Hernia: Hernia [shàn], English hernia; commonly known as hernia, is a part of human tissue or organ that leaves its original part and enters another part through a gap, defect or weak part of the body. There are umbilical hernia, inguinal hernia, hiatal hernia, incisional hernia, surgical recurrent hernia, white line hernia, femoral hernia and other types. Most of the hernias are caused by coughing, sneezing, excessive exertion, abdominal hypertrophy, straining to defecate, pregnancy in women, excessive crying in children, and degenerative changes in the strength of the abdominal wall in the elderly.
Clinical manifestations
They are classified as inguinal hernia, inguinal hernia, femoral hernia, umbilical hernia, white line hernia, incisional hernia, incarcerated hernia, strangulated hernia, etc.
General symptoms: protruding when standing, disappearing when lying on the back, and returning to the abdominal cavity with pressure. However, incarcerated hernia and strangulated hernia are painful and difficult to push back into the abdominal cavity. The hernia is prone to adhesions and intussusception if left to develop, so it should be treated early.
Pathogenesis
Most hernias are due to long-standing areas of weakness in the body. Usually weak areas in the abdominal wall are innate and become thinner with age, trauma or surgical incisions. Lifting heavy objects or doing heavy physical work can increase the severity of a hernia. Although hernias are more common in men than in women, they can occur in anyone and can be caused by a number of factors, including actions or activities that add extra pressure to the abdominal wall, such as: chronic coughing or asthma, such as in smokers; obesity; abdominal stress during urination and defecation; pregnancy; and abdominal stress when lifting heavy objects
Types of hernia
(according to the location of the disease)
Inguinal hernia: this type of hernia can appear and occur at any age, but the peak occurs in early childhood, with 80% – 90% occurring in boys, followed by older adults.
Abdominal wall hernia: this type of hernia occurs mainly in the area around the navel, and women account for the majority of hernia patients. Most occur between the ages of 20 – 50 years.
Umbilical hernia: occurs in the navel, which is raised in a circular pattern inside the navel. Umbilical hernia occurs in 10% —-20% in infants, children and secondly more common in adult women.
Scrotal hernia (scrotal hernia): In men, it occurs in the scrotal area, producing a scrotal hernia that is significantly enlarged in severe cases and makes walking extremely difficult. In women, it occurs in the ovaries and causes significant swelling of the lower body with painful swelling.
Incisional hernia: This type of hernia occurs at the site of an earlier original surgical incision wound scar. Incisional hernias may occur months or years after the surgical procedure.
Symptoms
Clinical symptoms may vary depending on the size of the hernia sac or the presence or absence of complications. The basic symptom is a reducible mass in the inguinal region that starts small and appears only when the patient is standing, working, walking, running, or coughing heavily, and that retracts on its own when lying down or when pressed by hand. There is generally no special discomfort, only occasional local distension and involvement pain. As the disease progresses, the mass may gradually increase in size and descend from the groin into the scrotum or labia majora, making walking difficult and affecting labor. A refractory hernia has a slightly more painful clinical presentation. The main feature is that the hernia mass cannot be completely retracted.
Intrusive hernia often occurs when there is a sudden increase in intra-abdominal pressure such as strong labor or defecation, and is often clinically manifested by a sudden increase in the size of the hernia mass with significant pain. The mass cannot be retracted by lying down or pushing it by hand. The mass is tense and hard, and there is significant tenderness. If the embedded content is the greater omentum, the local pain is often mild; if it is the intestinal canal, not only is the local pain obvious, but it may also be accompanied by paroxysmal abdominal cramps, nausea, vomiting, constipation, and abdominal distension. Once the hernia is embedded, there is less chance of self-retraction; the symptoms of most patients gradually worsen and will eventually become strangulated hernia if not treated in time. In the case of intestinal wall hernia, it is easy to be ignored because the local mass is not obvious and there is not necessarily a manifestation of intestinal obstruction.
Dangers of hernias
Hernia firstly affects the digestive system of the patient, resulting in symptoms such as lower abdominal cramping, abdominal flatulence, abdominal pain, constipation, poor nutrient absorption, easy fatigue and decreased physical fitness. Since the inguinal region is adjacent to the genitourinary system, older patients are prone to bladder or prostate diseases such as frequent urination, urgent urination, and increased nocturia; children may be affected by the normal development of testicles due to the extrusion of the hernia; and middle-aged and young patients are prone to sexual dysfunction. The inflammatory swelling of the intestinal canal or omentum inside the hernia sac due to extrusion or collision may cause difficulty in hernia retraction, leading to intussusception, intestinal obstruction, intestinal necrosis and other dangerous conditions.
Differential treatment
1. Inguinal hernia
The hernial sac protrudes through the deep ring of the inguinal canal (internal ring) on the lateral side of the infundibular artery, passes obliquely through the inguinal canal inward, downward, and forward, then penetrates the superficial ring of the inguinal canal (subcutaneous ring) and can enter the scrotum, which is called indirectinguinal hernia. Hiatal hernia is the most common type of extra-abdominal hernia.
Presentation and diagnosis
The most important clinical manifestation is the presence of a reducible mass at the external ring of the inguinal canal. Initially, the mass protrudes obliquely along the inguinal canal towards the opening of the external ring during prolonged standing, walking or coughing. Later the mass gradually increases in size and extends into the scrotum. The upper end of the mass is narrow and the lower end is wide and shaped like a pear, and it appears to have a stalk that extends into the inguinal canal. The mass is protruding with a feeling of falling or mild soreness and swelling.
The patient is examined in a lying position with the affected hip flexed and the inguinal region relaxed. The lump can be retracted by gently pressing it in an outward and upward direction along the inguinal canal. If the inguinal ligament is pressed 2 cm above the midpoint of the inguinal ligament and the patient is made to stand and cough, the protrusion of the mass can be prevented and the mass will reappear when the pressing finger is removed. In case of incomplete hiatal hernia, the contents of the hernia do not protrude from the external ring and a finger can be inserted into the mouth of the external ring. The patient is made to cough and the impact is felt. If the hernia is refractory, the mass may be difficult or only partially retracted during the examination. If the herniated mass cannot be retracted after protrusion and an impaction occurs, the herniated mass has severe pain, high tension, and pressure pain.
If the herniated contents are not released and then blood flow obstruction occurs, the herniated mass turns into strangulated hernia with ischemic necrosis of the intestinal canal and acute inflammatory manifestations such as redness, swelling, heat and pressure pain, and physical signs of peritonitis. Sometimes the symptoms of systemic infection such as high fever and chills are extremely obvious, and severe cases may be complicated by infectious shock
Surgical principles of hiatal hernia
In children, only high ligation of the hernia sac and hernia repair are performed to avoid affecting the development of the spermatic cord and testes and disrupting the physiological occlusion mechanism of the inguinal canal. Hernioplasty is rarely performed unless there is a large defect in the abdominal wall.
High ligation of the hernia sac: In order to destroy the residual peritoneal sphincter it is necessary to transect the hernia sac and dissect its proximal end to the internal ring, where the extraperitoneal fat layer can be seen and its deep surface is the mural peritoneum. At this level, the hernia sac neck is ligated with a silk thread at a high level, and the distal hernia sac is usually left open without removal of the sac.
Hernia repair: As the hiatal hernia develops, the internal ring is gradually enlarged and the peritoneal strength is further weakened. Therefore, hernia repair must be performed after high ligation of the hernia sac. Hernia repair should include two concepts: repair of the enlarged internal ring and repair of the weak inguinal canal. Before repairing the inguinal canal, the enlarged internal ring must be explored and repaired otherwise recurrence is inevitable. For this reason, it is necessary to continue dissecting the levator muscle after the hernia bursa is forcibly tied at the root to better expose the stretched internal ring and the intercondylar ligament, and to suture the intercondylar ligament to reduce the internal ring so that it can only accommodate the passage of the spermatic cord.
2.Direct inguinal hernia
Direct inguinal hernia is a direct inguinal hernia in which the hernia sac protrudes directly from posterior to anterior without passing through the internal ring and without entering the scrotum through the triangle of the inferior abdominal wall artery. Hiatal hernia is the most common type of extra-abdominal hernia. (1) Treatment measures
In principle, surgery should be performed if there is no contraindication to surgery. In view of the fact that incarcerations rarely occur in direct inguinal hernias, a hernia brace can be used to relieve symptoms in elderly and frail patients or those with other chronic illnesses that cannot tolerate surgery.
Since there is no obvious hernia neck and hernia sac, only the loose protruding peritoneum needs to be removed during surgery. Sometimes the hernia can be converted to a hiatal hernia and then ligated in high position. The repair can be done using the Madden method to strengthen the transverse abdominal fascia. The Bassini or Halsted method can also be used to strengthen the posterior wall of the inguinal canal. It is important to note that the McVay method is preferable to the Madden method for large direct hernias.
(2) Clinical presentation
Hernia is usually seen in middle-aged and elderly frail patients. It is usually asymptomatic, with only a slight soreness and swelling when the herniated mass protrudes. The hernia ring, which is the weak zone of the Hessian triangle, is wide and has no obvious hernial neck. On physical examination, when the patient is made to stand, the hernia mass protrudes above the pubic symphysis and bulges in a hemispherical shape. After retraction, hand pressure on the Hessian triangle can block the hernia mass from reappearing.
(3) Differential diagnosis
Hernia can be differentiated from hiatal hernia by not entering the scrotum. The hernia may also remain protruding after retraction of the hernia mass with pressure on the internal ring. Intraoperatively, it can be judged by the relationship between the hernia ring and the inferior abdominal wall artery, which is located medial to the inferior abdominal wall artery.
(4) Principles of medication
1.Elective surgery and good general condition do not require the application of antimicrobial agents. 2.Inserted hernia or combined with other systemic disorders, the elderly and frail, that is, the application of drugs including medication box “A” and “B”.
(5) Auxiliary examination
(1) For patients with direct hernia without comorbidities, the examination protocol should focus on box “A”; (2) For patients with combined lung infections and other diseases, the examination protocol may include box “A” and “B 2. For patients with combined pulmonary infections and other diseases, the examination protocol may include examination box “A” and “B”.
3.Femoral hernia
Clinical manifestations.
(1) Protruding mass in the oval fossa of the femur with swelling and pain, mostly seen in women over middle age.
(2) The mass is not large, hemispherical and not easily retractable.
(3) The femoral hernia is prone to impaction, which is often accompanied by acute mechanical intestinal obstruction, in addition to local hardening of the mass and increased pain. Basis of diagnosis.
Women of middle age or older with a hemispherical mass in the oval fossa of the femur.
Principles of treatment.
(1), Trans-inguinal ligament repair on the inguinal ligament, mainly for huge femoral hernias or for embedded or strangulated ones.
(2) Transinguinal ligament repair, mainly for older patients or smaller femoral hernias.
Principles of dosing.
(1) Elective surgery for femoral hernia is generally not indicated with antimicrobial agents.
(2) In case of incarcerated or strangulated hernia, or in case of non-incarcerated or strangulated hernia but combined with respiratory and urinary tract infection, the drug should be applied, including the drug box “A” and “B”.
(3) In case of postoperative complications or frailty of strangulated hernia, in addition to the application of “A” and “B”, we can also consider the application of new special drugs and support symptomatic treatment.
Auxiliary examination.
(1) The special case of reversible femoral hernia examination is based on the examination box “A”.
(2) In cases of embedded femoral hernia with mechanical intestinal obstruction or severe disease, the examination protocol may include examination box “A” and “B”.
(3) When the diagnosis is unclear or needs to be differentiated from other diseases, the examination special case may include examination box “A” and “B”.
4.Umbilical hernia
The abdominal viscera are dislodged through the umbilical hole to the subcutaneous. Umbilical hernia is a common occurrence in dogs, and the contents of the hernia may be the sickle ligament, omentum, or small intestine. The etiology is most often due to congenital defects in umbilical development, incomplete closure of the umbilical hole, or may be due to too much tension in the umbilical hole after birth, the umbilical cord being left too short, or infection of the umbilical cord. Symptoms
A round bulge of varying size appears in the umbilicus, which is soft to touch, painless and heatless. The hernia hole can be felt by pressure, and the hernia contents can be returned when squeezing the hernia sac or when the animal is lying on its back, and the bulge increases after struggling or eating. In a few cases, the hernia contents become adherent or embedded, the wall of the sac is tense on palpation, and the hernia contents cannot be returned by compression or changing the position. If the embedded temple contents are intestinal tubes, the symptoms of acute abdomen are manifested. The symptoms include abdominal pain, abdominal discomfort, abortion, vomiting, fever, and in severe cases, shock.
Treatment
Some of these hernia can subside on their own as the body grows. In the case of umbilical hernia, surgical repair is required. The procedure is performed by placing the patient in a supine position under general anesthesia, with routine sterilization of the abdominal floor and the area around the hernia sac. A shuttle-shaped incision is made on the skin of the hernia sac to open the sac and expose the contents of the hernia. If the hernia contents are not adherent and not occluded, they are returned to the abdominal cavity via the diseased ring, and if they are adherent to the hernia sac or ring, the adhesions are carefully stripped or removed (omentum, falciform ligament). In case of intussusception, first check whether the hernia contents (e.g. intestinal canal) are necrotic, and if not, carefully retract them. If the hernia ring is too small for pneumothorax, the ring can be enlarged and then returned; if it is necrotic, the necrotic segment of the intestine must be removed and then returned by anastomosis. The temple ring is repaired, the temple hole is closed, and the abdominal wall is sutured.
Incisional hernia
The reason why longitudinal abdominal incisions are more common in incisional hernias is that the fibers of all layers of the abdominal wall, including muscles and fascia sheaths, in addition to the rectus abdominis muscle, are by and large transverse, and a longitudinal incision is bound to cut these fibers; when suturing these tissues, the sutures tend to slip between the fibers; the sutured tissues are often subjected to transverse indexing force of the muscles and are prone to wound dehiscence. In addition, although the longitudinal incision does not cut off the strong rectus abdominis muscle, the intercostal nerve can be cut off because of its strength, thus reducing the anatomical factors mentioned above in addition to improper surgical operation is an important cause of incisional hernia, the most important of which is the destruction of the abdominal wall tissue due to incisional infection, (the resulting abdominal incisional hernia accounts for about 50% of all cases) altogether it is such as retention of drainage for too long, the incision is too long, so that the intercostal nerve is cut off after many abdominal wall incisions are not sutured tightly. In addition, poor healing of the incision is also an important factor, such as atrophy and obesity of the abdominal muscle due to poor nutrition in old age.
Methods to prevent incisional hernia.
1 Adequate preparation before surgery
2 control of abdominal pressure and strenuous activity after surgery
3 Avoid wound infection
4Suture technique and suture material of the surgeon
5Control of diabetes and weight
6Preventing colds and maintaining regular bowel movements
7Protect the wound with a lap band after surgery
Methods of hernia treatment
Surgical treatment
There are three types of surgical treatments: hernia repair, hernia patch repair, and hernia laparoscopic repair
Hernia repair: repairing the hernia ring by suturing the tissue around the defect
Hernia patch repair: repair of the hernia orifice by covering the defect with a patch material
Hernia laparoscopic repair: Hernia patch repair is done laparoscopically
Ways to reduce the pain of a hernia
The root of the upper thigh, medically called the “groin”, is the most common area for men to develop a hernia. A hiatal hernia often protrudes outward from the inguinal canal within the abdominal wall of the lower abdomen, or directly into the scrotum. This type of hernia is characterized by an intermittent mass, which often protrudes when standing, walking or coughing, especially when doing heavy labor, and there is often localized swelling and discomfort. At this time, labor should be stopped immediately and bed rest should be taken with smooth breathing, and the painful mass will be slowly incorporated back into the abdominal cavity. If the swelling does not disappear after rest, the swelling can be slowly pushed back into the abdominal cavity by hand. For hernias that still cannot be recovered by the above methods, one can also try padding the buttocks or head-low-foot-high position, and then push the hernia mass into the abdominal cavity continuously and slowly by hand, with gentle movements to prevent rupture of the intestinal canal. For patients with a hernia that has been repositioned, especially if the hernia mass has been protruding for a long time, it is important to observe the abdomen and if there is an increase in abdominal pain with localized pressure and rebound pain, the patient should be seen immediately in the hospital and may have to be treated surgically.
For another type of hernia that cannot be retracted, called “incarcerated hernia”, the pain will increase and the mass will become tense and hard. If the incarcerated hernia is prolonged, it is important not to blindly push the mass back into the abdominal cavity. Because the embedded intestine may be ischemic and necrotic, if it is forced back into the abdominal cavity, there is a risk of intestinal necrosis and perforation. Such patients should be treated immediately in the hospital and should not take any chances to avoid delaying the treatment. For patients with recurrent hernias, an appropriate time should be chosen for surgical repair to achieve a radical cure.
Comparison of three types of surgical treatments
Traditional hernia repair: there is a large incision (about 6-8 cm long); requires hospitalization for about 7-10 days; routine anti-infection; postoperative pain and other discomfort are common; recurrence rate is about 20%; full recovery time is about 3 months for common hernia and about 6-12 months for extra large hernia.
Tension-free hernia patch repair: there is a medium incision (about 4-6 cm long); hospitalization is required for about 3-7 days; routine anti-infection; recurrence rate is about 1%; full recovery time is about 1 month for common hernia and about 3-6 months for extra large hernia.
Hernia laparoscopic repair: 3 small incisions (about 1 cm long); hospitalization of 4-7 days; routine anti-infection; general anesthesia is necessary; complications such as poking and placing the mirror and pneumoperitoneum may occur; recurrence rate of about 10%; full recovery time of about 1 month for common hernia and about 3-6 months for extra large hernia.
Correct choice of treatment method
After suffering from hernia, the treatment plan can be selected according to the following procedures according to the length of the disease, the severity of the disease and the presence of other diseases.
1. Consider hernia belt treatment for infants and children with reversible hernia. If the condition is not too severe, about 95% of infants and children can be cured by this method.
Most patients should be considered for surgical treatment, but the use of a hernia belt before surgical treatment is also useful to prevent further progression of the disease and to prevent the occurrence of acute complications such as hernia impaction and intestinal obstruction.
The surgical treatment of pediatric hernia is difficult because the organs and tissues are delicate, and the vas deferens and spermatic artery are easily damaged, so hernia surgery may affect the patient’s future fertility and cause sterility.
1. Children cry and fuss after surgery because they do not cooperate with the treatment, which can easily cause comorbidities and have a high recurrence rate and greater danger.
2. Surgical treatment of pediatric hernia often requires general anesthesia, which can easily damage brain cells and cause intellectual developmental disorders.
3. Therefore, patients with pediatric hernia should avoid surgical treatment as much as possible and choose to use professional institutions and specialized hospital drugs for professional guidance treatment.
Symptomatology of hernia diagnosis
The symptoms of hernia vary in severity and are related to the type of hernia, the condition of the hernia contents, the presence or absence of impaction and strangulation, etc. In the early stage of extra-abdominal hernia, there are only mild local symptoms, such as local distension and pain, reversible masses, etc., which do not affect the function of internal organs and have no systemic symptoms. With the increase of hernia contents, the local swelling and pain increase, accompanied by a feeling of falling. If the hernia contents are embedded, the corresponding systemic symptoms will appear. If the hernia contents are small intestine or colon, symptoms of intestinal obstruction such as paroxysmal abdominal pain, abdominal distension, nausea, vomiting and anal stoppage of defecation and exhaustion may occur. If the contents of the hernia are the bladder and kidney, there may be obvious urinary symptoms, such as frequent urination, urgent urination, painful urination, hematuria and pain in the lower back. If the contents of the hernia are the fallopian tubes, ovaries or greater omentum, there may be dull abdominal pain, dull lumbosacral pain and non-specific gastrointestinal symptoms such as loss of appetite, dyspepsia and intestinal flatulence. In case of strangulation of the hernia contents, systemic toxic symptoms such as fever, elevated white blood cell count, disturbance of water, electrolyte and acid-base balance, and even shock may occur in varying degrees. The diagnosis of intra-abdominal hernia is extremely difficult, especially in congenital intra-abdominal hernia, which is diagnosed as mechanical intestinal obstruction and is only confirmed after dissection. The diagnosis of postoperative intra-abdominal hernia, combined with the history of surgery, should be suggestive, but it may be misdiagnosed as adhesive intestinal obstruction. Traumatic diaphragmatic hernia is highly symptomatic, often associated with respiratory or (and) circulatory dysfunction, and is easily diagnosed when combined with a history of trauma. Congenital diaphragmatic hernias, on the other hand, have atypical symptoms and are easily misdiagnosed. Esophageal hiatal hernia is often misdiagnosed as chronic gastritis, peptic ulcer, reflux esophagitis, carditis, etc.
In conclusion, the symptomatology of hernia is rich, and the diagnosis of extra-abdominal hernia can often be made on the basis of symptomatic manifestations, with special attention to early symptoms, local symptoms, and the evolution of symptoms; therefore, a thorough medical history is essential. For early hernias without masses, hernias with small embedded masses, hernias with heavy systemic symptoms that mask local symptoms, internal hernias, diaphragmatic hernias, etc., symptoms should be used as a guide, combined with physical examination and ancillary tests to achieve the correct diagnosis of hernias. At the same time, when diagnosing intestinal obstruction, the possibility of hernia should be considered in the etiological analysis, and we must not be satisfied with the diagnosis of intestinal obstruction and miss the diagnosis of incarcerated hernia, which leads to strangulation and necrosis of the hernia contents.
Physical examination of hernia
Local signs, local signs of extra-abdominal hernia appear early and are more obvious. The typical sign is a locally elevated, reversible or irreversible mass. The location, size, shape, tension and presence of pressure pain of the mass vary depending on the type of hernia and its contents. The mass of inguinal hernia is mostly round or pear-shaped and passes through the internal ring of inguinal canal, through the inguinal canal, out of the mouth of the external ring and into the scrotum. The external ring opening is wide and the inguinal canal is relaxed, so that the mass no longer protrudes after the return of the hernia contents and finger pressure on the internal ring opening (2 cm above the midpoint of the inguinal ligament). Direct inguinal hernia masses are mostly semicircular in shape and protrude forward from the hesselbach triangle without entering the internal ring of the inguinal canal or the scrotum. Femoral hernia masses are located under the inguinal ligament and are smaller and not easily retractable. White line hernia and umbilical hernia masses are hemispherical in shape and are mostly asymptomatic. Lumbar hernia masses are deep, not easily palpable, and may have localized pressure pain. Occlusal hernia and perineal hernia masses require rectal fingering to find the masses. Intra-abdominal hernia masses are often not palpable, and if they are palpable and painful, they are often suggestive of ingrowth and strangulation of the hernia contents. Recurrent hernia masses are soft, with little tenderness, and often appear when abdominal pressure is increased by standing, coughing, or defecation, and disappear with lying down or pressure on the surface of the mass. If the contents of the hernia are intestinal mix, intestinal sounds can be heard on auscultation of the mass, and there is a “gurgling” sound when the mass is returned under pressure.
2. Systemic signs
(1) Gastrointestinal signs: Gastrointestinal obstruction is the main sign, such as: abdominal distension, intestinal pattern, abdominal pressure pain of different degrees and different ranges. In the case of intra-abdominal hernia strangulation, rebound pain, abdominal muscle tension and other signs of peritoneal irritation are present. Hyperactive bowel sounds and air-over-water sounds can be heard on abdominal auscultation.
(2) Urinary system signs; when the herniated content is the bladder, there may be mild suprapubic pressure pain, and if the ureter or its opening is obstructed, there may be pressure pain and percussion pain in the kidney area, and occasionally enlarged kidneys may be found.
(3) Respiratory signs: mainly seen in diaphragmatic hernia, a large amount of hernia contents enters the thoracic cavity, which may affect the expansion of the alveoli on the affected side, resulting in impaired gas exchange and hypoxemia. The main signs are rapid breathing, blue lips, shortness of breath and cough. Pestle finger and barrel-shaped chest may appear in chronic disease course.
(4) Circulatory signs; mostly seen in diaphragmatic hernia, to be distinguished from pericardial hernia, in elderly patients and in patients with pre-existing cardiac insufficiency. Diaphragmatic hernia can displace the mediastinum, squeeze the heart to reduce cardiac output, and pericardial hernia can cause acute pericardial tamponade, which is commonly associated with increased heart rate and decreased blood pressure, and even acute signs of heart failure such as cyanosis, edema, hepatomegaly, and jugular vein anger.