscera is sufficiently stressed, it can easily break through the mouth and enter the inguinal canal. Because the female inner ring and the inguinal canal are relatively narrow, It is rare to have a slash.
When the transverse abdominis aponeurosis arch and intra-abdominal oblique muscle attachment point is high or underdeveloped, muscle damage, abdominal wall incision causes nerve damage and muscle atrophy affects its contraction, and inflammation adhesion restricts its movement, making it difficult to close with the inguinal ligament The physiological protective effect is invalid. When the pressure in the abdominal cavity is large enough, it is easy to break through the mouth and enter the inguinal canal. In this case, although the peritoneal sheath has been locked, the peritoneal wall can pass through the groin. The tube protrudes to form a new sac, which in turn leads to the occurrence of acquired inguinal hernia.
Regardless of pediatric or adult inguinal hernia, intra-abdominal hypertension plays an important role in its development and development, and weak intra-abdominal hypertension and abdominal wall resistance is often the true cause of acquired inguinal hernia, inguinal hernia incarceration It is also the result of a sudden increase in intra-abdominal pressure.
Because the composition of the inguinal canal is mostly fascia, connective tissue such as aponeurosis and ligament, the strength of these tissues is related to collagen metabolism. Therefore, in the past 20 years, some scholars have carried out the pathogenesis and mechanism of inguinal hernia from the biological point of tissue. A large number of studies have found that the amount of hydroxyproline in the tissue of patients with inguinal hernia is reduced, the collagen production is low, and the proliferation rate of fibroblasts is inhibited. Some scholars have the same anterior rectus sheath of the inguinal hernia in the inguinal hernia. The study of the site specimens revealed that the collagen fibers in the anterior sheath of the rectus abdominis near the inguinal region were fine, weak, and had low collagen content, and the content and binding rate of hydroxyproline were also significantly lower than those of the latter; in the fibroblast culture test. The latter rate of cell proliferation is higher than the former.
Cannon and Read (1981) found that severe smokers have a high incidence of emphysema and lung cancer, and a high incidence of inguinal hernia. They believe that smoking can cause a decrease in circulating inhibitory protein lysing enzymes (such as 1-antitrypsin). It causes the decomposition of collagen to increase, and the production of proteolytic enzymes (including elastase) in the lungs enters the blood circulation, destroying the body's collagen and elastin, causing emphysema in the lungs and causing emphysema in the lungs, and destroying in the groin area. The transverse fascia and the transverse abdominis decidual layer cause the occurrence of sputum. Some people think that inguinal hernia may be a local manifestation of systemic collagen metabolism disorder. Collagen catabolism exceeds the abnormal state of anabolism, which inevitably causes the connective tissue that constitutes the inguinal canal. The structure is weak and becomes the pathological basis of inguinal hernia.
Prevention
Adult inguinal hernia prevention
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 degenerative changes of the abdominal muscles. It is one of the important predisposing factors for inguinal hernia in the elderly. Smoking or reducing the amount of smoking.
2. Actively prevent and treat diseases that promote increased intra-abdominal pressure, such as chronic bronchitis, emphysema, and enlarged prostate.
Complication
Adult inguinal hernia complications Complications constipation intestinal obstruction bloating
1. Incarcerated : is a common complication of inguinal hernia, patients (a few people may have no history of inguinal hernia) in the case of intense labor, severe cough or defecation and other intra-abdominal pressure surge, sudden increase in sputum Large, hard, can not return to the abdominal cavity, the pain is significantly increased, persistent and tender, if the incarcerated sputum content of the intestine can occur abdominal cramps, nausea, vomiting, constipation, abdominal distension and other symptoms of intestinal obstruction.
2. Strangulated sputum: If the incarcerated sputum is not treated in time, further development will result in strangulated sputum, causing serious complications such as intestinal perforation, peritonitis, etc. Strangling sputum generally occurs in the incarceration time over 24 to 48 hours. However, a few severe cases can also be strangulated in less than 24 hours. Strangulated sputum often has toxemia, such as elevated body temperature, increased pulse, and even toxic shock; severe water, electrolytes and acid-base disorders; Redness, swelling, pain and other inflammatory manifestations of the skin, ischemic necrosis in the late intestinal wall, perforation, intestinal contents spillage, first intracapsular infection, and then can cause acute cellulitis or abscess in the covered layer, the infection extends to the peritoneum Acute diffuse abdominal inflammation.
Symptom
Adult inguinal hernia symptoms Common symptoms Nausea involved pain inguinal pain Lower abdominal pain Pain in the groin or closed hole Abdominal distension Constipation Painless scrotal mass
(1) Inguinal mass: The important clinical manifestation of inguinal hernia is that there is a mass in the inguinal region. The early mass is small and can be confined to the inguinal region. As the disease progresses, the mass gradually enlarges and enters the scrotum, forming an upper end narrow and outwardly inclined. Into the inguinal canal, the lower end is wide, full, similar to the pear-like typical inguinal hernia, easy to reversal inguinal hernia, the mass often stands, walks, labor or cough, appears automatically and returns when resting quietly, or After the massage by hand, the intractable inguinal hernia is caused by the slight friction between the contents of the sputum and the inner wall of the sputum. The adhesion between the two is gradually formed, so that the contents of the sputum cannot be pushed back completely into the abdominal cavity, so the lumps only It is reduced to varying degrees, and does not disappear with the change of body position and abdominal pressure. It is common in patients with long disease duration and large hernia sac.
(2) local pain: easy to reversal inguinal hernia except for a mass in the inguinal region, often no special symptoms, occasional local pain, and even cause pain in the upper abdomen or umbilical cord, difficult to reversing inguinal hernia is different degrees The soreness and the feeling of falling, these symptoms occur with the appearance of the mass, and the mass disappears and eases.
(3) indigestion or chronic constipation: this symptom is more common in the sliding inguinal hernia, because the cecum, sigmoid colon or bladder and other organs have formed part of the hernia sac, so patients often have some "dyspepsia" and chronic constipation and other digestive tract Symptoms and urinary insufficiency, sliding sputum is generally a huge mass, more common in men over 40 years old, and the right side is more than the left side.
Examine
Adult inguinal hernia
There are a small number of patients, because the hernia sac is small, the bulge is not obvious, it is not easy to attract attention or the lumps are not obvious, and there are often unexplained pain in the lower abdomen or groin area, and there are other sputum or special type slashes. Such as Richter, Littre, etc., it is very difficult to diagnose in time. For these situations, the following auxiliary examinations can be used.
1. Herniography: It 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 surgery. The choice to 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, for its effective surgical treatment A more 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 contents, the blood flow velocity, to understand whether there is strangulation and necrosis.
3. Standing X-ray film: Inflated air in the incarcerated inguinal hernia, stepped gas-liquid equal intestinal obstruction signs, help to confirm the diagnosis.
4. CT scan: It 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 adult inguinal hernia
Diagnostic criteria
In general, the inguinal hernia can be diagnosed based on the above symptoms and physical examination, but pay attention to the following aspects:
1. Clinical type: The difference should be refractory, difficult to reversible, incarcerated and strangulated inguinal hernia, and different treatment options are developed according to different clinical types.
2. Pay attention to the diagnosis of occult oblique sputum: in the early stage, the sac of the sac is only confined to the inguinal canal, and there is no outer ring. The sac block only appears in the groin area, and it has a slightly rounded or elliptical hemispherical mass. The patient is obese, and the presence of sputum can be neglected due to obvious signs of abdominal abdomen.
3. Pay attention to the diagnosis of slidability: the symptoms of sloping squinting are similar to those of general sacral sputum. Generally, it is not easy to diagnose before surgery, but some special clinical manifestations are helpful for diagnosis. If the content of sputum is descending colon or sigmoid colon, The patient can only defecate after the reduction of the sputum; if the bladder is large, there is often a phenomenon of "cutting urine" when urinating, that is, the pain of the ankle after urination, the sputum shrinks after the first urination, and soon there is urine, forming One discharge of urine twice.
4. Note the possibility of two sputum coexistence: in some elderly patients, because of abdominal wall relaxation, it can be seen on the same side of the squat and straight sputum, called saddle hernia; about 15% of patients can occur simultaneously on both sides In addition, the inguinal hernia can also coexist with femoral hernia and other abdominal hernias.
Differential diagnosis
In general, inguinal hernia is a disease that is easy to diagnose, but it is easy to be confused with certain diseases, and should be distinguished.
1. Indirect groin area, femoral hernia:
(1) The position of the sputum and the way of the sputum: To have a complete, three-dimensional understanding of the local anatomy of the groin area, it is necessary to judge whether the iliac crest is a triangle or a femoral tube. The elderly with an inguinal hernia can enter the scrotum and return After pressing the inner ring, the sputum block no longer appears. The straight sputum is rare. The Hesselbach triangle position is on the inner side. Regardless of the length of the disease, it does not enter the scrotum. The inner ring is still pressed out, and the femoral hernia appears in the inferior and inferior groin. There is a big gap between the anatomical position and the former, and the inguinal hernia and the straight iliac crest will not expand to this position.
(2) The shape of the sacral block: the inguinal hernia block is often elliptical or pear-shaped, with a pedicle on the top; the straight scorpion is hemispherical and the base is wider; although the femoral hernia is also hemispherical, but in the supine After returning to the contents, the clam block does not completely disappear, and the impact when coughing is not as significant as the first two.
(3) Incarceration: The oblique intrusion, the incarceration rate of the femoral hernia is high, and the incarceration does not occur.
(4) Intraoperative attention to the relationship between the inferior epigastric artery and the sacral neck: In some cases, the relationship between the inferior epigastric artery and the sacral neck should be examined during surgery to be surely oblique or straight.
2. Other diseases in the area:
(1) testicular hydrocele: the disease is due to the distal end of the sheath is not closed, there is a mass in the scrotum, if the scrotum enters the scrotum, especially difficult to relapse, should be with the testicular hydrocele Identification, the swelling of the hydrocele is completely confined in the scrotum, the upper boundary can be clearly touched; and the inguinal hernia is from the abdominal cavity, the upper boundary of the mass can not be touched in vitro, the pedicle has a pedicle into the deep abdominal cavity At the site, the lumps were examined by light transmission test. The hydrocele was able to transmit light (ie, positive), while the sacral block was not able to transmit light. The inguinal hernia was able to lick the parenchyma of the parenchyma in the posterior mass of the mass; The testicles are in the middle of the effusion, so all the tumors are cystic and can not be paralyzed and the testis of parenchyma. When the testicular hydrocele is infected, it should be differentiated from the incarcerated oblique sputum. The former has a longer non-resettable A history of the mass, a local inflammatory response, and the patient has no clinical manifestations of intestinal obstruction.
(2) traffic hydrocele: also known as congenital hydrocele, the sheath sac is connected with the abdominal cavity, the shape of the tumor is similar to the testicular hydrocele, but often appears slowly after a few hours of getting up And gradually increase, lying or squeezing the mass, because the effusion into the abdominal cavity, its volume can be gradually reduced, the light transmission test is positive.
(3) spermatic hydrocele: This disease is formed by the fact that the sheath of the spermatic cord above the testis is not closed. It is characterized by small mass and upper and lower bounds. The lower boundary and the testicle are clearly defined. Or pinch and disappear, the mass is located above the testis in the groin area, there is a sac sexy, can pull up and down when pulling the testicles, but no cough impact, no history of return, positive light transmission test.
(4) varicocele: because the left spermatic vein enters the left renal vein at a right angle, and the right side enters the inferior vena cava to form an obtuse angle, and the reflux is smooth; in addition, the left spermatic vein is often compressed by the sigmoid colon filled with feces. Therefore, varicocele is usually on the left side, while the oblique sac is more common on the right side. The varicocele is slightly thicker, and the degree of varicose is related to the development of the disease course, the length of standing time, etc. There is no cough and impact, the scrotum is loose when standing, the venous plexus is twisted at the upper end of the testicle, which is like a wart, and the varicocele test is negative, and the palpation is sputum-like.
(5) testicular torsion: testicular torsion is more common in patients with testicular hypoplasia, patients with sudden testicular severe pain, and have nausea, vomiting, and some shock state, its clinical manifestations such as local pain, abdominal pain, nausea, vomiting, etc. Symptoms of sacral hernia are quite similar, but testicular torsion is far less common than incarcerated sputum, patients with testicular swelling, scrotal edema, unclear boundary between testis and epididymis, tenderness, and mild tolerable testicles in patients' past history Pain, testicular torsion, often misdiagnosed as incarcerated oblique hernia, but patients with oblique hernia have a history of reversible mass, and after the incarceration, gastrointestinal symptoms are more significant.
(6) testicular insufficiency: cryptorchidism is mostly located in the inguinal canal, due to hypoplasia, the mass is smaller than the normal testis, the palpation mass is firmer, the edge is clear, there is a special testicular pain when squeezed by hand, at the same time The testicles are not touched in the affected scrotum. It should be noted that 50% to 90% of patients with incomplete testicular sinus have groin.
(7) uterine round ligament cyst: female patient, the mass is located in the inguinal canal, there is a circular mass in the inguinal area that gradually increases or the size changes are not obvious, the boundary is clear, the quality is tough and the capsule is sexy, the tension is high, can not be returned, squeeze The pressure is sore, no pedicle extends into the deep part of the abdomen, no cough impact, accompanied by local redness and pain during infection, but no intestinal obstruction.
(8) lymph nodes in the inguinal hernia: chronic inflammation of the lymph nodes above the inguinal ligament sometimes becomes swollen, which is easily misdiagnosed as oblique hernia, but the lymph nodes are separated by nodules, the quality is hard, and the expansive cough test is negative. If the primary infection is found, More helpful in identification.
(9) Sexually transmitted lymphogranuloma: a mass can also be formed in the inguinal region. The patient has a history of unclean sexual intercourse. There have been primary damage to the external genitalia, such as small papules, purulent sputum, etc., unilateral or bilateral inguinal lymphadenopathy. , pain, surface red or purple-red skin, mostly along the inguinal ligament in a sausage-like arrangement, if necessary, can be used for Frei's test to confirm the diagnosis.
(10) waist cold abscess: has gradually disappeared, spinal tuberculosis and pelvic tuberculosis of cheese-like pus along the psoas muscle into the groin area, the mass is often larger, more lateral than the inguinal hernia, more partial to the armpit It has nothing to do with the outer ring and the scrotum. It can have a shock when coughing. It is slightly reduced after lying down. The edge is not clear, but there is a sense of fluctuation. It can also be further diagnosed according to the history of tuberculosis and X-ray film.
