Hernia repair
All suspected femoral hernias should be referred directly to secondary care without the requirement for funding approval.
For hernias other than femoral the clinician proposing this intervention is not required to secure prior approval from the Armed Forces Health Commissioning team and can proceed with treatment if the criteria in the relevant policy are met.
Abdominal wall hernia repair is regarded as a procedure of low clinical priority and therefore not routinely funded.
Please refer to EBI Guidance 2B Repair of minimally symptomatic inguinal hernia
Initial management of patients with hernia
Watchful waiting: is a safe option for people with minimally symptomatic inguinal hernias. Delaying and not doing surgical repair unless symptoms increase is acceptable because acute hernia incarcerations occur rarely. Many people with an inguinal hernia are asymptomatic or minimally symptomatic and may never need surgery.
The decision to refer patients with BMI >35: requires particular care, as the benefits of intervention may well be outweighed by risks of surgical intervention, including poorer healing and higher complication rates. If in doubt, the clinician may refer the patient, but should advise them that surgery may not be an appropriate option for them. Referral to local weight management programmes should be offered.
Patients who smoke should be informed of clinical advice that hernia recurrence rates are 3 times higher in smokers. Patients who smoke should be offered support to stop smoking with a referral to a stop smoking service.
Surgical treatment can be considered for the following type of hernia:
- inguinal hernia
- umbilical / epigastric hernias.
The clinician proposing this intervention is required to secure prior approval via Blueteq from the Armed Forces Health Commissioning team
One or more of the following criteria should be met:
- symptoms of significant pain or discomfort are such that they interfere with activities of daily living; or
- the hernia is difficult or impossible to reduce; or
- it is an inguino-scrotal hernia; or
- the hernia increases in size month on month
Exclusions
The following can be referred direct to secondary care and are not required to secure prior approval:
- incisional hernia
- irreducible hernia
- recurrent hernia which has occurred within 12 months of the original hernia repair or are complex repair
- all suspected female groin hernia(s) should be referred urgently to secondary care
Laparoscopic hernia repair
Laparoscopic hernia repair is not commissioned for primary unilateral hernia repair. Laparoscopic hernia repair is commissioned only for bilateral hernia repair (where the patient has bilateral hernias with external swelling on clinical examination) or for recurrent hernia.
Hernia surgery is not commissioned for impalpable hernias found incidentally during laparoscopic repair of a hernia on the other side.
Evidence base
Laparoscopic cholecystectomy for asymptomatic gallstones
The clinician proposing this intervention is not required to secure prior approval from the Armed Forces Health Commissioning team and can proceed with treatment if the criteria in the relevant policy are met.
NHS England will fund
The removal of the gallbladder for asymptomatic (or symptoms subsequently deemed related to) gallstones is commissioned for patients fulfilling one of the following criteria in accordance with NICE CG188 and the associated quality standard:
- patients with diabetes mellitus / transplant recipient patients / patients with cirrhosis who have been managed conservatively and subsequently develop symptoms
- where there is clear evidence of patients being at risk of gallbladder carcinoma
- where there is clear evidence of patients being at risk of gallbladder or pancreatic complications
- confirmed episode of gallstone induced pancreatitis
- confirmed episode of cholecystitis
- episode of obstructive jaundice caused by biliary calculi
Symptomatic gallstones should be managed in line with the AOMRC evidence based interventions proposals 2Q Cholecystectomy and 2P ERCP in acute gallstones