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  • Inguinal hernia - Causes, symptoms and treatment. MF.

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    Inguinal hernia - protrusion from the abdominal cavity of internal organs or parts thereof together with the parietal peritoneum covering them( a thin translucent membrane lining the inside of the abdominal wall) under the skin through the inguinal canal. The inguinal canal is located in the groin area on both sides and represents a gap between the broad abdominal muscles, through which men normally pass the spermatic cord and the nerves accompanying it, and in women there is a round ligament of the uterus. This channel has an oblique direction: from top to bottom, from outside to inside and from behind, forward. In men, it has a length of 4-5 cm, while in women it is somewhat longer, but narrower than in men. The canal has an external opening( superficial inguinal ring) located on the pubic bone and an inner opening( deep inguinal ring), which is an opening in the transverse fascia covering the anterior abdominal wall from the inside, at the point of passage through this wall of the spermatic cord( round ligament of the uterusamong women).Schematic representation of the inguinal hernia in a man.
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    Like any abdominal hernia, inguinal hernia has a hernia gates( it is the inguinal canal), a hernial sac( it is formed by a parietal leaf of the peritoneum) and the contents of the hernial sac( it can be a large epiploon, small intestine, blind, sigmoid colon, vermiform appendix,bladder, female genital organs).The hernial sac, in turn, has a mouth, neck, body and bottom.

    Schematic representation of the main elements of a hernia: 1-abduction gut;2 - parietal peritoneum;3 - anterior abdominal wall;4 - hernial gates;5 - hernial sac;6 - sheaths of the hernial sac;7 - hernial contents - loop of the intestine

    Inguinal hernias are most often observed among all external hernias of the abdomen and account for 75% of their total number.

    Causes of inguinal hernia

    There are congenital and acquired inguinal hernias. Congenital inguinal hernia constitute the bulk of hernias in children( up to 90%), but can also occur in adults( about 10-12%).They are caused by a congenital anatomical feature consisting in the non-opening of the so-called vaginal process of the peritoneum, which forms during the descent of the testicle from the abdominal cavity to the scrotum, with the peritoneal cavity directly communicating with the cavity of the scrotum, which creates conditions for the onset of congenital hernia.

    Acquired inguinal hernia formed during life and accounted for 85% of the total number of inguinal hernias. Depending on the anatomical features of their structure, they are subdivided into straight lines and oblique.

    The occurrence of acquired inguinal hernia may be due to local and general causes. Common causes are divided into predisposing and producing.

    Predisposing causes are:

    1) heredity( genetically determined predisposition to the appearance of a hernia);
    2) age( with the age the probability of occurrence of a hernia increases due to the developing muscle weakening and a decrease in the elasticity of the anterior abdominal wall);
    3) sex( great weakness of the inguinal region in men);
    4) features of a build;
    5) the degree of fatness( rapid weight loss promotes the appearance of a hernia);
    6) frequent delivery in women;
    7) paralysis of the nerves innervating the muscles of the abdominal wall.

    Generating factors are factors that cause an increase in pressure in the abdominal cavity. These include:

    1) heavy physical labor;
    2) heavy delivery;
    3) constipation;
    4) difficulty urinating( may be due to prostatic adenoma, narrowing of the urethra);
    5) persistent cough( with respiratory diseases: tuberculosis, chronic bronchitis).

    In the case of inguinal hernia, the cause of the local nature is the presence of the inguinal canal itself - the "weak" place of the abdominal wall.

    Symptoms of inguinal hernia

    Manifestations of inguinal hernia depends on its size and on what organ it is in. Characteristic are pain and discomfort in the groin, especially when walking, indigestion and sometimes urination. In the inguinal region appears swelling, increasing with straining and coughing. With large inguinal hernias in men, the corresponding side of the scrotum increases, and its skin is stretched, while the penile deviates in the opposite direction. With a very large inguinal hernia, the penis can completely hide under the skin.

    When inguinal hernia of large size, its contents cease to independently go into the abdominal cavity. If the bladder is in the inguinal hernia, urination is disturbed, which can occur in two doses, sometimes requiring the patient to take the forced position of the body;As the urinary bladder is filled with urine, hernia size increases.

    Inguinal-scrotal hernia of large size.

    Irreachable inguinal and scrotal hernia can be confused with edema of the testicle( hydrocele), which also increases the size of the scrotum due to the accumulation of fluid in it. The inguinal hernia can also be treated with varicocele - varicose veins of the spermatic cord: when it is in the patient in the vertical position of the body, blunt, burgeoning pains appear in the scrotum and a slight increase in its size is noted, but the enlarged veins collapse easily when pressing on them and lifting the scrotum upward. In women, inguinal hernia may have a cyst of the round ligament of the uterus passing through the inguinal canal.

    Examination for suspected inguinal hernia

    Laboratory examination for uncomplicated inguinal hernia does not have an independent diagnostic value. In case of hospitalization, a general clinical examination( general blood test, general urine test, biochemical blood test, blood glucose, hepatitis, HIV, syphilis) is performed for planned surgery for hernia, which allows to exclude contraindications to surgical intervention.

    Treatment of inguinal hernia

    Treatment of inguinal hernia - operative. Radical surgery for inguinal hernia( inguinal hernia repair) consists in removal of the hernial sac and strengthening of a weak portion of the anterior abdominal wall( inguinal canal) in the area of ​​the hernial graft by means of plastic surgery by local tissues; plastic surgery is also possible by sewing into a hernia defect a mesh graft made of polypropylenemethod of Liechtenstein).The operation is performed under local anesthesia or general anesthesia.

    Polypropylene mesh for hernioplasty.

    Currently, laparoscopic herniation techniques are becoming widespread. Their advantages are the reduction of traumatic surgery, early return of patients to active activities, good cosmetic effect. However, there are drawbacks, which include: the need for an operation under general anesthesia, the possibility of damaging intra-abdominal organs and vessels, damage to the peritoneal cover in four places( 3 points of trocar insertion and opening of the peritoneum over the hernial gates), which can lead to the development of an adhesion process inabdominal cavity.

    Preoperative preparation for uncomplicated inguinal hernia is reduced to the appointment of a hygienic bath and cleansing enema on the eve of surgery, shaving the hair in the groin, emptying the bladder before surgery.

    Recurrences of inguinal hernias after surgical treatment are quite common: with oblique inguinal hernia in the range of 3-15%, with straight - in 15-35%.

    Lethal outcomes in surgical treatment of uncomplicated hernias are extremely rare( up to 0.04%).The total number of postoperative complications does not exceed 4.8%, and wound suppuration - 0.2%.

    Temporary disability after hernia repair is an average of 1 month. The workers of heavy physical labor are transferred for a period of up to 6 months to easy work. The development of recurrent hernia is a contraindication to all types of physical labor associated with significant or moderate physical stress, prolonged walking, long-term business trips for a long distance from medical institutions, which is associated with the threat of infringement of the hernia.

    The only radical method of treatment of congenital inguinal hernia is the operative method. The development of anesthesiology now allows performing a surgical operation at any age immediately after the detection of a hernia, including a newborn. However, in the presence of such relative contraindications as rickets, prematurity, some advanced diseases, under condition of absence of complications of inguinal hernia, the planned surgical intervention can be transferred to later terms - up to the age of 6-12 months. The purpose of the operation is to remove the hernial sac, and in contrast to hernia repair in adults, the strengthening of the anterior abdominal wall in the child is not necessary. With the development of infringement of congenital inguinal hernia, urgent surgical intervention is shown, but in weak, premature babies, and also in the presence of therapeutic contraindications, in the first 12 hours after infringement it is possible to conduct conservative treatment aimed at facilitating self-directed hernia repair. To this end, inject atropine and narcotic painkillers, apply a 15-minute warm bath, the child is placed on his back with an elevated position of the pelvis. In the absence of the effect of conservative treatment, emergency surgery is shown for 1.5 hours.

    Complications of inguinal hernia

    The main complications of inguinal hernia are: strangulation, coprostasis, irreparability, inflammation and damage to the hernia. More rarely occur neoplasms and foreign bodies of a hernia.

    Infringement of the inguinal hernia is the most frequent and life-threatening complication due to sudden compression of its contents and requires urgent surgical treatment. The organs of the abdominal cavity released into the hernial sac are most often squeezed in the hernial portal at the level of the neck of the hernial sac. The infringement can be elastic and caloric, it is also possible to combine them.

    With elastic infringement more than usual the number of organs of the abdominal cavity quickly jumps through the hernial gates, which overstretch at the time of a sudden increase in intra-abdominal pressure caused by considerable physical exertion, coughing, straining or other factors. After stopping the increase in intra-abdominal pressure, the hernial gates return to their previous state, which leads to the infringement of the hernia. When inguinal hernia infringement often occurs in the area of ​​the external opening of the inguinal canal. At this type of infringement, the compression of the released intestines occurs from the outside.

    Calvary infringement occurs more often in the elderly and is caused by the weakening of undulating motions of the intestine, aimed at promoting its contents. In this case, a large amount of contents accumulates in the intestine in the hernial sac, which leads to compression of the hinge loop of this intestine, and then to the pressure of the hernial gate on the hernial contents. Thus, the calf infringement is aggravated by the elastic, and mixed infringement develops.

    In the impaired organ develop circulatory and lymph circulation disorders. Fluid from the vessels swims into the lumen of the intestine and into the cavity of the hernial sac( hernial water), which further increases the infringement. Develops necrosis of the intestine, starting with its mucous membrane. The gangrene of the intestinal wall often leads to its perforation, the exit of intestinal masses with the microbes contained in them into the hernial sac and the development of peritonitis. Because of the development of circulatory disorders, pathological changes occur not only in the most strangulated intestine, but also in the intestinal parts leading to and away from it.

    Coprostasis ( congestion) develops in cases where the contents of the hernial sac is the large intestine, resulting in a disorder of the motor function of the intestine. Promotes the development of coprostasis irreparable hernia, abundant food intake and sedentary lifestyle. It is more common in patients of senile age with increased body weight. It manifests itself with intractable constipation, abdominal pain and nausea, rarely vomiting. Coprostasis can lead to a colonic infringement of the hernia.

    The invasiveness of hernia arises as a result of the development in the hernial sac of fusion of the internal organs with each other and with a hernial sac, which is caused by traumatization of the hernial contents. Irreversibility can be partial( when part of the contents of the hernia can be directed into the abdominal cavity, and the other part is not) or complete( all the contents of the hernia do not fit into the abdominal cavity).
    Inflammation of the hernia develops when the hernial sac is infected, which is possible with acute inflammation of the appendix( appendicitis) or Meckel's diverticulum, which fell into the hernial sac, with tuberculosis of the peritoneum. At the same time, the general condition of patients suffers, body temperature rises, chills occur, vomiting, stool retention and difficulty in venting. The size of the hernia increases, the blush above it turns red.

    Damage to the hernia can lead to rupture of the intestine in the hernial sac and occur with a sudden increase in intra-abdominal pressure, with direct injury to the hernia or due to contusion of the abdominal wall away from the hernia.

    Neoplasms of a hernia are very rare, can result from the contents of a hernia, a hernial sac or surrounding tissues and organs. The most common are lipomas( adipose) of the hernial sac.

    Foreign objects in the hernial sac can be swallowed by the patient objects, worms, stones of the bladder.

    Prevention of inguinal hernia

    In terms of preventing the emergence of herniations, regular physical training is important as a means of strengthening the muscles of the anterior abdominal wall and the body in general. Important is also the fight against obesity and, importantly, with a strong weight loss after it, as these pathological conditions create favorable conditions for the formation of hernias. As organizational measures in production, the correct selection of workers for hard physical labor is necessary in accordance with their physical capabilities and health status.

    To prevent the development of complications of inguinal hernia, early detection of people suffering from hernias is of great importance and directing them to planned surgical intervention before the complications develop. For this purpose, it is important to organize preventive examinations of the population, in particular, among people of school and retirement age.

    Doctor surgeon Kletkin ME