Hernia Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • All abdominal hernias
  • The guidance covers adults age 18+

Commissioning Statement:

  • Referrals for the surgical treatment of Inguinal (in Men) and Umbilical and Incisional Hernias (in all adults) are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • For those patients who are not eligible for treatment under these policies consideration will be on an individual basis via the CCGs Prior Approval Process in accordance with NHS North Kirklees and NHS Wakefield CCG Commissioning Policy

Assessment

Signs and Symptoms

  • A hernia usually presents as a lump, and patients often experience pain or discomfort that can limit daily activities and the ability to work. In addition, hernias can present as a surgical emergency should the bowel strangulate or become obstructed due to the hernia.

History and Examination

  • Check weight
    • Evidence suggests that overweight or obese patients have an increased risk of postoperative complications including infection and severe pain following groin hernia surgery. Obesity has also been associated with the development of umbilical and incisional hernias as well as an increased risk of recurrence following surgical repair of incisional hernias. - see Health Optimisation - Best Practice Statement for further information
  • Check smoking history
    • Smoking is a recognised risk factor for both the development and recurrence of inguinal hernias and is thought to contribute to the development of incisional hernias. Evidence suggests there is an increased risk of postoperative complications following inguinal hernia surgery, in patients who smoke. - see Health Optimisation - Best Practice Statement for further information

Red Flags

Seek immediate or urgent specialist advice/treatment if:

  • Pulsatile swelling
  • Inflammation
  • Severe pain
  • Patients with symptoms of incarceration, strangulation or obstruction should be referred as an emergency
  • Suspected femoral hernias, inguinal hernias in women, and any irreducible hernias should be referred urgently due to the increased risk of incarceration/strangulation

Investigations

Undertake the following to aid diagnosis, inform management or prior to referral:

  • Ultrasound is available when the primary care clinician is in doubt about the diagnosis, such as swelling in the groin

Management

  • No treatment is required for asymptomatic or minimally symptomatic hernias, unless femoral hernias which should be referred as there is a higher incidence of strangulation
  • Patients with minimally symptomatic inguinal hernias who have significant co-morbidity and do not want to have surgical repair can be managed conservatively in primary care

Health Optimization - Best Practice

  • Obesity
    • Patients with a BMI >30 should be encouraged by their Clinician to lose weight prior to surgery and signposted to appropriate support to address lifestyle factors that would improve their fitness for surgery and recovery afterwards.
    • There is a clinical balance between risk of surgical complications with obesity and the risk to delaying any surgery.
    • See Weight Management Care Pathways
  • Smoking
    • In line with 'Healthy Lives, Healthy People; a tobacco control plan for England', local authorities and health professionals are committed to encourage more smokers to quit.
    • Smoking remains the leading cause of preventable morbidity and premature death in England.
    • There is sufficient evidence to suggest that people who smoke have a considerably increased risk of intra- and post-operative complications such as chest infections, lung disorders, wound complications and impaired healing.
    • See Smoking Cessation Care Pathways

Referral

Referral Criteria

Commissioning Statement:

  • Referrals for the surgical treatment of Inguinal (in Men) and Umbilical and Incisional Hernias (in all adults) are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • For those patients who are not eligible for treatment under these policies consideration will be on an individual basis via the CCGs Prior Approval Process in accordance with NHS North Kirklees and NHS Wakefield CCG Commissioning Policy

Referral Instructions

  • e-Consultation is not currently available for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation. If relevant signpost patient to Inguinal hernia Decision Making aid which can be printed off for the patient if required

Patient Information/Public Health/Self Care


Assurance & Governance

  • This guidance was developed on: 04.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 05.2017
  • Publication Date: 05.2017
  • Review Date: 04.2019
  • Ref No: GS3 - 04.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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