This page was printed from The OSCAR website at
Only the electronic version is maintained, once printed this is no longer a controlled document
This commissioning statement refers to:
This commissioning statement does not refer to:
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:
Patient info leaflet – inguinal hernias
RightCare shared decision-making aid
The Royal College of Surgeons 2013 - High Value Care Pathway for groin hernia1 (which includes a useful flow chart) states that GPs should refer:
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.
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: