I. Inguinal hernia
A hernia sac that protrudes through the deep ring of the inguinal canal (inner ring) lateral to the infundibular artery, passes obliquely inward, downward, and forward through the inguinal canal, then penetrates the superficial ring of the inguinal canal (subcutaneous ring), and can enter the scrotum is called an inguinal 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 mass can be retracted by gently pressing it in an outward and upward direction along the inguinal canal. If the inguinal ligament is pressed at 50px 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.
II. Direct inguinal hernia
A straight inguinal hernia is one in which the hernia sac protrudes directly from the posterior to the anterior through the rectal hernia triangle on the medial side of the inferior abdominal wall without passing through the internal ring and without entering the scrotum. Hiatal hernia is the most common type of extra-abdominal hernia.
1.Treatment measures
If there is no contraindication to surgery, in principle, surgical treatment should be performed. In view of the fact that incarcerated hernia rarely occurs, a hernia support can be used to relieve symptoms in old and frail people or those with other chronic illnesses who cannot tolerate surgery.
Since there is no obvious hernia neck and hernia sac, only the loosely 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, so it is rare to have an impaction. 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 herniated mass from reappearing.
3. Differential diagnosis
Hernia can be differentiated from hiatal hernia by not entering the scrotum. The hernia may also protrude after retracting the hernia mass and pressing on the internal ring. Intraoperatively, the hernia ring 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.
3. femoral hernia
Clinical manifestations.
1. Protruding mass in the oval fossa of the femur with distension and pain, mostly seen in women over middle age.
The mass is not large, hemispherical and not easily retractable.
In addition to local hardening of the mass and increased pain, it is often accompanied by more obvious manifestations of acute mechanical intestinal obstruction.
Basis of diagnosis.
Women of middle age or older with a hemispherical mass in the oval fossa of the femur.
Principles of treatment.
1, Transinguinal ligament repair on the inguinal ligament, mainly used for huge femoral hernias or for embedded or strangulated ones.
2.Subinguinal repair, mainly for older patients or smaller femoral hernias.
Umbilical hernia
The internal organs of the abdominal cavity are dislodged to the skin through the umbilical hole. 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 non-heating, and the hernia hole can be felt by pressure. 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 abdominal pressure and strenuous activities after surgery
3, avoid wound infection
4, the surgeon’s suturing technique and suture material
5.Control of diabetes and weight
6.Prevent colds and flu to keep urine and stool usually
7.Protect the wound with 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 opening 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
Comparison of the three types of surgical treatments
Traditional hernia repair: one large incision (about 6-8 cm long); hospitalization of about 7-10 days; routine anti-infection; postoperative pain and other discomfort; recurrence rate of about 20%; full recovery time of about 3 months for a normal hernia and 6-12 months for a 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%; complete recovery time of about 1 month for common hernia and about 3-6 months for extra large hernia.