Inguinal hernia is commonly known as “small intestine gas” and “hernia”, also known as “fox hernia” in Chinese medicine. It is an extra-abdominal hernia that occurs in the inguinal region (below the abdominal wall, at the root of the thigh), where organs or tissues in the abdominal cavity, such as the small intestine, appendix, greater omentum, and even organs such as the bladder, ovaries, and fallopian tubes, enter the inguinal canal or even the scrotum/labia through congenital or acquired abdominal wall defects. It often presents as a localized mass that bulges under the skin and is easily seen and palpable. There are two types of inguinal hernias: inguinal hernia and inguinal hernia.
Inguinal hernia is a common and frequent disease unique to human beings and is not uncommon in our surroundings. Prince Charles of the United Kingdom, former President Saddam of Iraq, Taiwanese writer Li Ao, famous soccer players Kaka, Gerrard, Lampard and Owen have all suffered from hernias. According to incomplete statistics, more than 20 million cases of inguinal hernia repair are performed worldwide every year. According to domestic epidemiological surveys, there are about 2 million new cases of inguinal hernia in China every year, with an overall incidence of 0.3%-0.6%. With the acceleration of the aging process in society, the incidence of the disease continues to rise, with an incidence of >1% in people over 60 years of age. It occurs in the majority of males, with a male to female incidence ratio of approximately 15:1, and is more common on the right side than on the left. All inguinal hernias in pediatric patients are hiatal hernias, a congenital disease with an incidence of about 2% to 4% in newborns, most of them occurring within 2 years of age, usually in the first few months of life, decreasing after 1 week of age, less frequent from 18 to 45 years of age, and increasing significantly after 65 years of age.
Inguinal hernia is a common and difficult disease, and at present, there are still large misunderstandings in the treatment of hernia disease in China. Many people think that hernia is not a serious disease and do not take it seriously, and some patients rush to the doctor after getting the disease, believing in the small advertisements that “no injection, no medicine, no surgery, no recurrence” and go to some unregulated medical places for treatment, which leads to a series of complications and side effects. For this reason, this section will reveal the causes and consequences of inguinal hernia and explain the common misconceptions about the disease. Before doing so, you need to understand the following questions.
Why do people develop inguinal hernias?
The exact pathogenesis of inguinal hernia is still not fully understood. On the one hand, there are human anatomical and physiological factors, i.e. congenital factors, and on the other hand, there are acquired predisposing factors.
1. Insufficiency of the sphincter
The unclosed sphincter is one of the anatomical bases for the occurrence of congenital inguinal hernia. During embryonic development, the testis descends from the abdominal cavity through the inguinal canal into the scrotum, and the peritoneum moves down with the testis to form the sheath, and the lower part of the sheath becomes the testicular sheath and is atretic shortly after birth. If the sheath is completely or partially unclosed, the abdominal contents thus enter the inguinal canal and scrotum, forming an inguinal hernia. In women, there is no descent of the testes, so there is no sphincter, and the inguinal canal is only passed by the round ligament of the uterus, which is smaller than in men, thus the incidence of inguinal hernia is greatly reduced.
2, weak or dysfunctional abdominal wall
The inguinal region is the only region of the body that is not covered by muscle tissue, but only a relatively thin layer of transverse abdominal fascia, which causes the inguinal region to bear a threefold increase in intra-abdominal pressure after humans walk upright. Various causes of tissue collagen metabolism and composition changes caused by the weakness of the abdominal wall, such as the elderly abdominal wall muscle atrophy, tendon degeneration, reduced strength, coupled with obesity or long-term illness in bed and other factors, is very likely to lead to abdominal wall muscle atrophy, abdominal wall insufficiency and inguinal hernia.
3.Increased intra-abdominal pressure
Intra-abdominal pressure and instantaneous intra-abdominal pressure changes are the driving force behind the production of an extra-abdominal hernia. Elderly people often suffer from chronic bronchitis, hypertrophy of the prostate gland, habitual constipation and other diseases. Long-term chronic coughing, difficulty in urination and straining to defecate result in increased intra-abdominal pressure, which displaces and compresses the intra-abdominal organs to the weak area of the abdominal wall. In addition, long-term heavy physical activity, women’s pregnancy, cirrhosis ascites, etc. can also slowly cause an increase in abdominal pressure, which is related to the occurrence of inguinal hernia.
4.Other
Genetic factors, smoking, obesity, etc. may be related to the occurrence of inguinal hernia.
How do I know I have an inguinal hernia?
As mentioned earlier, inguinal hernia is caused by a defect in the abdominal wall in the inguinal region, that is, a “hole” inside the abdominal wall.
The organs in the abdominal cavity protrude from their normal position through the “hole” in the abdominal wall. The typical clinical manifestation is a soft mass in the inguinal region, which is small at the beginning of the disease and only appears when the abdominal pressure increases, such as when straining to defecate, coughing, moving, or when the baby cries, and can be retracted by gentle pressure and become smaller or disappear when lying on the back. Initially, most patients with inguinal hernia do not experience any specific discomfort or occasionally have localized distension and involvement pain. The diagnosis of a typical inguinal hernia can be established on the basis of history, symptoms and physical examination. In cases of atypical symptoms, imaging such as ultrasound or MRI/CT can help establish the diagnosis.
As the disease increases, the mass may gradually increase in size and even descend gradually from the inguinal region to the scrotum or labia majora. With the increase of herniated contents, the local distension and pain increase, accompanied by a feeling of falling, which makes walking difficult and affects labor. If the hernia contents are stuck and cannot be retracted, the hernia is an incarcerated hernia. If the intestine is incarcerated, not only local pain is obvious, but also intestinal obstruction such as paroxysmal abdominal cramps, abdominal distension, nausea, vomiting and constipation. If left untreated, the symptoms of most patients will gradually worsen and eventually develop into strangulated hernia, with intestinal necrosis, intestinal perforation, septic sepsis, shock, and even life threatening in severe cases.
In addition, parents should check for inguinal hernia if the infant appears to be crying and refusing to eat for no reason.
What should I do if I have an inguinal hernia?
Many people think that a painless disease does not need treatment, and the potential great harm of inguinal hernia is often overlooked until the pain caused by the mass seriously affects daily life, and only then do they think of going to the hospital to see a doctor. In fact, the hernia mass of inguinal hernia can gradually increase in size as the disease continues, continuously aggravating the damage to the abdominal wall increasing the patient’s pain, making treatment more difficult, and even affecting the function of the patient’s urinary and reproductive systems. Once the hernia mass fails to retract, it should be treated quickly at the hospital, as it can be a direct threat to life in case of strangulation. Therefore, hernia should not be taken lightly and should be treated early. Except for a few special cases, surgical treatment is recommended.
1. Non-surgical treatment
Theoretically, inguinal hernia in infants has the potential to heal on its own because the abdominal muscles gradually get stronger as the body develops. Therefore, conservative treatment is usually recommended for infants under six months of age who do not have an incarcerated or strangulated hernia, mainly by avoiding increased intra-abdominal pressure such as crying, constipation, and violent coughing, and by paying attention to observation. If necessary, a pediatric hernia belt can be used, but if the inguinal hernia is very large, or if the repeated protrusion and return fails, or if the incarceration is too long, surgery should be performed as soon as possible. The chance of self-healing of hernia in infants over six months of age is significantly reduced. The possibility of self-healing in children over one year old is almost non-existent, and surgery is recommended after a clear diagnosis. Generally speaking, surgery for hernia is safe and reliable without any sequelae.
Asymptomatic or mildly symptomatic inguinal hernias in men can be treated either by close observation or by elective surgery. For those who are old and frail or have other reasons that contraindicate surgery, medical hernia belts can be chosen to provide temporary relief of symptoms. However, long-term use of the hernia belt may cause adhesion between the neck of the hernia sac and the contents of the hernia (intestinal canal) in the abdominal wall, which may increase the difficulty of future surgery.
2.Surgical treatment
Surgical operation is the only reliable method to treat inguinal hernia. Individualized surgical methods should be selected according to the patient’s condition and the different medical and technical conditions. Pre-surgical preparation includes blood tests, medical evaluation, chest X-ray and electrocardiogram. Pre-operative smoking cessation should be performed, and those with constipation, chronic cough, difficulty in urination and other conditions with increased abdominal pressure should be treated before surgery. Elderly patients with chronic medical diseases should be evaluated for risk before surgery, especially in patients with cardiac and pulmonary diseases, which need to be treated and managed before surgery.
The vast majority of pediatric inguinal hernia patients have insignificant abdominal wall weakness, and a simple ligation of the “hole” in the abdominal wall (i.e., high ligation of the hernia sac) is all that is needed to achieve satisfactory results. Minimally invasive laparoscopic pediatric hernia surgery is now considered to be the main alternative to traditional surgery. Laparoscopic surgery is short, safe and effective. Pediatric hernia requires only 1-2 small holes of about 5 mm in the stomach, and the patient can be off the floor and processed for discharge within one day after surgery.
Surgical treatment of inguinal hernia in adults can be divided into traditional surgery and modern tension-free repair surgery, which aims to plug the “hole” in the abdominal wall and strengthen the weak abdominal wall. Traditional surgery is a direct tissue-to-tissue suture, which emphasizes “sewing”, just like taking a thick silk thread and sewing the hole directly to a torn pocket of a garment, while tension-free repair emphasizes “patching”, which means patching the hole with various patches. Traditional repair surgery has a history of more than 100 years and has made great contributions, but it has been difficult to overcome the shortcomings such as excessive tension after forcing the tissues and tissues together and suturing them, local pain after surgery, and high recurrence rate (about 10%). With the advancement of medicine, tension-free repair surgery, which has been gradually developed in the last two decades, has become the mainstream procedure for the treatment of inguinal hernia in adults, using various repair materials (synthetic patches) implanted in the inguinal region to repair the “hole”, and the implanted patch becomes a structure, just like a house needs to be built with reinforcement. The patch then grows inward through the body’s own tissues and local tissue scars are formed to achieve the purpose of the repair, and in about 3 months the patch and the body’s tissues are completely integrated and do not have to be removed, with almost no effect on the body. It is characterized by tension-free, light pain and fast recovery, and some patients can be operated under local anesthesia on an outpatient basis, with a low recurrence rate (about 1-3%), but an incision scar of about 4-5 cm will remain on the abdominal wall.
With the increasing maturity of minimally invasive laparoscopic techniques, they are being used more and more in the field of surgery. A laparoscopic hernia repair is a tension-free hernia repair performed laparoscopically, usually with three 5-10 mm holes in the abdominal wall, plus a patch and other instruments, to complete the entire procedure. Laparoscopic surgery is cosmetically effective, less invasive, with less postoperative pain, faster recovery, and lower recurrence rates. It is especially effective for recurrent hernia and bilateral hernia. However, its disadvantages are higher than open surgery in terms of operation time and cost, relatively longer learning curve, and higher technical requirements for surgeons. It can only be performed by a small number of surgeons with formal training in lumpectomy skills.
It should be emphasized that the current evidence does not indicate which of open or laparoscopic surgery should be performed as a routine procedure and should be based on the experience of the surgeon and the patient’s specific situation. However, with the development of laparoscopic techniques, improvements in surgical instruments, and advances in hernia repair materials, laparoscopic hernia repair will have good prospects for development and application
What should I pay attention to after surgery?
Patients who have undergone surgery under local anesthesia do not need to fast from water and can eat after surgery. Patients undergoing general anesthesia can eat easily digestible food 6 hours after waking up on the day of surgery if there is no vomiting or other discomfort, and can slowly get out of bed on the first day after surgery and be discharged 2-3 days after surgery. Young patients with no underlying medical disease can be discharged from bed within 24 hours after surgery. Postoperative antibiotics are generally not required unless the patient is at high risk for infection, such as advanced age, obesity, diabetes mellitus, and combined immunocompromised conditions.
Keep the wound clean and dry. If the wound pain affects defecation, take oral painkillers as prescribed by the doctor. Patients with constipation can take laxative medication or use open cork for treatment. After the operation, pay attention to keep warm, prevent colds and avoid coughing. If you cannot avoid it, you should press the wound with your hand and cough again. Actively and correctly treat prostate enlargement. Patients with diabetes should keep their blood sugar under normal control. Return to the hospital for regular follow-up as prescribed by the doctor. If the wound is red, swollen, hot, painful or bleeding, and the scrotum is swollen, please feel free to return to the hospital for treatment. Usually, you can resume your daily work 1-2 weeks after surgery. Activities that cause increased abdominal pressure, such as lifting heavy objects, running, hiking, and strenuous exercise such as going up and down stairs for long periods of time, should be avoided for 3 months after surgery.
Due to the lack of understanding of this disease in many patients, they have not been able to receive timely and standardized diagnosis and treatment for a long time. We summarize the most common misconceptions about the disease that many patients encounter clinically, in order to help patients improve their understanding of the disease and eliminate concerns.
1. Is a mass in the groin an inguinal hernia?
Inguinal mass is the most common clinical symptom and sign in surgery. According to the incidence, they can be broadly classified into inguinal hernia, chronic lymphadenitis, metastatic cancer of lymph nodes, lymphoma, soft tissue nodules in the inguinal region (such as lipoma, fibroma, etc.), testicular syringomyelia, cryptorchidism and tuberculosis. The main common manifestation of these diseases is the presence of a mass in the inguinal region, which is sometimes confusing in diagnosis. Generally, they should be judged based on medical history and clinical manifestations, and relevant auxiliary examinations should be performed for differentiation if necessary.
2.Think it is not life-threatening, so it can be treated or not
The population of inguinal hernia patients in China is very large, but the actual consultation rate is still very low, and the proportion of those who receive surgical treatment is even lower. The reasons for this are not only the wrong belief that inguinal hernia is a “minor disease” and not life-threatening, but also the location of the disease next to the external genitalia, which makes some patients too shy to go to the hospital, and the fact that some patients are afraid of surgery and hope for a solution through conservative treatment.
Inguinal hernia is not self-healing and long-term neglect of treatment can lead to aggravation of the condition. Once the hernia fails to retract to form an incarcerated hernia, it can lead to severe pain, intestinal obstruction, intestinal necrosis, perforation, septic sepsis, and even death. Therefore, when symptoms of hernia appear, such as obvious inguinal mass or painful sensation, one should go to a regular hospital as soon as possible. In cases of serious complications due to delayed treatment, patients often need to undergo greater surgery. Therefore, the earlier you seek medical attention, the easier it is to treat and the better the results.
3. Fear of surgery and belief in conservative treatment methods
For inguinal hernia, the most effective treatment is surgery. Many tragedies are related to the lack of patient awareness. Many patients are still misled by the false advertisements circulating in the society. Some unscrupulous “doctors” take advantage of patients’ concerns and fears and advocate “new technology” with good efficacy and no surgery for hernia to cheat them. At present, non-surgical treatments such as Chinese herbal medicine, belly button stickers and hernia belts are unable to solve the problem and may even cause very serious consequences. It is especially important to point out that there are still some non-surgical treatments such as “local injection of hernia” in the domestic medical market, which lack scientific basis and can bring a series of troubles to patients and should be discarded.
In today’s highly developed modern medicine, numerous medical practices have proved that tension-free hernia repair is a minimally invasive and safe treatment method. It is minimally invasive, with quick recovery and low recurrence rate. At the same time, the development of hernia repair surgery under local anesthesia has enabled more patients who were originally unable to tolerate surgery due to advanced age or cardiopulmonary insufficiency to have access to treatment.
Therefore, the majority of patients with inguinal hernia should have a scientific and correct understanding of this disease. Therefore, patients with inguinal hernia should have a scientific and correct understanding of the disease, eliminate misconceptions about the disease, achieve early detection and diagnosis, and receive regular professional treatment in a timely manner.