Login

Hernia management and repair in adults

 

 

This guidance applies to adults aged 19yr and over.

Hernia repairs are subject to criteria-based access in commissioning terms (previously referred to as procedures of limited clinical benefit), therefore the referral letter must state how the criteria (see below) are met.

 

INITIAL MANAGEMENT IN PRIMARY CARE

Weight management:

  • Risk of surgery may outweigh benefits in patients withBMI>35. If in doubt refer as per guidelines below, but advise surgery may not be an appropriate option.
     
  • Offer local referral to weight management programme.

 

Smoking cessation:

  • Warn patients that hernia recurrence rates are 3x higher in smokers compared to non-smokers.
     
  • Encourage smokers to stop and offer information on local cessation support services.

 

 

GROIN (FEMORAL & INGUINAL)

ALL femoral hernias are routinely commissioned for urgent referral due to increased risk of incarceration or strangulation.

In women, ALL suspected groin hernias should be urgent referrals.


Primary Care Flow Diagram:

 

ASA 1 = healthy patient

ASA 2 = patient with mild systemic disease

ASA 3 = patient with severe systemic disease

ASA 4 = patient with severe systemic disease that is a constant threat to life

Royal College of Surgeons and British Hernia Society, Commissioning guide 2016

 

Useful patient information post groin surgery:

https://www.rcseng.ac.uk/patient-care/recovering-from-surgery/groin-hernia-repair/what-to-expect-after-the-operation/


 

UMBILICAL

Surgical treatment is commissioned where patients meet the criteria below:

  • Pain/discomfort that causes significant functional impairment*
     
  • Increase in size month on month
     
  • To avoid incarceration or strangulation of bowel in at risk patients, e.g. where the hernia is difficult or impossible to reduce
     

 

INCISIONAL

Surgical treatment is commissioned where patients meet the criteria below:

  • Pain/discomfort that causes significant functional impairment*

  • Conservative management has been tried first, e.g. weight reduction where appropriate

 

 

IMPALPABLE HERNIA AND GROIN PAIN

Surgery is not commissioned in patients with groin pain and no visible external swelling; this includes patients found to have an impalpable hernia on ultrasound.

Management of persistent groin pain that has not resolved after a period of watchful waiting should be based on individual clinical assessment. Where persistent pain is severe and there is diagnostic uncertainty, referral options include MSK for assessment or imaging.

 

 

DIVARICATION OF RECTI / DIASTASIS

Separation of the rectus abdominus muscles (run from ribs & sternum to pubic bones).

Surgical treatment is commissioned where patients meet the criteria below:

  • The patient has a clinical need for reconstructive surgery following trauma

  • Congenital divarication of recti
     
  • It is disabling and causes significant functional impairment*

 

Surgery is not commissioned:

  • For cosmetic concerns
     
  • Pregnancy related diastasis

 

*SIGNIFICANT FUNCTIONAL IMPAIRMENT

Is defined as a restriction or interference with an individual’s capacity to meet personal, social or occupational demands. Please state the impairment the individual is experiencing on the referral letter.

 

 

REFERENCES

Royal College of Surgeons and British Hernia Society, Commissioning guide 2016

KCCG Commissioning policies for 2021 to 2022

 

 

Review date                           October 2021

Next review date                    October 2022

GP Sifter                                 Dr Laura Vines

Version                                   3.0