Hernia

Key Messages

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.

This guidance covers all abdominal hernia; a link to the CCG Hernia policy is available here.

For any hernia

  • Patients with symptoms of incarceration, strangulation or obstruction should be referred.

Femoral hernias

  • All suspected femoral hernias should be referred to secondary care due to the increased risk of incarceration or strangulation. In women, these should be referred urgently.

Inguinal hernias

  • All inguinal hernias should be considered for referral to secondary care. Men with minimally symptomatic inguinal hernias who have significant comorbidity and do not want to have surgical repair can be managed conservatively in primary care

Umbilical and Para-umbilical hernias

  • Should only be referred if considered at risk of strangulation and they fulfil the referral criteria

Incisional hernias

  • Should not be referred unless they fulfil the referral criteria

Divarication of recti

  • Surgical repair of divarication of the recti/diastasis of abdominal muscle (without herniation) is not routinely funded

Please note pre-referral criteria are applicable in this referral.

To see information required please see Referral Section, referrals submitted without this information will be returned.

Please note primary care is requested to follow In Shape for Surgery best practice which can be seen here.

Assessment

Signs and Symptoms

A hernia is defined as a protrusion of an organ or tissue out of the body cavity in which it normally lies, through the structures normally containing it.

They usually present as a lump, and patients often experience pain or discomfort that can limit daily activities and the ability to work.

Very rarely, hernias can present as a surgical emergency e.g., should herniated 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.

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.

Check current employment

Differential Diagnoses

  • Groin Strain
  • Hydrocoele
  • Spermatocele
  • Varicocele
  • Undescended testis
  • Lipoma
  • Lymphadenopathy or abscess of the groin
  • Ileus

Red Flags

  • Pulsatile swelling
  • Inflammation
  • Severe pain

Investigations

The CCG no longer commissions ultrasound for the diagnosis of groin hernia.

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. In women, these should be referred urgently.

Lifestyle Management

All patients with a BMI greater than 30 should be encouraged to lose weight and referred to local weight management programmes where appropriate, prior to elective hernia repair; Obesity is also a risk factor for developing incisional and umbilical hernias and as a result recurrence rates may be higher in obese patients.

All patients should be encouraged to stop smoking and offered information on local smoking cessation support services prior to elective hernia repair; since smoking is a recognised risk factor for developing a hernia, as well as increasing the risk of recurrence and postoperative complications following surgical repair.

Referral

Referral Criteria

Minimum information needed for all hernia types
  • Smoking status - date
  • BMI - date
  • BP - date
Groin Hernia

In women all groin hernias should be urgently referred to secondary care due to the increased risk of incarceration or strangulation.

In men all femoral hernias should be referred to secondary care and all inguinal hernias should be considered for referral to secondary care.

Men with minimally symptomatic inguinal hernias who have significant comorbidity and do not want to have surgical repair can be managed conservatively in primary care.

Surgical Management of Inguinal Hernia

For asymptomatic or minimally symptomatic inguinal hernias in men, a watchful waiting approach is advocated including providing reassurance, pain management etc. under informed consent.

  • Surgical treatment will only be routinely commissioned when one or more of the following criteria is met:
  • History of incarceration, difficulty in reducing the hernia or risk of strangulation.
  • Pain or discomfort sufficient to cause significant functional impairment*.
  • Inguino-scrotal hernia.
  • A hernia that is increasing in size month on month.
  • Suspected strangulated or obstructed hernia.
  • Inguinal hernia in women.
Umbilical Hernia

Referral for specialist advice and surgery, if appropriate, will only be routinely commissioned when one or more of the following criteria is met. Referrals submitted without this information will be returned:

  • Pain or discomfort sufficient to cause significant functional impairment*.
  • A hernia that is increasing in size month on month.
  • If the patient is considered at risk of incarceration or strangulation.
Incisional Hernia

Referral for specialist advice and surgery, if appropriate, will only be routinely commissioned when both of the following criteria are met, referrals submitted without this information will be returned:

  • Pain or discomfort sufficient to cause significant functional impairment*
  • Appropriate conservative management has been tried first e.g. weight reduction, smoking cessation where appropriate

* Note: Significant functional impairment is defined as:

  • Symptoms that result in an inability to sustain employment despite reasonable occupational adjustment, or act as a barrier to employment or undertake education.
  • Symptoms preventing the patient carrying out self-care, maintaining independent living or carrying out carer activities.

Surgical repair of divarication of recti/diastasis of abdominal muscle (without herniation) is not routinely funded.

Please note primary care is requested to follow In Shape for Surgery best practice which can be seen here.

Referral Instructions

Refer using e-Referrals

  • Specialty: Surgery – Not Otherwise Specified
  • Clinic type: Hernias
  • Service: DRSS-South Devon & Torbay-Surgery Not Otherwise Specified- Devon CCG - 15N

Referral Forms

DRSS Referral Proforma

Supporting Information

Patient Information

MyHealth patient information - Hernia

Hernia - NHS Website

The British Hernia Centre

Evidence

Hernia Surgery in Adults - Cambridgeshire and Peterborough CCG

Pathway Group

This guideline was signed off by the NHS Devon CCG Clinical Pathway Group.

Publication date: July 2017
Updated date: December 2021

Last updated: 15-12-2021

 

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