Treatment of hernias of the anterior abdominal wall

A hiatal hernia (HH, hiatal hernia, gastric hernia) is an enlargement of the esophageal opening of the diaphragm through which the esophagus normally penetrates into the abdominal cavity, and with a hernia, an abdominal organ, most often the stomach, penetrates into the chest. Sometimes intestinal loops and, extremely rarely, the spleen penetrate into the chest with hiatal hernia. This disease is quite common, it is found on average in 40% of the world's population. Fortunately, for the majority it does not cause any problems, but in 5 - 7% of all gastroenterological patients, complaints are caused by this particular disease (Figure 1).

How do hernias form?

Hernias occur in the area of “weak spots” of the anterior abdominal wall, under the influence of intra-abdominal pressure. Factors that cause its increase are called producing factors and include: physical activity, cough, childbirth and all those cases when the abdominal press tenses.

“Weak spot” is the area of the abdominal wall where the muscular aponeurotic part is most thinned. This may be the place of muscle attachment to the aponeurosis or physiological openings (inguinal rings, umbilical ring).

An increased risk of hernias is observed in people with predisposing factors: connective tissue weakness syndrome, damage to the nerves innervating the abdominal wall, as well as the presence of postoperative scars.

Etiology of the phenomenon

In the chest area there is cartilage tissue, which can become deformed due to external actions or damage. As a result, a lump may develop due to calcification of the cartilage.

In addition, calcium salts can be deposited in the area of the sternum cartilage due to arthrosis or osteochondrosis, after which a lump develops on the chest in a certain area.

Overgrowth of bone tissue may also occur. More often than not, this is an age-related illness and cannot be cured unless it causes some discomfort.

The prerequisite may be other tissues and systems in the given area, from lymph nodes to viral diseases of the epidermis.

What does a hernia consist of?

All hernias, regardless of location and size, have a common structure and consist of the following components:

A hernial orifice is a defect of the anterior abdominal wall, mainly in the aponeurosis. Through them, the internal organs leave the abdomen and end up under the skin. If the hernial orifice is wide, then through it the contents can freely return to the abdominal cavity.
Hernial sac is a sheet of stretched peritoneum covering organs that extend beyond the abdominal cavity through the hernial orifice. The hernial sac is covered with several membranes, these also include subcutaneous tissue and skin.
The contents of the hernial sac are the internal organs or their individual parts that extend beyond the abdominal cavity through the hernial orifice.

What is the xiphoid process of the sternum?

What is it - the xiphoid process of the sternum? This is the smallest part of the bone, which can vary in size or shape, have a bifurcated top or a small hole in the middle.

In the upper, lateral part of the process there is a small notch connected to the cartilage of the seventh rib. The given element is connected to the body in a stationary state; at the point of contact, the bones have hyaline cartilage ( one of the types of connective tissue, distinguished by a dense, elastic intercellular substance that forms special shells, capsules, around chondrocyte cells and groups

As the body ages, the process fuses with the thoracic part of the body.

If a person sees unusual pain effects in the chest area, especially with pressure, this may indicate various kinds of diseases that are associated with damage to organs in the chest part of the body or a nearby area ( some part of a larger structure

Such organs ( An organ is a separate collection of various types of cells and tissues that perform a specific function within a living organism

) are:

stomach;
gallbladder;
heart

If the disease is associated specifically with these organs, then a person may experience pain not only when pressing on the xiphoid process, but also with the slightest strain on the body, as well as after each snack.

There are other prerequisites for the disease. For example, sliding rib cartilage, which is formed due to severe injuries. At first, a person will experience extremely powerful pain in the chest area, but after some time it will disappear and will only appear when pressing on the appendix. In such cases, the pain will be of a dull nature.

The gastrointestinal tract is another cause of pain when pressing. If a person has a stomach ulcer, inflammatory processes can spread to fatty tissue and reach the chest area. In this case, you can watch for symptoms such as:

nausea, vomiting;
loss of appetite;
heartburn, etc.

The cause of pain in the sternum when pressed can be a hernia of the xiphoid process. As a rule, its development is influenced by a hereditary factor or severe trauma ( damage, which is understood as a violation of the anatomical integrity or physiological functions of organs and tissues of the human body, resulting from external influence

). The xiphoid process can have several openings covered by a fibrous plate.

For the above reasons it may not be available. Then internal, closely located organs (fatty tissue or elements of the peritoneum itself) begin to penetrate through the hole. A preperitoneal lipoma develops.

A real hernia of the xiphoid process is a rare disease.

The symptoms of the disease are as follows:

painful feelings in the chest;
unusual bulging at the site of the xiphoid process;
upon palpation (palpation), the contents of the hernial sac are felt;
during reduction, the hard edges of the hernia gate are felt.

If a patient experiences similar symptoms, it is entirely possible that he has a hernia of the xiphoid process. To make a clear diagnosis, it is important to visit a specialist and undergo appropriate diagnostics, including an x-ray examination.

This type of hernia can only be cured by surgical intervention. Before the operation, the patient is prescribed a differential examination to clarify the diagnosis, since similar symptoms are inherent in a number of pathologies. Quite often, doctors came across situations where a hernia was disguised as ailments of other organs, such as heart disease, ulcers, gastritis or angina.

The operation to remove a hernia is considered easy. The surgeon processes the bag, suturing the gate of the opening of the xiphoid process. Organs caught in it undergo arthrotomy. The doctor disconnects the appendix from the chest, making an incision of about 9 cm.

The appearance of unusual compactions can result from muscle rupture in the anterior region of the peritoneum. Very often, the causes of this condition are powerful injuries that stimulate the development of the tumor. For research, the doctor prescribes certain tests, listens to the patient’s complaints and conducts an examination. Based on the results obtained, a strategy for treating the tumor is selected.

In medical practice, there is such a pathology as xyphoidalgia. Given disease ( this is a condition of the body, expressed in disruption of its normal functioning, life expectancy and its ability to maintain its homeostasis

) has a second name - xiphoid process syndrome. It manifests itself when organs that have cooperative supply (innervation) with the process are damaged. These include:

diaphragm diseases;
ulcer;
damage to lymph nodes, etc.

In such cases, patients, as a rule, do not have pain in the xiphoid process itself, but in the area behind it.

In some situations, the patient may experience some constriction in the larynx and attacks of nausea. Pain ( unpleasant or painful sensation, experience of physical or emotional suffering

) has a nagging disposition, can intensify over time and last for a couple of hours. A person may also make the discomfort worse by moving or eating a large meal.

All patients with xyphoidalgia have impaired posture. It can be either barely noticeable or extremely pronounced. As mentioned earlier, pain associated with the xiphoid process can easily be confused with something else. So, for example, xyphoidalgia needs to be differentiated from pathologies associated with:

with pain in the heart;
with the digestive system;
with lungs.

Xiphoid process syndrome can have a variety of symptoms. Treatment measures begin only after a clear diagnosis has been established. Sometimes this can be quite difficult to do.

To identify pathology, the patient undergoes:

X-ray of the lungs and spinal column;
FGS of the stomach;
ECG;
in some cases - MRI.

In some cases, the patient is sent for examination, which includes a general blood test, OAM (general urinalysis); fluorography, etc. Thanks to the diagnostics provided, the specialist has the opportunity to see the clearest picture of the patient’s health status, the presence/absence of pathological defects and the location of the disease, if present.

Experts recommend a specific method for healing xiphoid process syndrome, which the patient can use without the help of others. To begin with, it is important to change your position and sit in such a way that your back straightens in the chest area (straighten your shoulder blades). To place ( Place - location, position, location, state, point, etc.

When pain occurs, ice cubes wrapped in a kitchen towel should be applied for 10 minutes.

If you have xyphoidalgia, you should not:

Spinal traction.
Gymnastic exercises that may lead to other diseases. It is better to master the exercise therapy of Dr. A. N. Sukhoruchko, created specifically for the treatment of xiphoid process syndrome.
Straightening the spine without the help of others.

All this can only increase the pain syndrome. It is worth considering that the discomfort of xyphoidalgia cannot be calmed with the help of Novocaine, Baralgin, Ketorol and other painkillers. Such pathologies can be cured by a chiropractor.

Source: https://spina-health.com/mechevidnyj-otrostok-grudiny/

What types of hernias are there?

Depending on the anatomical location, external and internal hernias are distinguished. External ones include:

Umbilical hernia.
Inguinal hernia.
Hernia of the white line of the abdomen.
Postoperative hernia.
Paracolostomy hernia.
Lumbar hernia.
Perineal hernia.
Obturator hernia.
Hernia of the xiphoid process.
Sciatic hernia.

Hernias that form inside the abdominal cavity are considered separately. With such hernias, internal organs can be located in pockets of the peritoneum or penetrate into the chest cavity through the openings of the diaphragm.

Depending on the size of the hernia, they are divided into:

Small: hernial orifice less than 4 cm
Medium: hernial orifice from 4 to 10 cm
Large: hernial orifice larger than 10 cm

Hernias are also classified according to the degree of development:

initial - a small depression is identified in a weak spot of the abdominal wall - a triggering factor for the formation of a hernia;
canal - internal organs begin to sink into the hernial opening;
complete - the internal organs have passed through the hernial orifice and are located under the skin.

According to the clinical course, hernias are divided into:

reducible - the contents of the hernial sac move freely from the abdominal cavity to the hernial sac and back.
irredeemable.
strangulated - a condition in which the hernial orifice puts pressure on the structures of the released organ, which leads to disruption of its blood supply and can lead to necrosis. There are: elastic strangulation, fecal strangulation, parietal strangulation, retrograde strangulation, Meckel's diverticulum strangulation, Broca's hernia.

Location and structure

Location of the xiphoid process in the chest
The xiphoid process is located in the center of the chest. It got its name because of its characteristic shape - sharp and elongated. At an early age, the process has a cartilaginous structure; as a person grows older, it hardens and, closer to 30 years of age, grows to the bony base of the sternum.

Just below the xiphoid process is a ganglion of nerves called the solar plexus. The shape and size of the bone formation in different patients may differ by several centimeters within the physiological norm.

What are the symptoms of a hernia?

In the initial stages, a hernia may manifest itself as discomfort or slight pain during physical activity at the site of hernia formation. As the aponeurosis thins or the tissues of the anterior abdominal wall weaken, a painless protrusion appears, disappearing when pressure is applied to it. With each new episode of increased intra-abdominal pressure, the hernial orifice will increase in size, and the sac will stretch due to an increase in the volume of contents.

External abdominal hernias that occur without complications are characterized by such general symptoms as: the presence of a hernial protrusion, discomfort in the hernia area, dysfunction of the organs that make up the hernial contents.

Diseases of the gastrointestinal tract

There are also cases when discomfort in the area of the xiphoid process is a consequence of any abnormalities of the gastrointestinal tract. For example, this is how a stomach ulcer can manifest itself. In this regard, it is recommended to pay attention not only to pain, but also to such accompanying symptoms as vomiting or nausea, heartburn, lack of appetite, etc.

Why is a hernia dangerous?

Any hernia is dangerous for the development of complications. The most serious complication of a hernia is strangulation. It occurs when the blood supply to the contents of the hernial sac is disrupted and tissue necrosis occurs.

An equally serious complication is intestinal obstruction. As a result of the prolonged presence of intestinal loops inside the hernial sac, they are compressed, the movement of intestinal contents through them is disrupted, and intestinal obstruction forms.

It is very important to understand that the development of complications can occur suddenly, against the background of complete well-being: on vacation, at the dacha, while traveling - in situations where qualified medical care is difficult to access or not available at all. Treatment of hernia complications requires emergency intervention, and delay can lead to a sharp deterioration in a person’s condition and significantly worsen the prognosis of delayed treatment.

Therefore, it is better to get rid of the hernia before complications develop.

Other reasons

If the xiphoid process of the sternum constantly hurts, then the cause of this may well be sliding costal cartilage syndrome. As a rule, this pathological condition occurs as a result of severe injuries. In this case, the person experiences pain in the sternum, which gradually subsides and manifests itself exclusively during pressure. It should be noted that such unpleasant sensations are dull in nature.

Often, having gotten rid of severe pain, the patient believes that the disease has gone away on its own and he no longer needs qualified help. However, sliding costal cartilage syndrome can quite easily lead to inflammatory reactions in the xiphoid process.

Hernia treatment

It is only possible to completely get rid of a hernia through surgery. There are also conservative methods to alleviate the condition of a hernia, but their use is possible only if there are contraindications to surgery.

Contraindications to elective surgical treatment include severe concomitant diseases, malignant processes in advanced stages, acute diseases and pregnancy. It is important to note that complicated hernias must be operated on urgently for health reasons.

The smaller the size of the hernia, the easier the operation for both the surgeon and the patient. In turn, the treatment of giant hernias represents a major surgical problem and requires the use of non-standard approaches to its elimination.

Hernioplasty (hernia repair) is the name of an operation to “liquidate” a hernia with plastic surgery of a defect in the anterior abdominal wall.

Diagnosis of hiatal hernia

The main role in diagnosis is played by X-ray examination with barium and gastroscopy.

X-rays are performed on an empty stomach using a barium contrast solution. The doctor monitors the passage of contrast through the esophagus and stomach on the X-ray machine screen. Thanks to X-ray examination, it is possible to identify the size of the hernia, the presence or absence of reflux of gastric contents into the esophagus, the presence or absence of disturbances in the passage of contrast through the esophagus and stomach.

Gastroscopy allows you to assess the condition of the esophageal mucosa, the presence or absence of inflammation, erosions, ulcers, and the presence of narrowing. In the vast majority of cases, these two studies are sufficient to make the correct diagnosis. In some cases, a CT scan is performed to evaluate the presence or absence of a hiatal hernia and its size. If there are non-esophageal manifestations or an unclear clinical picture, daily pH measurements are performed. A thin probe is installed into the lumen of the esophagus for 24 hours, which records the reflux of gastric contents into the esophagus, making it possible to identify the connection between complaints and reflux of gastric contents.

What are the methods of anterior abdominal wall plastic surgery?

Plastic methods can be tension or non-tension.

Tension is a type of plastic surgery performed using the patient’s own tissues. This method received this name because, in order to eliminate a hernia defect, the tissues must be “tightened” and sewn together. The resulting tension in the tissues can cause pain after surgery and result in a possible relapse. At the present stage of development of medicine, this method of closing hernias defects is significantly inferior to non-tension methods.

Tension-free plastic surgery involves the use of modern mesh prostheses to strengthen the anterior abdominal wall. The prosthesis is a polypropylene network, which, due to its flexibility, strength and high degree of tissue “germination”, has shown its reliability and safety when used in hernia repair. Mesh prostheses come in different sizes, from small ones with a diameter of 5 cm for umbilical hernias, to large ones of 50 x 50 cm for giant incisional hernias. Modern three-dimensional mesh systems make it possible not only to strengthen the hernia defect in the form of a “patch”, but to completely fill it, significantly reducing the risk of relapse. In some situations, a special mesh is installed, the surface of which is coated with a special composition that allows it to safely contact the abdominal organs and avoid the formation of adhesions between them.

The open hernia repair operation consists of several stages:

Isolation of the hernial sac. A skin incision is made above the hernial protrusion, the hernial sac is freed from the surrounding subcutaneous fatty tissue. The “hernial orifice” is distinguished.
The hernial sac is opened, the condition of the contents of the hernial sac is assessed, and if there are no complications, the contents are immersed in the abdominal cavity.
The hernial sac is excised, stitched and plunged into the abdominal cavity.
The integrity of the anterior abdominal wall is restored (plasty is performed).

What is the xiphoid process?

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Possible causes of pain

Pain in the area of the xiphoid process that occurs with pressure can have a number of circumstances, these are:

sternum injuries;
chondropathy (Tietze syndrome, “sliding rib”, etc.);
pathological processes in organs located in the projection of the MO;
MO hernia;
tumors;
consequences of osteochondrosis;
other rare pathologies.

A traumatic effect on the xiphoid process (for example, a powerful blow) can cause a fracture or rupture of the muscle, but even a simple bruise is often accompanied by intense pain that increases with breathing, coughing or sudden movements. Most often, bruises go away without much healing, but injury to this area tends to last for a long time ( a form of physical and mental processes, a condition for the possibility of change

) manifest itself as pain when pressing on the bone.

Trauma and damage can contribute to the development of chondropathy, of which Tietze syndrome (TS) and sliding rib are distinguished.

Tietze syndrome

TS often occurs without any special circumstances; it manifests itself as local pain at the junction of the first or pair of upper ribs with the sternum. The pain may radiate to the xiphoid process, pressure on which is also painful. TS is an aseptic inflammation of cartilage tissue and requires conservative treatment.

Among the reasons considered to be the causes of Tietze syndrome are metabolic disorders, hypovitaminosis, calcium deficiency in the body, joint and muscle diseases, excessive overload, infections, and age-related changes.

Manifestation of slipping rib syndrome

Slipping rib syndrome (SRS) is a pathology in which pain is localized at the tips of the rib bones or in the area where they connect to the sternum.

In the 2nd option, painful feelings may intensify when pressure is applied to the MO.

The pathology develops against the background of recurrent subluxation of the costal cartilage, which leads to increased mobility of the rib (sliding), while the bone will affect the intercostal nerve, causing pain.

Problems in the abdominal cavity

Pathologies of the abdominal organs can cause pain in the MR area, which often does not have an exact localization. Pressure on the xiphoid process increases the intensity of pain. These diseases include:

gastritis and stomach ulcers;
pancreatitis;
cholecystitis;
pathologies of the food tract.

Diseases of the gastrointestinal tract can be distinguished from musculoskeletal pathologies by the presence of additional signs: heartburn, belching, nausea and vomiting, diarrhea (constipation). Ultrasound and blood tests help diagnose the disease.

Flatulence

One should not exclude such a problem as flatulence. Even in a healthy person, consuming products that cause excessive gas formation puts extra pressure in the intestinal tract, and since the upper part of the colon is adjacent to the MR area, pain and discomfort may occur in this part of the sternum.

Heart pathologies

The spread of pain to the area of the xiphoid process often accompanies pathologies of the heart.

Angina pectoris most often manifests itself as pain in the left and central parts of the chest, but pressing on the musculoskeletal region increases the pain (as does sudden movements, physical or nervous tension).

It must be remembered that in case of a heart attack, obstruction or rupture of a coronary artery, nitroglycerin does not relieve pain; in such cases, urgent medical attention is required.

Inflammatory processes of the respiratory system

Pain in the area of the bladder can be caused by pathologies of the respiratory organs: pneumonia, bronchitis, tuberculosis, tumors. The presence of additional symptoms (cough, weakness, sweating, high temperature) helps to distinguish pulmonary pathologies.

Hernia of the xiphoid process

There is a disorder in which the source of pain in the central part of the sternum is the xiphoid process itself - a hernia of the sternum.

Most often, this pathology is caused by developmental defects, in which the MO splits, bends, and creates holes of different sizes in it. Fatty tissue of the peritoneum can protrude through the holes, causing pain.

From time to time, these bumps can be seen or felt through the skin. Similar pathological configurations are rare in medical practice.

Thoracic osteochondrosis

Another disorder that causes pain in the MO area is osteochondrosis of the thoracic spine and associated pathologies, most notably protrusions and herniated intervertebral discs.

The gradual loss of elastic parameters by the disc leads to convexity of its tissues into the area where nerve fibers are located, compression of which is characterized by pain.

The intensity and localization of pain depends on the placement, size and direction of the hernial bulge.

Other prerequisites

Other causes of pain in the central part of the chest include xiphodynia (hypersensitivity of the xiphoid process), pathologies of regional vessels, fibromyalgia, benign tumors (lipomas, chondromas), cancer, developmental anomalies (for example, aplasia of the xiphoid process).

Healing

The healing of a diagnosed disease is prescribed and supervised by a specialist. For musculoskeletal pathologies, the usual course of therapy includes taking non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, muscle relaxants, and chondroprotectors. Pain of the highest intensity can be relieved with the help of anesthetic blockades. After completing the first phase of healing, physiotherapeutic procedures are recommended.

A group of diseases of the gastrointestinal tract is treated by a gastroenterologist. The course of therapy must certainly be accompanied by a diet, which, for certain acquired actions, is prescribed for life.

Healing ( faith healing (as well as healing by prayer, divine healing) is a doctrine that asserts the possibility of supernatural physical healing from an illness or congenital (acquired) defect of the body

) cardiovascular disease involves normalizing blood pressure and taking a number of different medications, the purpose of which depends on the person’s condition and the type of cardiac pathology; almost all products are taken for life.

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Surgery is indicated when there is a danger to life or in case of prolonged intense pain. For example, surgical treatment of slipping rib syndrome ( one of the paired arched flat bones running from the spine to the sternum and making up the rib cage in vertebrates

) means removal of a pathological area of the rib bone. The critical size of a herniated disc is also a reason for surgery.

Prevention

Specific prevention consists of following the instructions of the treating doctor. This includes diet, taking supportive foods, avoiding intense overloads, and physical therapy. Congenital anomalies require repeated monitoring with examinations.

Conclusion

Soreness in the area of the xiphoid process can indicate many different diseases. The only correct strategy in a variant ( one of several editions of a work (literary, musical, etc.) or an official document; modification of any part of the work (different readings of individual

) the appearance of such pain - contact a medical institution.

Attempts at self-diagnosis and treatment are fraught with incorrect diagnosis with the following harm to health.

Source: https://OrtoCure.ru/kosti-i-sustavy/boli-i-hrusty/v-mechevidnom-otrostke-grudiny-pri-nadavlivanii.html

Is it possible to operate a hernia without incisions using modern mesh prostheses?

Yes, you can!

At the moment, laparoscopic hernioplasty is the operation of choice for the treatment of various types of hernias. This operation is performed through punctures in the anterior abdominal wall. The surgeon inserts a video camera into the abdominal cavity and, using additionally inserted manipulators, releases the hernial sac from its contents. In the second stage, the surgeon separates the peritoneum of the hernial sac from the tissues of the anterior abdominal wall, dissects it and places a special mesh prosthesis on the hernial orifice. Then, the mesh is reinforced on top with the previously separated peritoneum.

Thanks to this, the prosthesis does not form adhesions with internal organs. This method of plastic surgery avoids tissue tension and greatly reduces the likelihood of relapse. The absence of large incisions on the anterior abdominal wall contributes to a comfortable course of the postoperative period.

How does the postoperative period proceed?

After laparoscopic hernia repair, pain is practically not felt and is therefore easily controlled using tablet painkillers.

The only reminder of the operation was discomfort in the area of small punctures on the anterior abdominal wall.

In uncomplicated cases, discharge from the hospital occurs within 2-3 days. The time frame for returning to work, on average, does not exceed 10-14 days.

Traditional open surgery is characterized by pain in the postoperative period. However, carrying out comprehensive pain relief in a hospital allows you to reduce its severity and feel comfortable throughout the entire recovery period.

After discharge from the hospital, you will be advised to limit physical activity for a period determined by your attending physician based on the complexity of the treatment performed.

Why does the sternum protrude?

The baby’s chest bulges more often during pathological actions in the chest cavity than during a physiological hypersthenic constitution.

Pectus excavatum and keeled breasts are congenital conditions. They appear when the formation of bone and cartilage structures is disrupted due to genetic abnormalities. Clinical studies have established that the given pathology is inherited.

When a baby has a protruding bone in the center of the upper body, timely healing can prevent future development of the deformity.

Read more about chest deformities in children here.

In adolescence, constant pressure on the protruding keel leads to the fact that the sternum returns to its normal state ( a concept denoting a set of stable values of variable parameters of an object

). With the help of orthoses and other orthopedic devices, it is possible to exclude surgical treatment, which is prescribed for severe displacement of the ribs and chest cavity.

There are more rare innate premises ( this is a statement intended to justify or explain some argument

) pathology. Poland and Spouse syndrome occur in 1 in 40,000 newborns. Pigeon bump (funnel chest) is observed more often than carinatum of the chest.

With Poland syndrome in children, other stigmas of disembryogenesis are observed:

underdevelopment of the subclavian artery;
egg hypoplasia;
leukemia;
paralysis of the facial and optic nerves.

Poland's symptom causes pronounced cosmetic imperfections. If they are not treated at an early stage, compression of the lungs and heart occurs.

Syndrome ( a set of symptoms with common etiology and pathogenesis

) The wife is characterized by progressive breast dystrophy and intrauterine growth disorder of the bone structure. As the pathology progresses, it is inherited according to an autosomal recessive principle and is associated with chromosomal abnormalities.

Who deals with surgical treatment of external abdominal hernias?

You can always contact the clinic of coloproctology and minimally invasive surgery for surgical treatment.

Qualified specialists regularly perform laparoscopic interventions for hernias of the anterior abdominal wall. In some cases, we also use traditional open surgery.

At KKMH, treatment of hernias is carried out both on a paid basis and under the compulsory medical insurance policy.

Sign up for a consultation by phone +7 (499) 11-03-222.