Chapter 4 DISCUSSION
4.1. GENERAL CHARACTERISTICS
4.1.1. About age
Through this study, we performed surgery on 176 patients with 193 cases of inguinal hernia aged 40 years and older, applying polypropylene mesh placement according to the Lichtenstein method to treat inguinal hernia at Hue Central Hospital and Hue University of Medicine and Pharmacy Hospital, with the results: average age was 69.43 ± 11.58, the lowest was 40 and the highest was 92 years old (Figure 3.1).
In Vuong Thua Duc's study, the average age was 54.5 ± 27.7 years old, the youngest was 18 years old and the oldest was 93 years old [3]. Nguyen Van Lieu's average age was 54.16 ± 27.36, the youngest was 40 and the oldest was 91 years old [10]. Ngo Viet Tuan's average age was 61.67 ± 13.12, the youngest was 40 and the oldest was 90 years old [16].
Author Elorza Ortie, mean age 59, minimum 27 years and maximum 92 years [55]. Author Frey, mean age 59, minimum 40 years and maximum 92 years [60].
We found that: the average age of this study is higher than that of authors Nguyen Van Lieu and Ngo Viet Tuan. In this study, the age group of 50 - 79 is dominant at 72.1%, Nguyen Van Lieu showed that: the age group of 40 - 50 is dominant at 70.04% [10], [16]. Thus, inguinal hernia is more likely to occur in older patients.
4.1.2. Distribution of inguinal hernia by gender
This study, (Table 3.1) in 176 patients, there were 173 males 98.3% and 3 females 1.7%. According to Vuong Thua Duc, Lichtenstein technique was 98% male, 2% female [3]. Authors: Linden, 92% male, 8% female [84]. Malik, 97% male, 3% female [88]. Negro, male
93%, female 7% [97].
From domestic and foreign studies, we found that inguinal hernias are predominantly in men > 90%. Because men are the main labor force of the family and society, doing heavy labor, often working to create material wealth for society. In addition, men also participate in physical activities.
Exercise and sports. Heavy activities often cause abdominal wall muscle contraction, increasing abdominal pressure, so hernias often occur. Our study is similar to the study of Vuong Thua Duc and Malik.
4.1.3. Geography and occupation
In this study, (chart 3.2) patients in rural areas were 60.8%, mountainous areas 3.4%, and cities 35.8%. Patients in rural and mountainous areas were dominant at 64.2%. The number of patients doing heavy labor was 22.1%, light labor was 7.4%, retired cadres were 14.8%, and over working age, meaning: previously doing heavy labor, now old and no longer working, was 55.7% (chart 3.3).
Inguinal hernias are related to work: in rural areas, people often work in the fields, work on farms, fish, carry loads, work as craftsmen, etc., which involve manual labor and heavy work, which is a favorable factor for inguinal hernias. In cities, people often do business, administration (civil servants, teachers, etc.) which involve mental labor, so the work is lighter, so inguinal hernias rarely occur.
In the elderly, the abdominal wall muscles, fascia, and fascia are altered and weakened, the tissue ages, the connective tissue changes, and the abdominal wall cannot withstand the constant increase in abdominal pressure, so inguinal hernias are likely to occur.
According to Nguyen Van Lieu, 58.43% of patients do heavy labor, 19.1% of patients do administrative work, and 22.46% of patients do other jobs [9].
Author Malik, heavy manual labor 64.6%, heavy technical labor 26.3%, medium labor 7.9%, administrative work 1.2% [88].
Research results show that inguinal hernia is related to heavy work, exertion increases peritoneal pressure, frequent contraction of abdominal muscles - inguinal, this is a favorable factor leading to inguinal hernia. As in the elderly, retired people due to fascia changes, poor elasticity, loose tissue leading to weakened abdominal wall in the groin area causing inguinal hernia.
4.1.4. Time of illness
According to author Nguyen Van Lieu, patients with the disease ≤ 1 year 10.1%, patients with the disease > 1 year to 5 years 59.6%, patients with the disease > 5 years
30.3%. Of which, the shortest duration of illness was 3 months and the longest was 50 years [9], [10].
According to Ngo Viet Tuan, patients with the disease: 1 month - 3 months 27.6%, 3 months to 1 year 36.6%, 1 year to 5 years 23.4%, over 5 years 12.4%. The shortest duration of the disease is a few days and the longest is 20 years [16]. Author Ohana, the average duration of the disease is 24 months [100].
In this study (Table 3.4), patients had the disease for: less than 1 year 41.4%, 1 year to 5 years 44.9%, 5 years to 10 years 6.3%, over 10 years 7.4%. The shortest duration of the disease was 1 month and the longest was 53 years.
The duration of the disease is over 1 year, accounting for 58.6%, which shows that the awareness and understanding of patients about inguinal hernia is still limited, so the detection, examination at medical facilities for consultation and early surgery is still low. In addition, patients in rural and mountainous areas account for 64.2%, due to difficulties in traveling, low educational level, information about this disease is not widely disseminated, and basic medical services are still inadequate. Therefore, patients with inguinal hernia are detected late and often go to medical facilities for treatment late, affecting the results of surgery later.
According to Holzheimer, the longer the disease duration, the more unfavorable the outcome. The probability of not being able to push the hernia sac up increases from 6.5% at 12 months to 30% at 10 years. The disease duration after 3 months has a risk of strangulation of 2.8%, increasing to 4.5% after 2 years. In the case of femoral hernia, the risk of strangulation is 22% after 3 months, increasing to 45% after 21 months. Inguinal hernia causes serious complications such as: strangulated inguinal hernia, causing intestinal obstruction, which can lead to intestinal necrosis, intestinal perforation causing peritonitis, affecting the health and threatening the patient's life. Strangulated hernia often occurs in indirect and femoral hernias because the neck of the hernia sac is narrow [72].
In indirect hernia, when the hernia is small, it only widens the deep inguinal ring, but when the hernia is large, it will affect the posterior wall of the inguinal canal. At that time, the hernia pushes the inferior epigastric vascular bundle inward and gradually occupies the internal inguinal fossa, causing the deep inguinal ring to widen inward and widen the inguinal canal toward the superficial inguinal ring, causing inguinal-scrotal hernia. Thus, the time the patient comes for hernia treatment
The later the inguinal hernia, the more difficult it will be to perform surgery. The hernia mass can adhere to each other or to the hernia sac, causing inflammation and ischemia [72].
Chung's study showed that: patients with painless inguinal hernia will progress to have symptoms over time. Therefore, surgical treatment of inguinal hernia is recommended for patients with early, painless inguinal hernia [44].
4.1.5. Medical history
Regarding medical history, it is worth paying attention to diseases that increase peritoneal pressure frequently, cause muscle contraction, dilate the fascia, accumulate over time and weaken the abdominal wall, favorable factors for inguinal hernia to occur such as: prolonged cough, chronic bronchitis, bronchial asthma, chronic obstructive pulmonary disease, benign prostatic hyperplasia, urethral stricture, prolonged constipation [9], [17].
Respiratory and cardiovascular diseases are risk factors related to anesthesia methods so we choose local anesthesia and regional anesthesia, limiting the indication for placing artificial mesh by endoscopic TAPP or TEP technique because endotracheal anesthesia is required.
In this study (Table 3.5), we recorded 30 patients with a history of internal medicine including: chronic bronchitis 4.6%, bronchial asthma 2.3%, chronic obstructive pulmonary disease 0.6%, prostate adenoma 4%, chronic constipation 5%. Thus, if considering the favorable factors causing inguinal hernia, it accounts for 17.1%.
According to Nguyen Van Lieu, there were 8 patients with pulmonary tuberculosis, accounting for 3.86%, and 12 patients with bronchial diseases, accounting for 5.79% [10].
Author Amato, medical history increased in elderly patients, under 70 years old: prostate adenoma 30%, chronic obstructive pulmonary disease 6.12%. But, over 70 years old: prostate adenoma 60%, chronic obstructive pulmonary disease 12.5% [25].
Regarding the medical history of the authors, Bin Tayair: chronic constipation 14.4%, chronic cough 14.9%, benign prostatic hyperplasia 10.9%, bronchial asthma 6.5%, urethral stricture 1.0% [35]. Neumayer: chronic obstructive pulmonary disease 5%, chronic cough 7.9%, benign prostatic hyperplasia 17% [98].
Compared with the research results of authors around the world, we found that: the older the patient, the more the history of internal medicine, which is a potential factor that aggravates after anesthesia and after surgery. Therefore, it is necessary to carefully exploit the patient's medical history to limit the risk of cardiovascular and respiratory complications after surgery. In this study, the history of common internal medicine is similar to the research of domestic and foreign authors. However, the rate varies according to each study. Diseases that increase abdominal pressure and require the patient to exert themselves such as: chronic obstructive pulmonary disease, prolonged cough, bronchial asthma, chronic constipation, prostate adenoma, urethral stricture, are risk factors that create favorable conditions for inguinal hernia to easily occur.
4.1.6. History of surgical procedures
In this study (Table 3.6), 176 patients with inguinal hernia, including 33 patients with a history of surgery, accounting for 18.8%. Of these, 8 had Mac Burney appendectomy, accounting for 4.6%, 11 had midline laparotomy, accounting for 6.3%, 4 had open bladder stone surgery, accounting for 2.3%, 8 had open prostatectomy, accounting for 4.6%, and 2 had laparoscopic prostatectomy, accounting for 1.1%.
History of recurrent inguinal hernia surgery included: 16 right inguinal hernia surgeries (8.3%), 12 left inguinal hernia surgeries (6.2%) (Table 3.8).
According to Nguyen Van Lieu, 27 patients had prostate fibroid surgery (13.04%), 7 patients had Mac Burney appendectomy (3.38%), and 9 patients had contralateral inguinal hernia surgery (4.34%) [10].
Regarding surgical history: author Beltrán, first inguinal hernia: appendectomy 40%, urological surgery 41%, other abdominal surgeries 9%. Recurrent inguinal hernia: appendectomy 35%, urological surgery 28%, other abdominal surgeries 9% [35].
Old incisions: midline above the umbilicus, midline above - below the umbilicus or midline below the umbilicus are less affected when performing open inguinal hernia surgery with artificial mesh placement using the Lichtenstein method because the incision in the groin area is not fibrotic.
However, is a history of appendectomy related to inguinal hernia? In 1911, author Hoguet was the first to describe
described the association in patients with inguinal hernia after appendectomy. Other researchers also dispute this view [9], [56], [116].
Right inguinal hernia often occurs after appendectomy, most notably the low incision following the cosmetic incision, this incision is likely to cause injury to the hypogastric iliofemoral nerve. Through the examination recorded on the electromyogram, the corresponding results are obtained, while some studies show that cutting the nerve that innervates the transverse abdominis muscle will cause inguinal hernia.
Therefore, it can be said that the transverse abdominal muscle participates in the closing mechanism of the deep inguinal ring, so when damaged, the closing mechanism of the deep inguinal ring will not be completed and will cause inguinal hernia later. Some other studies show that if the nerve fibers that innervate the muscles in the groin area are partially or completely damaged, the consequences will lead to hernia [9], [15], [19], [34], [56], [116].
4.2. CLINICAL FEATURES
4.2.1. Location of hernia
According to the research results of authors such as Beeraka, right inguinal hernia 54%, left inguinal hernia 28%, bilateral inguinal hernia 18% [33]. This study, (chart 3.4) right inguinal hernia 49.4%, left inguinal hernia 40.9%, bilateral inguinal hernia 9.7%. Thus, from the research results, it shows that: inguinal hernia often occurs on the right side more than the left side and rarely occurs on both sides at the same time.
Unilateral and bilateral inguinal hernia, authors such as: Corcione, unilateral inguinal hernia 80.5% and bilateral 19.5% [45]. Hetzer, unilateral inguinal hernia 91.9% and bilateral 8.1% [69]. Vironen, unilateral inguinal hernia 90.7% and bilateral 9.3% [118]. This study, unilateral inguinal hernia 90.3% and bilateral 9.7%.
The authors' research results show that unilateral inguinal hernia often occurs and accounts for over 80%, bilateral inguinal hernia rarely occurs and accounts for a low percentage.
4.2.2. Primary - recurrent hernia
According to authors such as Beltrán, primary inguinal hernia 78%, recurrent inguinal hernia 22% [34]. Campanelli, primary hernia 88.3% and recurrent hernia 11.7%. [41]. This study, primary inguinal hernia 85.5%, recurrent inguinal hernia 14.5%.
From studies showing that the recurrence of surgically repaired inguinal hernias varies from author to author. However, the rate of recurrent inguinal hernias remains high after surgical treatment of inguinal hernias, the issue of choosing the surgical method is very important to reduce the recurrence rate. This study, (chart 3.5) recurrent inguinal hernias 14.5%, higher than Campanelli, and lower than Beltrán.
4.2.3. Classification of hernias by anatomical location
In this study, we based on clinical examination and combined assessment of anatomical lesions, based on the inferior epigastric artery landmark, the location of the hernia sac, the posterior wall of the inguinal canal (transverse fascia) during surgery, classified into 3 types as follows: (chart 3.6) indirect inguinal hernia 106 cases 54.9%, direct inguinal hernia 55 cases 28.5%, combined inguinal hernia 32 cases 16.6%.
Table 4.1. Classification results according to anatomical location of the authors.
Author
Hernia indirect | Hernia direct | Hernia combination | |
Nguyen Van Lieu [10] | 72.22% | 16.20% | 11.58% |
Ali [23] | 62.69% | 32.3% | 5% |
Amid P. K [26] | 44% | 43.1% | 12.5% |
Frey M. D [60] | 47.4% | 36.4% | 16.1% |
Goldstein M. S [63] | 70% | 21% | 8.5% |
Koch [78] | 65.6% | 29% | 5.4% |
Linden [84] | 57.15% | 34.81% | 8.04% |
Zwaal P. V [123] | 46.98% | 34.90% | 18.12% |
This study | 54.9% | 28.5% | 16.6% |
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4.2.4. Classification of inguinal hernia according to Nyhus
The above classification of indirect, direct, and combined inguinal hernias is often simple and easy to perform, but it does not fully reflect the assessment of anatomical damage to the inguinal region in inguinal hernia pathology.
Therefore, many authors have proposed different classifications such as: Harkins (1959), Casten (1967), Halverson and Mc Vay (1970), Gilbert (1989), Lichtenstein
(1987), Nyhus (1991), Nyhus (1993), Bendavid (1994), Aachen (1995), Zollinger (2003), EHS (2007). But Nyhus Lioyd M is the one who paid much attention to the classification of inguinal hernias, which was accepted and applied by many surgeons in many countries around the world according to his classification [72], [114], [122].
The authors classified according to Nyhus as: Dedemadi, type II: 59%, type IIIA: 30.5%, type IIIC: 10.5% [52]. Elorza Ortie, type II: 10.97%, type IIIA: 39.02%,
Type IIIB: 35.77%, Type IV: 14.22% [55].
In this study, (table 3.8) we applied the classification table of author Nyhus [122]. With the results of 193 inguinal hernia cases as follows: type IIIA 22.3%, type IIIB 63.2%, type IVA 6.2%, type IVB 6.2%, type IVD 2.1%.
According to Nguyen Van Lieu, a study of 216 cases of inguinal hernia treated with Shouldice surgery, including 207 patients ≥ 40 years old, had the following results: type II: 12.50%, type IIIA: 16.65%, type IIIB: 66.65%, type IV: 4.20% [10].
4.3. ASA CLASSIFICATION OF HEALTH AND METHODS OF ANESTHESIA
4.3.1. ASA Health Classification
Our study included 176 surgically repaired inguinal hernias according to Lichtenstein, ASA health classification: type I 66.5%, type II 32.4%, type III 1.1% (chart 3.7).
In the Lichtenstein technique, the ASA classification of the authors is as follows: Dalenbäck, type I 85.3%, type II 14.1%, type III 0.6% [46]. Eklund, type I 83.78%, type II 13.51%, type III 2.7% [54]. Frey, type I 51.5%, type II 39.4%,
Type III 9.1% [60]. Ohana, type I 53%, type II 32%, type III 14% [100].
Through research by authors around the world, it shows that: inguinal hernia surgery is only performed for patients with ASA type I, type II and very few type III and not for type IV, type V except when the inguinal hernia is strangulated.
From this study, as well as from other authors, patient selection according to ASA health classification, type I and type II prevail. Inguinal hernia often occurs in the elderly with a history or severe internal medical disease, affecting the treatment results, it is necessary to consider when indicating surgery, should eliminate risk factors, to bring good results.