Abstract
Aim
The purpose was to investigate the basic histological structure of the internal inguinal ring in patients operated on for primary indirect inguinal hernia.
Patients and Methods
The study involved a sample of 72 consecutive male patients over 15 years of age, submitted to elective surgery for unilateral primary inguinal hernia. The primary outcome measures were the histological findings of the internal inguinal ring. Patients were divided into three groups according to age: group 1 included patients between 15 and 40 years of age, group 2 patients between 41 and 70 years of age, and group 3 patients older than 71 years of age.
Results
All samples from the internal inguinal ring comprised fibrous fascial tissue with elastic fibres which were thicker in groups 1 and 2, and thinner in group 3 (p<0.0001). Adipose tissue between elastic fibres was absent in group 1 (p=0.003), and was present in group 3 (p=0.001). Vascular sclerosis was minimum in group 1, moderate in group 2, and important in group 3 (p<0.0001). Acute or chronic inflammatory cells were absent in all patients. These changes were more significant with age, according to the analysis with multiple linear regression.
Conclusions
The basic histological characteristics of the internal inguinal ring in patients with indirect inguinal hernia consisted of reduced density and thickness of elastic fibres, and increased adipose tissue between elastic fibres, changes which became more significant with increasing age. Vascular sclerosis was also more severe in older patients compared to younger patients. These histological changes all appeared to be related to ageing.
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References
Wirtschafter ZT, Bentley JP. Hernias as a collagen maturation defect. Ann Surg 1964; 160:852–9
Klinge U, Binnebösel M, Mertens PR. Are collagens the culprits in the development of incisional and inguinal hernia disease? Hernia 2006; 10:472–7
Pans A, Albert A, Lapière CM, Nusgens B. Biochemical study of collagen in adult groin hernias. J Surg Res 2001; 95:107–13
Friedman DW, Boyd CD, Norton P, Greco RS, Boyarsky AH, Mackenzie JW, et al. Increases in type III collagen gene expression and protein synthesis in patients with inguinal hernias. Ann Surg 1993; 218:754–60
Quintas ML, Rodrigues CJ, Yoo JH, Rodrigues AJ Jr. Age related changes in the elastic fiber system of the interfoveolar ligament. Rev Hosp Clin Fac Med Sao Paulo 2000; 55:83–6
Rodrigues AJ Jr, Rodrigues CJ, da Cunha AC, Yoo JH. Quantitative analysis of collagen and elastic fibers in the transversalis fascia in direct and indirect inguinal hernia, Rev Hosp Clin Fac Med Sao Paulo 2002; 57:265–70
Goldstein SL. Mechanism and metabolic characteristics of hernia formation. Prob Gen Surg 2002; 19:1–6
Bórquez PM, Garrido LO, Manterola CD, Peña PS, Schlageter CT, Orellana JJ, et al. Collagen and elastic fibers of skin connective tissue in patients with and without primary inguinal hernia. Rev Med Chil 2003; 131:1273–9
Bórquez PM. Estudio inmunohistoquímico del colágeno tipo I y tipo III en piel de pacientes con hernia inguinal primaria. Rev Chil Cir 2005; 57:489–94
Szczesny W, Cerkaska K, Tretyn A, Dabrowiecki S. Etiology of inguinal hernia: Ultrastructure of rectus sheath revisited. Hernia 2006; 10:266–71
Franz MG. The biology of hernias and abdominal wall. Hernia 2006; 10:462–71
Meyer AL, Berger E, Monteiro O Jr, Alonso PA, Stavale JN, Gonçalves MP. Quantitative and qualitative analysis of collagen types in the fascia transversalis of inguinal hernia patients. Arq Gastroenterol 2007; 44:230–4
Casanova AB, Trindade EN, Trindade MR. Collagen in the transversalis fascia of patients with indirect inguinal hernia: A case-control study. Am J Surg 2009; 198:1–5
Franz MG. The biology of hernia formation, Surg Clin North Am 2008; 88:1–15
Amato G, Marasa L, Sciacchitano T, Bell SG, Romano G, Gioviale MC, et al. Histological findings of the internal inguinal ring in patients having indirect inguinal hernia. Hernia 2009; 13:259–62
Dickson AR. The inguinal ring in oblique inguinal hernia. Cal West Med 1931; 35:204–7
Lunn HF. The anatomy of inguinal hernia. Ann R Coll Surg Engl 1948; 2:285–98
Peacock E.E., Madden J.W., Studies on the biology and treatment of recurrent inguinal hernia: II. Morphological changes, Ann Surg 1974; 179:567–71.
Skandalakis JE, Gray SW, Skandalakis LJ, Colborn GL, Pemberton LB. Surgical anatomy of the inguinal area. World J Surg 1989; 13:490–8.
Menck J, Lierse W. The fascia of the inguinal canal ring. Chirurg 1991; 62:117–20.
Feleshtynskyi Ia.P, Hrabovyi OM, Chynba OV. Differentiated approach to surgical treatment of inguinal hernia in accordance with morphologic characteristics of musculo-aponeurotic structures of inguinal channel. Klin Khir 2007; 10:22–6
Barría C, Beltrán MA, Contreras MA, Cruces KS. Histology of the internal inguinal ring: It is really a novelty? Hernia 2010; 14:339–40
Lichtenstein IL, Shulman AG, Amid PK, Montflor MM. The tension-free hernioplasty. Am J Surg 1989; 157:188–93
Wantz GE. Experience with the tension-free hernioplasty for primary inguinal hernia in men, J Am Coll Surg 1996; 183:351–6.
Hernandez-Granados P, Quintáns-Rodríguez A. Early complications in tension-free hernioplasty: Comparison between ambulatory and short-stay surgery. Hernia 2000; 4:238–41
Hernandez-Granados P, Ontañon M, Lasala M, Garcia C, Arguello M, Medina I. Tension-free hernioplasty in primary inguinal hernias: A series of 2054 cases. Hernia 2000; 4:141–3
van Wessem KJ, Simons MP, Plaisier PW, Lange JF. The etiology of indirect inguinal hernias: Congenital and/or acquired? Hernia 2003; 7:76–9
Wolloscheck T, Gaumann A, Terzic A, Heintz A, Junginger T, Konerding MA. Inguinal hernia: Measurement of the biomechanics of the lower abdominal wall and the inguinal canal. Hernia 2004; 8:233–41
Bendavid R. The unified theory of hernia formation. Hernia 2004; 8:171–6
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Beltrán, M.A., Barría, C., Rodríguez, F. et al. Histology of the internal inguinal ring in patients with indirect inguinal hernia. Hellenic J Surg 86, 368–374 (2014). https://doi.org/10.1007/s13126-014-0161-6
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DOI: https://doi.org/10.1007/s13126-014-0161-6