Hernia Repair – Criteria Led Commissioning Statement

Scope

This commissioning statement refers to:

  • Surgical treatment of inguinal hernias in adult men, and umbilical or incisional hernias in all adults.
  • Hernia repair which is a surgical operation for the correction of a hernia (a bulging of internal organs or tissues through the wall that contains it.)
  • Hernias can occur in many places, including the abdomen, groin, diaphragm, brain, and at the site of a previous operation.

This commissioning statement does not refer to:

  • suspected femoral hernias, inguinal hernias in women, and any irreducible hernias, which should be referred urgently due to the increased risk of incarceration/strangulation

Status

Eligibility Criteria

An approach of watchful waiting is recommended for asymptomatic or minimally symptomatic abdominal hernias; watchful waiting is considered safe. Appropriate conservative management should also be tried first eg weight reduction or support from surgical appliances or underwear.

Surgical treatment should only be offered when one of the following criteria are met:

  • Pain/discomfort interfering significantly with activities of daily living
  • The hernia is difficult or impossible to reduce
  • There is a risk of incarceration or strangulation of bowel
  • Comorbidity is present that will likely significantly in- crease the risks associated with surgery at a later date
  • AND the patient has been a non-smoker for at least 8 weeks.

Patient info leaflet – inguinal hernias

RightCare shared decision-making aid

Lifestyle Factors - 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
Please Note: The life style factors above are not a restriction to the commissioning statements unless otherwise stated

Evidence/Rationale

The Royal College of Surgeons 2013 - High Value Care Pathway for groin hernia1 (which includes a useful flow chart) states that GPs should refer:

  • all patients with an overt or suspected inguinal hernia to a surgical provider except for patients with minimally symptomatic inguinal hernias who have significant comorbidity AND do not want to have surgical repair (after appropriate information provided)2, 3
  • irreducible and partially reducible inguinal hernias, and all hernias in women as 'urgent referrals'4, 5
  • patients with suspected strangulated or obstructed inguinal hernia as 'emergency referrals'4, 5
  • all children <18 years with inguinal hernia to a paediatric surgical provider

Watchful waiting (WW) is regarded as an acceptable option for men with minimally symptomatic or asymptomatic inguinal hernias by the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients6 (Level 1B evidence) and by a number of RCTs, concluding that it is an acceptable option for men with minimally symptomatic inguinal hernias7. Delaying surgical repair until symptoms increase is safe because acute hernia incarcerations occur rarely. More recently, the European Hernia Society has developed World Guidelines for Hernia Management which also supports this approach 8.

https://www.europeanherniasociety.eu/fileadmin/downloads/Rotterdam/HerniaSurgeGuidelinesPART3QUALITY-GLOBAL.pdf

Analysis of 336 patients randomised to watchful waiting in the American College of Surgeons Watchful Waiting Hernia Trial found readily identifiable patient characteristics can predict those patients with minimally symptomatic inguinal hernia who are likely to "fail" watchful waiting hernia management9. These include pain with strenuous activities, chronic constipation and prostatism. Higher levels of activity reduced the risk of this combined outcome but there is no mention of BMI. Consideration of these factors will allow surgeons to tailor hernia management optimally.

Another study found that with follow up over 10 years, a total of 68% of men had had elective surgery, more commonly men older than 65 years, with pain10. They conclude that, although WW is a reasonable and safe strategy, symptoms are likely to progress and an operation will be needed eventually.

More recently a study concluded that a commissioning policy restricting funding for elective hernia repairs (but notably across all types) had led to a significant increase in emergency hernia repairs11. They carried out a retrospective cohort study on around 2550 patients who underwent repair of inguinal, umbilical, incisional, femoral or ventral hernias over a 3 year period.

The number of elective hernia repairs reduced from 857 over 12 months before the funding restrictions to 606 in the same period afterwards (p < 0.001). Over the same time period, however, a significant rise in total emergency hernia repairs was demonstrated, increasing from 98 to 150 (p < 0.001). 30-day readmission rates also increased from 5.1 % before the policy introduction to 8.5 % afterwards (p = 0.006). They concluded that the funding restrictions introduced in 2011 were followed by a statistically significant and unintended increase in emergency hernia repairs in their trust, with associated increased risks to patient safety.

A "watchful waiting" approach is also supported by other CCGs, including the Leeds CCGs. Their clinical guidelines commissioning position is that hernia repair is not routinely commissioned for:

  • Men with an asymptomatic or a minimally symptomatic inguinal hernia (discomfort or pain that does not restrict daily activity - adopt watchful waiting)
  • Men with groin pain and an ultrasound detected, but clinically impalpable, hernia (consider musculo-skeletal referral)
  • Post-operative follow up for low risk cases (ie no evidence of clinically significant haematoma, injury to the bowel or major blood vessels, deep infection, ischaemic orchitis, recurrence)

References

  1. Royal College of Surgeons 2013 - High Value Care Pathway for groin hernia (Sept 2013 – currently under review) https://www.rcseng.ac.uk/-/media/files/rcs/standards-and-research/nscc/hernia_commissioning-guide_published.pdf
  2. Collaboration, I.T., Operation compared with watchful waiting in elderly male inguinal hernia patients: a review and data analysis. J Am Coll Surg, 2011. 212(2): p. 251-259 e1-4.
  3. Chung, L et al, Long-term follow-up of patients with a painless inguinal hernia from a randomized clinical trial. Br J Surg, 2011. 98(4): p. 596-9.4
  4. .Bay-Nielsen, M., et al., Quality assessment of 26,304 herniorrhaphies in Denmark: a prospective nationwide study. Lancet, 2001. 358(9288):p. 1124-8.
  5. Nilsson, H., et al., Mortality after groin hernia surgery. Ann Surg, 2007.245(4): p. 656-60.
  6. Simons, M.P., et al., European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia : the journal of hernias and abdominal wall surgery, 2009. 13(4): p. 343-403.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719730/
  7. Fitzgibbons (2006); Watchful waiting versus repair of inguinal hernia in minimally symptomatic men, a randomised controlled trial. JAMA: 295; 285-292 https://www.ncbi.nlm.nih.gov/pubmed/16418463
  8. European Hernia Society World Guidelines for Hernia Management 2016) http://www.europeanherniasociety.eu/fileadmin/downloads/Rotterdam/HerniaSurgeGuidelinesPART1TREATMENT.pdf
  9. Sorosi G A et al A clinician's guide to patient selection for watchful waiting management of inguinal hernia. Annals of Surgery March 2011http://onlinelibrary.wiley.com/o/cochrane/clcentral/articles/192/CN-00778192/frame.html
  10. Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias Fitzgibbon et all Annals of Surgery 2013 http://onlinelibrary.wiley.com/o/cochrane/clcentral/articles/697/CN-00962697/frame.html
  11. The impact of healthcare rationing on elective and emergency hernia repair. Orchard et al Hernia.2016 Jun;20(3):405-9. doi:10.1007/s10029-015-1441-y. Epub 2015 Nov 23 https://www.europeanherniasociety.eu/fileadmin/downloads/Rotterdam/HerniaSurgeGuidelinesPART3QUALITY-GLOBAL.pdf

Assurance & Governance

  • This policy was developed on: 05.2017
  • This policy was approved by: Clinical Strategy Group (NK) and Clinical Cabinet (WK)
  • Date approved: 05.2017
  • Publication Date: 05.2017
  • Review Date: 04.2018
  • Ref No: PA17 - 05.2017
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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