List of Abbreviations
IAP – intra-abdominal pressure
BMI – body mass index
CT – computed tomography
MRI – magnetic resonance imaging
РКИ – randomized controlled trial
SCT – spiral computed tomography
US – ultrasound examination
COPD – chronic obstructive pulmonary disease
ECG – electrocardiography
EchoCG – echocardiography
ACST – anterior component separation technique
AHS – America Hernia Society
EHS – European Hernia Society
IPOM – intraperitoneal onlay mesh
eTEP-RS – endoscopic totally extraperitoneal Rives-Stoppa repair
MILOS – Retromuscular minimally invasive hernia repair
EMILOS – Endoscopic retromuscular minimally invasive hernia repair
SCOLA – Subcutaneous endoscopic laparo-endoscopic onlay approach
PCST – Posterior component separation technique
Terms and Definitions
A hernia is the protrusion of internal organs covered by peritoneum through natural or artificial openings (resulting from trauma or surgical interventions) in the abdominal wall, pelvic floor, or diaphragm beneath the outer integuments of the body or into another cavity.
The constituent elements of a hernia are: the hernia ring, the hernia sac, and the hernia contents.
The hernia ring is a congenital or acquired defect in the musculo-aponeurotic layer of the abdominal wall.
The hernia sac is the portion of the parietal peritoneum that protrudes through the hernia ring.
The contents of the hernia sac may be represented by any abdominal organ, but most frequently by the greater omentum or a loop of the small intestine.
An umbilical hernia is a primary hernia with a defect located along the midline within the umbilical ring.
A linea alba hernia is a primary hernia with the center of the defect located along the midline above the umbilicus up to the xiphoid process.
A Spigelian hernia is a primary hernia with a defect located in the area of the semilunar line.
A lumbar hernia is a primary hernia with a defect located in the area of the Grynfeltt-Lesshaft triangle or Petit's triangle.
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 (strangulated) hernia is the acute or gradual compression of one or more abdominal organs within the hernia ring, leading to impaired blood supply and ultimately to necrosis. Both external (in abdominal wall defects) and internal (in peritoneal recesses, diaphragmatic and pelvic floor apertures) 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 (partial incarceration) is known in literature as "Richter's hernia". In this case, the bowel is compressed not across its entire circumference, 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 ensuing consequences. Partial incarceration most frequently 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 (e.g., umbilical hernia or linea alba hernia).
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
A primary abdominal wall hernia is the protrusion of internal organs covered by peritoneum through various natural openings in the musculo-aponeurotic layer of the abdominal wall. Such openings ("weak spots") include, for example, the umbilical ring, gaps in the linea alba, Petit's triangle, etc.
Depending on the region where the hernia defect is located, primary abdominal wall hernias include: umbilical hernia, linea alba hernia, Spigelian hernia, and lumbar hernia.
An umbilical hernia is the protrusion of abdominal organs through the umbilical ring.
A linea alba hernia is the protrusion of abdominal organs through an opening located along the midline in the space between the xiphoid process and the umbilicus. The most frequent location is the epigastric part of the linea alba, which is why these hernias are often called epigastric hernias. Hernias may also frequently be located above the umbilical ring, which is why they are termed umbilical or paraumbilical hernias.
A Spigelian hernia belongs to lateral abdominal wall hernias. Depending on the location of the hernial protrusion, preperitoneal hernias (located between the transversalis fascia and the aponeurosis of the internal oblique abdominal muscle), interstitial hernias (whose hernia sac emerges between the internal and oblique abdominal muscles), and simple hernias (whose hernia sac is located directly subcutaneously) are distinguished. Spigelian hernias are more frequently unilateral.
A primary lumbar hernia is a defect in the lumbar region, bounded superiorly by the twelfth rib, inferiorly by the iliac crest, anteriorly by the external oblique muscles, and posteriorly by the spine. Lumbar hernias can be anatomically classified as superior (Grynfeltt-Lesshaft triangle hernia) and inferior (Petit's triangle hernia). They are most commonly associated with developmental defects of muscles and aponeurosis, resulting in weak areas predisposed to hernia development.
The constituent elements of a hernia are: the hernia ring, the hernia sac, the hernia contents, and the hernia coverings. There are cases where there is no distinct hernia ring, but the muscle layer is absent over a large extent of the abdominal wall, causing the scarred aponeurotic layer to gradually bulge under the influence of intra-abdominal pressure.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
In the structure of risk factors for the development of primary abdominal wall hernias, precipitating factors (those increasing intra-abdominal pressure) predominate, such as obesity, ascites, constipation, increased physical exertion, pregnancy, and others. Predisposing factors also play a role, such as connective tissue dysplasia, African and American ethnicity, Down syndrome, Beckwith-Wiedemann syndrome, and diastasis recti [1,2,3].
The pathogenesis of hernia strangulation has been studied quite thoroughly. Characteristic dynamic changes are common to all types of strangulation [4,5,6]. Due to compression (strangulation) within an especially narrow hernia ring, ischemia of the incarcerated organs develops. Compression of the nerve elements of the incarcerated organ, particularly the intestinal mesentery, leads to severe pain. 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 strangulation, a closed cavity forms within the hernia sac, containing an organ or organs whose blood supply is impaired. A strangulation furrow forms at the site of compression of the intestinal loop, omentum, and other organs, which remains clearly visible even after the strangulation is resolved. If a loop of intestine is incarcerated, venous stasis initially occurs within it, soon causing edema of all layers of the intestinal wall. The incarcerated intestinal loop necrotizes fairly rapidly, within a few hours (in elastic strangulation), 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 serosal layer. Not only the part of the intestine located inside the hernia sac suffers during strangulation, 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 its wall becomes sharply 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 [5]. 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 spread over a insignificant distance from the strangulation zone [6].
Recommendations on the level of resection of the afferent and efferent segments of the incarcerated loop are built upon the established fact of the severity of pathomorphological changes in the incarcerated non-viable small intestine. The limits of resection of the afferent limb of the intestine must always exceed the limits of resection of the efferent loop. High strangulated obstruction developing as a result of strangulation is accompanied by early vomiting. Early repetitive 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 production of toxins. Simultaneously, plasma transudation and diapedesis of blood formed elements occur both into the lumen of the incarcerated intestine and into the cavity of the hernia sac. The fluid (herniary 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 break down, the herniary water acquires a pink and then a red-brown color. The necrotized intestinal wall ceases to serve as a barrier for the escape of microbial flora beyond it. The exudate becomes purulent with an unpleasant odor. Inflammation spreads to the tissues surrounding the hernia. A "phlegmon of the hernia sac" is formed. These changes, together with damage to the afferent segment of the intestine, are fraught with the risk of purulent complications—phlegmon of the hernia sac, abdominal wall, peritonitis, sepsis.
1.3 Epidemiology of the Disease or Condition
Primary hernias of the abdominal wall are widespread and account for approximately 10–15% per 100,000 population according to most studies. At the same time, data indicate that up to 25% of patients have small asymptomatic umbilical hernias according to ultrasound data [7].
Umbilical hernia is more frequently observed in early childhood (0–5 years) in both sexes, at an older age (61–70 years) in men, and at middle age (31–40 years) in women [8]. In Russia, 47,987 elective surgeries for primary umbilical hernias were recorded in 2023. The proportion of operations using mesh implants in the open method was 65.17%, and laparoscopic interventions accounted for 5.58%. Mortality in elective surgeries was recorded at 0.02% [9]. Hernias of the linea alba are less common, more frequently performed in men aged 51–70 years and in women aged 41–50 years [8].
Spigelian hernia and lumbar hernias are rare forms of primary abdominal wall hernias. Spigelian hernia accounts for 0.1–2.0% of all anterior abdominal wall hernias [10]. It is observed at the age of 40–70 years, more frequently in women. About 25% of Spigelian hernias are incarcerated [11,12]. About 300 cases of primary lumbar hernias have been described in world literature [13,14]. The vast majority of lumbar hernias are unilateral [15,16,17] and more common in men [18].
1.4 Features of Coding the Disease or Condition
K42.0. Umbilical hernia with obstruction, without gangrene.
K42.1. Umbilical hernia with gangrene.
K42.9. Umbilical hernia without obstruction or gangrene.
K43.6. Other and unspecified anterior abdominal wall hernia with obstruction, without gangrene.
K43.7. Other and unspecified anterior abdominal wall hernia with gangrene.
K43.9. Other and unspecified anterior abdominal wall hernia without obstruction or gangrene
1.5 Classification of the disease or condition
The current classification system for both primary and incisional abdominal wall hernias was published in 2009 by the European Hernia Society (EHS) based on consensus discussions among hernia specialists [19]. This classification is based on the location and size of the hernia ring. According to location, primary abdominal wall hernias are divided into medial (umbilical hernia, hernia of the linea alba) and lateral (lumbar hernias, Spigelian hernias). Since primary abdominal wall hernias usually have a round or oval hernia ring, the size is described using a single parameter—the diameter of the defect. According to the size of the hernia ring, primary abdominal wall hernias are divided into small (0–2 cm), medium (more than 2 to 4 cm), and large (more than 4 cm).
According to the latest EHS and AHS recommendations, umbilical hernias and hernias of the linea alba were divided into small (up to 1 cm in diameter), medium (from 1 to 4 cm in diameter), and large (more than 4 cm in diameter) depending on the diameter of the hernia defect [20].
The definitions "recurrent umbilical hernia", "recurrent hernia of the linea alba", etc., should be abandoned, as these hernia variants etiopathogenetically belong to incisional hernias and their treatment corresponds to the principles of treatment of incisional ventral hernias. Therefore, the terms "primary umbilical hernia", "primary hernia of the linea alba", etc. are also not used.
1.6 Clinical presentation of the disease or condition
The main symptoms of the disease are the presence of a hernia protrusion and pain in the hernia region. The protrusion appears during straining or in the upright position of the patient and disappears or decreases in the supine position without or after manual reduction. Pain in the hernia protrusion area occurs during physical exertion, walking, and sudden movements. Nausea, eructation, abdominal bloating, and constipation frequently occur. The development of a hernia usually proceeds slowly. The protrusion gradually increases, acquiring a round or oval shape. With long-standing existence, umbilical hernias can reach giant sizes, become irreducible, and pain in the lumbar region appears. With the growth of the hernia size, there is a decrease in the physical activity of patients, as well as an impairment of their work capacity [4,21,22].
2. Diagnostics, medical indications and contraindications for diagnostic methods
Diagnostic criteria
The diagnosis of a primary abdominal wall hernia is established based on:
1) Patient complaints of a protrusion in the abdominal wall area; pain is the main symptom of incarceration. It occurs at the moment of incarceration, most often during some physical exertion, and does not subside after physical effort stops.
2) Determination upon examination and palpation of an elastic mass emerging through the abdominal wall defect. In case of incarceration, the protrusion becomes not only tense but also sharply painful.
3) Additional diagnostic methods (ultrasound, CT) in the absence of obvious clinical signs of a primary abdominal wall hernia.
2.1 Complaints and Anamnesis
When taking a history from a patient with a suspected primary abdominal wall hernia, it is recommended to pay attention to complaints of a protrusion in the abdominal wall area, pain in the protrusion area, dyspeptic disorders, sensations of discomfort, and restriction of physical activity [4,6,14,21,22].
Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.
Comments. The hernia ring may be small and harbors the risk of strangulation, while large ones cause complaints and a feeling of heaviness due to the exit of internal organs into the hernia sac and adhesive processes within it. Increasing in size, the hernia can reach significant proportions, leading to a loss of work capacity [4,6,14,21,22].
To determine a possible incarceration of a primary abdominal wall hernia, it is recommended to clarify with the patient the onset time of pain and whether the hernia was reducible and painless previously [4,5,6,23].
Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.
Comments. Uncomplicated incarcerated hernia is characterized by sudden pain in the area of the hernia protrusion, the intensity of which depends on the type of incarceration, 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. In a patient with an incarcerated hernia complicated by intestinal obstruction, crampy abdominal pain, thirst, dry mouth, repeated vomiting, and delayed stool and gas passage are added [4,5,6,23].
2.2 Physical Examination
The main diagnostic method for a primary abdominal wall hernia is physical examination of the patient (visual inspection and palpation of the abdominal wall), which is recommended to be performed while the patient is standing and lying down in order to identify the abdominal wall defect and the hernia protrusion [4,6,14,21,22].
Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.
Comments. The diagnosis of a primary abdominal wall hernia is usually established during the physical examination of the patient. The examination is performed in the standing and horizontal positions. When examining the abdomen in the standing position, a protrusion is identified. In the supine position, the reducibility of the hernia sac contents can be determined. All sections of the abdominal wall should be carefully palpated so as not to miss other hernia protrusions. Diagnosis of small primary abdominal wall hernias during physical examination is difficult, especially in individuals with a large layer of subcutaneous fat on the abdominal wall [4,6,14,21,22]. Abdominal palpation during bowel incarceration is painful, especially above and over the site of incarceration. One should always keep in mind the possibility of Richter's (parietal) incarceration, in which the volume of the hernia protrusion is sometimes not detectable. An incarcerated hernia complicated by phlegmon of the hernia sac is recognized by an edematous, hot-to-the-touch hernia protrusion, skin hyperemia, and subcutaneous tissue edema. Fluctuation in the hernia area and crepitus in the tissues surrounding the hernia protrusion may appear [4,5,6,23].
2.3 Laboratory Diagnostics
All patients with primary abdominal wall hernias are recommended to undergo a standard set of laboratory tests to assess comorbidity status: complete blood count, urinalysis, general clinical biochemical blood test [24,25,26,27].
GPP CLoE 4Level of Recommendations — C. Level of Evidence — 4.
Comments. Uncomplicated primary abdominal wall hernia does not affect laboratory parameters. Laboratory tests are prescribed to patients before surgical intervention [24,25,26,27].
2.4 Instrumental Diagnostics
Patients with suspected primary abdominal wall hernia in the absence of overt clinical signs are recommended to undergo an ultrasound examination (ultrasound) of the abdominal cavity (comprehensive), including the abdominal wall, to identify a defect in the musculo-aponeurotic layer, as well as to assess the state of the hernia sac and determine its contents [28,29,30].
GPP CLoE 4Level of Recommendations — C. Level of Evidence — 4.
Comments. Physical examination occupies the main place in the diagnosis of abdominal wall hernias. At the same time, an accessible and effective instrumental method in patients with primary abdominal wall hernias should be considered a comprehensive ultrasound examination of the abdominal cavity, including the abdominal wall, which allows:
- 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;
- 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;
- performing differential diagnosis of a primary abdominal wall hernia with other conditions (for example, linea alba hernia with preperitoneal lipoma of the anterior abdominal wall or umbilical hernia with urachal cyst, etc.);
- detecting simultaneous surgical pathology of the abdominal cavity organs;
- ultrasound of the incarceration zone confirms the presence of incarceration, the viability of the incarcerated organ (presence or absence of blood flow using color Doppler mapping), and the degree of inflammatory changes [28,29,30].
Patients with suspected incarceration of a primary abdominal wall hernia are recommended plain abdominal radiography to detect distended intestinal loops with horizontal fluid levels, a symptom confirming a serious complication of an incarcerated hernia — intestinal obstruction [23].
GPP CLoE 5Level of Recommendations — C. Level of Evidence — 5.
In complex cases of diagnosing primary abdominal wall hernias, it is recommended to supplement the examination with computed tomography (CT) of the abdominal cavity to detect a hernia protrusion or defect in the anterior abdominal wall, as well as to clarify the condition of tissues and organs in the area of the hernia protrusion [5,6,23,30,31,32].
GPP CLoE 3Level of Recommendations — C. Level of Evidence — 3.
Comments. Data on the use of CT in the diagnosis of primary abdominal wall hernias are insufficient. CT of the abdominal cavity is proposed for obese patients, as well as for patients with large hernias without clear borders of the hernia gates or patients with rare hernias, such as lumbar hernias. CT of the abdominal cavity is also the method of choice for diagnosing postoperative complications after surgical treatment of primary abdominal wall hernias: differential diagnosis of incisional ventral hernia, seroma, and bulging or residual hernias. Currently, there are no studies devoted to preoperative MRI diagnostics of primary abdominal wall hernias [5,6,23,30,31,32].
2.5 Other Procedures
Patients with a primary abdominal wall hernia and concomitant comorbidity are recommended a consultation with a relevant medical specialist (cardiologist, pulmonologist, endocrinologist, etc.) before surgery [4,21,22].
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
In the presence of a primary abdominal wall hernia with clinical manifestations, as well as in the presence of an asymptomatic umbilical hernia or linea alba hernia with a hernia gate diameter of more than 1 cm, elective surgical treatment is recommended to eliminate the hernia and prevent potential complications [4,21,22,32,33,34,35].
GPP CLoE 4Level of Recommendations — C. Level of Evidence — 4.
Comments. For primary abdominal wall hernias, the main method of treatment is surgical. Surgical treatment 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) [4,21,22,32,35]. However, it is believed that active outpatient monitoring is feasible for asymptomatic umbilical hernia or linea alba hernia with a hernia gate diameter of less than 1 cm with a high degree of safety for the patient. Nevertheless, about 19% of such patients subsequently undergo surgical treatment [33,34].
When signs of incarceration of a primary abdominal wall hernia are detected, emergency surgery is recommended to save the patient's life [4,5,6,22,23,36,37].
Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.
3.2. Conservative treatment
In case of contraindications to surgery, conservative treatment is recommended for patients with a primary abdominal wall hernia [4,22].
GPP CLoE 5Level of Recommendations — C. Level of Evidence — 5.
Comments. Conservative treatment is designed to eliminate certain distressing symptoms for the patient, and to prevent the enlargement of the hernia and its incarceration. The basis of such treatment is wearing an abdominal binder [4,22].
3.3. Surgical treatment
According to the nomenclature of medical services, the term "mesh implant" is used for the surgical treatment of hernias. According to global literature, the terms "mesh" and "endoprothesis" are used to define the material implanted into the layers of the abdominal wall. The term "mesh" encompasses all types of materials implanted into the abdominal wall layers. However, in Russian, the term "setka" (mesh) is not entirely appropriate for use, since currently not all materials implanted into the abdominal wall layers have a mesh structure; therefore, this definition should be abandoned. Based on the foregoing, to designate the material implanted into the abdominal wall layers during the surgical treatment of abdominal wall hernias, it is recommended to use the term "endoprothesis" (implant), which in turn may have a mesh structure and be defined as a "mesh endoprothesis".
Surgical treatment methods vary depending on the access route, the method of hernia repair, the use of an endoprothesis, and the type of endoprothesis. There are no clear recommendations regarding the choice of a single optimal treatment method for each specific type and size of hernia. However, an algorithm exists for determining surgical tactics depending on the size and type of the primary abdominal wall hernia.
In patients with primary abdominal wall hernias, it is recommended to perform surgical treatment using mesh implants (A16.30.002.002, A16.30.004.011), surgical treatment using video-assisted endoscopic technologies (A16.30.002.001, A16.30.004.010) and, in rare cases, autoplasty (A16.30.002, A16.30.004) [6,21,13,38,39,40,41,42,43,44].
GOM ALOE 1Grade of Recommendation – A. Level of Evidence – 1.
Comments. Currently, open and video-endoscopic approaches are used for anterior abdominal wall reconstruction. Open techniques include: "Onlay" endoprothesis implantation (over the fascial defect), "Sublay" (in the rectus abdominis muscle sheath), as well as "IPOM" (intraperitoneal placement of the endoprothesis).
Laparoscopic (endoscopic) repair of primary abdominal wall hernia (surgical treatment of umbilical hernia using video-endoscopic technologies, laparoscopic anterior abdominal wall repair for hernias) is an operation for primary abdominal wall hernia using video-endoscopic technology, utilizing rigid endoscopic video systems and endoscopic instruments for working within the abdominal cavity or artificially created spaces in the abdominal wall for prosthetic hernia repair. Laparoendoscopic methods include: the IPOM technique (intraperitoneal placement of the endoprothesis without closure of the hernia defect), the IPOM+ technique (intraperitoneal placement of the endoprothesis with closure of the hernia defect), the eTEP technique (extended totally extraperitoneal hernioplasty), the TES technique (totally endoscopic anterior abdominal wall restoration with sublay placement of the endoprothesis), MILOS and EMILOS (minimally invasive and endoscopic variants of open anterior abdominal wall restoration with sublay placement of the endoprothesis), TAPP (transabdominal preperitoneal approach/repair), SCOLA (subcutaneous laparoscopic repair with onlay placement of the endoprothesis), and others [6,21,13,38,39,40,41,42,43,44].
In patients with a primary abdominal wall hernia whose hernia orifice width is greater than 1 cm in diameter, it is recommended to use prosthetic hernioplasty techniques via an open (A16.30.002.002, A16.30.004.011) or video-endoscopic approach (A16.30.002.001, A16.30.004.010) [44,45,46,47,48,49].
GPP CLoE 4Level of Recommendations — C. Level of Evidence — 4.
Comments. Treatment of a primary abdominal wall hernia using an endoprothesis leads to a reduced recurrence rate compared to autoplasty [44,45,46,47,48,49].
For small hernias (hernia orifices up to 1 cm in diameter), to eliminate the abdominal wall defect, it is recommended to perform either open surgery using an endoprothesis (A16.30.004.011, A16.30.002.002) or autoplasty (Mayo repair, Sapezhko repair, etc.) (A16.30.004, A16.30.002) [40,48].
GPP CLoE 4Level of Recommendations — C. Level of Evidence — 4.
Comments. For defects less than 1 cm in size, available studies have not revealed a significant difference in recurrence rates and quality of life between patients operated on using an endoprothesis and those undergoing autoplasty [20,40,48].
In patients with a hernia orifice diameter from 1 to 4 cm when using an open approach (A16.30.004.011, A16.30.002.002) to prevent hernia recurrence, it is recommended to use an endoprothesis that overlaps the abdominal wall defect area by at least 3 cm in all directions; when using a video-endoscopic approach (A16.30.002.001, A16.30.004.010), by at least 5 cm [20,50].
GOM CLOE 5Grade of Recommendation – C. Level of Evidence – 5.
Comments. Currently, there are no evidence-based studies to recommend a specific overlap area of the endoprothesis to reduce the number of recurrences after primary abdominal wall hernia reconstruction. However, according to the EHS and AHS guidelines for the treatment of primary abdominal wall hernias, an overlap area of 3 cm was associated with a lower recurrence rate in the reconstruction of primary abdominal wall hernias measuring 1 to 4 cm [20,50].
For large primary abdominal wall hernias with a hernia orifice diameter greater than 4 cm, in order to achieve the best outcome, it is recommended to perform open surgery using an endoprothesis (A16.30.004.011, A16.30.002.002) or video-endoscopic surgery (A16.30.002.001, A16.30.004.010) [6,20,43,51,52,53,54].
GPP CLoE 4Level of Recommendations — C. Level of Evidence — 4.
Comments. As in patients with incisional ventral hernias, it is possible to use reconstructive techniques for hernia defect closure (i.e., with approximation of the hernia orifice edges) and bridging hernioplasty techniques (i.e., placement of the endoprothesis in the tissues of the hernia region as a "bridge"). Open reconstructive hernioplasty techniques include: "Onlay" endoprothesis implantation (over the fascial defect), "Sublay" (in the rectus abdominis muscle sheath), as well as "IPOM" (intraperitoneal placement of the endoprothesis). Open bridging hernioplasty techniques include "Bridging" techniques (placement of the endoprothesis as a "bridge" in various layers of the anterior abdominal wall).
A rare category of patients should be highlighted who have developed primary abdominal wall hernias, typically umbilical hernias with reduction of the abdominal cavity volume or a hernia defect greater than 10 cm. In the surgical treatment of this category of patients, anterior or posterior component separation techniques (ACST and PCST) are used, either via an open (A16.30.004.011, A16.30.002.002) or laparoendoscopic approach (A16.30.002.001, A16.30.004.010). It should be noted that these techniques are traumatic, carry a risk of complications, and at the present stage, their widespread use is not recommended. Patients requiring these techniques should be operated on in specialized herniology departments [6,20,43,51,52,53,54].
When choosing a video-endoscopic approach (A16.30.002.001, A16.30.004.010) to achieve the best outcome, the surgeon is recommended to take into account the anticipated complexity of the surgery, the technical equipment capabilities of the medical organization, personal experience, and preparedness to perform this operation [43,44].
GPP CLoE 4Level of Recommendations — C. Level of Evidence — 4.
When a diagnosis of incarcerated primary abdominal wall hernia is established, it is recommended to perform emergency surgery to eliminate ischemia of the incarcerated internal organs as soon as possible from the moment of the patient's admission to the hospital [4,6,20,23].
Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.
Comments. Early surgical intervention for incarcerated hernia with obstruction is critical, since delayed diagnosis can lead to bowel resection with a more prolonged recovery and associated complications. All diagnostic measures must be performed as rapidly as possible. Preoperative preparation includes emptying the urinary bladder, hygienic preparation of the surgical area, insertion of a nasogastric tube and evacuation of gastric contents, and antibiotic prophylaxis 30 minutes before surgery. In severe cases, intensive preoperative preparation is performed in the ICU or intensive care unit. Preoperative preparation on the operating table is also possible. The main objectives of surgery for uncomplicated incarcerated primary abdominal wall hernia are the elimination of incarceration, assessment of the viability of the incarcerated organ, and hernioplasty, including the use of synthetic materials. If there are doubts about bowel viability, it is permissible to postpone the decision on its resection, using programmed relaparotomy or diagnostic laparoscopy after 12 hours. Bowel resection, if non-viable, is performed according to generally accepted principles. For small bowel incarceration, resection with anastomosis is performed. The method of completing large bowel resection is determined individually. Various surgical options are possible depending on the incarcerated bowel segment, the condition of the abdominal wall, and the presence of peritonitis and sepsis [4,6,20,23].
Surgical treatment of a primary abdominal wall hernia using a mesh implant (A16.30.004.011, A16.30.002.002) to achieve the best outcome is recommended for patients with no signs of bowel incarceration [23,37,56].
GPP CLoE 4Level of Recommendations — C. Level of Evidence — 4.
Comments. The choice of hernioplasty method is based on the contamination of the surgical field, hernia size, and surgeon experience. An increased probability of surgical site infection may indicate an additional risk of repair when using a mesh endoprosthesis [23,37,56].
In an infected surgical field, to minimize potential complications for hernia defects larger than 3 cm, it is recommended to use tissue repair (A16.30.004, A16.30.002) [23,37,56].
Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.
Comments. In surgeries for incarcerated primary abdominal wall hernia, the question of the feasibility of using an endoprosthesis is the most acute. To date, there is insufficient evidence base on this issue [23,37,56].
For lumbar hernia, to achieve the best outcome, it is recommended to use an open approach with preperitoneal placement of the endoprosthesis (A16.30.004.011) or a video-endoscopic approach with preperitoneal or intraperitoneal placement of the endoprosthesis (A16.30.004.010) [58,59,60].
GPP CLoE 3Level of Recommendations — C. Level of Evidence — 3.
Comments. Surgical treatment of lumbar hernia is a technically challenging procedure because coverage of the hernia defect with an endoprosthesis is limited due to the proximity to bone structures. Therefore, it is recommended to consider referring patients with lumbar hernias to specialized hospitals [58,59,60].
In patients with liver cirrhosis, to achieve the best outcome, elective open surgical treatment using a mesh implant (A16.30.004.011, A16.30.002.002) is recommended after liver function compensation (target MELD score below 15) [64,65,66].
GPP CLoE 4Level of Recommendations — C. Level of Evidence — 4.
Comment: patients with a primary abdominal wall hernia and liver cirrhosis are indicated for an open hernioplasty technique using an endoprosthesis. If liver function cannot be compensated, elective surgical treatment is not indicated for these patients [64,65,66].
3.4. Preoperative preparation
Before elective surgery for a primary abdominal wall hernia, to achieve the best outcome, patients are advised to quit smoking 4–6 weeks prior and achieve weight loss to a BMI below 35 kg/m² [20,38,67,70].
GPP CLoE 5Level of Recommendations — C. Level of Evidence — 5.
3.5. Postoperative complications
Postoperative pain
In patients operated on for primary abdominal wall hernias, in the event of postoperative pain, it is recommended to administer analgesics and wear an abdominal-stabilizing binder to relieve pain [4,22,24,34].
Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.
In patients operated on for primary abdominal wall hernias, in the case of chronic postoperative pain, it is recommended to perform ultrasound (comprehensive) or CT of the abdominal organs to rule out seroma or hernia recurrence and, consequently, the development of a postoperative incisional hernia as a potential cause of pain [28,71].
GCR BLEL 2Grade of Recommendation – B. Level of Evidence – 2.
In patients operated on for primary abdominal wall hernias, in the case of chronic pain, it is recommended to perform injections of local anesthetics (amides) into the chronic pain trigger points (endoprosthesis fixation sites) for pain relief. If ineffective, removal of the endoprosthesis fixator (metal staples, suture) is recommended [44].
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 in the surgical area, peaks approximately 3 hours after surgery, and subsides within 3 days postoperatively. Neuropathic postoperative pain is associated with nerve injury and has a clear localization at the injury site 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).
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 after hernia repair using an endoprosthesis. Clinical detectability is up to 35%. Seroma is not a complication of this surgery, but rather a consequence of the intervention, peaking around the 7th day and resolving in almost all patients by the 90th day after surgery. 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. The severity and duration of seroma depend on the method of endoprosthesis placement, fixation technique (frequent fixation, transabdominal sutures through the hernia sac), hernia irreducibility, and the number of previous laparotomies. Methods for seroma prevention may include: excision of the hernia sac; its ablation; closure of the hernia defect; prosthesis fixation that allows fluid to drain from the hernia sac; drainage of the endoprosthesis bed; wearing compression garments [72,73].
In patients operated on for primary abdominal wall hernias, in the event of symptomatic chronic seroma development, it is recommended to perform puncture with aspiration of the contents [73,74,75].
GCR BLEL 2Grade of Recommendation – B. Level of Evidence – 2.
Comments. Aspiration carries a risk of seroma and endoprosthesis infection. Recurrent seromas may require surgical revision with excision of the mesothelial lining [72,73,74,75].
Surgical Site Infection
In patients operated on for primary abdominal wall hernias, to prevent endoprosthesis infection, it is recommended to adhere to the following rules: mandatory preoperative sanitation of chronic foci of infection, antibiotic prophylaxis, changing surgical gloves before handling the endoprosthesis during surgery, and preventing contact between the endoprosthesis and the patient's skin [44,75,76].
Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.
In patients operated on for primary abdominal wall hernias, when a surgical site infection develops, endoprostheses based on polytetrafluoroethylene and polyester are recommended to be removed; polypropylene-based endoprostheses are recommended to be preserved via surgical wound revision with installation of closed irrigation-suction drainage (cavity drainage by active suction) or vacuum therapy [44,75,76].
Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.
3.6. Antibiotic prophylaxis
In patients with primary abdominal wall hernias, as a prevention of surgical site infection, it is recommended to use first-generation cephalosporins. As part of targeted prophylaxis (proven MRSA risk), vancomycin** may be used [20,44,77].
GPP CLoE 5Level of Recommendations — C. Level of Evidence — 5.
Comment: according to the latest edition of the EHS and AHS guidelines for the treatment of primary abdominal wall hernias, antibiotic prophylaxis is indicated when using an endoprosthesis; there is no evidence regarding the need for systemic antibacterial drugs when performing tissue repair [20,44,77].
3.7. Prevention of thromboembolic complications
In patients with primary abdominal wall hernias, prevention of thromboembolic complications is recommended taking into account the risk factors of each individual patient in accordance with the Russian Clinical Practice Guidelines for the Diagnosis, Treatment, and Prevention of Venous Thromboembolic Complications [78].
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 early as possible, use compression knitwear intraoperatively and in the postoperative period, and administer low-molecular-weight heparins (ATC heparin group) in prophylactic doses recommended by the manufacturer for patients of the corresponding risk category [78].
Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
For patients who underwent surgery for medium and small primary abdominal wall hernias with an uneventful postoperative period, special therapeutic measures are not recommended [5,6].
Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.
Comments. In these cases, apart from the administration of analgesics and wound care, no specific treatment is required. Postoperative care includes early patient mobilization; patients are allowed to walk starting from the second day, along with a course of exercise therapy (physical therapy) and adequate pain management using non-narcotic analgesics (anti-inflammatory and antirheumatic drugs) for 2–3 days.
In patients who underwent surgery for primary abdominal wall hernias, sports and heavy physical exertion are not recommended in the first 2–3 months after surgery [5,6].
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 uneventful postoperative course may range from 1 to 2 months.
5. Prevention and Dispensary Observation
There are no reliable methods for preventing primary abdominal wall hernias, as there are no ways to influence the predisposing causes of the disease.
To prevent hernia recurrence and, consequently, the formation of an incisional ventral hernia in the postoperative period, patients are recommended to quit smoking, limit prolonged and heavy physical labor, and undergo prevention and treatment of COPD, prostatitis, and constipation [20,31].
GPP CLE 5Grade of Recommendation – C, Level of Evidence – 5.
Dispanserization (clinical follow-up) is recommended for non-operated patients with primary abdominal wall hernias who have severe comorbidities or refuse surgical treatment [5,6,20,40,48,79].
GPP CLE 5Grade of Recommendation – C, Level of Evidence – 5.
A follow-up visit (examination, consultation) by a surgeon for a patient who has undergone surgery for a primary abdominal wall hernia is recommended at least once a year for 3 years [79].
Level of Evidence CGrade of Recommendation 5Level of Recommendation – C. Level of Evidence – 5.
Comments. The follow-up visit (examination, consultation) includes taking a patient history, physical examination and palpation of the abdominal wall, and, if necessary, an ultrasound examination of soft tissues (one anatomical zone) and abdominal organs (comprehensive) [6,79].
6. Organization of Medical Care
The organization of medical care for patients with primary abdominal wall hernias is carried out in accordance with the Procedure for the Provision of Medical Care to the Adult Population in the Profile "Surgery" (Order of the Ministry of Health of the Russian Federation No. 922n of November 15, 2012).
Primary specialized health care is provided by a surgeon. Upon suspicion or detection of an abdominal wall hernia, general practitioners, district general practitioners, general 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 it is impossible to provide medical care 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 settings and day care settings and includes the prevention, diagnosis, and 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 primary abdominal wall hernias can be performed in surgical departments of medical organizations at all levels. In patients with primary abdominal wall hernias and comorbidities, 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 level III medical organizations.
Indications for planned hospitalization:
Presence of the diagnosis "umbilical hernia, linea alba hernia, Spigelian hernia, lumbar hernia" for elective surgical intervention.
Indications for emergency hospitalization:
Presence of the diagnosis "complicated umbilical hernia, complicated linea alba hernia, complicated Spigelian hernia, complicated lumbar 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
№ | Quality criteria | Performance evaluation |
|---|---|---|
1. | Patients with primary abdominal wall hernia and concomitant comorbidities underwent a consultation with a relevant medical specialist prior to surgery. | Yes/no |
2. | First-generation cephalosporins were used in patients with primary abdominal wall hernias to prevent surgical site infections. | Yes/no |
3. | Patients with primary abdominal wall hernias underwent prevention of thromboembolic complications taking into account the patient's risk factors. | Yes/no |
4. | Patients with primary abdominal wall hernias underwent elective surgical treatment in the absence of contraindications. | Yes/no |
5. | In patients with primary abdominal wall hernias with a hernia defect width of 1 to 4 cm using an open approach, the mesh overlap area was at least 3 cm in all directions from the defect closure zone; using a video-endoscopic approach, the mesh overlap area was at least 5 cm. | Yes/no |
6. | Patients with primary abdominal wall hernia presenting with incarceration underwent emergency surgery. | Yes/no |
7. | Absence of chronic pain, postoperative seroma, and surgical site infection in the postoperative period. | Yes/no |
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Appendix A1. Working Group Composition
Belokonev V.I., Doctor of Medical Sciences, Professor (Samara)
Belousov A.M., PhD in Medicine (St. Petersburg)
Gogia B.Sh., MD, PhD (Moscow)
Gorsky V.A., MD, PhD, Professor (Moscow)
Ivanov I.S., MD, PhD, Professor (Kursk)
Kabanov E.N., PhD in Medicine, Associate Professor (Yaroslavl)
Kovaleva Z.V., PhD in Medicine (Samara)
Matveev N.L., MD, PhD, Professor (Moscow)
Olovyanny V.E., MD, PhD (Moscow)
Orlov B.B., PhD in Medicine (Moscow)
Parshikov V.V., MD, PhD (Nizhny Novgorod)
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)
Tevyashov A.V., PhD in Medicine (Yaroslavl)
Shestakov A.L., MD, PhD (Moscow)
Ettinger A.P., MD, PhD, Professor (Moscow)
Yurasov A.V., MD, PhD (Moscow)
Yuriy A.V., PhD in Medicine (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."
Methods of recommendation validation:
external expert review;
internal expert review.
Description of the guideline validation methodology
The recommendations have been discussed and approved by leading specialists of specialized Federal Centers of Russia and practicing physicians.
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 with primary abdominal wall 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 assessment 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)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized clinical trials with meta-analysis |
2 | Individual studies with reference method control or individual randomized clinical trials and systematic reviews of studies of any design, excluding randomized clinical trials with meta-analysis |
3 | Studies without sequential reference-standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Scale for assessing levels of reliability of evidence (LRE) for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitation interventions)
LoE | Definition |
|---|---|
1 | Systematic review of randomized controlled trials with meta-analysis |
2 | Individual randomized clinical trials and systematic reviews of studies of any design, excluding randomized clinical trials with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Scale for assessing levels of recommendation grades (LRG) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitation interventions)
LoE | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
C | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence; all considered efficacy criteria (outcomes) are unimportant, all studies have low methodological quality and their conclusions regarding the outcomes of interest are inconsistent) |
Appendix A3. Reference Materials
List of medical service codes (current nomenclature)
A03.16.001 – Esophagogastroduodenoscopy
A05.10.006 – Electrocardiogram recording
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
A16.30.002 – Surgical treatment of umbilical hernia
A16.30.002.001 – Surgical treatment of umbilical hernia using video-assisted endoscopic technologies
A16.30.002.002 – Surgical treatment of umbilical hernia using mesh implants
A16.30.004 – Surgical treatment of anterior abdominal wall hernia
A16.30.004.010 – Laparoscopic repair of anterior abdominal wall hernias
A16.30.004.011 – Surgical treatment of anterior abdominal wall hernia using mesh implants
A16.17.002 – Segmental resection 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 region
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
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Patients should start walking on the first day after surgery. Every patient is unique and has a different pain threshold and physical conditioning level, so there is no minimum or, conversely, maximum walking distance. Driving may be resumed as soon as the patient feels confident they can do so safely for themselves and others. Swimming, visiting bathhouses, and saunas must be avoided until the postoperative wounds have healed completely. Jogging, cycling, and going to the gym are permitted within the patient's comfort limits, though it is advisable to reduce physical exertion 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 following primary anterior abdominal wall hernia surgery, though restrictions may apply depending on underlying internal organ diseases. Healthy foods rich in protein and vitamins will promote postoperative wound healing. To normalize bowel function, it is necessary to consume fiber-rich foods and adequate fluids, which will help prevent 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