Extra-abdominal hernia: A hernia occurs when an organ or tissue leaves its normal anatomical site and enters another site through a congenital or acquired weak point, defect or orifice.
Intra-abdominal hernias are formed by the entry of organs or tissues into the interstitial sac of the abdominal cavity, such as omental foramen hernia. In true ventral hernia, the contents of the hernia must be located within a hernia sac composed of the peritoneal wall layers, which can be distinguished from visceral prolapse.
I. Clinical types
1. Reproducible hernia: the hernia contents can be easily retracted into the abdominal cavity;
2. Irreducible hernia: the hernia contents cannot be completely retracted into the abdominal cavity, but it does not cause serious symptoms, mostly due to adhesions between the greater omentum and the hernia sac;
3. Sliding hernia: the retroperitoneal organs are subsequently pulled down and slide out of the hernia ring and form part of the hernia sac, which often cannot be returned and is also a kind of refractory hernia;
4.Inserted hernia: When the hernia ring is narrow and the intra-abdominal pressure is suddenly increased, the hernia contents enter the hernia sac by forcibly expanding the neck of the sac and get stuck by the neck of the sac, so that the contents cannot be returned to the abdominal cavity, producing a series of symptoms such as abdominal pain and vomiting;
5. strangulated hernia: the blood supply of the embedded hernia contents is impaired or even completely blocked, resulting in necrosis of the hernia contents and causing peritonitis. The common extra-abdominal hernias are inguinal hernia, femoral hernia, umbilical hernia and incisional hernia according to the location of occurrence.
Clinical manifestations
Inguinal hernia: It is an extra-abdominal hernia that occurs in the inguinal region and can be divided into two types: inguinal hernia and inguinal hernia.
Inguinal hernia: it is mostly seen in infants and middle-aged men, with the right side being more common. Initially, the symptoms are not obvious, and only swelling and slight pain in the inguinal region appear when the intra-abdominal pressure is increased such as standing, walking or violent coughing, and later there may be a compound mass in the inguinal region or scrotum, which disappears after lying down or being pushed by hand. Entrapment and strangulation may occur. The mass is visible in the inguinal region and falls into the scrotum then it is mostly pear-shaped, small at the upper end and wide at the lower end, soft in texture, and the mass is palpated with a sensation of impact when coughing. When lying flat or pushing outward and upward, the mass can be returned and pressed at the mouth of the inner ring after retraction, and the patient is made to cough to increase abdominal pressure, and the mass does not appear.
Direct inguinal hernia: Mostly seen in elderly and frail patients, especially those with prostatic hypertrophy, difficulty in urination, chronic bronchitis and habitual stools.
Extra-abdominal hernia: A hernia occurs when an organ or tissue leaves its normal anatomical site and enters another site through a congenital or acquired weak point, defect or orifice. Intra-abdominal hernias are formed by the entry of organs or tissues into the interstitial sac of the abdominal cavity, such as omental foramen hernia. In true ventral hernias, the contents of the hernia must be located within a hernia sac made up of layers of the peritoneal wall, which can be distinguished from a prolapsed viscus.
Umbilical hernia: Umbilical hernia is most commonly seen in children and obese menstruating women. In children, umbilical hernias appear as hemispherical masses in the umbilicus during crying and constipation, without other discomfort. In adults, abdominal pain, nausea, vomiting and other gastrointestinal symptoms may occur with umbilical hernia. Umbilical hernias in children usually do not exceed 2 cm, and the abdominal wall defect is mostly palpable above the umbilicus, while in adults the umbilical hernia is not easily retractable and the hernia ring or the abdominal wall defect at the umbilicus can be palpable. When intussusception occurs, the hernia mass hardens and manifestations of abdominal pain and intestinal obstruction occur.
Incisional hernia: History of surgery. When standing, walking, coughing, or abdominal exertion, a mass protrudes from the abdominal wall incision, which may be accompanied by indigestion, abdominal distention, vague abdominal pain, and other discomfort. On examination, the abdominal incision can be seen to be elevated at the surgical scar, and a soft mass may be seen, which is obvious on standing and disappears after lying down, and can be palpated plus the surrounding abdominal muscle cleavage, abdominal wall defect, and hernia contents.
III. Pathogenesis
Decreased strength of the abdominal wall and increased intra-abdominal pressure are the two main causes of ventral hernia.
1. reduced strength of the abdominal wall: there are many potential factors that cause reduced strength of the abdominal wall, the most common ones being.
① Certain tissues crossing the abdominal wall, such as the spermatic cord or the uterine round ligament crossing the inguinal canal, the femoral artery crossing the femoral canal, and the umbilical vessels crossing the umbilical ring;
② the white line of the abdomen can also become a weak point of the abdominal wall due to underdevelopment;
③ poor healing of surgical incisions, trauma, infection, abdominal wall nerve injury, old age, prolonged illness, and muscle atrophy due to obesity are often the causes of reduced strength of the abdominal wall. Biological studies have found that the collagen metabolism in the tendon membrane of patients with inguinal hernia is disturbed, the content of hydroxyproline, one of its main amino acids, is reduced, the fibroblasts in the anterior sheath of the rectus abdominis muscle proliferate abnormally, and the ultrastructure contains irregular microfibers, thus affecting the strength of the abdominal wall, and it was also found that the pro-elastic tissue dissociation activity in the plasma of smokers with direct hernia patients is significantly higher than that of normal people.
2, increased intra-abdominal pressure: chronic cough, chronic constipation, urinary difficulties (such as bunions, bladder stones), ascites, pregnancy, weight lifting, frequent crying of infants, etc. are common causes of increased intra-abdominal pressure. Although normal people sometimes have increased intra-abdominal pressure, but if the strength of the abdominal wall is normal, the hernia will not occur.
Western medical treatment
1. Non-surgical treatment: inguinal hernia within one year of age can be suspended without surgery, and the inner ring can be compressed with a cotton girdle to prevent the protrusion of the hernia mass, which can partially heal itself as the abdominal muscles grow stronger. The umbilical hernia of children can be fixed with adhesive tape, that is, after the umbilical hernia is returned, the umbilicus is cushioned with a small piece of soft flannel and a 5 cm piece of adhesive tape is applied transversely to the umbilicus from the mid-axillary line on one side and is changed every l-2 weeks. For elderly and frail people who are not suitable for surgery, a hernia belt can be compressed on the inner ring, wrapped during the day and lifted at rest. For early incarcerated hernia, a trial of manual resetting should be performed in the hospital. After successful resetting, it should be observed for 24 hours to note whether the abdominal disease improves.
2. Surgical treatment: In principle, surgical treatment should be performed for all types of ventral hernia, and there are many treatment methods, but the general principles are high ligation of the hernia sac neck, hernia repair and hernioplasty.
V. Chinese medicine treatment
Internally, 15 grams of cumin can be used as a decoction for internal use; or 5 tablets of astragalus, 2-3 times a day. For external treatment, 60 grams of raw aromatic herbs, coarsely ground, 60 grams of table salt, stir-fried in wine and vinegar, and ironed on the affected area frequently with a cloth bag.