Incisional ventral hernia: clinical guidelines

List of Abbreviations

IAP – intra-abdominal pressure

GI – gastrointestinal tract

BMI – body mass index

CT – computed tomography

LPIVH – laparoscopic incisional ventral hernia repair

MRI – magnetic resonance imaging

IVH – incisional ventral hernia

PSH – parastomal hernia

US – ultrasound examination

EHS – European Hernia Society

Terms and Definitions

An abdominal wall hernia is a condition in which internal organs protrude from the abdominal cavity along with the parietal layer of the peritoneum.

The main criterion for an incisional hernia is the presence of an abdominal wall defect at the site of a postoperative scar.

External abdominal hernias consist of the hernia ring, hernial sac, hernia contents, and hernia coverings.

The hernia ring is a congenital or acquired defect in the musculo-aponeurotic layer of the abdominal wall.

The hernial sac is a stretched, scar-altered area of the parietal peritoneum that has emerged through the hernia ring. The hernial sac comprises the orifice (the part bordering the abdominal cavity); the neck (the section located within the hernia ring); the body (the main, largest part of the sac); and the fundus (the distal part of the hernial sac). In a sliding hernia, one of the walls of the hernial sac is formed by an organ located mesoperitoneally.

The hernia contents are the internal organs that have emerged from the abdominal cavity and are located within the hernial sac. The contents of the hernial sac may be represented by any abdominal organ, but most frequently by the greater omentum or a loop of the small intestine.

A recurrent incisional hernia is a hernia that appears in the area of a previously performed operation for an incisional hernia.

A parastomal hernia is a protrusion of the abdominal wall tissues resulting from the emergence of abdominal organs in the area of an intestinal stoma.

A trocar-site hernia is a variant of an incisional hernia, representing a musculo-aponeurotic defect of the abdominal wall with a hernial protrusion that occurs after a laparoscopic procedure at the site of trocar insertion, detected by clinical or instrumental examination.

Early complications of hernioplasty are complications that develop within up to 30 days postoperatively. Early complications associated with hernioplasty are divided into general and local. General complications are those associated with the impairment of vital bodily functions, i.e., systemic disorders. Local complications are those that occur directly in the area of the surgical procedure.

Late complications of hernioplasty are complications that develop 30 days or more postoperatively.

An incarcerated hernia is the acute or gradual compression of one or more abdominal organs in the hernia ring, leading

to impaired blood supply and, ultimately, necrosis. Both external (in abdominal wall defects) and internal (in peritoneal recesses, diaphragmatic and pelvic floor openings) hernias can become incarcerated.

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.

Richter's hernia is known in the literature as a partial enterocele. In this condition, the intestine is compressed not across its entire lumen, but only partially, usually in the area opposite its mesenteric border. In this case, mechanical intestinal obstruction does not occur, but there is a real danger of necrosis of the intestinal wall with all the ensuing consequences. Richter's hernia most commonly affects the small intestine, but cases of similar incarceration of the stomach and large intestine have been described. This type of incarceration never occurs in large hernias; it is characteristic of small hernias with narrow hernia rings (femoral hernia, umbilical hernia, hernia of the linea alba).

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

According to the definition of the European Hernia Society (EHS), an incisional ventral hernia (IVH) is any abdominal wall defect, with or without a hernial protrusion, occurring at the site of a postoperative scar following abdominal surgery, detected by clinical examination or imaging.

The constituent elements of a hernia are: the hernia ring, the hernial sac, the hernia contents, and the hernia coverings. There are cases where a distinct hernia ring is absent, but the muscular layer is missing over a large extent of the abdominal wall, causing the scar-altered aponeurotic layer to gradually begin protruding under the influence of intra-abdominal pressure.

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

The causes of incisional ventral hernias are diverse. The surgical technique of laparotomy closure and postoperative wound infection are considered the most important causal factors increasing the risk of incisional hernia formation.

The occurrence of incisional hernias within the first year after surgery is most often caused by early postoperative complications (suppuration of the postoperative wound, evisceration), which, in turn, may develop due to an unjustified choice of surgical access, traumatic operating, poor hemostasis, suturing of heterogeneous tissues, placement of excessively tight or loose sutures on aponeurotic structures, improper choice of suture material, bringing out tampons and drains through the main wound, poor postoperative wound care, inadequate choice of antibiotic therapy, etc. [1,2]. Important etiological factors leading to the development of incisional hernias within the first year after surgery include conditions and diseases that contribute to increased intra-abdominal pressure: psychological agitation, coughing, intestinal paresis, chronic constipation, difficulty urinating, etc. [3].

Factors contributing to an increased risk of incisional hernias include male sex, elevated BMI, advanced age, diabetes mellitus, jaundice, anemia, the use of vasopressor drugs, and smoking [4]. Postoperative respiratory failure, aneurysmal disease, chronic malnutrition, administration of hormonal drugs, renal failure, oncological diseases, multiple surgeries through the same access, chronic obstructive pulmonary disease, benign prostatic hyperplasia, and ascites also lead to the development of incisional hernias.

Impaired collagen metabolism and diastasis of the rectus abdominis muscles predispose to the development of incisional hernias at later stages. The causes of hernias at these stages are often impaired collagen synthesis associated with obesity, cachexia, advanced age, anemia, hypoproteinemia, oncological diseases, liver diseases, diabetes mellitus, etc. [2,5,6,7].

It has been confirmed that the aforementioned risk factors influence the number of repeated recurrences. When planning surgery, counseling the patient regarding the expected postoperative course, and predicting long-term recurrence, these risk factors must be taken into account. Nevertheless, the main factors are: an unjustified choice of hernioplasty technique during the primary surgery, incorrect sizing of the mesh implant, and poor technical execution of the surgery [1,2,3].

After small hernias form on the abdominal wall, they increase in size over time due to the constant impact of intra-abdominal pressure, contraction of the diaphragm, and muscles of the anterolateral abdominal wall. As a result, abdominal organs shift through the abdominal wall defect, enlarging the latter and forming a hernial protrusion.

Multivariate analysis showed that an increased risk of trocar-site hernia is promoted by a larger incision size, wound infection, diabetes mellitus, and obesity [8, 9, 10]. The risk of trocar-site hernias is high when using a Hasson cannula or a single-incision access trocar [11, 12].

The pathogenesis of hernia incarceration has been studied quite thoroughly. Common to all types of incarceration are characteristic dynamic changes [1,2,3,13]. As a result of compression (strangulation) within the particularly narrow hernia ring, ischemia of the incarcerated organs develops. Compression of the nerve elements of the incarcerated organ and, in particular, the mesentery of the intestine leads to severe pain syndrome. Pain causes persistent spasm of the anterior abdominal wall muscles, which exacerbates the incarceration of the hernia contents up to necrosis. At the moment of incarceration, a closed cavity is formed in the hernia sac, containing an organ or organs whose blood supply is impaired. At the site of compression of the intestinal loop, omentum, and other organs, a strangulation furrow is formed, which remains clearly visible even after the reduction of the incarceration. If an intestinal loop is incarcerated, venous stasis initially occurs in it, which soon causes edema of all layers of the intestinal wall. The incarcerated intestinal loop undergoes necrosis quite rapidly, within a few hours (in elastic incarceration), starting from the mucosa. This fact must be borne in mind when the viability of the intestine is assessed solely by the appearance of its serosa.

During incarceration, 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, distending it, and its wall becomes markedly thinned. Blood circulation in arterioles and capillaries is impaired. Intra-abdominal pressure increases, which at levels above 20 mmHg can lead to the development of the so-called abdominal compartment syndrome—multiple organ dysfunction syndrome [2,3]. The longer the duration of incarceration, 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 incarceration zone [13].

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 incarceration is accompanied by early vomiting. Early recurrent vomiting rapidly leads to dehydration, loss of vital electrolytes and proteins. In the closed lumen of the ischemic intestine, the decomposition of intestinal contents begins, characterized by the production of toxins. Simultaneously, plasma transudation and diapedesis of formed blood elements occur both into the lumen of the incarcerated 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 formed blood elements enter and undergo destruction, the hernia water acquires a pink, and then red-brown color. The necrotic intestinal wall ceases to act as a barrier to the escape of microbial flora beyond it. The exudate acquires a purulent character with an unpleasant odor. Inflammation spreads to the tissues surrounding the hernia. A "hernia sac phlegmon" is formed. These changes, together with the damage to the afferent segment of the intestine, carry the risk of developing purulent complications: phlegmon of the hernia sac, abdominal wall phlegmon, peritonitis, and sepsis.

1.3 Epidemiology of the Disease or Condition

Despite improvements in surgical technique and the use of modern suture materials, at least 10% of laparotomies are complicated by hernia formation, and in risk groups, the incidence reaches 31%. There are numerous papers dedicated to various aspects of the surgical treatment of this pathology, but the problem largely remains insufficiently resolved. There are about 200 methods of abdominal wall repair for incisional hernias, and the recurrence rate after various autoplastic surgeries reaches 60%. Even with the use of mesh implants, the recurrence rate varies widely and can exceed 30%. The number of recurrences is particularly high in large and giant hernias [14,15,16,17]. In Russia in 2022, 42,681 elective surgeries for ventral incisional hernia were recorded. The proportion of surgeries using mesh implants in open surgery was 80.3%, and for laparoscopic interventions—4.82%. Mortality for elective surgeries was recorded at 0.15%. A total of 12,141 patients were hospitalized with incarcerated ventral incisional hernia, with an overall mortality rate of 5.02%. Incarcerated ventral incisional hernia accounted for 24.4% of the total number of hospitalized patients with incarcerated hernias, presenting the highest mortality rate. A total of 11,456 patients (94.4%) were operated on, with a mortality rate of 5.17% [18]. The data are comparable to similar national studies [96].

1.4 Features of Coding the Disease or Condition

K43.0 Incisional hernia with obstruction, without gangrene

K43.1 Incisional hernia with gangrene

K43.2 Incisional hernia without obstruction or gangrene

K43.3 Parastomal hernia with obstruction, without gangrene

K43.5 Parastomal hernia without obstruction or gangrene

1.5 Classification of the disease or condition

The classification of postoperative ventral hernias is necessary for choosing the optimal treatment method and for analyzing scientific data. Using a single classification allows for the comparison of various treatment options for postoperative hernias in clinical trials [19,20,21,22,23].

Currently, there are many classifications of postoperative hernias, although none of them has gained widespread practical use. In Russia, the classification of postoperative hernias by K.D. Toskin and V.V. Zhebrovsky (1990) [24] is well known, based on the assessment of the size of the hernia protrusion, taking into account the anatomical principle of dividing the abdominal wall into 9 regions. According to this classification, the following are distinguished:

• small hernia — occupies less than 1 abdominal region, does not alter the configuration of the abdomen, and is palpable only;

• medium hernia — occupies part of a region, protruding it;

• extensive hernia — occupies an entire region, deforming the abdomen;

• giant hernia — occupies 2–3 regions or more, markedly deforming the abdomen and hindering the patient's walking.

At the beginning of the 19th century, the classification by J.P. Chevrel and A.M. Rath [25] gained the greatest popularity. The classification was based on the determination of three parameters: hernia localization, width of the hernia defect, and presence of recurrence.

• According to localization, medial (M) hernias are distinguished: M1 — supraumbilical, M2 — umbilical, M3 — infraumbilical, M4 — total midline (from the xiphoid process to the pubic bone); and lateral (L) hernias: L1 — subcostal, L2 — flank, L3 — iliac, L4 — lumbar.

• According to the width of the hernia defect: W1 (< 5 cm); W2 (5–10 cm); W3 (10–15 cm); W4 (>15 cm).

• According to recurrence frequency: no recurrence (R0), number of recurrences (R1; R2, etc.).

The classification proposed by the European Hernia Society (EHS) is the result of precise criteria definition and comprehensive discussion (Table 1).

Postoperative hernias are classified according to three parameters: localization, width of the hernia defect, and presence of recurrence. According to localization on the abdominal wall: midline (M); lateral (L). According to the width of the hernia defect: W1 (small) — <4 cm; W2 (medium) — ≥4–10 cm; W3 (large) — ≥10 cm. According to recurrence frequency: R0; R1; R2; R3, etc.

Table 1. European Hernia Society (EHS) classification of postoperative ventral hernias [26].

Midline (M) hernia includes 5 zones (W1–W5) (Fig. 1): M1 — subxiphoid (from the xiphoid process to 3 cm caudally), M2 — epigastric (from 3 cm below the xiphoid process to 3 cm above the umbilicus), M3 — umbilical (3 cm above and below the umbilicus), M4 — infraumbilical (from 3 cm below the umbilicus to 3 cm above the pubis), M5 — suprapubic (from the pubic bone to 3 cm cranially). Lateral (L) hernia includes 4 zones: L1 — subcostal (lateral to the rectus muscle between the costal margin and a horizontal line 3 cm above the umbilicus), L2 — flank (lateral to the rectus muscle between horizontal lines 3 cm below and above the umbilicus), L3 — iliac (lateral to the rectus muscle between a horizontal line 3 cm below the umbilicus and the iliac region), L4 — lumbar (lateral to the anterior axillary line).

Fig. 1. Midline and lateral zones of the abdominal wall.

The EHS classification requires measuring the size of the hernia defect during surgery. The width of the hernia defect is defined as the largest horizontal distance in centimeters between the edges of the hernia defect (Fig. 2). In the case of multiple hernia defects, the width is measured between the most laterally located edges of the hernia defects. The length of the hernia defect is defined as the largest vertical distance in centimeters between the most cranial and most caudal edges of the hernia defect.

Hernia localization is of great importance for choosing the surgical strategy. It is necessary to consider the proximity of the hernia to bony structures, tension in the hernia sac, and the composition of the fascial layers.

There is a consensus among experts that ventral and incisional hernias must be classified prospectively to obtain useful data that will help approach the understanding of hernia recurrence, allow for the comparison of results, and optimize treatment algorithms.

Fig. 2. Measurement of hernia gate (defect) dimensions.

Comments. The number of previous surgeries, the size of the hernia defect and hernial protrusion, risk factors, and regenerative capacity should be included in any classification system and recorded in patient documentation [26].

• Trocar-site hernias are recommended to be classified as ventral incisional hernias of the anterior abdominal wall [26].

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

Comments: The diagnosis of a trocar-site hernia, in full accordance with the definition of this hernia as an incisional ventral hernia, is established based on the patient's corresponding complaints, as well as an abdominal wall defect and/or hernial protrusion confirmed upon examination and assessment (including instrumental methods) in the projection of the postoperative scar in the trocar placement zone [26]. It should be taken into account that the diagnosis of trocar-site hernias, which are often small in size, is difficult during physical examination in patients with an excessive subcutaneous fat layer. Some authors classify early postoperative eventrations into the trocar wound—whose distinctive feature is the absence of a hernia sac—as trocar-site hernias. Complications associated with trocar use occur in 1–6% of cases [27, 28], including trocar-site hernias in 0.2–27.6% [29, 30, 31, 32, 33].

1.6 Clinical presentation of the disease or condition

The main symptoms of the disease are the presence of a hernial protrusion and pain in the hernia region. The protrusion appears when the patient strains or assumes an upright position and disappears or decreases in a supine position, either spontaneously or after manual reduction. Pain in the area of the hernial protrusion occurs during physical exertion, walking, and sudden movements. Nausea, eructation, abdominal distension, and constipation frequently occur. The development of a hernia usually proceeds slowly. The protrusion gradually increases in size, acquiring a round or oval shape. With long-standing incisional hernias, they reach giant sizes, become irreducible, and pain appears in the lumbar region. As the size of the hernia increases, there is a decrease in patients' physical activity and an impairment of their working capacity. In some of them, as a result of multiple operations, the anterior abdominal wall is disfigured by wide scars that can be so thin that intestinal loops are easily palpable beneath them. Sometimes intestinal peristalsis is visually noticeable. Wide, thinned scars of the abdominal wall are prone to maceration and ulceration, which can lead to hernia rupture [1, 34].

2. Diagnostics, medical indications and contraindications for diagnostic methods

Diagnostic criteria

The diagnosis of incisional ventral hernia is established based on:

1) The patient's complaints of a protrusion in the abdominal wall and a history of previous abdominal surgeries; pain is the main symptom of strangulation. It occurs at the moment of strangulation, most often during some form of physical strain, and does not subside upon cessation of physical effort.

2) The identification during inspection and palpation of an elastic mass emerging through an abdominal wall defect in the projection of the postoperative scar. During strangulation, the protrusion becomes not only tense but also sharply painful.

3) Additional diagnostic methods (ultrasound, CT) in the absence of obvious clinical signs of an incisional ventral hernia.

2.1 Complaints and Anamnesis

• When taking a history from a patient with suspected incisional ventral hernia, it is recommended to pay attention to complaints of a protrusion in the postoperative scar area, pain in the protrusion area, dyspeptic disorders, discomfort, and limitation of physical activity [1, 2, 8, 9].

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

Comments. Hernia defects can be small and pose a risk of strangulation, while large ones cause complaints and a feeling of heaviness due to the descent of internal organs into the hernia sac and adhesive processes within it. As it enlarges, the hernia can reach significant proportions, leading to disability. Incisional ventral hernias most frequently occur within 1–2 years after surgery. Symptom development is observed in 33–78% of patients with an incisional ventral hernia [1, 2, 8, 9].

• In order to determine potential strangulation of an incisional ventral hernia, it is recommended to clarify with the patient the onset time of pain and whether the hernia was reducible and painless prior to this [1, 2, 3, 13].

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

Comments. Uncomplicated strangulated hernias are characterized by sudden pain in the area of the hernial protrusion—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 hernial protrusion. In a patient with a strangulated hernia complicated by intestinal obstruction, spasmodic abdominal pain, thirst, dry mouth, repeated vomiting, and delayed passage of stool and gas join the clinical picture.

2.2 Physical Examination

• The main diagnostic method for incisional ventral hernia is physical examination of the patient (visual inspection and palpation of the abdominal wall), which is recommended to be performed with the patient in both standing and lying positions in order to identify the abdominal wall defect and the hernial protrusion [1, 2, 8, 9].

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

Comments. Usually, the diagnosis of an incisional hernia is established during physical examination of the patient. The examination is performed in both standing and supine positions; the patient's abdomen and upper third of both thighs must be exposed. When examining the abdomen in the standing position, a protrusion is identified in the area of the postoperative scar as a result of aponeurosis diastasis. In the supine position, the reducibility of the hernia sac contents can be determined, while straining or having the patient raise their upper body allows for determining not only the dimensions of the hernia but also the presence of additional hernias lateral to the main one. All parts of the abdominal wall should be carefully palpated so as not to miss other hernial protrusions. The diagnosis of small incisional hernias during physical examination is difficult, especially in individuals with significant subcutaneous fat deposition on the abdominal wall. Abdominal palpation during intestinal strangulation is painful, especially above and superior to the site of strangulation. One should always keep in mind the possibility of Richter's (partial/parietal) strangulation, in which the volume of the hernial protrusion is sometimes not detectable. A strangulated hernia complicated by phlegmon of the hernia sac is recognized by an edematous, hot-to-the-touch hernial protrusion, skin hyperemia, and subcutaneous tissue edema. Fluctuation in the hernia area and crepitus in the tissues surrounding the hernial protrusion may appear.

2.3 Laboratory Diagnostics

• All patients with incisional ventral hernias are recommended to undergo a standard set of laboratory tests to assess comorbidity status: complete blood count, urinalysis, and general biochemical blood panel [35, 36, 37, 38, 39].

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

Comments. Uncomplicated incisional hernia does not affect laboratory parameters. Laboratory tests are prescribed to patients with incisional ventral hernias prior to surgical intervention [35, 36, 37, 38, 39].

2.4 Instrumental Diagnostics

• Patients with suspected incisional ventral hernia in the absence of obvious clinical signs are recommended to undergo a comprehensive ultrasound examination (US) of the abdominal cavity, including the abdominal wall, to detect a defect in the muscle-aponeurotic layer in the area of the postoperative scar, as well as to assess the condition of the hernia sac and determine its contents [40].

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

Comments. Physical examination plays a primary role in the diagnosis of abdominal hernias. At the same time, ultrasound of the abdominal wall and abdominal cavity should be considered an accessible and effective instrumental method in patients with incisional ventral hernias, which allows for:

- determining the exact localization, true size, and shape of the main hernia defect, as well as identifying additional hernia gates;

- studying the shape and contents of the hernia sac: the presence of intestinal loops, greater omentum, urinary bladder wall, and other abdominal cavity organs in it;

- diagnosing foci of chronic inflammation in the soft tissues of the abdomen in the hernia area (chronic inflammatory infiltrates, suture-related granulomas, abscesses, ligature fistulas);

- studying the features of the adhesive process in the hernia sac and abdominal cavity, performing differential diagnosis between an irreducible and incarcerated hernia, as well as between partial and acute intestinal obstruction within the hernia sac;

- investigating the specific topographic changes of the muscle-aponeurotic structures of the anterior abdominal wall that occur during the formation of an incisional hernia, and determining the presence and severity of tissue atrophy;

- detecting simultaneous surgical pathology of the abdominal cavity organs;

- performing early diagnosis of postoperative wound complications (infiltrate, seroma, suppuration);

- assessing the quality of the performed abdominal wall repair in the long-term postoperative period;

- performing early diagnosis of disease recurrence with a high degree of reliability.

- Ultrasound of the incarceration zone confirms the presence of incarceration, the viability of the incarcerated organ (presence or absence of blood flow evaluated via color Doppler sonography), and the degree of inflammatory changes.

• Patients with suspected incisional hernia incarceration are recommended to undergo plain abdominal radiography to detect distended intestinal loops with horizontal fluid levels, a sign confirming a severe complication of an incarcerated hernia — intestinal obstruction [2,3,13].

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

• In complex diagnostic cases of incisional hernias, it is recommended to supplement the examination with abdominal computed tomography (CT) to identify the hernia protrusion or a defect in the anterior abdominal wall, as well as to clarify the condition of tissues and organs in the hernia protrusion area [41,42,43].

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

Comments. There is insufficient data on the use of CT in diagnosing abdominal wall hernias. Existing literature sources focus predominantly on narrow issues. For example, in the presence of a purulent fistula in the surgical scar area, which may be associated with an infected suture or a previously implanted mesh, but may also be caused by an intestinal fistula. In these situations, computed tomographic fistulography is recommended. In cases of abdominal trauma, among other diagnostic procedures, abdominal CT is recommended to identify possible post-traumatic ventral hernias [41]. CT is recommended in cases of obesity, a history of multiple surgeries, large hernias with indistinct contours of the hernial sac, post-traumatic hernias, and for the diagnosis of rare ventral hernias [42,43,44].

Currently, a number of studies describe the use of CT after laparoscopic ventral hernia repair. It was reported on 50 patients who underwent laparoscopic surgery and underwent clinical examination 1 year postoperatively, including CT and diagnostic laparoscopy. Recurrences were correctly diagnosed in 98% of cases by CT and in 88% of cases by physical examination [45]. In a prospective study of 35 patients after laparoscopic repair, four observations of abdominal wall bulging in the surgical area were reported, in which CT successfully differentiated between seroma and hernia recurrence [46]. CT is the method of choice for postoperative differential diagnosis of recurrence, seroma, and bulging or residual hernias. Currently, there are no studies focusing on preoperative MRI diagnostics of ventral hernias.

There is insufficient evidence regarding the utility of CT in routine practice. In certain cases, such as post-traumatic hernias, obese patients, as well as patients with large hernias without clear boundaries of the hernia ring or with rare hernias (e.g., lumbar hernias), CT may be justified [43,44,47,48].

• Patients with suspected hernia recurrence are recommended to undergo abdominal CT [21,22].

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

Comments. In diagnosing hernia recurrence, the reliability of CT surpasses physical examination. In special cases, including, for example, post-traumatic hernias, rare hernias such as lumbar or Spigelian hernias, or in obesity, the use of CT may be justified.

Abdominal CT helps assess the anatomical details of the hernia ring, the hernial sac and its contents, the condition of the abdominal wall muscles, and often allows the detection of hidden hernia defects. Precise determination of the hernia ring dimensions makes it possible to pre-select an appropriate implant [45,46].

2.5 Other Procedures

• Patients with incisional hernias and concomitant comorbidity are recommended to have an appointment (examination, consultation) with a relevant medical specialist (appointment (examination, consultation) with a cardiologist, pulmonologist, endocrinologist, etc.) before surgery [1,14,17,49].

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

3.1. Indications for surgical treatment

• Patients with incisional hernias are recommended elective surgical treatment [14,15,16,17,50].

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

• If signs of incisional hernia incarceration are detected, emergency surgery is recommended [13].

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

Comments. For ventral and incisional hernias, the main treatment method is surgical. The treatment of incisional hernias aims to eliminate the hernia, relieve symptoms (pain and discomfort), prevent complications (incarceration, respiratory disorders, or skin lesions), or manage acute complications (intestinal obstruction and incarceration).

Precise data on the incidence of incarceration or acute intestinal obstruction in incisional hernias are lacking. No controlled studies have analyzed the dynamics of incisional hernia size over time, risk factors for incarceration, or the development of discomfort and pain syndrome.

Surgical intervention for acute complications (incarceration, intestinal obstruction) is performed in 5–15% of patients with incisional hernias. Emergency surgery is associated with a high complication rate. Incarceration in umbilical hernias occurs five times more frequently compared to incisional hernias.

The presence of an incisional hernia is a direct indication for elective surgery. In the early stages of hernia formation, tissue and organ changes are less pronounced, and the surgical intervention itself is less complex and more effective [14,15,16,50].

3.2. Contraindications for surgical treatment

• Elective surgical treatment for patients with incisional hernias is not recommended in the presence of absolute contraindications [14,15,16,50].

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

Comments. Absolute contraindications are:

• acute coronary syndrome, unstable angina, Canadian Cardiovascular Society (CCS) class 4 angina, history of myocardial infarction less than 6 months ago;

• heart failure NYHA class III–IV;

• uncorrected arterial hypertension;

• severe cardiac rhythm and conduction disorders;

• chronic lung diseases in the acute stage or complicated by grade 3 respiratory failure;

• severe bronchial obstruction syndrome;

• presence of decompensated diabetes mellitus;

• liver cirrhosis in the decompensated stage;

• acute purulent and infectious diseases;

Relative contraindications to elective surgery include:

• hernias that developed after palliative operations in cancer patients;

• period of less than 6 months elapsed since the previous laparotomy;

• period of up to 12 months after extensive surgical wound suppuration.

3.3. Conservative treatment

• If there are contraindications to surgery, patients with incisional ventral hernias are recommended conservative treatment [13].

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

Comments. Conservative treatment aims to relieve symptoms that are distressing for the patient, prevent hernia enlargement and strangulation. The mainstay of such treatment is wearing an abdominal binder. The complex of conservative measures includes dietary management and, if necessary, medications aimed at preventing constipation [13].

3.4. Surgical treatment

• Patients with incisional ventral hernias are recommended surgical treatment using mesh implants, surgical treatment using video-endoscopic technologies, and in rare cases, autoplasty [13,17,50,51,52,53,54,55].

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

Comments. Depending on the hernia size, an appropriate surgical intervention must be selected:

For small and medium incisional ventral hernias: surgery for small and medium postoperative hernia (mild form, autoplasty), surgery for small and medium postoperative hernia (complex form, infected conditions), surgical treatment of anterior abdominal wall hernia using mesh implants or laparoscopic anterior abdominal wall hernioplasty.

For large incisional ventral hernias: surgery for large postoperative hernia (autoplasty), surgery for large postoperative hernia in infected conditions, surgery for large postoperative hernia using mesh implants, or surgery for large postoperative hernia using video-endoscopic technologies.

For giant incisional ventral hernias: surgery for giant postoperative hernia (autoplasty), surgery for giant postoperative hernia in infected conditions, surgery for giant postoperative hernia using mesh implants, or surgery for giant postoperative hernia using video-endoscopic technologies.

When surgically treating an incisional hernia using implants (mesh prostheses), several placement techniques are possible: Onlay, Sublay, IPOM, and Inlay. At the same time, mesh hernioplasty can be performed either with approximation of the hernia defect edges ("reconstructive repair") or without edge approximation ("corrective repair"), i.e., placing the prosthesis in the tissues of the hernia region without tension "as a bridge" ("bridging") [13,17].

The “Onlay” technique involves fixing the mesh prosthesis superficially to the fascial defect;

In the “Sublay” technique, the mesh prosthesis is placed within the rectus abdominis muscle sheath, directly behind the muscles.

The “IPOM” technique involves intraperitoneal placement of the mesh prosthesis and its fixation to the anterior abdominal wall.

The “Inlay” technique involves suturing the mesh prosthesis to the edges of the fascial defect in a bridging fashion.

• In patients with incisional hernias accompanied by a reduction in abdominal cavity volume, it is recommended to use open component separation techniques of the abdominal wall (surgery for a large incisional hernia using mesh implants, surgery for a giant incisional hernia using mesh implants) as well as laparoscopic approaches (surgery for a large incisional hernia using video-endoscopic technologies, surgery for a giant incisional hernia using video-endoscopic technologies) to prevent abdominal compartment syndrome [17,55,56,57,58,59,60,61,62,63].

GGR CLOE 4Grade of Recommendations — C. Level of Evidence — 4.

• Patients with incisional hernias who require surgical component separation techniques are recommended to be operated on in surgical departments specializing in the treatment of this pathology [17,55,56,57,58,59,60,61,62,63].

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

• In the surgical treatment of incisional hernias using mesh implants, it is recommended to select the size of the implant so that it overlaps the hernia defect by at least 5 cm to reduce recurrence rates. For large hernias, a wider overlap is recommended compared to small hernias [64,65,66,67,68,69,70,71].

GGR ALOE 3Grade of Recommendations — A. Level of Evidence — 3.

Comments. According to literature data, the mesh prosthesis should overlap the hernia defect by at least 5 cm in all directions, and this overlap should increase proportionally to the size of the defect. The need for a more extensive overlap is due to the fact that a larger prosthesis will contact a greater area of the abdominal wall, thereby increasing the tissue ingrowth area and, consequently, biological fixation. It is also important to completely cover the entire postoperative scar to avoid any unprotected area of the abdominal wall where new hernias or a recurrence could develop.

Significant overlap of the hernia defect by the mesh prosthesis is associated with a lower recurrence rate.

The mesh prosthesis used for laparoscopic ventral hernia repair must overlap the hernia defect by at least 5 cm in all directions. For adequate fixation and integration of the implant, dissection from the abdominal wall must be performed—depending on the location of the hernia defect—relative to the falciform ligament, round ligament of the liver, or adipose tissue along the median umbilical fold [64,65,66,67,68,69,70,71].

• When repairing abdominal wall defects greater than 3 cm in diameter or recurrent hernias of any size, it is recommended to use a mesh prosthesis to minimize the risk of hernia recurrence [67,71,72].

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

Comments. Autologous tissue repair (suturing native tissues) is associated with a high rate of hernia recurrence compared to mesh-based repair. Autologous repair should be used only for small hernias, provided there are no potential risk factors for recurrence.

A BMI above 30 kg/m2 or a hernia defect size greater than 8–10 cm significantly increases the risk of recurrence.

• When choosing the method of abdominal wall repair, it is recommended to consider the patient's risk factors and the size of the hernia defect [17,67,71,72,73,74].

GGR ALOE 3Grade of Recommendations — A. Level of Evidence — 3.

Comments. Obesity is a risk factor for the development of incisional hernias and leads to an increased incidence of perioperative complications and recurrences after open hernioplasty. There are many reasons for this, including prolonged wound healing time, impaired pulmonary function, and higher intra-abdominal pressure. Other risk factors for hernia recurrence include male sex, advanced age, diabetes mellitus, anemia, hypoproteinemia, smoking, aneurysmal disease, rectus abdominis diastase, chronic malnutrition, corticosteroid therapy, use of vasopressor drugs, renal failure, oncological diseases, multiple operations through the same surgical access, chronic obstructive pulmonary disease, benign prostatic hyperplasia, and ascites [2,4,5,6,7].

Laparoscopic (endoscopic) repair of incisional ventral hernia (LIHVH) (surgery for incisional hernia using video-endoscopic technologies, laparoscopic repair of the anterior abdominal wall for hernias) is an operation for incisional hernia utilizing video-endoscopic technology, which employs rigid endoscopic video systems and endoscopic instruments to work within the abdominal cavity or artificially created spaces in the abdominal wall for the purpose of prosthetic hernia repair [22,75,76,77,78,79].

• When choosing LIHVH (surgery for incisional hernia using video-endoscopic technologies, laparoscopic repair of the anterior abdominal wall for hernias), the surgeon is recommended to consider the anticipated complexity of the procedure, the technical equipment available at the medical institution, and their own experience and proficiency in performing this surgery [77,78,79].

GGR ALOE 3Grade of Recommendations — A. Level of Evidence — 3.

Comments. Before surgery, the surgeon must take into account that previous hernioplasties, large defect sizes (>8–10 cm in diameter), irreducibility of the hernia, specific locations (subxiphoid, suprapubic, iliac, subcostal, lumbar), a large hernia sac with a narrow neck, obesity, and the presence of ascites all increase the complexity and duration of LIHVH.

• In patients with incisional hernias, surgery using video-endoscopic technologies is not recommended in the presence of general contraindications to pneumoperitoneum, marked reductions in abdominal cavity volume (the hernia sac accommodates more than 20% of the abdominal contents), when a skin graft is overlying the intestine due to open-abdomen treatment, or following severe abdominal trauma and multiple extensive abdominal surgeries [77,78,79,80,81].

GGR ALOE 3Grade of Recommendations — A. Level of Evidence — 3.

Comments. There are no data regarding the effect of LIHVH on the course of pregnancy. In other cases, LIHVH is a safe and effective operation with a low risk of surgical site infection and a short hospital stay.

• In patients with incisional hernias and diabetes mellitus, surgery using video-endoscopic technologies (surgery for incisional hernia using video-endoscopic technologies, laparoscopic repair of the anterior abdominal wall for hernias) is recommended to minimize the risk of surgical site infection [82].

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

• In patients with a BMI of 35 kg/m2 or higher, surgery using video-endoscopic technologies (surgery for incisional hernia using video-endoscopic technologies, laparoscopic repair of the anterior abdominal wall for hernias) is recommended as the preferred method of hernia treatment [82,83].

GGR CLOE 4Grade of Recommendations — C. Level of Evidence — 4.

Comments. LIHVH is feasible in patients with obesity (BMI > 30 kg/m2), morbid obesity (BMI > 40 kg/m2), and super-obesity (BMI > 50 kg/m2). The complication rate of laparoscopic surgery in patients with a BMI > 40 kg/m2 is higher than in patients with a BMI < 40 kg/m2. The recurrence rate increases at a BMI > 30 kg/m2. At the same time, the rate of complications—especially wound-related ones—is lower in obese patients following laparoscopic surgery than after open hernioplasty.

• Obese patients are recommended to achieve weight loss prior to surgical intervention [82,83].

GGR BLOE 3Grade of Recommendations — B. Level of Evidence — 3.

• Surgical treatment of incisional hernia is not recommended in patients with liver disease with negative prognostic factors: age over 65 years; > 15 points on the Model for End-Stage Liver Disease (MELD) scale; albumin level <30 g/L; [84,85].

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

Comments. Compensated liver cirrhosis of Child-Pugh class A-B is not a contraindication for elective laparoscopic incisional hernia repair. Surgery is also effective and safe after parenchymal organ transplantation [84].

• For recurrent hernias after open repairs, it is recommended to perform surgery using video-endoscopic technologies (incisional hernia repair using video-endoscopic technologies, laparoscopic anterior abdominal wall hernia repair) to minimize the risk of recurrence and surgical site infection, as well as to increase the likelihood of detecting hidden hernia defects [76,77,78,86].

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

Comments. Laparoscopic incisional hernia repair has advantages such as mesh placement against unaffected tissues, a lower risk of provoking surgical site infection, and the ability to detect hidden hernia defects.

• When a diagnosis of incarcerated incisional hernia is established, emergency surgery is recommended to eliminate ischemia of the incarcerated internal organs as soon as possible after the patient's admission to the hospital [1, 2, 13, 14, 24, 97].

GCR CLEL 5Grade of Recommendation – C. Level of Evidence – 5.

Comment. Early surgical intervention for incarcerated hernia with obstruction is crucial, as delayed diagnosis can lead to bowel resection with longer recovery and associated complications. All diagnostic measures must be performed as quickly as possible. Preoperative preparation includes bladder emptying, hygienic preparation of the surgical site, nasogastric tube insertion and evacuation of gastric contents, and antibiotic prophylaxis 30 minutes before surgery. In severe patient conditions, intensive preoperative preparation is performed in the ICU or intensive care unit. Preoperative preparation on the operating table is possible. The main tasks of surgery for uncomplicated incarcerated incisional hernia are the release of incarceration, assessment of the viability of the incarcerated organ, and hernioplasty, including the use of synthetic materials. If bowel viability is questionable, it is permissible to postpone the decision on resection using planned relaparoscopy or diagnostic laparoscopy after 12 hours. Bowel resection, if non-viable, is performed according to generally accepted principles. In case of small bowel incarceration, its resection with anastomosis is performed. The choice of the method for completing large bowel resection is determined individually. Various surgical options are possible depending on the incarcerated bowel segment, abdominal wall condition, presence of peritonitis, and sepsis (Appendix A3) [1, 2, 13, 14, 24, 97].

• Surgical treatment of incisional hernia using mesh implants is recommended for patients without signs of bowel incarceration [97].

GCR CLEL 5Grade of Recommendation – C. Level of Evidence – 5.

Comments. The choice of hernioplasty technique is based on the contamination of the surgical field, hernia size, and surgeon's experience. An increased probability of surgical site infection may indicate an additional risk for synthetic mesh repair [97].

• For irreducible and incarcerated incisional hernias, surgical treatment using video-endoscopic technologies is recommended only by a surgeon with extensive experience in performing this procedure [76,77,78,97,98].

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

Comments. With the advancement of equipment, techniques, and skills, the use of laparoscopy in complex and emergency surgeries has significantly expanded. Laparoscopic surgery has become a routine method for treating incarcerated hernias, and its use continues to expand over time. Clinical outcomes remain unchanged, while hospital stays have been reduced [77,78,97,98].

• Surgery for incisional hernia is recommended to be performed under combined endotracheal anesthesia [1, 2, 13, 14, 24].

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

• For patients with parastomal hernias, surgical treatment is recommended using mesh implants (incisional hernia repair using mesh implants), video-endoscopic technologies (laparoscopic anterior abdominal wall hernia repair), and in rare cases – tissue repair (small and medium incisional hernia repair) [99,100,101,102,103,104,105,106,107].

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

Comments. Open, laparoscopic, and extraperitoneal approaches can be used in the surgical treatment of parastomal hernias. The mesh can be placed in onlay, inlay, sublay, or IPOM positions. Sugarbaker, Keyhole, PPHR (Pauli parastomal hernia repair), Sandwich, ePauli, and other techniques can be used for parastomal hernioplasty [99,100,101,102,103,104,105,106,107].

Parastomal hernia repair without a mesh (tissue repair) is not recommended due to the high risk of recurrence [99].

Stoma transposition is also not recommended, as relocating the stoma carries up to a 70% risk of developing a hernia at the new site [99]. However, in patients with large and giant parastomal hernias, as well as in recurrent hernia, the STORRM (Stapled Transabdominal Ostomy Reinforcement with Retromuscular Mesh) procedure can be used. The hernia recurrence rate with this technique is 17% [100].

3.5. Preoperative preparation

• Patients scheduled for elective surgery are recommended standard mechanical bowel preparation to increase the working space and reduce the risk of peritoneal contamination in case of inadvertent enterotomy [1,8,49].

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

• Preoperative urinary catheterization is recommended for expected long procedures and when hernias are localized in the suprapubic region [1,8,49].

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

3.6. Postoperative complications

Postoperative pain

• For postoperative pain, it is recommended to administer analgesics and wear an abdominal binder to stabilize the abdominal wall [1,14,15,71].

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

• For chronic postoperative pain, it is recommended to perform ultrasound or CT of the abdominal organs to rule out seroma or hernia recurrence as a potential cause of pain [87,108].

GCR CLEL 4Grade of Recommendation – C. Level of Evidence – 4.

• For chronic pain, it is recommended to perform local anesthetic (amide) injections into the chronic pain sites (mesh fixation points). If ineffective, removal of the mesh fixation device is recommended, with or without resection of the lateral/terminal neuroma [78].

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

Comments. Acute postoperative pain is a natural consequence of surgical trauma. It is poorly localized around the surgical site, peaks approximately 3 hours after surgery, and subsides within 3 days. Neuropathic postoperative pain is related to nerve injury and has a clear localization at the site of trauma or within the innervation zone.

Subacute postoperative pain lasts up to 4–6 weeks, and chronic pain lasts over 3 months (2–4% of patients). Chronic pain is more common after laparoscopic repair of lateral (L) hernias.

Factors unrelated to laparoscopic incisional hernia repair contributing to chronic postoperative pain include: age, sex, preoperative pain, psychological factors, and cognitive impairment.

Dynamic and mechanical intestinal obstruction

• When dynamic intestinal obstruction develops, it is recommended to prescribe gastrointestinal motility stimulants (anticholinesterase drugs), insert a nasogastric tube, and encourage early mobilization of the patient [13].

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

Comments. The incidence of dynamic intestinal obstruction lasting longer than 24 hours after incisional hernia repair ranges from 3% to 16-20% according to various sources. The probability of this condition correlates with mesh size and the extent of adhesiolysis. Mechanical obstruction and unrecognized enterotomy must be ruled out.

Mechanical intestinal obstruction with intraperitoneal mesh placement (IPOM technique) may be related to bowel entrapment between the abdominal wall and the mesh due to inadequate fixation, formation of secondary adhesions to the mesh or fixation device, or bowel strangulation at the laparoscopic access site. Treatment is carried out in accordance with guidelines for managing patients with mechanical intestinal obstruction.

Postoperative seroma

Postoperative seroma (accumulation of serous fluid in the surgical wound area) can be detected by comprehensive abdominal ultrasound in almost every patient in the early period following hernia repair using a mesh prosthesis. Clinical detectability is up to 35%. Seroma is not a complication of this surgery, but merely a consequence of the intervention, peaking around the 7th day and resolving in almost all patients by the 90th day postoperatively. Beyond this period, seroma is considered chronic (3-4% of cases). Symptomatic chronic seroma should be considered a surgical complication. The rate of such complications in video-endoscopic surgery does not differ from open hernioplasty [87].

The severity and duration of seroma depend on the mesh placement technique, prosthesis fixation technique (frequent fixation, transabdominal sutures through the hernia sac), hernia irreducibility, and the number of previous laparotomies.

Methods of seroma prevention may include: excision of the hernia sac; its ablation; closure of the hernia defect; mesh fixation that allows fluid to drain from the hernia sac; drainage of the mesh bed; wearing compression garments.

• In cases of symptomatic chronic seroma, its puncture with aspiration of the contents is recommended [17,87,88].

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

Comments. Aspiration carries a risk of infection of the seroma and the mesh. Recurrent seromas may require surgical revision with excision of the mesothelial lining.

Surgical Site Infection

• If cellulitis develops in the surgical area, treatment with a short course of systemic antibacterial drugs is recommended [89].

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

Comments. Cellulitis is rare after laparoscopic repair of ventral hernia, occurring in 2-4% of patients. The cause is considered to be infection entering through punctures from transabdominal sutures or an inflammatory response to the mesh.

Laparoscopic hernioplasty is accompanied by a significantly lower incidence of wound infection than open hernioplasty (approximately 1% versus 10%).

Prosthesis infection during laparoscopic repair of ventral hernia is also rare (<1%).

• To prevent mesh infection, it is recommended to adhere to the following rules: mandatory preoperative treatment of chronic foci of infection, antibiotic prophylaxis, changing gloves before handling the mesh during surgery, and preventing contact of the mesh with the patient's skin [78,89].

GCR CLOE 5Grade of Recommendation – C. Level of Evidence – 5.

• If infection develops in the surgical area, meshes based on polytetrafluoroethylene and polyester are recommended to be removed; meshes based on polypropylene are recommended to be preserved by surgical revision of the postoperative wound with the installation of closed continuous irrigation drainage or negative pressure wound therapy [78,89].

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

• Following the removal of the infected mesh, it is recommended to adhere to one of the following options:

1. primary skin or aponeurosis closure with delayed repair after 6-9 months;

2. component separation with negative pressure wound therapy;

3. repair with a biological mesh after mandatory preparation of a well-vascularized bed, combined with negative pressure wound therapy [78,89].

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

Postoperative bulging

Postoperative bulging of the abdominal wall at the site of the closed hernia defect is a problem in both laparoscopic repair of ventral hernia and open surgery performed without closure of the hernia defect, with onlay-bridge mesh placement. According to various sources, it develops in 1.6-17.4% of patients. In the majority of patients (~80%) after laparoscopic repair of ventral hernia without defect closure, approximation of the defect edges over the mesh is observed over time.

• In patients with symptomatic bulging in whom ultrasound and CT do not confirm hernia recurrence, closure of the hernia defect over the implant is recommended, but no earlier than 6 months after the previous surgery [78].

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

Hernia recurrence

The long-term recurrence rate after laparoscopic ventral hernia repair (LVHR) is less than 5%, which is comparable to the average recurrence rate after open procedures. Hernia defect size is one of the factors determining recurrence rates. With W1 and W2 transverse defect sizes, the recurrence rate after LVHR does not significantly differ from that after open mesh hernioplasty. With a W3 transverse defect size, the recurrence rate after LVHR occupies an intermediate position between those after open «Onlay» and «Sublay» mesh hernioplasty. Other factors contributing to recurrence include obesity and other causes of chronic increased intra-abdominal pressure, inadequate mesh size, inadequate fixation, unrecognized hernia defects, mesh infection, and trauma.

• Prophylactic mesh placement in the trocar paraumbilical wound (surgical treatment of incisional hernia using mesh implants) is recommended in high-risk patients – those over 65 years of age, with diabetes mellitus, chronic lung diseases, and obesity [90].

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

Comments: Placement of a mesh implant in the trocar paraumbilical wound in patients over 65 years of age, with diabetes mellitus, chronic lung diseases, and obesity can be an effective method for preventing trocar hernia development [90].

3.8. Antibiotic prophylaxis

• Standard antibiotic prophylaxis is recommended for patients with incisional hernias undergoing surgical treatment [78,89,91,92,93].

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

Comments. Currently, there are no unequivocal recommendations regarding the necessity of antibiotic prophylaxis. Nevertheless, antibiotic prophylaxis is apparently recommended in patients with risk factors (advanced age, systemic corticosteroid administration, immunosuppressive therapy, obesity, diabetes, or oncological diseases), as well as in the presence of surgical risk factors (prolonged surgery, infected conditions, presence of drains or urinary catheter).

• For patients with incisional hernias undergoing surgical treatment, the administration of a first- or second-generation cephalosporin or amoxicillin/clavulanate** in standard dosages is recommended 30–60 minutes before surgery. Vancomycin** may be used as part of targeted prophylaxis (proven MRSA risk) [89,91,92].

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

• Antibiotic prophylaxis is not recommended for patients undergoing surgery for incisional hernia using video-endoscopic technologies in the absence of risk factors [93].

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

• A 48-hour antimicrobial prophylaxis is recommended for patients with incarcerated incisional hernia and bowel resection [97].

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

• Antimicrobial therapy is recommended for patients with incarcerated incisional hernia and peritonitis [97].

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

Comments. In aseptic hernia repair, the source of infection is usually Staphylococcus aureus from the external environment or the patient's skin flora. In patients with bowel strangulation, the surgical field may be contaminated by bacterial translocation from incarcerated ischemic bowel loops, as well as a result of bowel resection. Both antimicrobial therapy and surgical intervention are always recommended for patients with peritonitis [97].

3.9. Prevention of thromboembolic complications

• Prevention of thromboembolic complications is recommended taking into account the risk factors of each specific patient in accordance with the Russian clinical guidelines for the diagnosis, treatment, and prevention of venous thromboembolic complications [94].

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

• Postoperatively, for the prevention of thromboembolic complications, it is recommended to mobilize the patient as quickly as possible, use compression stockings intraoperatively and in the postoperative period, and use low-molecular-weight heparins (heparin group B01AB) in prophylactic doses recommended by the manufacturer for patients of the corresponding risk category [94].

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

4. Medical Rehabilitation and Sanatorium-Resort Treatment

• Special therapeutic measures are not recommended for patients operated on for medium and small incisional hernias with an uneventful postoperative period [3,13,71].

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

Comments. In these cases, apart from pain medication and wound care, no specific treatment is required. Early mobilization of patients is carried out after surgery; patients are allowed to walk starting from the second day, and a course of physical therapy (exercise therapy) and adequate pain relief using non-narcotic analgesics are administered for 2–3 days.

• Sports and heavy physical exertion are not recommended for patients during the first 2–3 months after surgery [3,13,71].

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

Comments. The average period of occupational rehabilitation in patients with an uncomplicated postoperative course may vary from 1 to 2 months.

5. Prevention and Dispensary Observation

• To prevent the formation of postoperative ventral hernia, patients who have undergone abdominal surgery are recommended to undergo prevention of purulent complications [3,13,71].

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

Comments. These include prophylactic prescription of antibiotics and the use of antimicrobial suture material.

• To prevent the development of postoperative ventral hernia in patients undergoing abdominal surgery, it is recommended to use long-term absorbable or non-absorbable monofilaments for laparotomy wound closure, preferably size 2/0 sutures [3,13,71].

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

Comments: Randomized controlled trials have proven that the prophylactic use of mesh to reinforce the suture line after laparotomy reduces the incidence of postoperative hernias from 35.9% to 1.5% in high-risk patient groups (patients with obesity or abdominal aortic aneurysm). Furthermore, applying a continuous suturing technique with small, frequent bites along the edges of the laparotomy wound decreases the incidence of postoperative hernia formation.

• A follow-up clinical appointment (examination, consultation) with a surgeon for a patient after postoperative ventral hernia repair is recommended at least once a year for 3 years [95].

GPP CLOE 5Level of recommendation evidence — C. Level of data validity — 5.

Comments. A follow-up clinical appointment (examination, consultation) with a surgeon includes taking the patient's history, examining and palpating the postoperative scar and abdominal wall, and, if necessary, soft tissue ultrasound and comprehensive abdominal ultrasound.

6. Organization of Medical Care

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

Primary specialized health care is provided by a surgeon. If a postoperative ventral hernia is suspected or detected, general practitioners, district general practitioners, general practice physicians (family physicians), specialist physicians, and mid-level medical personnel shall refer the patient in the prescribed manner for a consultation at the surgeon's office to receive primary specialized health care. If it is impossible to provide medical care within the framework of primary health care and if 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 postoperative ventral hernias can be performed in surgical departments of medical organizations of all levels. In complex cases of postoperative ventral hernias (giant, repeatedly recurrent, with mesh infection), in patients with comorbidities, including cardiovascular and respiratory systems, diabetes mellitus, or when there are indications for simultaneous operations, it is advisable to perform surgical treatment in the surgical departments of third-level medical organizations.

Indications for planned hospitalization:

Presence of the diagnosis "uncomplicated postoperative ventral hernia for elective surgery".

Indications for emergency hospitalization:

Presence of the diagnosis of complicated postoperative ventral hernia (incarceration, intestinal obstruction, gangrene) for emergency surgical intervention.

Indications for patient discharge from the hospital:

Patient mobilization after surgery, restoration of gastrointestinal tract function, 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)

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

Gorsky V.A., MD, PhD, 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)

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)

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, anesthesiologists-resuscitators, medical students, surgical residents.

Methodology for evidence collection

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;

• assessment of the level of evidence according to the evidence rating scheme (Tables A2.1–A2.3).

These clinical guidelines present the levels of evidence for recommendations in accordance with the draft methodological guidelines for assessing the validity of evidence and the persuasiveness of recommendations from 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

• 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."

• Order of the Ministry of Health of the Russian Federation dated March 29, 2019, No. 173n "On Approval of the Procedure for Dispensary Observation of Adults" (Registered April 25, 2019, No. 54513).

Methods of recommendation 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

The update 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 incisional ventral hernias. The decision to update is made by the Russian Ministry of Health based on proposals submitted by professional medical non-profit organizations. The formulated proposals must take into account the results of a comprehensive evaluation of surgical methods, medical devices, and the results of clinical approbation.

Scale for assessing levels of reliability of evidence (LRE) for diagnostic methods (diagnostic interventions)

Rating scale for levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Grading system for the levels of evidentiary certainty (LEC) of recommendations for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Appendix A3. Reference Materials

List of medical service codes (current nomenclature)

A03.16.001 – Esophagogastroduodenoscopy

A05.10.006 – Electrocardiogram recording

A05.30.005 – Magnetic resonance imaging of abdominal organs

A06.09.006 – Chest fluorography

A06.30.005.001 – Computed tomography of the abdominal cavity and retroperitoneal space

A06.30.005.004 – Spiral computed tomography of the abdominal organs with intravenous bolus contrast enhancement, multiplanar and three-dimensional reconstruction

A09.05.034 – Blood chloride level test

A12.05.006 – Determination of Rhesus system D antigen (Rh factor)

A12.06.043 – Determination of blood group antibody levels

A16.30.004.003 – Surgery for small and medium incisional hernia (mild form)

A16.30.004.004 – Surgery for small and medium incisional hernia (complex form)

A16.30.004.005 – Surgery for large incisional hernia

A16.30.004.006 – Surgery for large incisional hernia in infected conditions

A16.30.004.007 – Surgery for giant incisional hernia

A16.30.004.008 – Surgery for giant incisional hernia in infected conditions

A16.30.004.010 Laparoscopic anterior abdominal wall repair for hernias

A16.30.004.011 Surgical treatment of anterior abdominal wall hernia using mesh implants

A16.30.004.012 – Surgical treatment of incisional hernia using mesh implants

A16.30.004.013 – Surgery for large incisional hernia using video-endoscopic technologies

A16.30.004.014 – Surgery for giant incisional hernia using video-endoscopic technologies

A16.30.004.015 – Surgery for large incisional hernia using mesh implants

A16.30.004.016 – Surgery for giant incisional hernia using mesh implants

A16.17.002 - Segmental excision of damaged small intestine

A16.17.011 - Enteroenterostomy

A16.17.012 - Creation of entero-enteroanastomosis

A16.17.006 - Creation of small-to-large intestinal anastomosis

A16.17.007 - Ileostomy

A16.18.007 - Colostomy

A16.18.016 - Right hemicolectomy

A16.18.029 - Resection of ileocecal angle

A16.19.019.003 - Obstructive resection of sigmoid colon

A16.30.006 - Laparotomy

A16.18.002 - Partial excision of large intestine

A16.18.003 - Excision of large intestine with end-to-end anastomosis

A16.18.006 - Resection and stoma formation

A26.06.040 – Determination of antibodies to Hepatitis B virus surface antigen (HBsAg) in blood

A26.06.041.002 – Determination of total class M and G antibodies (anti-HCV IgG and anti-HCV IgM) to Hepatitis C virus in blood

A26.06.048 – Determination of class M and G antibodies (IgM, IgG) to Human immunodeficiency virus HIV-1 in blood

A26.06.049 – Determination of class M and G antibodies (IgM, IgG) to Human immunodeficiency virus HIV-2 in blood

A26.06.082 – Determination of antibodies to Treponema pallidum in blood

B01.003.004.005 – Infiltration anesthesia

B01.003.004.006 – Epidural anesthesia

B01.003.004.007 – Spinal anesthesia

B03.005.006 – Coagulogram (exploratory hemostasis screening)

B03.016.002 – Complete blood count (CBC)

B03.016.004 – General clinical blood biochemistry panel

B03.016.006 – Urinalysis

Dimensions of standard implants

Surgical mesh for abdominal hernia, made of synthetic polymer, non-absorbable. A sterile flat or three-dimensional woven/knitted or porous material made from one or more non-absorbable synthetic polymers (e.g., polypropylene, polyethylene), intended for permanent implantation in abdominal hernia (e.g., inguinal, ventral/incisional, umbilical, femoral) and for use in the correction of fascial defects; the product is not intended for use outside the abdominal cavity and is not used for diaphragmatic hernias. As a rule, materials with various properties are available; the product can be of a ready-made shape or can be cut to the desired size/shape. Disposable items necessary for implantation (e.g., introducer needles) may be included.

Dimensions of polypropylene implants: 15x10 cm; 15x15 cm; 30x30 cm; 36x26 cm; 45x30 cm.

Dimensions of polyester implants: 20x15 cm; 20x20 cm; 30x15 cm; 30x30 cm; 45x30 cm.

Surgical mesh for abdominal hernia, polymer-composite. A sterile flat or three-dimensional (3-D) woven/knitted material made from one or more polymers, including an absorbable polymer (e.g., polyglycolic acid) and a non-absorbable polymer (e.g., polyethylene), intended for permanent implantation in abdominal hernia (e.g., inguinal, incisional ventral, umbilical, femoral) and for use in the correction of fascial defects. It can also be used as a temporary scaffold for tissue regeneration. Disposable items necessary for implantation (e.g., guiding needles, trocars) may be included.

Mesh dimensions: 15x7.5 cm; 15x10 cm; 15x15 cm; 30x15 cm; 30x30 cm.

Surgical mesh for abdominal hernia, collagen. A sterile absorbable flat or three-dimensional (3-D) implantable material made from animal-derived collagen, intended for permanent implantation in abdominal hernia (e.g., inguinal, incisional ventral, umbilical, femoral) and for use in the correction of fascial defects. It can also be used as a temporary scaffold for tissue regeneration. Disposable items necessary for implantation (e.g., guiding needles, trocars) may be included.

Dimensions of implants for intraperitoneal placement: 11.4x11.4 cm; 15.2x7.6 cm; 15x10 cm; 15.2x10.2 cm; 15x15 cm; 20x15 cm; 20.3x15.2 cm; 25x20 cm; 25.4x15.2 cm; 30x20 cm; 33x25.4 cm; 35.5x25 cm; 35.6x30.5 cm; 37x28 cm.

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Patients should start walking from the first day after surgery. Each patient is unique and has a different pain threshold and level of physical fitness, so there is no minimum or, conversely, maximum walking distance. Driving a car is allowed to begin as soon as the patient feels that they can truly do it safely for themselves and others. Swimming, visiting public baths and saunas should be avoided until the postoperative wounds have completely healed. Jogging, cycling, and going to the gym are allowed within the patient's comfort level. At the same time, it is recommended to reduce physical loads at the gym.

Wearing a postoperative binder is recommended for 1–2 months following surgical treatment, taking into account the nature of the surgery, the patient's age, and their overall health status. However, not all physicians advocate for the use of a postoperative binder.

There are no specific dietary restrictions after incisional hernia surgery, although there may be some depending on the presence of internal organ diseases. Healthy food rich in proteins and vitamins will help postoperative wounds heal. To normalize bowel function, it is necessary to consume fiber-rich foods and plenty of fluids, which will help prevent the occurrence of constipation.

As a rule, patients can return to desk-based office work within 1–2 weeks. Returning to heavy physical labor is possible 4–8 weeks after surgery. It should be noted that these figures are approximate—they depend on the postoperative course and the patient's physical condition.

In the long term, patients can engage in normal activities. There is absolutely no evidence that strenuous activity (in the long or even short term) increases the likelihood of hernia recurrence.

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

Not provided