An inguinal hernia is a hernia formed when an intra-abdominal organ protrudes through a defect in the inguinal region to the surface of the body, commonly known as a “hernia”. According to the relationship between the hernia ring and the inferior abdominal artery, inguinal hernias are divided into two types: inguinal hiatal hernia and inguinal straight hernia. There are two types of inguinal hernias: congenital and acquired. Inguinal oblique hernias protrude from the deep ring of the inguinal canal (transversus abdominis fascialis ovalis) located lateral to the inferior abdominal wall artery, travel inward, forward obliquely through the inguinal canal, then penetrate the superficial inguinal ring (subcutaneous ring) and can enter the scrotum, accounting for 95% of inguinal hernias. Direct inguinal hernias protrude directly from the inguinal triangle on the medial side of the inferior abdominal wall from posterior to anterior without passing through the internal ring and without entering the scrotum, accounting for only 5% of inguinal hernias. The incidence of direct hernias has increased in elderly patients, but hiatal hernias are still the most common. If left untreated, it can easily lead to serious complications. Etiology Decreased strength of the abdominal wall muscles and increased intra-abdominal pressure are the main causes of inguinal hernia. Muscle atrophy in the elderly makes the abdominal wall weak, and the inguinal region is even weaker, with blood vessels, spermatic cord or round ligament of the uterus passing through it, providing a channel for hernia formation. In addition, diseases such as coughing and asthma, constipation and difficulty in urination due to prostatic hyperplasia in the elderly cause an increase in abdominal pressure, which provides the impetus for hernia formation. Clinical manifestations 1. Repeatable hernia is characterized by the appearance of a repeatable mass in the inguinal region, which starts small and appears only when the patient is standing, working, walking, running, coughing or crying. There is generally no special discomfort, only occasional local distension and involvement pain. With the development of the disease, the mass may gradually increase in size and descend from the groin to the scrotum or labia majora, making walking difficult and affecting labor. The mass is pear-shaped with a stalk, narrow at the upper end and wide at the lower end. The mass may disappear on its own when lying down, or it may disappear by gently squeezing and pushing the mass outward and upward by hand, and it may disappear by retraction into the abdominal cavity. The mass is soft, smooth, and has a drum sound when tapped. When retracting, there is often resistance first; once retraction starts, the mass disappears more quickly. If the contents of the hernia are large omentum, the mass is tough and inelastic, with a turbid sound on percussion and slow retraction. After the hernia mass is retracted, the examiner can use the tip of the finger to gently reach upward through the scrotal skin along the spermatic cord into the enlarged external ring and ask the patient to cough. The presence of an occult inguinal hernia can be determined by this test. The compression of the internal ring test can be used to identify a hiatal hernia from a straight hernia, which can still appear when the patient is instructed to cough after the hernia mass has been retracted by pressing the finger firmly against the internal ring. Sliding hiatal hernia is characterized by a large, difficult-to-recover hernia that cannot be completely retracted. The cecum that slides out of the abdominal cavity often adheres to the anterior wall of the hernia sac. In addition to the incomplete retraction of the mass, there are also symptoms such as indigestion and constipation. During surgical repair, the slipped cecum or sigmoid colon may be mistaken for a part of the hernia sac and be cut open. 3. Incarcerated hernia often occurs when there is a sudden increase in intra-abdominal pressure such as labor or defecation, and is usually a hiatal hernia. It is characterized clinically by a sudden increase in 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 with marked tenderness. If the embedded content is the greater omentum, the local pain is often mild; if it is an intestinal collaterals, not only the local pain is obvious, but also the signs of mechanical intestinal obstruction such as paroxysmal abdominal cramps, nausea, vomiting, constipation and abdominal distension. Once the hernia is embedded, the above symptoms will gradually worsen, and if not treated in time, it will eventually become strangulated hernia. 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. The clinical symptoms of strangulated hernia are more serious. Patients have persistent severe abdominal pain, frequent vomiting, vomit containing coffee-like blood or bloody stool; abdominal signs show asymmetric abdominal distension, signs of peritoneal irritation, diminished or absent bowel sounds; abdominal puncture or lavage is bloody fluid; X-ray examination shows isolated distended intestinal mix or tumor-like shadow; body temperature, pulse rate, white blood cell count gradually increases, and even signs of shock. Direct inguinal hernia is a reducible mass in the inguinal region, located above the pubic symphysis, hemispherical in shape, mostly without pain or other discomfort. The hernia mass appears when standing and disappears when lying down. The mass does not enter the scrotum, and the neck of the hernia is wide and rarely entrapped. The abdominal wall defect can be directly felt in the inguinal triangle after return of the hernia, and there is a swelling sensation of impact on the fingertips when coughing. It can be differentiated from hiatal hernia. In bilateral straight hernias, the hernia masses are often symmetrical on both sides of the midline. Diagnosis The vast majority of inguinal hernias can be diagnosed on the basis of the patient’s clinical symptoms and physical examination. If the hernia is relatively small and the presentation is atypical, the diagnosis can be basically confirmed by ultrasound examination. Treatment Treatment of inguinal hernia includes conservative treatment and surgery. Once the inguinal hernia fails to retract and forms an intussusception, it can lead to intestinal obstruction, even intestinal necrosis and perforation, and even death. Conservative treatment Conservative treatment includes hernia belt, hernia brace, Chinese herbal medicine, etc. These methods can relieve the symptoms or delay the development of the disease, but they cannot cure it, and some improper conservative treatments can aggravate the disease. This method is only suitable for infants under 2 years old, the elderly and frail or those with serious diseases. Special hernia belts are often used to press the hernia ring and relieve the symptoms. Surgery Surgery is the only reliable treatment for inguinal hernia in adults and is less likely to recur. Easily recurring hernias can be treated with elective surgery, while refractory hernias should be limited to short-term surgery, and incarcerated and strangulated hernias must be treated with emergency surgery to avoid serious consequences. Surgical treatment is subdivided into traditional tissue-to-tissue tension suture repair and tension-free hernia repair techniques, which are currently internationally recognized as tension-free hernia repair techniques, including open surgery and laparoscopic surgery. (1) Traditional surgery: Patients are fasted before and after surgery, and they have to be bedridden for several days after surgery, given fluids and placed urinary catheters. Open tension-free hernia repair, introduced from abroad, is rapidly gaining popularity. The surgery can be performed under local anesthesia, with a low recurrence rate, little pain, generally only 2-5 days of hospitalization, or even outpatient surgery, and fast postoperative recovery. (2) Laparoscopic inguinal hernia repair: In recent years, significant progress has been made in laparoscopic surgery. Laparoscopic total extraperitoneal repair (TEP for short) requires only two 0.5M and one 1M incisions without entering the abdominal cavity, pulling the hernia pouch back into the abdominal cavity extraperitoneally, and covering the herniated gap with artificial mesh. This method is suitable for the treatment of bilateral inguinal hernia and recurrent hernia, and it is less invasive, with quick recovery and low recurrence rate.