Inguinal and femoral hernia: clinical guidelines

List of Abbreviations

CT – computed tomography

MRI – magnetic resonance imaging

ICU – intensive care unit

IH – inguinal hernia

FH – femoral hernia

РКИ – randomized controlled trial

TAPP – transabdominal preperitoneal repair

TEP – totally extraperitoneal repair

US – ultrasound examination

EAES – European Association for Endoscopic Surgery

EHS – European Hernia Society

COPD – chronic obstructive pulmonary disease

Terms and Definitions

A hernia is defined as the protrusion of peritoneal-covered internal organs through natural or artificial openings (resulting from trauma or surgical interventions) in the abdominal wall, pelvic floor, or diaphragm into the subcutaneous tissues or another body cavity. Such natural openings of the abdominal wall include the inguinal canal, which is the site of IH formation.

The main criterion for an inguinal/femoral hernia (IH/FH) is the presence of an abdominal wall bulge in the inguinal/femoral canal region. The components of a hernia are: the hernia ring, the hernia sac, and the contents of the hernia sac.

Hernia ring – a congenital or acquired defect in the musculo-aponeurotic layer of the abdominal wall.

Hernia sac – the portion of the parietal peritoneum that protrudes through the hernia ring. The contents of the hernia sac may include any abdominal organ, but most frequently consist of the greater omentum or a loop of the small intestine.

Strangulated hernia – acute or gradual compression of one or more abdominal organs within the hernia ring, leading to impaired blood supply and, ultimately, necrosis.

Elastic incarceration occurs after the sudden protrusion of a large volume of abdominal organs through a narrow hernia ring at the moment of a sharp increase in intra-abdominal pressure due to heavy physical exertion. The protruded organs do not spontaneously reduce back into the abdominal cavity. Due to compression (strangulation) in the narrow ring of the hernia ring, ischemia of the incarcerated organs develops, leading to severe pain syndrome. Pain causes persistent spasm of the anterior abdominal wall muscles, which exacerbates the incarceration. Unresolved elastic incarceration leads to rapid (within a few hours) necrosis of the hernia contents.

Fecal incarceration is the compression of hernia contents as a result of sudden overfilling of the afferent intestinal loop located within the hernia sac. The efferent loop of this intestinal loop is sharply flattened and compressed in the hernia ring along with the adjacent mesentery. As a result, strangulation develops, similar to that observed in elastic incarceration. However, a longer period is required for the development of bowel necrosis in fecal incarceration.

Retrograde incarceration is when at least two intestinal loops are present in the hernia sac in a relatively viable condition, while the greatest changes are suffered by the third, intermediate loop located inside the abdominal cavity.

Parietal strangulation – known in the literature as "Richter's hernia". In this condition, the bowel is compressed not across its entire lumen, but only partially, typically at the site opposite its mesenteric border. While mechanical intestinal obstruction does not occur, there is a genuine risk of intestinal wall necrosis with all ensuing consequences. Parietal strangulation most frequently affects the small intestine, though cases involving the stomach and colon have been described. This type of strangulation never occurs in large hernias and is characteristic of small hernias with narrow hernia rings.

Littre's hernia – isolated strangulation of a Meckel's diverticulum within an inguinal or femoral hernia. Due to compromised blood supply, the strangulated Meckel's diverticulum undergoes necrosis more rapidly.

Amyand's hernia – isolated strangulation of the appendix within an inguinal or femoral hernia.

Recurrent IH – a hernia that develops in the area of a previously performed herniorrhaphy.

Early complications of inguinal/femoral hernioplasty – complications developing within 30 days postoperatively. Early complications include local wound complications such as seroma and hematoma, as well as urinary retention, testicular and scrotal edema, among others.

Late complications of inguinal hernioplasty – complications developing 30 days or more postoperatively. Late complications include chronic pain, suture fistulas, pseudocysts, testicular atrophy, and others. The most significant are recurrences.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Inguinal hernia – protrusion of peritoneal-covered internal organs through the inguinal canal.

Femoral hernia – protrusion of peritoneal-covered internal organs through the femoral canal. The femoral canal is the space enclosed between the superficial and deep layers of the fascia lata, extending from the femoral ring to the saphenous opening. Normally, it is filled with adipose tissue and only constitutes a canal in the presence of a hernia, whose sac emerges into the subcutaneous tissue through one of the lacunae of the cribriform fascia. These sites serve as the point of strangulation in a femoral hernia. The length of the canal ranges from 0.5–1 cm to 3 cm [1].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

The causes of inguinal and femoral hernias can be divided into two groups: predisposing factors – sex, age, body build, anatomical weakness of the inguinal canal walls, etc., and precipitating factors – conditions that increase intra-abdominal pressure (heavy physical labor, pregnancy and childbirth, gastrointestinal diseases leading to delayed bowel emptying, etc.) [2,3,4].

IHs can be congenital or acquired, indirect or direct. A congenital IH is always indirect and develops solely as a result of failure of the processus vaginalis of the peritoneum to obliterate. The development of acquired indirect and direct IH is largely due to anatomical weakness of the anterior and posterior walls of the inguinal canal [3,5].

FHs also occur as congenital and acquired forms. Congenital FH is observed in children under 1 year of age. More frequently, FH is acquired and arises due to regular increases in intra-abdominal pressure (due to various causes such as pregnancy and childbirth, physical overexertion, constipation, etc.), rapid and drastic weight loss, hip dislocation, etc. [5].

Sex is a risk factor for IH/FH. IH occurs in 82.6% of males [2]. This is explained by the anatomical structure of the male inguinal canal: the deep inguinal ring is larger, the inguinal triangle (intercolumnar space) is higher, etc. FHs are more common in females due to the larger size of the femoral ring. The width of the femoral ring (the distance between the femoral vein and the lacunar ligament) averages 1.2 cm in men and 1.8 cm in women [2,6,7].

When the aponeurosis of the external oblique abdominal muscle is poorly developed and contains numerous interaponeurotic clefts, the risk of indirect IH is significantly higher. A weak external oblique aponeurosis is observed in 17.7% of healthy individuals and in 32.6% of hernia-bearing individuals [8,9]. The risk of indirect IH is substantially higher when the internal oblique abdominal muscle does not participate in forming the anterior wall of the inguinal canal and does not cover the deep inguinal ring [3,9]. This anatomical variant is found in 17% of healthy individuals and in 48% of hernia-bearing individuals [2].

The probability of direct IH is significantly higher in individuals with a high inguinal intercolumnar space (triangular shape), where the posterior wall of the inguinal canal in the medial inguinal fossa is markedly weakened. A triangular inguinal space is observed in 5.3% of healthy individuals and in 55.5% of hernia-bearing individuals. This shape of the inguinal space is reliably more common in individuals with a brachyorphic body type, male-pattern abdomen, hypogastric height greater than 7.5 cm, and inguinal ligament inclination angle greater than 35˚ [2,3,4]. Inadequate development of the aponeurotic structures reinforcing the transversalis fascia in the area of the lateral and medial inguinal fossae (interfoveolar ligament, conjoint tendon, reflected ligament) leads to large dimensions of the deep inguinal ring and inguinal space, resulting in a high risk of IH formation [2,5,10,11].

Morphological changes in the inguinal region also play an important role in the development of femoral hernia, specifically stretching and fraying of the ligamentous apparatus, laxity of the lacunar ligament, widening of the space between the femoral vein and the lacunar ligament, insufficient density and narrowness of the femoral ring enclosing the vessels; relaxation, splitting, and fraying of the iliopubic tract, most frequently developing in women; and weakness and defects in the transversalis fascia [5,12,13].

It is well established that IH/FH occur significantly more often in individuals over 40 years of age [11]. This is attributed to age-related thinning and fraying of the external oblique aponeurosis [14] and transversalis fascia [10,15], enlargement of the deep inguinal ring [16], increase in the height of the inguinal space [3], and atrophic processes in the lateral abdominal muscles [14,17].

Damage to the branches of the iliohypogastric and ilioinguinal nerves during surgical approaches in the lateral and inguinal regions of the anterior abdominal wall leads to impaired innervation of the internal oblique and transverse abdominal muscles, which form the walls of the inguinal canal, and consequently increases the risk of inguinal hernia (IH) [10].

Spermatic cord lipoma, which occurs in 32.4–72.5% of healthy individuals, is also a risk factor for IH [18]. A growing lipoma enlarges the deep inguinal ring and exerts pressure on the lower edges of the internal oblique and transverse abdominal muscles, which contributes to an increase in the height of the inguinal triangle.

An important risk factor for IH/femoral hernia (FH) is the presence of undifferentiated connective tissue dysplasia, which is found in 76.2% of IH cases [19,20] and is characterized by weakness of aponeurotic structures due to impaired collagen synthesis. Currently, the role of matrix metalloproteinases in the etiology of IH is being actively studied. In patients with IH, the transversalis fascia of the abdomen shows high levels of various types of metalloproteinases and a low content of their inhibitors [5].

One of the leading causes of femoral hernia formation is previous inguinal hernia surgery due to enlargement of the femoral ring caused by tension on the inguinal ligament [21,22]. An important factor leading to femoral hernia formation is prolonged elevation of intra-abdominal pressure during pregnancy, when the preperitoneal adipose tissue is essentially pressed into the initially enlarged femoral ring. In addition, during pregnancy, impaired venous outflow leads to an increase in the diameter of the external iliac vein and, consequently, expansion of the femoral ring opening through which it passes. After childbirth, the vein collapses, and the preperitoneal tissue enters the resulting gap, initiating the process of hernia formation.

The pathogenesis of hernia strangulation is quite well studied. Characteristic dynamic changes are common to all types of strangulation [23,24,25]. Due to compression (strangulation) within the particularly narrow hernia ring, ischemia of the strangulated organs develops. Compression of the nerve elements of the strangulated organ and, in particular, the mesentery of the intestine leads to severe pain syndrome. The pain causes persistent spasm of the anterior abdominal wall muscles, which exacerbates the strangulation of the hernia contents, potentially leading to necrosis. At the moment of strangulation, a closed cavity forms within the hernia sac containing the organ or organs whose blood supply is impaired. At the site of compression of the intestinal loop, omentum, and other organs, a strangulation furrow forms, which remains clearly visible even after the relief of strangulation. If the intestine is strangulated, venous stasis initially occurs within it, which soon causes edema of all layers of the intestinal wall. The strangulated intestinal loop necrotizes fairly quickly, within a few hours (in elastic strangulation), starting from the mucosa. This fact must be remembered when the viability of the intestine is assessed solely by the appearance of its serosa.

During strangulation, not only the part of the intestine located within the hernia sac suffers, but also its afferent segment located in the abdominal cavity. As a result of developing intestinal obstruction, contents accumulate in the afferent intestine, stretching it and causing its wall to become sharply thinned. Blood circulation in arterioles and capillaries is disrupted. Intra-abdominal pressure increases, which at levels above 20 mmHg can lead to the development of so-called abdominal compartment syndrome—multiple organ dysfunction syndrome [26]. The longer the duration of strangulation, the more pronounced the pathological changes in the afferent loop. The efferent intestine appears collapsed. Ischemic changes in it are minimal and extend over a short distance from the strangulation zone [25].

Based on the established fact of the degree of pathomorphological changes in the incarcerated non-viable small intestine, recommendations on the level of resection of the afferent and efferent segments of the incarcerated loop have been formulated. The margins of resection of the afferent limb of the intestine must always be greater than the margins of resection of the efferent loop.

High strangulation obstruction resulting from strangulation is accompanied by early vomiting. Early, repeated vomiting rapidly leads to dehydration, loss of vital electrolytes and proteins. In the closed lumen of the ischemic intestine, decomposition of intestinal contents begins, characterized by the formation of toxins. Simultaneously, plasma transudation and diapedesis of formed blood elements occur both into the lumen of the strangulated intestine and into the cavity of the hernia sac. The fluid (hernia water) that accumulates in the closed cavity of the hernia sac (due to transudation and exudation) is initially transparent and colorless (serous transudate). As blood formed elements enter and disintegrate, the hernia water acquires a pink and subsequently red-brown color. The necrotized intestinal wall ceases to serve as a barrier to the escape of microflora beyond its boundaries. The exudate becomes purulent with an unpleasant odor. Inflammation spreads to the tissues surrounding the hernia, forming a "phlegmon of the hernia sac." These changes, together with damage to the afferent segment of the intestine, pose a risk of purulent complications—phlegmon of the hernia sac, abdominal wall phlegmon, peritonitis, and sepsis.

In elastic strangulation, the mechanisms of pain syndrome, rapid necrosis of the strangulated organ (within a few hours), and rapidly increasing intoxication come to the fore. An essential condition for the development of elastic strangulation is the presence of a narrow hernia ring. Most commonly, the small intestine or a segment of the greater omentum is strangulated, and less frequently, the colon. Organs located mesoperitoneally are very rarely strangulated: for example, the cecum, urinary bladder, uterus, and its appendages. Strangulation of the intestine is the most dangerous due to the possibility of its necrosis and the development of severe strangulated intestinal obstruction, which causes progressive intoxication.

Fecal strangulation is characterized by the presence of a wide hernia ring. In this case, physical exertion is of lesser importance than in elastic strangulation; impaired intestinal motility and slowed peristalsis are much more significant, which is frequently observed in elderly patients. Fecal strangulation typically occurs as a complication of a long-standing irreducible hernia. The efferent intestinal loop along with its mesentery is compressed not elastically, but by the expanding volume of the afferent loop. These pathogenetic conditions delay the onset of ischemic changes in the intestine. Therefore, a longer period is required for the development of intestinal necrosis in fecal strangulation.

In retrograde strangulation, the greatest changes occur in the third, intermediate loop located in the abdominal cavity. It experiences the worst blood supply conditions because its mesentery is bent several times as it enters and exits the hernia sac. Retrograde strangulation proceeds significantly more severely than conventional strangulation. Peritonitis develops more frequently in this condition because the main pathological process unfolds not in the closed hernia sac, but in the free abdominal cavity.

In Richter's hernia (parietal strangulation), mechanical intestinal obstruction does not occur, but there is a real danger of intestinal wall necrosis with all the ensuing consequences.

Littre's hernia (strangulation of Meckel's diverticulum) or Amyand's hernia (strangulation of the appendix) within an inguinal or femoral hernia is accompanied by rapid necrosis of the organ. This is associated with the compromised blood supply conditions of the strangulated diverticulum or appendix [5,27].

1.3 Epidemiology of the Disease or Condition

The choice of surgical treatment for patients with IH remains an urgent issue today, due to the high prevalence of the disease and its predominant occurrence in working-age individuals [28,29]. Hernia recurrences in practical surgery occur in 2–20% of patients after traditional hernioplasty methods and in 35–40% after repeated surgeries, whereas after mesh prosthetic techniques, recurrence averages 1–5% [30,31,32]. Over the past 40 years, more than 50 new surgical techniques have been proposed, and the total number of methods and modifications for IH repair exceeds 300. This indicates ongoing research into new, more effective surgical approaches and surgeons' dissatisfaction with the treatment outcomes of IH [33].

In the Russian Federation in 2022, more than 123,000 elective operations for IH were performed with a mortality rate of 0.02%. IH surgeries accounted for 54.5% of the total number of hernioplasties. The proportion of mesh endoprostheses used in open hernioplasty methods reached 66.6%, while the share of operations using video-assisted endoscopic technologies was 17.9%. For FH, 5,171 surgeries were performed, accounting for 2.3% of the total number of elective surgeries for abdominal wall hernias, with a mortality rate of 0.1%. The proportion of video-assisted endoscopic surgeries for FH was 18.7% [34].

In 2022, more than 24,000 patients were hospitalized with strangulated IH, accounting for 50.0% of the total number of patients with strangulated abdominal wall hernias, with a mortality rate of 1.73%. The proportion of laparoscopic surgeries for this hernia localization was 4.26%, with a mortality rate of 0.20% [34].

1.4 Features of Coding the Disease or Condition

K40.0 Bilateral inguinal hernia with obstruction, without gangrene.

K40.1 Bilateral inguinal hernia with gangrene.

K40.2 Bilateral inguinal hernia without obstruction or gangrene.

K40.3 Unilateral or unspecified inguinal hernia with obstruction, without gangrene.

K40.4 Unilateral or unspecified inguinal hernia with gangrene.

K40.9 Unilateral or unspecified inguinal hernia without obstruction or gangrene.

K41.0 Bilateral femoral hernia with obstruction, without gangrene

K41.1 Bilateral femoral hernia with gangrene

K41.2 Bilateral femoral hernia without obstruction or gangrene

K41.3 Unilateral or unspecified femoral hernia with obstruction without gangrene

K41.4 Unilateral or unspecified femoral hernia with gangrene

K41.9 Unilateral or unspecified femoral hernia without obstruction or gangrene

1.5 Classification of the disease or condition

Existing classifications of inguinal hernias are numerous. They are based on describing the relationship of the defect to the epigastric vessels. The division of inguinal hernias into "direct" (medial to the vessels) and "indirect" (lateral) dates back to Cooper (1844) [32].

In 2007, the European Hernia Society (EHS) proposed its classification of inguinal and femoral hernias. It makes it possible to determine the type of hernia quite accurately and, when studying various types of hernioplasty, to objectively evaluate the advantages and disadvantages of each method depending on the hernia type (Table 1). In addition, its use is advisable in order to standardize the obtained results and compare them with global data [35]. For convenience, it is suggested to check the required boxes in the table.

EHS Inguinal/Femoral Hernia Classifications (Table 1)

• To determine the type of inguinal hernia, it is recommended to use the European Hernia Society (EHS) classification [35].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

Classification of strangulated hernias [5,6].

According to the mechanism of strangulation:

• elastic;

• fecal.

According to the strangulated organ:

• greater omentum;

• gastrointestinal organs (small intestine, colon, appendix);

• uterine appendages;

• urinary bladder.

Special types of strangulation:

• retrograde;

• richter's hernia (parietal);

• littre's hernia (strangulation of Meckel's diverticulum in an inguinal hernia).

Consequences (complications) of unreduced strangulation:

• acute intestinal obstruction;

• purulent peritonitis;

• phlegmon of the hernia sac.

1.6 Clinical presentation of the disease or condition

In two-thirds of patients, the symptoms of inguinal/femoral hernias are discomfort or pain in the groin area. In one-third of patients, symptoms are absent, and there is only a painless bulge in the groin. An inguinal/femoral hernia presents as a tumor-like protrusion in the groin region, soft and elastic upon palpation. Inguinal/femoral hernias can be bilateral. An uncomplicated hernia is easily reduced into the abdominal cavity, appears in the upright position and under strain, accompanied by pulling and aching sensations in the groin. Irradiation of pain to the lower abdomen, lower back, and sacrum is possible. Small hernias may be asymptomatic. As the hernia increases in size, complaints appear, their intensity increases, and working capacity becomes limited. Constipation may occur, as well as urinary disorders, painful urination, and urinary retention in the case of a sliding hernia of the urinary bladder. Large inguinal hernias can descend into the scrotum [2,6,9]. A femoral hernia can be spherical, hang down, and sometimes rise upward, lying above the inguinal ligament. Less commonly, it can also descend into the scrotum or labium majus [5].

The presence of a soft-elastic consistency of the swelling (protrusion) in the groin area(s), which reduces into the abdominal cavity and changes in size under the influence of factors increasing intra-abdominal pressure (upright position of the patient, physical exertion, coughing). Pain sensations (discomfort) in the area of the hernia protrusion may appear or intensify under the influence of factors that increase intra-abdominal pressure [5,23]. The influence of triggering factors on the formation of inguinal/femoral hernias is currently a debatable issue. Many experts believe that episodic heavy lifting, constipation, and prostatitis increase the risk of developing inguinal/femoral hernias. However, supporting evidence is insufficient [36,37,38].

Clinical symptoms of a strangulated hernia

An uncomplicated strangulated hernia is recognized by sudden pain in the hernia area, the intensity of which depends on the type of strangulation, the affected organ, and the patient's age; the inability to reduce a previously freely reducible hernia; an increase in the volume of the hernia protrusion; tension and tenderness upon palpation of the hernia protrusion; and the absence of the "cough impulse" sign.

In a patient with a strangulated inguinal/femoral hernia complicated by intestinal obstruction, the local symptoms of strangulation are joined by the clinical picture of acute intestinal obstruction: colicky abdominal pain, thirst, dry mouth, repeated vomiting, and delayed passage of stool and gas. Examination reveals abdominal distension, increased peristalsis, and a "splash sound" in the absence of peritonitis symptoms.

A strangulated inguinal/femoral hernia complicated by phlegmon of the hernia sac is recognized by an edematous hernia protrusion that is hot to the touch, skin hyperemia, and subcutaneous edema extending beyond the hernia protrusion; fluctuation in the hernia area and the presence of crepitus in the tissues surrounding the hernia protrusion may appear. The general reaction is characterized by the addition of systemic inflammatory response symptoms.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Diagnostic criteria

The diagnosis of an inguinal/femoral hernia is established based on:

1. The patient's characteristic complaints of a protrusion in the groin area and pain in the protrusion area in case of hernia strangulation.

2. The detection during examination and palpation of an elastic formation in the groin area that is reducible into the abdominal cavity through the abdominal wall defect, or a painful, tense, and irreducible formation in case of hernia strangulation.

2.1 Complaints and Anamnesis

Characteristics of complaints and anamnesis data typical for patients with inguinal/femoral hernias are specified in section 1.6.

• When diagnosing a strangulated inguinal/femoral hernia, it is recommended to pay attention to the patient's complaints of constant intense pain in the hernia protrusion area and its irreducibility [5,6,39,40].

GPP CLoE 5Level of Recommendations — C. Level of Evidence — 5.

Comment: The diagnosis of "reduced strangulated hernia" can be made if there are clear indications from the patient regarding the fact of strangulation of a previously reducible hernia, the duration of irreducibility, and the moment of its spontaneous reduction. A hernia whose spontaneous reduction occurred (and was documented in medical records) in the presence of medical personnel should also be considered a reduced strangulated hernia.

2.2 Physical Examination

• When examining the inguinal region in a patient with suspected inguinal/femoral hernia to clarify the diagnosis, it is recommended to ask them to strain or cough; in this case, the hernia protrusion will be visualized if it was not previously visible, or it will increase in size [38,39,40].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

Comment: The examination of a patient with suspected inguinal hernia begins with inspection of the inguinal region, palpation of the inguinal region with digital examination of the superficial inguinal ring, the femoral triangle, and percussion of the hernia protrusion. A swelling (protrusion) of soft-elastic consistency is detected, which reduces into the abdominal cavity in the horizontal position of the patient or upon pressure, and reappears with coughing and straining. The "cough impulse" sign is positive. Palpation may reveal the irreducibility of the hernia [23,39]. Uncomplicated strangulated hernias are characterized by sudden pain in the hernia area, the intensity of which depends on the type of strangulation, the affected organ, and the patient's age, the inability to reduce a previously freely reducible hernia, and an increase in the volume of the hernia protrusion. A patient with a strangulated hernia complicated by intestinal obstruction develops colicky abdominal pain, thirst, dry mouth, repeated vomiting, and delayed passage of stool and gas [5]. A strangulated hernia complicated by phlegmon of the hernia sac is recognized by an edematous hernia protrusion that is hot to the touch, skin hyperemia, and subcutaneous edema. Fluctuation in the hernia area and the presence of crepitus in the tissues surrounding the hernia protrusion may appear. There is evidence that femoral hernias manifest more frequently with strangulation and are diagnosed during emergency surgical interventions, which requires constant vigilance when assessing the condition of patients admitted for emergency treatment with symptoms of acute intestinal obstruction [6].

• In the case of an uncomplicated inguinal/femoral hernia, when palpating the hernia protrusion in the groin area, it is recommended to cautiously attempt to reduce it into the abdominal cavity and determine the abdominal wall defect (hernia gate) in the area of the inguinal canal or femoral triangle [5,30,41,42].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

Comment: The examination is recommended to be performed with the patient in the horizontal position. With typical hernia symptoms, a clinical examination alone is sufficient, the sensitivity of which for inguinal hernias is 74.5–92%, and the specificity is 93%. Differential diagnosis of direct and indirect hernias is not mandatory. Knowing the type of inguinal hernia rarely affects the indications for surgical intervention, so preoperative differentiation of the inguinal hernia type is of little significance [28,43].

• In case of hernia strangulation or suspected strangulation, even if it reduces spontaneously, immediate hospitalization in an emergency surgery department is recommended [5,14].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

Comment: It is unacceptable to attempt reduction of a hernia if strangulation is suspected. The reduction effect may be false. This can lead to rupture of the hernia sac, reduction of necrotic strangulated organs or their parts into the abdominal cavity, and damage to the contents of the hernia sac [14].

2.3 Laboratory Diagnostics

Laboratory tests are of no significance in the diagnosis of uncomplicated inguinal/femoral hernia. They are prescribed during preoperative patient preparation. The scope of laboratory tests depends on the patient's comorbid conditions, the intended type of anesthesia, and the surgical treatment method.

• In cases of strangulated inguinal/femoral hernia, laboratory tests are recommended to be performed according to the standards established within the medical organization for patients with acute abdominal surgical pathology [13].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

2.4 Instrumental Diagnostics

• In the case of a clear clinical diagnosis of inguinal/femoral hernia, additional imaging studies are not recommended [41,44,45,46].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

Comment: In most cases, accurate diagnosis of inguinal/femoral hernias is possible through a physical examination. Imaging studies are indicated if the presence of an inguinal/femoral hernia is unclear, or if the physician is unsure whether the mass in the inguinal region is caused by a hernia. Difficulties in clinical diagnosis may arise in the early stages of hernia formation, which can be accompanied by pain [41,44,45,46].

• When inguinal/femoral hernia is suspected, but clinical signs are ambiguous, ultrasound examination of the soft tissues of the inguinal region is recommended as the first-line imaging method [45,47,48,49,50,51].

GCR ALEL 2Grade of Recommendation – A. Level of Evidence – 2.

Comment: Soft tissue ultrasound has high specificity, is inexpensive and widely available, and is therefore considered the most cost-effective diagnostic modality for patients with inguinal hernia. Ultrasound has maximum diagnostic value in patients with difficulties in the clinical diagnosis of inguinal and femoral hernias. It allows for precise measurement of the hernia ring dimensions, characterization of the hernia contents, diagnosis of spermatic cord lipoma and contralateral hernia protrusion, and differential diagnosis with other pathological conditions. The sensitivity and specificity of ultrasound in routine practice depend on the experience of the performing physician. Correlation with surgical findings has demonstrated that ultrasound has a sensitivity of 33% and specificity of 100% [45,47,48,49,50,51]. In strangulated inguinal/femoral hernia complicated by intestinal obstruction, abdominal ultrasound may reveal dilated bowel loops and pendular peristalsis.

• In cases of an unclear clinical picture and dubious soft tissue ultrasound findings, abdominal CT is recommended as an additional diagnostic method to detect occult inguinal/femoral hernia [39,52,53,54].

GCR ALEL 2Grade of Recommendation – A. Level of Evidence – 2.

Comment: CT is advisable to use in patients with severe obesity, rare forms and recurrences of hernia formations, and previous multiple abdominal surgeries. Non-contrast CT provides an overall accuracy of 94% [39,52,53,54].

• Abdominal MRI is recommended for patients with suspected inguinal hernia as an additional data source when ultrasound and CT results are insufficiently informative in the presence of occult inguinal/femoral hernia [52,55,56,57].

GCR BLEL 2Grade of Recommendation – B. Level of Evidence – 2.

Comment: Abdominal MRI utilizing the Valsalva maneuver is most informative for the differential diagnosis of pelvic hernias from musculoskeletal disorders and for diagnosing adhesions in the abdominal cavity. MRI has a specificity and sensitivity of over 94% in diagnosing inguinal hernias. It can diagnose tumors and sliding hernias of the urinary bladder [52,55,56,57].

2.5 Other Procedures

• In patients with giant inguinoscrotal hernias, functional diagnostic methods (assessment of unforced respiratory volumes and flows, pneumotachometry, echocardiography) are recommended to determine operative and anesthetic risk and to select the method of anesthesia and surgery [5,6].

GPP CLoE 5Level of Recommendations — C. Level of Evidence — 5.

• Diagnostic laparoscopy is recommended for strangulated inguinal/femoral hernias in cases of unclear acute abdominal pathology accompanied by deterioration of the general condition and the appearance of peritoneal signs [58,59].

GPP CLoE 4Level of Recommendations — C. Level of Evidence — 4.

Comment: Laparoscopy is recommended as a standalone procedure or as an alternative to diagnostic laparotomy to assess the extent and nature of damage and the condition of a spontaneously reduced bowel loop in the following cases: 1. strangulation of less than 2 hours, or suspected Richter's hernia, "false" reduction, or retrograde strangulated hernia; 2. strangulation of more than 2 hours, without clinical and instrumental signs of complicated strangulated hernia; 3. post-strangulation state (spontaneous reduction), if the fact of strangulation is unquestionable and the duration of strangulation was 2 hours or more [58,59].

• Differential diagnosis of inguinal hernias is recommended with inguinal lymphadenitis, soft tissue neoplasms, inflammatory infiltrate and abscess, endometrioid cyst, aneurysm, varicose vein transformation, and testicular ectopia [5,48,56,60].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

• Femoral hernias should be differentiated from lipoma, enlarged lymph nodes (including Rosenmüller-Pirogov node), tumor metastases, retroperitoneal lymphangioma extending into the inguinal and further to the femoral region, mesenchymal tumors of the upper third of the thigh, varicose veins of the great saphenous vein of the thigh, cold abscess in spinal tuberculosis, and femoral artery aneurysm [6].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

The strategy for treating inguinal and femoral hernias is surgical hernioplasty. Previously, the rationale for recommending surgery was the necessity to prevent internal organ strangulation. Currently, the rationale for surgical intervention for inguinal/femoral hernia is the treatment of existing or future symptoms, rather than solely the prevention of strangulation [42].

3.1. Conservative management

• Conservative treatment in the form of truss wear and watchful waiting is recommended only for patients with inguinal/femoral hernias who have absolute contraindications to surgery [38,62,63].

GPP CLoE 4Level of Recommendations — C. Level of Evidence — 4.

Comment: There are no effective methods of conservative treatment for inguinal/femoral hernias. Conservative measures (wearing a truss, physical activity restriction, dietary restrictions, laxative use) are aimed at reducing the likelihood of inguinal/femoral hernia complications, but not at their treatment. According to EHS guidelines, a watchful waiting strategy is safe and acceptable in men with asymptomatic inguinal hernias or hernias characterized by minimal symptoms. There is a high probability (>70%) that symptoms will progress over time and necessitate surgical intervention. In men with asymptomatic inguinal hernias or inguinal hernias with minimal symptoms, a watchful waiting strategy is recommended, especially in older age or in the presence of severe comorbid disease [38].

• In the case of strangulated inguinal/femoral hernia, conservative treatment is not recommended [14].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

Comment: In some cases, patients who have some experience in reducing their own hernia make repeated and often rather forceful attempts to reduce the strangulated hernia at home. Much less frequently, a physician makes such an error. As a result, a condition known as false reduction may occur, or a non-viable segment of the bowel may be displaced into the abdominal cavity, which is one of the extremely severe complications of this disease.

Possible variants of "false reduction": 1. In a multi-chamber hernia sac, strangulated contents may be displaced from one chamber to a deeper one, most commonly into the properitoneal tissue; 2. The entire hernia sac may be detached from surrounding tissues and reduced along with the strangulated organs into the abdominal cavity or properitoneal tissue; 3. There is a possibility of avulsion of the neck of the hernia sac, both from the body of the sac and from the parietal peritoneum. In this case, the strangulated organs are "reduced" into the abdominal cavity or properitoneal tissue.

It should be noted that the consequence of forceful reduction can be rupture of the strangulated bowel [14].

3.2. Surgical treatment

• Surgical treatment of inguinal/femoral hernia is recommended to be tailored to patient and hernia characteristics, surgeon expertise, and the resources of the medical institution. It is recommended to choose from the following surgical approaches: open tissue repair of inguinal-femoral hernia (autoplasty), open tension-free mesh repair of inguinal-femoral hernia, or video-endoscopic repair of inguinal-femoral hernia [40, 41].

GCR CLOCE 5Grade of Clinical Recommendation – C. Level of Clinical Evidence – 5.

Comment: Surgical treatment of inguinal hernia (IH) using mesh implants primarily involves the open Lichtenstein technique and endovideosurgical technologies, which are represented by two types of surgical interventions: transabdominal preperitoneal (TAPP) repair and total extraperitoneal (TEP) repair. Surgical treatment of IH using mesh implants via open access and endovideosurgical technologies are comparable in terms of the rate of early complications and recurrence, except for large (irreducible) inguinoscrotal hernias, for which open access is preferred [38,40,43].

Surgeries for femoral hernias are performed via femoral, inguinal, and endovideosurgical approaches. Procedures performed via open approaches are classified as anterior repairs, and endovideosurgical ones as posterior repairs. In open surgery, the femoral canal is closed using sutures placed between the inguinal ligament and Cooper's ligament, narrowing the space through which the hernial sac emerges; a mesh is also placed on the anterior wall or the femoral canal is filled with a synthetic plug using the Plug and Patch technique [64]. The question of whether to use a flat mesh or a 3D mesh device (Plug and Patch technique) in open femoral hernia repair has been investigated repeatedly [65, 66, 67]. Significantly better results regarding recurrence, postoperative pain, and foreign body sensation were obtained with preperitoneal flat mesh repair compared to 3D mesh repair [67]. Endovideosurgical methods for treating femoral hernias include laparoscopic (transabdominal) preperitoneal repair of the myopectineal orifice (TAPP) and total extraperitoneal repair of the myopectineal orifice (TEP) [62, 67].

The difference in approaches between endoscopic techniques provides a theoretical advantage in favor of TAPP, where it is easier to identify anatomical landmarks by starting the operation with diagnostic laparoscopy. In this regard, the presence and type of a hernia on the contralateral side can be identified before dissection begins. At the same time, TEP does not require opening and closing the peritoneum during hernioplasty. Studies comparing TAPP and TEP show similar complication rates in terms of seromas, scrotal edema, testicular atrophy, bladder injury, inguinal nerve injury, chronic pain, and recurrence. Complications directly related to the surgical access may vary. With TAPP, there is an increased risk of visceral injuries, whereas with TEP, the risk of vascular injuries is increased. The average incidence of bowel injury is about 0.1% and does not statistically differ from that of open surgery. The average incidence of bladder injury is also about 0.1%, which is statistically greater than in open surgery. The average incidence of major vascular injury is estimated at approximately 0.09% and does not statistically differ from that of open surgery [56].

• In the surgical treatment of femoral hernia without mesh implant (inguinal-femoral hernia repair), it is recommended to use the Lockwood, Bassini, and Rives-Parlavecchio techniques. When choosing a non-mesh inguinal hernia repair method, the Shouldice operation is recommended as the preferred choice [31, 40, 43, 68].

GCR CLOCE 5Grade of Clinical Recommendation – C. Level of Clinical Evidence – 5.

Comment: Compared to non-mesh hernioplasty methods, mesh-based techniques have a lower recurrence rate and an equal risk of postoperative pain. There is no convincing evidence that mesh implants cause more severe chronic pain.

Unlike inguinal hernia surgery, tissue-based repair for femoral hernia remains a common treatment method. A cohort study conducted by a specialized hernia center showed no significant differences in recurrence rates between auto- and alloplasty for femoral hernias [69], although some studies show that recurrence and reoperation rates after mesh repair were significantly lower [28, 65].

It remains unclear whether it is appropriate to compare the outcomes of the Shouldice technique, typically performed by highly skilled surgeons and/or in specialized centers, with the Lichtenstein procedure, which is generally performed by general surgeons with varying levels of experience [40, 70].

• Open mesh repair of inguinal-femoral hernia is recommended primarily for elderly patients with inguinal hernias [30, 31, 38, 43, 71, 72, 73].

GCR ALOCE 1Grade of Clinical Recommendation – A. Level of Clinical Evidence – 1.

Comment: Open surgery for inguinal hernia consists of separating the hernial sac from the anatomical structures of the spermatic cord, reducing the hernia contents, resection or reduction of the hernial sac, and repair and/or reinforcement of the fascial defect of the posterior wall of the inguinal canal with synthetic material (polypropylene mesh). The use of other implants to replace the standard flat mesh in the Lichtenstein technique is not currently recommended [38]. The Lichtenstein procedure can be performed under local, spinal, epidural, and general anesthesia, depending on the patient's condition and preference, and the setting of the procedure (inpatient or outpatient). The anesthesia method should be considered individually for each patient with an inguinal hernia.

• Open mesh repair of inguinal-femoral hernia is recommended for patients with large inguinoscrotal hernias and when general anesthesia is contraindicated [30, 38, 43, 71, 73].

GCR CLOCE 4Grade of Clinical Recommendation – C. Level of Clinical Evidence – 4.

• Local anesthesia for open mesh repair of inguinal-femoral hernia is recommended provided that the surgeon is experienced in this technique [6, 74, 75].

GGR CLOE 5Grade of Recommendations — C. Level of Evidence — 5.

Comment: Properly performed local anesthesia may be preferable to regional and general anesthesia in debilitated patients with severe systemic diseases. Local anesthesia has been shown to be associated with improved ventilation and oxygenation compared to general and regional anesthesia [75]. To ensure an adequate postoperative course and early mobilization of outpatients, it is advisable to use combined anesthesia techniques involving long-acting local anesthetics. Premedication, regional nerve blocks, and fascial compartment blocks significantly reduce the total dose of anesthetics administered during total intravenous anesthesia and often allow for the complete avoidance of opioid analgesics in the postoperative period. This serves as prevention of complications affecting the central nervous system (depression, senile psychoses), cardiovascular system (tachycardia, rhythm disorders, coronary ischemia), respiratory system, immune system, and others [40].

• For young patients with inguinal/femoral hernias, video-endoscopic inguinal-femoral hernia repair is recommended [28, 40, 41, 43, 60, 76].

GCR CLOCE 5Grade of Clinical Recommendation – C. Level of Clinical Evidence – 5.

Comment: Given the availability of resources and expertise, endoscopic techniques accelerate recovery, reduce the risk of chronic pain, and are cost-effective. Endoscopic inguinal hernia repair is the preferred approach for young, active patients, as they benefit most from the rapid recovery it provides. Endoscopic hernioplasty can be performed for all inguinal and femoral hernias, whether unilateral or bilateral, primary or recurrent. Endoscopic hernioplasty in patients after radical prostatectomy or cystectomy, with inguinoscrotal hernia, ascites, or undergoing peritoneal dialysis, as well as in cases of repeat endoscopic hernioplasty, should be performed by a surgeon with extensive experience in endoscopic inguinal hernia repair. Endoscopic inguinal hernia repair is associated with less postoperative pain compared to open hernioplasty, although differences in pain perception usually resolve within the first 6 weeks postoperatively. Endoscopic hernioplasty is more expensive than open inguinal/femoral hernia repair. The increased cost is notably due to the need for specialized equipment and general anesthesia [40,43,76,77].

• If a occult contralateral hernia is detected during video-endoscopic groin hernia repair (TAPP) for unilateral inguinal/femoral hernia, bilateral hernioplasty is recommended. However, this is not recommended when performing video-endoscopic totally extraperitoneal (TEP) groin hernia repair [40,43].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

Comment: Considering that the disease course in most patients with asymptomatic inguinal hernia may progress to symptomatic, an occult contralateral hernia discovered during endoscopic repair of a symptomatic unilateral hernia can be repaired during the same surgical procedure. This is only possible if this treatment option was discussed preoperatively and informed consent was obtained from the patient [40,43].

• During video-endoscopic surgical treatment of a unilateral inguinal/femoral hernia in the absence of an inguinal hernia on the contralateral side, prophylactic placement of a mesh implant on the opposite side is not recommended [43,76,77].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

• Video-endoscopic surgical treatment of inguinal/femoral hernia is recommended for patients with bilateral hernias [16,43,76,77].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

Comment: According to the EAES expert panel statement, endoscopic hernioplasty is ideal for patients with bilateral inguinal hernias, as access to both hernias is achieved through three small incisions, whereas open hernioplasty requires a large incision for each hernia [43].

• When a diagnosis of strangulated inguinal/femoral hernia is established, emergency surgical treatment is recommended to relieve ischemia of the strangulated internal organs as soon as possible after the patient's admission to the hospital (A16.30.001 Surgical treatment of inguinal/femoral hernia, A16.30.001.001 Surgical treatment of inguinal/femoral hernia using video-endoscopic technologies, A16.30.001.002 Surgical treatment of inguinal/femoral hernia using mesh implants) [5,6,27,39,40,43].

GGR CLOE 5Grade of Recommendations — C. Level of Evidence — 5.

Comment: All diagnostic procedures must be performed as quickly as possible. Preoperative preparation includes bladder emptying, hygienic preparation of the surgical site, placement of a nasogastric tube and evacuation of gastric contents, and antibiotic prophylaxis 30 minutes prior to surgery. In severe patient conditions, intensive preoperative preparation is carried out in the ICU or intensive care unit. Preoperative preparation can also be performed on the operating table. The main objectives of surgery for an uncomplicated strangulated inguinal/femoral hernia are the elimination of strangulation, assessment of the viability of the strangulated organ, and repair of the hernia defect. If there are doubts about bowel viability, it is permissible to postpone the decision on resection using planned relaparoscopy or diagnostic laparoscopy after 12 hours. Resection of the bowel, if non-viable, is performed according to standard principles [5,6,27,39,40,43].

• Surgery for a strangulated inguinal/femoral hernia is recommended to be performed under combined endotracheal anesthesia [5,6,39,40,43].

GPP CLoE 5Level of Recommendations — C. Level of Evidence — 5.

• In cases of spontaneous reduction of a strangulated inguinal/femoral hernia with a strangulation duration of less than 2 hours, it is recommended to transfer the patient to the surgical department for dynamic observation [40,43].

GGR CLOE 5Grade of Recommendations — C. Level of Evidence — 5.

• In case of self-reduction of an incarcerated hernia with an incarceration duration of more than two hours, diagnostic laparoscopy is recommended [40,43,78].

GGR CLOE 5Grade of Recommendations — C. Level of Evidence — 5.

• If the patient's condition deteriorates and peritoneal symptoms appear during dynamic observation, diagnostic laparoscopy is recommended [40,43,78].

GPP CLoE 5Level of Recommendations — C. Level of Evidence — 5.

• In incarcerated inguinal/femoral hernia complicated by phlegmon of the hernia sac, it is recommended to begin the surgery with a midline laparotomy [5,6,27,39,40,43].

GGR CLOE 5Grade of Recommendations — C. Level of Evidence — 5.

Comment: In case of small bowel incarceration, its resection with anastomosis is performed. The method of completing large bowel resection is decided on an individual basis. The ends of the bowel to be removed are closed tightly and isolated from the abdominal cavity. Then herniotomy is performed. The incarcerated necrotic part of the bowel is removed through the herniotomy incision. Primary hernioplasty is not performed; the purulent wound is drained. Placement of a nasointestinal tube is performed according to indications. The surgery ends with drainage of the abdominal cavity [5,6,27,39].

• For irreducible and incarcerated inguinal/femoral hernias, performing surgical treatment using video-endoscopic technologies is recommended only by a surgeon with extensive experience in performing this surgery [40,76,77,78].

GGR CLOE 5Grade of Recommendations — C. Level of Evidence — 5.

Comment: In general, the endoscopic approach in cases of incarcerated inguinal/femoral hernias allows for laparoscopic revision of the abdominal cavity in all patients and, therefore, can prevent missing existing bowel ischemia. In selected cases, diagnostic laparoscopy followed by endoscopic hernioplasty appears preferable. At the same time, an increase in operative time should be expected compared to intervention for an uncomplicated inguinal hernia. In most cases, under conditions of myorelaxation and pneumoperitoneum, reduction of the hernia contents into the abdominal cavity occurs with minimal intra-abdominal traction. Division of the hernia ring is best performed after partial mobilization of the preperitoneal space in the superolateral direction for an indirect hernia and in the superomedial direction for a direct hernia. If there are doubts about the viability of the incarcerated organ, the final assessment can be made after completing the plasty and closure of the peritoneum. Resection of a non-viable organ can be performed both extracorporeally and intracorporeally. The presence of peritonitis or soft tissue infection of the inguinal region against the background of bowel necrosis should prompt the surgeon to refrain from performing TAPP due to the high risk of infectious complications [27,77,78].

3.3. Antibiotic Prophylaxis

Extensive studies have been conducted on the efficacy of systemic antibiotic prophylaxis in reducing the incidence of postoperative surgical site infections during open inguinal/femoral hernia repair. A Cochrane systematic review on this topic was published in 2012. It was concluded that universal recommendations regarding systemic antibiotic prophylaxis cannot be given; nor can the abandonment of their use be recommended in settings with a high infection rate [80].

• When performing open hernioplasty in patients at low risk for infectious complications in surgical departments with a low rate of wound infections, antibiotic prophylaxis is not recommended [40,43,81,82,83,84,85].

GOM ALOE 1Grade of Recommendation – A. Level of Evidence – 1.

Comment: In open hernioplasty in patients at low risk for infectious complications in centers with a low rate of wound infections, antibiotic prophylaxis does not lead to a significant reduction in the number of wound infections.

• When performing open hernioplasty in surgical departments with a high rate of wound infections (>5%), antibiotic prophylaxis is recommended [40,43,81,82,83,84,85].

GOM ALOE 1Grade of Recommendation – A. Level of Evidence – 1.

Comment: Antibiotic prophylaxis does not reduce the incidence of wound infections in open mesh repair in patients with primary IH/FH. In modern clinical practice, there are no indications for the mandatory use of antibiotic prophylaxis during elective open repair for IH/FH. In the presence of risk factors for wound infection in patients (recurrent hernia, advanced age, immunosuppressive states, diabetes mellitus), antibiotic prophylaxis is mandatory [36,56,63].

• Routine antibiotic prophylaxis for elective surgical treatment of inguinal and femoral hernia using video-endoscopic techniques is not recommended [40,43,81,86,87].

GOM ALOE 1Grade of Recommendation – A. Level of Evidence – 1.

3.4. Prophylaxis of Thromboembolic Events

• Prevention of thromboembolic events during surgery for IH/FH is recommended taking into account the risk factors of each individual patient [88].

AC RLEL 3Level of recommendations rating – B. Level of evidence reliability – 3.

• Postoperatively, for the prevention of thromboembolic complications, is recommended to mobilize the patient as quickly as possible, use compression stockings during surgery and in the postoperative period, and administer low-molecular-weight heparins (ATC heparin group) at prophylactic doses recommended by the manufacturer for patients in the corresponding risk category [88].

AC RLEL 3Level of recommendations rating – B. Level of evidence reliability – 3.

3.5. Complications of Surgical Treatment of Inguinal/Femoral Hernias

The most common short-term postoperative complication is hematoma or seroma formation.

• Small hematomas formed after hernioplasty are recommended to be managed conservatively. For hematomas causing pain, it is recommended to perform soft tissue puncture with blood aspiration under local anesthesia. In the presence of a tense hematoma after an open surgery, it is recommended to perform surgical drainage/incision of the soft tissue hematoma [71,89,90].

GPP CLoE 4Level of Recommendations — C. Level of Evidence — 4.

Comment: The incidence of inguinal hematomas is lower after endoscopic repair compared to open surgery. In open surgery, the risk of hematoma ranges from 5.6% to 16%. With endoscopic techniques, the risk ranges from 4.2% to 13.1% [71,89,90,91].

• Seromas formed after IH/FH hernioplasty are not recommended to be punctured [8,71,89,92,93].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

Comment: The risk of seroma formation ranges from 0.5% to 12.2%. The incidence of this complication is higher after endoscopic repair. It is important to inform patients about the possibility of seroma formation after surgery, as it is a frequent adverse event. Patients may mistake the swelling in the surgical area resulting from seroma formation for a persistent inguinal hernia and assume the surgery was unsuccessful. However, the occurrence of a seroma is usually clinically insignificant. Most seromas resolve spontaneously within 6–8 weeks. If the seroma persists, it must be aspirated [71,78,89,94,97].

• In the case of mesh infection after endoscopic surgery, its removal is not recommended [71,89,90,96].

GPP CLoE 4Level of Recommendations — C. Level of Evidence — 4.

Comment: The use of a mesh implant is not associated with a higher risk of wound infection. After endoscopic repair, the estimated risk of infection is less than 1%, and after open surgery, it is 1.3%. Drainage and antibiotic therapy are usually sufficient [71,89,90,91].

• To prevent chronic postoperative pain, it is recommended to identify and isolate the inguinal nerves during open surgery [91,96,97].

GGR CLOE 5Grade of Recommendations — C. Level of Evidence — 5.

Comment: Pain lasting more than 3 months after surgery is considered chronic. Chronic pain is observed in 10-12% of patients after inguinal hernioplasty. The risk of chronic pain is lower after laparoscopic surgery compared to open surgery. The risk of chronic pain after open mesh placement is lower than after tissue hernioplasty without a mesh. The risk of chronic pain decreases with age [43,90,91,96,97].

3.6. Specifics of Surgical Treatment for Recurrent Inguinal and Femoral Hernias

Main causes of IH/FH recurrences

Recurrences of IH after surgical treatment are reported in 0.9 to 5.25% of cases according to various sources. Mesh-based repairs are characterized by a lower recurrence rate. Predisposing factors include the use of an inappropriately small mesh implant and technical errors in its fixation. The risk of recurrent hernia increases with postoperative purulent-inflammatory complications and when operating for recurrent IH (the more prior hernia recurrences in anamnesis, the higher the risk of a new recurrence). Mesh migration is one of the causes of recurrence. Mesh displacement can occur due to insufficient or improper fixation. Cases of mesh migration into the lumen of the urinary bladder and large intestine have been described [40,91,98].

• To prevent IH/FH recurrence, it is recommended to place a mesh implant that overlaps the internal inguinal ring by 4 cm, Hesselbach's triangle by 3 cm, and the pubic tubercle by 2 cm, while the Myopectineal orifice of Fruchaud (or corresponding opening) should match the diameter of the spermatic cord [77,91,98,99,100].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

Comment: The best solution to this situation is to use standard prosthetic meshes for inguinal hernioplasty rather than self-cut prostheses smaller than 7x12 cm.

Contributing factors for recurrent IH are the same as for other variants of anterior abdominal wall hernias: increased intra-abdominal pressure resulting from postoperative intestinal paresis, early intestinal obstruction (most commonly adhesive), concomitant diseases (COPD, benign prostatic hyperplasia), early excessive physical exertion, etc. [40].

• In the surgical treatment of inguinal and femoral hernias using video-endoscopic techniques (TAPP), it is recommended to use a mesh implant measuring at least 10x15 cm [43,76,77,101].

GPP CLoE 4Level of Recommendations — C. Level of Evidence — 4.

Comment: The use of a smaller implant is a risk factor for hernia recurrence. In cases of large hernia defects (>3-4 cm in direct hernias and >4-5 cm in indirect hernias), it is advisable to use a larger mesh implant, e.g., 12x17 cm [77]. The recurrence rate after endoscopic surgery remains consistently low and does not exceed 5% [43,76,77].

• In case of IH recurrence, it is recommended to use posterior inguinal hernioplasty (surgical treatment of inguinal and femoral hernias using video-endoscopic techniques (TAPP, TEP)) if anterior inguinal hernioplasty (surgical treatment of inguinal and femoral hernias using mesh implants (Lichtenstein procedure)) was previously performed [43,77,98].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

Comment: When hernia recurs after traditional open repair, employing an endoscopic approach results in reduced postoperative pain and faster rehabilitation [40,43,77].

• Surgical treatment using mesh implants (Lichtenstein procedure) is recommended for recurrent IH after surgical treatment using video-endoscopic techniques (TAPP, TEP) [40,43,77].

GPP CLoE 5Grade of Recommendation – C. Level of Evidence – 5.

Comment: For recurrent hernias, it is preferable to use a new, previously unutilized approach. Re-operating through an incision in the groin increases the risk of bleeding and wound infection, as well as nerve and spermatic cord injury. The posterior approach (from the abdominal cavity) does not go through scar tissue, allowing easier isolation of the hernia sac and hernioplasty during endoscopic surgery. In case of hernia recurrence after endoscopic surgery, an open inguinal approach should be chosen [40,43].

• Surgery for multiple hernia recurrences, chronic postoperative pain, or mesh infection is recommended to be performed by a surgeon experienced in managing complex IH/FH [43,98].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

3.7. Outpatient Management

The primary goal of outpatient treatment for patients with IH/FH is their active occupational and social rehabilitation, implying a prompt return to their usual lifestyle and previous work activities.

• For better social and occupational rehabilitation, patients with uncomplicated IH/FH are recommended to undergo surgical treatment in an ambulatory surgical unit [40,43,102].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

Comments: Most patients with uncomplicated inguinal/femoral hernias can be operated on in an outpatient setting just as safely and effectively as in inpatient settings, while being more cost-effective. Contraindications to outpatient treatment include a combination of reasons requiring direct physician monitoring of the patient for more than 24 hours: severe comorbid pathology, psycho-emotional, and social aspects. Inguinal/femoral hernia repair in a day surgery unit, provided appropriate technical equipment and the surgeon's experience, can be performed using any existing method of inguinal hernioplasty. The feasibility of performing surgery in a day surgery unit should be considered individually for each patient. Selected elderly patients may also undergo outpatient surgical treatment (surgical treatment of inguinal and femoral hernias using mesh implants under local anesthesia) [40,43,102].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

• On the first day after surgery for an uncomplicated inguinal/femoral hernia, in addition to analgesia with non-narcotic analgesics (in accordance with ATC: N02B Other analgesics and antipyretics), male patients are recommended to use a special scrotal support or briefs to keep the scrotum elevated. All patients are recommended early ambulation and slow walking within the ward [6,39,40].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

Comments: Surgical treatment of inguinal/femoral hernias in an outpatient setting promotes earlier rehabilitation. The periods of postoperative rehabilitation are quite variable and are determined not only by the nature of the surgical intervention performed, but also by the patient's pre-operative level of physical activity, concomitant diseases, and the severity of persistent pain syndrome [40,102]. Therefore, the decision on restricting physical activity is made individually. The average period of occupational rehabilitation in patients with an uncomplicated postoperative course can range from 1 to 2 months.

• In cases of incarcerated inguinal/femoral hernia, it is recommended to continue patient treatment in the intensive care unit in the first days of the postoperative period. Indications for transfer to the surgical ward are determined by the critical care specialist jointly with the surgeon [79].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

Comments: General common elements of treatment for this category of patients include: adequate analgesia; prevention and treatment of respiratory and cardiovascular failure; detoxification therapy, management of water-electrolyte and acid-base balance disorders; prevention and treatment of infectious complications; prevention and treatment of erosive and ulcerative lesions of the stomach and duodenum; restoration of gastrointestinal motility; hyperbaric oxygen therapy; enteral therapy if a nasointestinal tube is in place; therapeutic physical exercise and the earliest possible mobilization of the patient with mandatory abdominal binding. The scope and intensity of therapy are prescribed by the critical care specialist in accordance with the protocols recommended by the Association of Anesthesiologists and Intensivists.

• Patients who have undergone surgery for incarcerated inguinal/femoral hernia are recommended: follow-up by a surgeon at the outpatient clinic; wearing an abdominal binder for 2–4 months; restriction of physical activity on the abdominal wall for 6 months; in case of delayed abdominal wall repair – elective hospitalization for hernia elimination no earlier than 3–6 months after surgery and resolution of wound infection complications [14,27].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

5. Prevention and Dispensary Observation

There are no reliable methods for the prevention of inguinal/femoral hernias, as there are no ways to influence the predisposing causes of the disease.

• To prevent hernia recurrence in the postoperative period, patients are recommended to quit smoking, limit prolonged and heavy physical labor, and prevent and treat COPD, prostatitis, and constipation [40,43].

GPP CLE 5Grade of Recommendation – C, Level of Evidence – 5.

• Dispanserization (clinical follow-up) is recommended for unoperated patients with inguinal/femoral hernias who have severe comorbidities or refuse surgical intervention [40].

GPP CLE 5Grade of Recommendation – C, Level of Evidence – 5.

Comments: Given the high risk of recurrence, operated patients with recurrent hernias may constitute a special clinical follow-up group [77,91,96,97].

• Dispanserization visits (examination, consultation) by a surgeon for a patient after inguinal/femoral hernia surgery are recommended at least once a year for 3 years [91,98,103].

Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.

Comments: The clinical follow-up visit (examination, consultation) includes taking the patient's history, examination and palpation of the inguinal region, and, if necessary, ultrasound examination of soft tissues and abdominal organs (comprehensive) [91,98,103].

6. Organization of Medical Care

The organization of medical care for patients with inguinal hernias is carried out in accordance with the Procedure for Providing Medical Care to the Adult Population in the Profile "Surgery" (Order of the Ministry of Health of the Russian Federation No. 922n dated November 15, 2012).

Primary specialized health care is provided by a surgeon. Upon suspicion or detection of an inguinal/femoral hernia in a patient, general practitioners, district general practitioners, general practice physicians (family physicians), medical specialists, and mid-level medical personnel shall refer the patient in the established manner for a consultation at the surgeon's office to receive primary specialized health care. If medical care cannot be provided within the framework of primary health care and there are medical indications, the patient is referred to a medical organization providing specialized medical care in the profile "Surgery".

Specialized medical care is provided by surgeons in inpatient and day-care settings and includes the prevention, diagnosis, treatment of diseases and conditions requiring the use of special methods and complex medical technologies, as well as medical rehabilitation.

Surgical treatment of patients with inguinal and femoral hernias can be performed in surgical departments of medical organizations at all levels. In complex inguinal/femoral hernias (multiple recurrences, with endoprosthesis infection), in patients with concomitant diseases, including cardiovascular and respiratory systems, diabetes mellitus, or when there are indications for simultaneous operations, it is advisable to perform surgical treatment in surgical departments of third-level medical organizations.

Indications for planned hospitalization:

Presence of a diagnosis of uncomplicated inguinal/femoral hernia for elective surgical intervention.

Indications for emergency hospitalization:

Presence of a diagnosis of complicated inguinal/femoral hernia (incarceration, intestinal obstruction) for emergency surgical intervention.

Indications for patient discharge from the hospital:

Patient mobilization after surgery, absence of complications from the postoperative wound, internal organs, and body systems.

7. Additional Information

Not provided.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

Belokonev V.I., Doctor of Medical Sciences, Professor (Samara)

Blagovestnov D.A., Doctor of Medical Sciences, Professor (Moscow)

Gogia B.Sh., MD, PhD (Moscow)

Gorsky V.A., MD, PhD, Professor (Moscow)

Gulyaev A.A., Doctor of Medical Sciences, Professor (Moscow)

Ermakov N.A., Candidate of Medical Sciences (Moscow)

Zhdanovsky V.V., Candidate of Medical Sciences (Surgut)

Ivanov I.S., MD, PhD, Professor (Kursk)

Ivanov S.V., Doctor of Medical Sciences, Professor (Kursk)

Ilchenko F.N., Doctor of Medical Sciences, Professor (Simferopol)

Kabanov E.N., PhD in Medicine, Associate Professor (Yaroslavl)

Kovaleva Z.V., PhD in Medicine (Samara)

Lebedev N.N., Doctor of Medical Sciences, Professor (Moscow)

Matveev N.L., MD, PhD, Professor (Moscow)

Narezkin D.V., Doctor of Medical Sciences, Professor (Smolensk)

Olovyanny V.E., MD, PhD (Moscow)

Parshikov V.V., MD, PhD (Nizhny Novgorod)

Presnov K.S. (Moscow)

Protasov A.V., Doctor of Medical Sciences, Professor (Moscow)

Pushkin S.Yu., MD, PhD, Associate Professor (Samara)

Rybachkov V.V., MD, PhD, Professor (Yaroslavl)

Rutenburg G.M., MD, PhD, Professor (St. Petersburg)

Samartsev V.A., MD, PhD, Professor (Perm)

Struchkova A.D., PhD in Medicine (Moscow)

Kharitonov S.V., Doctor of Medical Sciences, Associate Professor (Moscow)

Cherepanin A.I., Doctor of Medical Sciences, Professor (Moscow)

Chernykh A.V., Doctor of Medical Sciences, Professor (Voronezh)

Shestakov A.L., MD, PhD (Moscow)

Shikhmetov A.N., Doctor of Medical Sciences (Moscow)

Ettinger A.P., MD, PhD, Professor (Moscow)

Yurasov A.V., MD, PhD (Moscow)

There is no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience of the clinical guidelines:

Surgeons

Internists

Ambulance doctors

Evidence gathering methodology:

Methods used for evidence collection/selection:

Search for publications in peer-reviewed journals with an impact factor >0.3;

Electronic database search:

Databases used for evidence collection/selection:

The evidence base for the guidelines includes publications from the Cochrane Library, PubMed, and MEDLINE databases. The search depth was 30 years.

Methods used for evidence analysis:

reviews of published meta-analyses;

systematic reviews with evidence tables.

Methods used for assessing the quality and strength of evidence:

expert consensus;

evaluation of the level of evidence in accordance with the evidence rating scheme (Tables A2.1.–A2.3.).

These clinical guidelines present the levels of certainty of evidence for recommendations in accordance with the draft methodological guidelines for assessing the certainty of evidence and the strength of recommendations of the Center for Expertise and Quality of Medical Care of the Russian Ministry of Health.

In accordance with this draft of recommendations, certain generally accepted diagnostic methods are assigned the level GPP (Good Practice Point) based on expert consensus.

Related Documents

These clinical guidelines were developed taking into account the following regulatory legal documents:

• Order of the Russian Ministry of Health No. 922n dated November 15, 2012, "On Approval of the Procedure for Providing Medical Care to Adults in the Field of Surgery."

• Order of the Russian Ministry of Health No. 203n dated May 10, 2017, "On Approval of Criteria for Assessing the Quality of Medical Care."

Methodology for validation of guidelines

Methods for guideline validation:

external expert review;

internal expert review.

Description of the guideline validation methodology

The recommendations were discussed and approved by leading specialists of specialized federal centers in Russia and practicing physicians. The draft clinical guidelines was reviewed at working group meetings in 2016–2017, and at the National Surgical Congress jointly with the XX Anniversary Congress of the Russian Society of Endoscopic Surgeons (Moscow, April 7, 2017)

Procedure for updating clinical guidelines

Updating is carried out at least once every three years or earlier, taking into account new information on the diagnosis and management of patients suffering from hypersplenism. The decision to update is made by the Russian Ministry of Health based on proposals submitted by medical professional non-profit organizations. The submitted proposals must take into account the results of a comprehensive evaluation of surgical methods, medical devices, and the results of clinical approbation.

Table A2.1. Scale for grading levels of evidence (LE) for diagnostic methods (diagnostic interventions)

Table A2.2. Level of Evidence (LoE) grading scale for preventive, therapeutic, and rehabilitative methods (interventions)

Table A2.3. Grade of Recommendation (GoR) grading scale for preventive, diagnostic, therapeutic, and rehabilitative methods (interventions)

Appendix A3. Reference Materials

None provided.

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

1–2 hours after surgery, the patient can walk independently at a slow pace. Mild pain in the surgical area is possible after the operation. It resolves either spontaneously within a few hours or after taking any painkiller tablet. Male patients are advised to wear a special scrotal support or briefs to keep the scrotum elevated.

Do not lift heavy objects for 2–3 weeks after surgery. The average duration of work recovery and return to sports for patients with an uncomplicated postoperative course ranges from 1 to 2 months.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

None provided.