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What is a inguinal hernia
Figure 1. A schematic diagram of inguinal hernia Inguinal hernia (PH) is a disease which results in the protrusion of abdominal organs under the skin through natural openings in the groin area of the abdomen. This is just one of the varieties of hernia, but the frequency of occurrence, it occupies a leading place among people of middle and old age. (Fig. 1)
Inguinal region in men and women has the shape of a triangle, limited by mutually perpendicular lines drawn through the pubic connection at the bottom and the most protruding portion of the hip bone on the side.
Men have a completely different anatomy of this area than women. In groin area men is a very important structure — the spermatic cord, in which is placed the artery, venous plexus, and VAS deferens. The first of them brings blood to the testes, venous plexus drains the blood into the abdominal cavity (with blood stasis may develop varicocele), and deferent duct is derived sperm from the testicles.
The main protective barrier of the inguinal region are the muscles and fascia — a powerful connective tissue structure that surrounds muscles and serves as their protection. External oblique, internal oblique and transverse muscles restrict the inguinal canal, and the transverse fascia acts as a rear wall. It is the weakness of the rear wall of the causes of inguinal hernias.
Figure 2. Anatomical structure the Anatomical structure of hernia hernia (Fig. 2) is the following:
- Gryzenia gate is a ring that consists of dense connective tissue, through which there is protrusion of organs under the skin. In this place it may be infringement of a hernia. Sizes vary from 2-3 cm to 10-15 cm in inguinal hernias. However, it is a narrow gate gryzenia more prone to infringement of the contents of the hernia SAC.
- The hernial SAC is part of the peritoneum (the thin membrane that covers the abdominal muscles from the inside) that came through the gate gryzenia under the skin. The hernial SAC can be up to 2-3 cm in length, but occasionally reach enormous sizes up to 30-40 cm
- The hernial contents can be any movable organ of the abdominal cavity. Sometimes with inguinal herniation outside the abdominal cavity can reach the entire small intestine (about 4 meters), spleen, Appendix, part of colon, the entire gland (a body made up of fatty tissue that covers all organs of the abdominal cavity).
The types of inguinal hernias
Depending on the origin of the hernia SAC of hernia are:
- Congenital – occur when there is no narashivanie vaginal process of the peritoneum, when the prolapse testicles into the scrotum before birth. They are only oblique.
- Acquired – occur mainly in adults who experience strong physical exertion. They are both direct and oblique.
The anatomical classification of the hernias are of the following types:
- PG slash – is characterized by the passage of the hernial SAC, composed of the spermatic cord with subsequent appearance of protrusions under the skin of the inguinal region, and in advanced cases and in the scrotum. Tends to infringements. Sizes vary from 4-5 cm to the giant 30-40 cm;
Figure 3. A sliding hernia
- video of PG– it is always acquired, never goes in the composition of the spermatic cord and does not descend into the scrotum, it is these characteristics it differs from the oblique inguinal hernia. This hernia is very rarely infringed. Size usually not very large, averaging 5-10 cm;
- moving PG from the name we can assume that this type hernia is characterized by incomplete penetration of the organ in the hernial SAC, and only one of its walls. Often in the hernial SAC is only part of the bladder, the cecum. Therefore, in this type of hernia, there is some difficulty when suturing of the hernia SAC during surgery; (Fig. 3)
- nadpuzyrnye PG – occurs when the weakness of the anatomical structures located just above your pubic bone. The protrusion is usually not very large;
- combination of PG – in this type of hernia the patient simultaneously, there are direct and oblique inguinal hernia, very rarely joins them nadpuzyrnye hernia.
Another important clinical classification, which depends on the choice of treatment:
Figure 4. Strangulated inguinal hernia
- pravima PG – characterized by own or with the help of hands reduction of the hernia content into the abdominal cavity. Usually, this hernia of small size and early stage of development, when no adhesions formed between tissues;
- irreducible PG – occurs when prolonged presence of a hernia, when the hernial SAC are connected by adhesion with the subcutaneous adipose tissue. The hernia to reduce a into the abdominal cavity cannot, however, content is not tense and may be slightly decreased or increased;
- strangulated PG – infringement impossible even with external assistance to reduce the contents of the hernia into the abdominal cavity. At the same hernial SAC is tense, painful. (Fig. 4)
To determine whether the inguinal hernia is strangulated or not, you can perform a simple task — holding with a hand a hernia, need to cough a few times. If the hernial protrusion increases and decreases – then the hernia pravima. Otherwise, if the coughing, the protrusion does not change its dimensions and continues to hurt – most likely, that the hernia is strangulated!
It is important to remember that if the infringement of a hernia require emergency surgery!
Causes of inguinal hernias
Among the main causes of inguinal hernia are the following:
- a genetic anomaly in which there is a genetically determined weakness of the connective tissue. This can not only develop inguinal hernias, but femoral, umbilical, as well as curvature of the spine, the typical dislocation of the joints;
- congenital abnormality characterized by the incomplete growth process of the peritoneum which occurs in all boys in the groin before birth, and should close in the first period of life;
- excessive exercise is hard work, and professional sports, weightlifting;
- problems with the gastrointestinal tract – constipation;
- damage to the nervous system – a stroke with the development of paralysis on one side of the body.
Symptoms of inguinal hernia or how to detect its presence? The main symptom of an inguinal hernia in men is the emergence of a protrusion in the groin area. In such a situation, it is required to conduct an external inspection of the inguinal regions. It should be noted that the protrusion may disappear in the normal position of the body, but when you cough, it re-penetrates the skin and becomes visible.
Palpation (feeling the body with hands) the inguinal region in the presence of a hernia, you can feel a rounded education, soft consistency, elastic, moderately or not painful.
If the formation or protrusion is evident, then you need to place your hand on the inguinal hernia to cough and at the same time, if the protrusion will increase and decrease in volume, it means that the hernia pravima/irreducible. If, when you cough, hernia size does not change, this indicates the infringement of a hernia and needed urgent surgery. This study is called the symptom of “cough push”.
With a significant increase in the protrusion, it can be determined even in the scrotum and be of gigantic proportions. Thus it is necessary to perform an ultrasound to distinguish the hernial contents from the scrotum.
To distinguish between direct or oblique hernia puhovoy not necessary, it is of practical value only to the surgeon.
What to do with the appearance of inguinal hernia?
Here the recipe is very simple not to panic, if this is a simple pravima or irreducible inguinal hernia. Routinely come for examination to the surgeon and further surgery.
However, if detected strangulated inguinal hernia, then you need to immediately call an ambulance and hospitalized in the surgical Department. If the hernia for 2 hours spravilas on their own, that requires medical supervision for at least 2 days, in a different situation — he needs immediate surgery.
Treatment of inguinal hernia from muschilecken without surgery
Treatment of inguinal hernia without surgery provides the effect on the basic causes of its development: the reduction of physical activity, a diet that does not lead to constipation, avoid prolonged static loads, treatment of chronic diseases of the Airways, which increases intra-abdominal pressure.
Figure 5. The effectiveness of retaining belt for inguinal hernia treatment very low Very often men are recommended to use a bandage belt for inguinal hernia, who is wrongly credited with a great therapeutic effect. But it should be used only when surgery is contraindicated, for example, in oncological pathology, severe concomitant pathology of the nervous system, cardiovascular system. In irreducible hernia the use of a brace is contraindicated. (Fig. 5)
Surgeons do not recommend wearing a bandage belt and the presence of upravenou inguinal hernia, since its efficiency is very low, and during the subsequent surgical intervention revealed a massive adhesions, which can lead to complications or relapse.
Thus, the use of the bandage is just a forced event, in any case not a substitute for surgery.
For surgical technique of inguinal hernia should be approached individually. It is best to perform the operation at the initial stage of development of a hernia, when she pravima. Another important point is the operation in the autumn-winter period.
The type of anesthesia selected by the anesthesiologist based on the characteristics of the patient – this can be local anesthesia, spinal anesthesia (a drug injected into the cerebrospinal fluid, thus anesthetized the entire lower part of the body), epidural anesthesia (anesthetic drug injected into the spine, while anesthetized only a certain area of the body), General anesthesia.
Consider some of the types of surgical interventions:
Hernioplasty by own tissues — is to remove the hernia SAC and performing a plasty of the inguinal canal’s own tissues:
- The Bassini method is performed suturing of the muscles of the inguinal region to the inguinal ligament, thereby strengthening the back wall of the inguinal canal, the spermatic cord is located beneath the aponeurosis. The method is rarely used in recent times, relapses. (Fig. 6)
Figure 6. The Method Of Bassini
- Method Polanskogo – one block on top is attached the aponeurosis and muscles to the inguinal ligament, while the spermatic cord travels under the skin, in consequence of the formation of adhesions between the elements of the cord and adipose tissue. (Fig. 7)
Figure 7. Method Polanskogo
- Method Shouldice – is the “gold” of inguinal hernioplasty. A special feature is the layered connection of tissues of the inguinal canal in four rows with one thread. (Fig. 8)
Figure 8. Method Shouldice
Hernia repair using mesh (allotransplantata) — is based on the use of synthetic materials for closure of the tissue defect. when this technique is used not absorbable mesh, is made from polyurethane, polypropylene. The main advantage over the previous type of plastic is the lack of tissue tension, greater strength of the artificial material.
- The method of Liechtenstein – the most recognized in the world, very popular, has low number of relapses. Is directed by the mesh on the muscles of the inguinal canal, with the spermatic cord is laid on the mesh is sutured over the fascia. The disadvantage of this method can be long-term pain and discomfort in the area of operations, and sometimes rejection of the mesh. The last complication is very rare, occurs with high sensitivity to foreign bodies and violation of asepsis (measures that prevent the ingress of infection in the wound surface). (Fig. 9)
Figure 9. The Method Of Liechtenstein
- Plug and patch technique (plug and patch) is a new method by which in the internal inguinal ring to enter the grid in the form of an umbrella, then it is attached to the muscle and covered by the aponeurosis. (Fig. 10)
Figure 10. Method plug and patch
- The Prolene hernia system is a special combination, one part of which the grid is to be entered predpisano, the other is attached to the muscle and covered by the aponeurosis.(Fig. 11)
Figure 11. The Prolene hernia system
Laparoscopic hernia repair — surgery is not in place, and are gradually being introduced into practice this new kind of surgery. Some of its disadvantages are high cost and low prevalence in different regions of the country. This kind of interventions require not only specific tools but also high qualification of the surgeon.
- Intraperitoneal technique (TAPP-Transabdominal preperitoneal hernia repair) – for the stomach to be made up to three small incisions through which laparoscopic instruments are introduced intraperitoneally and is the allocation of the hernial SAC, setting and suturing of mesh to the peritoneum. (Fig. 12)
Figure 12. Intraperitoneal method
- Extraperitoneal method (TEP – total extraperitoneal hernia repair) is the same as in the previous case there are 3-4 incision in the abdomen, but all manipulations are performed in subcutaneous adipose tissue.(Fig. 13)
Figure 13. Extraperitoneal method
The postoperative period
After the operation, hernioplasty of inguinal hernia in a planned manner, the patient needs about a day to stay in bed. After spinal anesthesia, the patient will not feel my lower body for approximately 4-6 hours. When the feeling will come back, you turn to the side. The first meal and water after 12-24 hours, you should start with the usual soup, jelly, sweet tea or plain mineral water. Further, the diet is expanded and allowed to eat the usual food of the patient.
To get out of bed allowed the next day after the operation, preferably with the help of strangers. Then gradually will have the strength and are allowed to walk independently.
- painkillers are introduced for the first 3-4 days;
- antibiotics (depending on the duration and course of the operation) for 1 to 3 days;
- anticoagulants (drugs that greatly reduce blood clotting) daily for 7 days, if there are comorbidities, after age 40, obesity, diseases of the veins of the lower extremities.
For 1-2 months categorically forbidden to engage in heavy physical work, you need to lead a gentle life, after 2 month you need to gradually increase the load.
It may seem that an inguinal hernia is a harmless physical pathology that can be ignored. However, there are very severe complications that occur with long-term presence of a hernia in men and can lead to very serious consequences. Here are some of them:
- Strangulation of an inguinal hernia is a very serious complication, which can occur at any time of the day, even at rest. But often while performing physical activities, sudden lifting from the bed, cough, and difficulty urinating. If the infringement within 2 hours you need to perform the operation and, if injured on viable, then just put it back in, hold hernioplastica by the above methods. If strangulated organ is not viable, it is necessary to carry out the removal or resection (partial removal of the organ) and make hernioplastica.
- Acute intestinal obstruction – this complication occurs during the formation of adhesions in the abdominal cavity with long-term presence of a hernia, and the constant reposition or applying a bandage. Can also occur when the hernia incarceration, when prejudiced thin or thick gut. When this complication is necessary to perform a laparotomy (incision of the abdomen in a vertical line from navel to pubis), to inspect all the organs and to remove the cause of obstruction. The postoperative period in this case increases significantly, is around 9-12 days.
- Dysfunction of the intestinal tract — occurs when prolonged presence of a hernia, especially when it is of large dimensions. A large part of the small intestine gets into the hernial SAC, then under the skin, changing the anatomic position of the bowel, leading to constipation. To solve this problem it is possible only surgically.
You need to repeat inguinal hernia can be treated only by surgery. Wearing the brace, avoidance of surgery, self reduction of the hernia has only temporary value and should not be used as a final treatment.
The effects of neoprenovaja inguinal hernia in men, as already mentioned, can become pinching, discomfort in the groin area, pain during exercise, the appearance of adhesions in the abdominal cavity, prolonged constipation, asymmetry of the abdomen.
Perform the operation on one of the above methods, the patient will get rid of the previously mentioned problems associated with the presence of inguinal hernia.