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Hernias (adults)

Checked: 17-09-2024 by Vicky Ryan Next Review: 16-09-2026

Principles of Management

Management of hernias in adults (aged 16 and over) across BNSSG ICB is largely guided by the Abdominal Wall Hernia Repair for Patients 16 Years and Over CBA Policy.

Further information can be found at the following links:

Inguinal hernias (all visible or palpable inguinal hernias in female patients and Inguinal-scrotal hernia in a male patient meet criteria for referral)
Femoral hernias (all femoral hernias in male and female patients meet criteria for referral)

Lumps in the Groin and Scrotum

If diagnosis is in doubt then a direct access USS can be requested on ICE. However, local radiologist advice is that clinically reducible hernias do not need USS confirmation and requests may be returned unless a clear clinical indication is given.

Referral Guidance

All referrals for groin or abdominal hernias in adults must meet the Abdominal Wall Hernia Repair for Patients 16 Years and Over CBA Policy. If a referral does not clearly state how the criteria are met then it may be returned by the BNSSG Referral Service or the provider.

Criteria to access treatment must include the following:

History of an episode of incarceration of the hernia or an inability to reduce the
hernia as evidenced in the patient’s primary care records OR
a high risk of strangulation (All hernias have a risk of strangulation, however in order to meet the criteria the patient needs to have had a significant episode such as an increase in pain for which they have attended primary care or A&E and there is documented evidence in the patients primary care record) OR
a) A progressive increase in size of hernia (month-on-month) as evidenced in the patient’s primary care records.

AND

b) Appropriate conservative management has been tried first as outcomes of
surgery are significantly better in non-smokers and in patients with lower BMI
– both should be evidenced in the patient’s primary care records.

NOTE: All suspected Femoral & Inguinal hernias in female patients, and all suspected Femoral & Inguinal-scrotal hernias in male patients should be referred to Secondary Care due to the increased risk of incarceration/strangulation.

All patients with abdominal hernias should receive safety-netting advice on symptoms and signs of strangulation or obstruction.

Referral for hernias in children (age under 16) do not have to meet the same criteria and should be referred appropriately using the paediatric hernia guidelines.

When referring, please consider pre-operative optimisation.

Red Flags

Exclude strangulation or obstruction, which are suggested by:

An acutely painful, firm, tender, irreducible mass (strangulation).
Vomiting, constipation, absence of flatus, and abdominal pain and distension (obstruction).

If there are features of strangulation or obstruction, arrange immediate surgical admission.

NICE CKS - Inguinal Hernia Scenario

Non-Surgical Management of Hernias

Local surgeons advise that non- surgical management of hernias that do not fulfil above criteria for referral can be safely managed with appropriate warnings. Patients should be advised about the risk of obstruction and incarceration. Episodes of pain or tenderness that are prolonged or severe would indicate emergency assessment for possible strangulation.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.