What are the treatment methods for adult indirect inguinal hernia?

1. Adult indirect inguinal hernia with hernia belt can't heal itself, and it may be incarcerated or strangulated, which requires surgical treatment. However, in case of special circumstances, it is not suitable for surgery and can be suspended. During the suspension of the operation, you can wear a hernia belt to compress the hernia ring. Wearing a hernia band for a long time can make the hernia contents adhere to the neck of the hernia sac, which is easy to cause irreversible hernia, and it is generally not recommended.

(1) Conditions for suspending the operation: ① For pregnant women who are pregnant for more than 6 months, there is less chance of hernia because the uterus often pushes the intestinal loop to the upper abdomen; ② People who are extremely weak or suffering from severe cardiovascular diseases, liver and kidney diseases and cannot tolerate anesthesia and surgery; ③ Patients with dermatosis at the operation site; (4) those with obvious hernia causes, such as prostatic hypertrophy, ascites due to liver cirrhosis, chronic bronchitis, emphysema, etc. ; ⑤ Patients with various diseases in active period, such as diabetes and tuberculosis. (Incarcerated hernia or strangulated hernia, except those who must be treated surgically); ⑥ Infected lesions exist in soft tissues of inguinal region.

(2) Contraindications of hernia band: The following situations should be regarded as contraindications of hernia band application: ① Irreversible incarceration, intestinal obstruction and strangulated hernia are absolute contraindications; (2) giant hernia or giant sac mouth; ③ Patients with hydrocele of spermatic cord or testicular insufficiency should not be treated with hernia band.

(3) How to use the hernia belt: The hernia belt must be customized according to the patient's posture and the size of the hernia sac. When in use, firstly, the hernia contents are taken back to the abdominal cavity, and the hernia cap is covered on the inguinal canal hernia inner ring, so that the inguinal canal is just closed to prevent hernia from protruding, and then the waist circumference is fixed. Hernia bands are usually worn during daytime activities and removed at night.

2. Surgical treatment of indirect inguinal hernia can not be treated in time, and the abdominal wall defect will gradually increase, which not only affects the working ability, but also brings difficulties to future surgical treatment.

The surgical principles of indirect inguinal hernia mainly include: high ligation and reinforcement of hernia sac and repair of inguinal wall.

(1) High ligation of hernial sac: High ligation of hernial sac refers to ligation above the neck of hernial sac to remove the proximal hernial sac, and the distal hernial sac can be removed or left in place according to the size of the hernial sac. Adults are only suitable for cases of intestinal necrosis caused by strangulation of oblique hernia. The purpose of high ligation is to eliminate the residual peritoneal sheath process and restore the normal state of peritoneal cavity in inguinal area.

Operation method: cut the hernia sac, check and take out the contents, then peel the hernia sac to the neck of the hernia sac, sew the inner pouch, and hang it on the deep surface of the oblique muscle of abdominal muscle after sewing.

Some people do not cut the hernia sac when ligating the high hernia sac. Owen did not take out the hernia sac, but sent it to the abdominal cavity for suture and ligation. Potts twisted the hernia sac before ligation to achieve the purpose of high ligation. It is also reported that it is necessary to cut the fascia of spermatic cord and separate it to the center to reach the level of preperitoneal fat, or to confirm the level of inner ring and inferior epigastric artery in order to achieve the purpose of high ligation, but it requires some experience and proficiency. Generally speaking, regardless of "internal purse", "external purse" or other treatment methods, as long as the ligation line is cut off, the stump can be retracted to the deep surface of transverse abdominis muscle and no longer exposed to the surgical field. It is not advisable to fix transverse abdominis and oblique abdominis with ligature, which will not only tear muscle fibers easily in the future, but also affect the movement of these muscles and make them lose some occlusal function.

(2) Repair of inguinal canal wall: In fact, repair of inguinal canal wall is to strengthen the defect of anterior wall or posterior wall of inguinal canal by using different adjacent tissues, that is, the weak part of abdominal wall, and to close the protruding channel of indirect hernia by sewing inguinal canal. Due to the different uses and repair methods of adjacent tissues, a variety of surgical methods have been derived and named after the founder of the operation. There are four kinds of traditional surgical operations commonly used in clinic.

①Ferguson's method: After high ligation of hernia sac, suture the lower edge of internal abdominal oblique muscle, transverse aponeurosis arch and conjoined tendon to the inguinal ligament on the superficial surface of spermatic cord (Figure 2), reinforce the anterior wall of inguinal canal and eliminate the weak area between them. This method is suitable for oblique hernia with small transverse aponeurosis arch and sound posterior wall of inguinal canal.

②Bassini method: After the hernia sac is ligated at a high position, the spermatic cord is lifted freely, and the lower edge of the internal oblique muscle, the transverse aponeurosis arch and the conjoined tendon are sutured to the deep inguinal ligament, and the posterior wall of the inguinal canal is strengthened, and the spermatic cord is moved between the internal oblique muscle and the aponeurosis of the external oblique abdomen (Figure 3), which is suitable for adults and indirect hernia with greatly weakened posterior wall strength of the inguinal canal. To judge the strength of the posterior wall of inguinal canal, aponeurosis of transverse abdominis and fascia of transverse abdominis, you can touch the inner ring with your fingers during the operation and push the abdominal wall out of the body surface to experience its strength. This operation is commonly used at present.

③ halsted method: lift the spermatic cord freely, sew the lower edge of the medial oblique muscle, the transverse aponeurosis arch and the same tendon to the deep inguinal ligament, then sew the upper and lower leaves of the outer oblique aponeurosis together or overlap the deep surface of the spermatic cord, and the spermatic cord moves to the subcutaneous area (Figure 4). Compared with Bassini's method, this method strengthens the posterior wall of inguinal canal, but the spermatic cord is under the skin, which may affect the development of it and testis, so it is not suitable for teenagers and is mostly used for oblique hernia with severe weakness of abdominal wall muscles in the elderly.

④McVay method: the transverse fascia of abdomen was cut at the upper edge of inguinal ligament in the posterior wall of inguinal canal, and the upper cutting edge was sutured with pubic comb ligament behind spermatic cord (Figure 5). The suture site reaches to the superior pubic branch, which not only strengthens the posterior wall of inguinal canal, but also changes the propagation direction of intra-abdominal pressure, strengthens the inguinal triangle and indirectly closes the femoral ring. It is suitable for giant oblique hernia and straight hernia.

However, it must be noted that this operation does not have the function of closing the inner ring. If the inner ring is obviously enlarged, it should still be repaired, or the upper cutting edge of the transverse fascia of the abdomen should be stitched on the front wall of the femoral sheath to narrow the inner ring to the extent that it can only pass through the spermatic cord. This operation has a deep repair, so we should pay attention to avoid damaging femoral vessels.

In modern times, many scholars have made in-depth research on the anatomy, physiology, pathology and pathogenesis of inguinal hernia, and pointed out that there are many defects in traditional inguinal hernia repair such as Bassini, Halsted, Ferguson and McVay. A. Traditional inguinal hernia repair only pays attention to strengthening the anterior or posterior wall of inguinal canal, but does not include the repair of transverse fascia, especially the inner ring, which fails to correct or close the hernia. According to Pascal's physics principle, the pressure of contents is the greatest at the defect site where the window is closed, thus laying a foundation for postoperative recurrence. B. Traditional hernia repair, especially McVay operation, often has great tension after repairing the defect, and it is easy to tear the tissue after operation or affect the healing due to poor blood circulation; C. In traditional hernia repair, inguinal ligament is mostly used as the fulcrum for repair, and the two ends of the ligament have a large span and a cable-like structure. It is often impossible to pull the tendon of the same tendon to one side of the ligament, but they are very close, so the suture repair with certain tension can only last for a few months; D. The inguinal ligament is actually a part of the aponeurosis of the external abdominal oblique, and the suture with the arch lower edge of the internal abdominal oblique muscle and the arch of the transverse abdominal aponeurosis is the repair of two different anatomical levels above the defect plane, which destroys the normal anatomy of the inguinal canal; E. The traditional hernia repair causes the displacement and fixation of the curved edges of the internal oblique muscle and transverse abdominal muscle, which destroys the normal physiological defense effect of these muscles contraction on the inguinal canal; Traditional inguinal hernia repair will lead to femoral hernia. According to Glassow( 1970), more than 25% of patients with femoral hernia have a history of inguinal hernia repair, because the traditional inguinal hernia repair uses inguinal ligament, which is pulled up and pulled up, and its tension suture repair makes the femoral ring open wider, which opens the door for hernia protrusion.

At present, the viewpoint of hernia repair is to attach importance to inner ring repair and stress tension-free suture at the same anatomical level, so as to restore the pathological anatomy of hernia to normal anatomical structure. At the same time, considering the physiological defense mechanism of inguinal region, try to restore its normal physiological function. Because the transverse fascia of abdomen is the main barrier to prevent hernia, the pathological and anatomical changes of transverse fascia of abdomen appear first and most seriously after hernia occurs. Therefore, in recent years, the focus of hernia repair is to repair the damaged transverse abdominal fascia and restore its anatomical integrity and continuity. The operation method is also improved on the basis of traditional operation.

(3) Shouldeice method: It was created by Canadian Shouldeice and his collaborators (1950 ~ 1953), so it is also called Canadian hernia repair. The key point of the repair is to cut the abdominal transverse fascia from the inner ring to the pubic tubercle, divide it into upper and lower pieces, sew the edge of the inner ring to make it smaller, and sew the lower piece to the deep surface of the upper piece first. Then overlap the upper lobe on the superficial surface of the lower lobe and sew it on the inguinal ligament, which is the key to the operation. Suture transverse abdominis muscle and oblique abdominis muscle to inguinal ligament in the lateral two layers, and sew ***4 layers.

Operation method: free and lift the spermatic cord, put your finger into the inner ring to explore the weakness and range of transverse abdominal fascia, cut the transverse abdominal fascia from the inner ring to the pubic tubercle along the direction of inguinal ligament, and cut off its weak parts, free the lower lobe to the inguinal ligament, and the upper lobe to the inner side of the deep surface of transverse abdominal muscle to the dorsal sheath of rectus abdominis, and sew the sound upper and lower lobes overlapping, that is, sew the cutting edge of the lower lobe to the deep surface of the upper lobe continuously from the pubic tubercle until a compact piece is formed. When the suture can just pass through the spermatic cord, sew the cutting edge of the upper lobe to the inguinal ligament in the opposite direction and go back to the pubic tubercle to tie 1 the other end of the suture. Then suture the lower edge of the internal oblique muscle, the transverse aponeurosis arch and the syntendinous tendon to the deep surface of the inguinal ligament and the aponeurosis of the external oblique abdomen, and finally suture the aponeurosis of the external oblique abdomen to the superficial surface of the spermatic cord. This method emphasizes the role of strengthening transverse abdominal fascia in hernia repair, and is suitable for oblique hernia with weak posterior inguinal wall and enlarged transverse abdominal fascia and inner ring (Figure 6).

(4)Madden method: The key point is to cut the posterior wall of inguinal canal, remove the weak part of transverse abdominal fascia, intermittently suture transverse abdominal fascia, and reconstruct the inner ring and posterior wall.

(5) Panka method: emphasize the accurate exposure and repair of the inner ring, find the aponeurosis arch of transverse abdominis muscle on the deep side of the arch edge of the internal oblique muscle, sew it with the iliopubic tract, and then sew it with the inguinal ligament to strengthen the repair.

(6) Preperitoneal hernia repair: it was first proposed by Nyhus. Its advantage is that the hernia sac can be ligated at a higher position, without changing or destroying the anatomical structure and physiological sealing mechanism of the inguinal canal, without cutting the transverse fascia of the inguinal canal, and the lower edge of the internal oblique muscle, the transverse aponeurosis arch of the abdomen and the ligament union can be sutured with inguinal ligament or pubic comb ligament.

Surgical method: a transverse incision was made from the top of the inner ring orifice to the pubic tubercle 3 ~ 4 cm, and the 1/3 medial incision was in front of the rectus abdominis. Incise subcutaneous tissue, anterior sheath of rectus abdominis, oblique muscle outside abdomen, oblique muscle inside abdomen and transverse abdominis, pull the rectus abdominis inward, horizontally cut the fascia of transverse abdominis into the preperitoneal space, and expose hernia sac, pubic comb ligament, iliopubic bundle and femoral ring. After high ligation of hernia sac, the femoral ring can be closed by suturing iliopubic tract with pubic comb ligament. For indirect inguinal hernia and direct inguinal hernia, the front and rear feet of transverse abdominal fascia sling should be sutured first, and then the tendon arch of transverse abdominal muscle should be sutured with iliopubic tract or Cooper ligament.

(7) Tension-free hernioplasty: In order to repair the weak part of inguinal region, traditional hernioplasty often sews together aponeurosis, muscle tissue or mucosal tissue with different anatomical levels, which destroys the repaired local tissue structure, increases tissue tension, and hinders tissue metabolism, thus becoming one of the factors of operation failure or hernia recurrence. In 1980s, according to the theory that the defect and destruction of transverse fascia of abdomen is the fundamental cause of inguinal hernia, Lichtenstein and others put forward the concept of tension-free hernia repair with local implantation of synthetic polymer mesh instead of traditional repair. After more than 20 years of clinical practice, tension-free hernia repair has the advantages of not disturbing the local anatomical relationship, no suture tension, less trauma, less postoperative pain, quick recovery and low recurrence rate.

①Stoppa method (preperitoneal netting): French doctor Stoppa( 1975) took polyester cloth as material, folded a large non-absorbent patch into an umbrella shape, stuffed it into the lower side between peritoneum and transverse fascia of abdomen through the inner ring opening, spread it around with the inner ring opening as the center, and stuck it on the abdominal wall with the help of intra-abdominal pressure to strengthen the weak transverse fascia of abdomen until fiber hyperplasia. According to the scope of the defect, the patch should cover the unilateral or bilateral preperitoneal space below the arch line, and the lower part should exceed the pubic muscle hole without suture.

Because of its long incision and wide anatomical separation range, it is also called "Giant Prosthetic Cyst Surgery (GPRVS)". Mainly used for recurrent hernia, giant hernia (including incisional hernia, umbilical hernia and hernia near stoma) and bilateral hernia.

②Lichtenstein's method (plain film repair): hernia sac was free, which was ligated at high position and repaired at the inner ring orifice with the traditional surgical method. After the spermatic cord is free, the mesh is placed flat on the posterior wall of inguinal canal, and the periphery of the mesh is continuously sutured with the surrounding tissues.

Lichtenstein et al. (1989 ~ 1993) performed Lichtenstein operation on 3 125 adult inguinal hernia patients, and only 4 cases recurred within 9 years, which is the most widely used tension-free hernia repair abroad.

③ Mesh plug method: Shulman and Lichtenstein( 1994) according to the characteristics of small inguinal hernia ring and intact posterior wall, rolled polypropylene patch into a plug shape to repair the defect, and fixed the edge and periphery of the plug with 2 ~ 5 stitches. They advocate that the mesh plug packing method is suitable for recurrent abdominal-femoral indirect hernia and direct hernia with a diameter less than 3.5cm.

④Rutkow method (mesh plug tension-free hernioplasty): The high free hernial sac is the same as the traditional operation, exposing the mesh opening. If the hernia sac is too small, ligation is not needed. If the hernia sac is too large, it can be transected 4 ~ 5 cm away from the hernia ring, close the proximal hernia sac, and open the distal hernia sac after careful hemostasis; The hernia sac is brought back to the abdominal cavity through the self-turning of the hernia ring opening, and a conical plug is placed in the hernia ring opening, the conical bottom of the plug is below the hernia ring opening, and the outer leaf edge of the conical plug is sewn and fixed with the transverse fascia of the abdomen; Free spermatic cord, flatten the spermatic cord and form a mesh. Leave a hole on the mesh for the spermatic cord to pass through, and properly sew and fix the periphery of the mesh with surrounding tissues to prevent the mesh from curling. This kind of operation has the advantages of simple operation, less injury, less complications and low recurrence rate. Can be completed under local anesthesia, get off the ground early, and quickly resume daily activities and work. It has become a classic operation of tension-free hernia repair (Figure 7).

⑤ Prozac (PHS): The three-in-one artificial patch of Prozac is a stereotyped product, including three parts: negative film, preperitoneal repair of pubic muscle hole by preperitoneal repair method; In the middle, a "plug" shaped like a cone is used to repair the hernia ring; Repair the surface patch of the posterior wall of inguinal canal.

(8) Laparoscopic inguinal hernia repair: Based on the theoretical basis of tension-free repair and the appearance of polymer mesh with good histocompatibility, it provides the necessary conditions for the implementation of laparoscopic hernia repair.

① Hernia sac neck clamp: Peep into bilateral inguinal hernia holes through umbilical laparoscopic observation hole. Pressing your fingers outside the inguinal canal is helpful to locate the hernia hole. If there is hernia, reset it by hand outside. After the hernia sac is confirmed to be empty, another incision is made at the horizontal semilunar line of the same umbilical cord, and a 12mm trocar and cannula are inserted, thereby inserting the stapler. Clamp the lateral end of the hernia hole with pliers, and install a clip every 5 ~ 6 mm in turn to close the hernia hole until it is close to the spermatic cord.

② Abdominal preperitoneal laparoscopic hernia repair: On the basis of Stoppa open preperitoneal repair, the peritoneum above the defect was laparoscopically cut and the preperitoneal space was dissected. After the hernia sac is taken out, a patch of appropriate size is selected to cover the inner ring orifice and the triangular area of direct hernia, and then the patch is sutured and fixed.

This method is simple to operate, can avoid the side injury caused by open surgery, has quick recovery and little pain, can treat bilateral hernia or contralateral subclinical hernia at the same time, has few postoperative complications and low recurrence rate, and is especially suitable for complex hernia and multiple recurrent hernia. Complications mainly include hernia sac effusion, urinary retention, inguinal hematoma and emphysema, scrotal hematoma and so on.

③ Intraperitoneal patch: This method is to directly cover the polypropylene patch on the inner surface of the defective peritoneum after the hernia contents are returned under laparoscopy. The surgical trauma is small, the operation is simple and the short-term curative effect is satisfactory. However, due to the direct contact between the patch and the internal organs, it will cause intestinal adhesion and even intestinal fistula. This operation was once abandoned, but with the appearance of anti-adhesion patch (e-PTFE), it is now widely used.

④ Total extraperitoneal repair: The main difference between this operation and abdominal preperitoneal repair is that "pneumoperitoneum" is established outside the peritoneum to separate the preperitoneal space, which avoids various complications of intra-abdominal operation, and also has the advantages of preperitoneal repair, so its clinical application is gradually increasing. However, for patients with a history of abdominal surgery and recurrent hernia, anatomical scar and adhesion are easy to cause injury, so we should be especially careful when choosing complete extraperitoneal repair.

Laparoscopic hernia repair, as a brand-new operation, has been gradually developed all over the world. This kind of operation causes less postoperative discomfort, less pain and quick recovery. Inguinal hernia and femoral hernia can be examined and treated at the same time. Laparoscopic hernia repair for recurrent hernia can avoid nerve injury and ischemic orchitis caused by the original approach. More and more patients and surgeons choose laparoscopic hernia repair.

3. Surgical Complications In addition to general surgical complications, there are the following major complications after inguinal hernia surgery.

(1) Hematoma or residual hernia sac effusion: Hematoma usually occurs when the hernia sac is large and free, and the peeling surface is large. If the anatomy is limited to the neck of the hernia sac and the hernia sac remains in place, the incidence rate can be reduced. If the hernia sac is left in place, its fracture is too narrow, which may lead to effusion in the sac. Residual intracapsular hematoma and hydrocele can be manifested as a mass in the operation area or scrotum in the early postoperative period, which may be mistaken for hernia repair error and relapse, but the mass does not extend into the abdomen and its upper boundary can be recognized. Small hematoma can be absorbed by itself, and large hematoma often needs aspiration. If the residual effusion is rarely absorbed spontaneously, aspiration can be tried. If it fails, it is necessary to open the effusion sac surgically so that the liquid can be absorbed by the surrounding tissues.

(2) Inguinal burning pain: Burning pain can involve the penis root, the upper scrotum (female pubic mound, labia majora) and the inner skin of the upper thigh. Walking, bending over and overstretching the buttocks will aggravate the burning pain. The cause of burning pain is the injury of ilioinguinal nerve and reproductive branch of reproductive femoral nerve (including cutting, suturing, scar involvement or oppression, etc. ). The former often occurs when the aponeurosis and the outer ring of the external oblique muscle are cut off, when the fascia of the levator testis is cut off or sutured, or when the aponeurosis arch is connected with the inguinal ligament or pubic comb ligament; The latter is often related to the incision or suture of levator testis fascia.

(3) Abdominal muscle weakness in the operating area: it is usually the result of nerve injury in ilioinguinal region or inferior ilioinguinal region, which is one of the reasons for the recurrence of inguinal hernia after operation. Iliohypogastric nerve's injury is most common when the inner leaf on the aponeurosis of the external oblique is loosened, and it can also occur when the residual pedicle of the neck of the ligated hernia sac is lifted and fixed on the deep surface of the transverse abdominis muscle to suture the nerve on the surface of the internal oblique muscle.

(4) Spermatic cord injury: Stripping hernial sac and strengthening the posterior wall of inguinal canal with free spermatic cord can lead to spermatic cord injury. If the internal spermatic artery (testicular artery) contained in the spermatic cord is damaged, it will lead to ischemic orchitis or testicular atrophy, because the anastomotic vas deferens artery is too small to maintain the blood supply to the testis alone. In addition, if the reconstructed inner and outer rings are too narrow to compress the spermatic vessels, the free spermatic cord will be twisted, which will lead to poor spermatic blood flow.

(5) Bladder injury: When suture the tendon of syndesmosis to inguinal ligament or pubic comb ligament during repair, if the needle is inserted too deeply, it may puncture the bladder. When the neck of the free hernia sac is too high to exceed the level of the hernia inlet, it may damage the bladder hidden in the preperitoneal fat. Bladder, as a part of sliding hernia, will be damaged when the hernia sac is free if it is not recognized. A full bladder is more likely to hurt.

(6) Vascular injury: There are some large blood vessels passing through the groin area, which can be caused by rough operation, needle dislocation and suture tearing, and atherosclerotic blood vessels are more likely to be damaged. Surgery of inner ring area (relieving incarceration, inner ring reduction, transverse fascia repair, etc.). ) can damage the inferior epigastric artery; Exposing pubic comb ligament and McVay repair can damage femoral vein; Using inguinal ligament repair, the external iliac artery or femoral artery will be damaged if the needle is inserted too deeply during suture. When these blood vessels are injured, the bleeding is more turbulent, and it is difficult to stop bleeding by compression. After complete exposure, it needs ligation or repair.

(7) Laparoscopic hernia: With the emergence of laparoscopic hernia repair and plastic surgery, there have been some reports of abdominal hernia at the entrance of laparoscopy in recent years. This is actually an incision hernia, which often manifests as intramural hernia. Because the hernia door is not big, this hernia may be incarcerated. To avoid this, sew the socket after pulling out the mirror.

(2) Prognosis

Most patients recovered well after operation, but 4% ~ 65% patients relapsed.