General Surgery CASES Top Ten Tips
1. It is safe to manage asymptomatic / low symptom reducible hernias conservatively. In these circumstances the risks of surgery outweigh the risks of conservatively management. These patients can be reassured and do not need referral to a surgeon. If symptoms worsen to a point that they are affecting ADLs or the hernia is becoming difficult to reduce then the patient can be referred at that point.
2. For those patients being managed conservatively we should encourage them to continue with their normal activities even if this includes heavy lifting / sports. This may lead to increasing symptoms and in those circumstances they should be referred for consideration of repair if they wish.
3. What are the risks of conservative management? There is a 9% chance per year that an asymptomatic hernia will become symptomatic. There is a 1% lifetime chance of strangulation of any asymptomatic hernia.
4. What are the risks of surgical repair? These are dependent on both the type of hernia and the characteristics of the patient but in general:
- 15-20% chance of post-operative pain for up to 1 year post operatively – more likely with open repair opposed to laparoscopic repair
- 3 % chance of hernia recurrence
- 1 % chance of other post-operative complication (haematoma/wound infection)
- 1-3 % of chronic life-changing intractable groin pain
5. BMI is important regarding risks of hernia repair:
- A BMI > 35 significantly increases the risks of post-operative complications and recurrence.
- Patients with a BMI > 40 will not be offered a hernia repair no matter how symptomatic their hernia is. The surgeons would ask that they attempt to reduce weight and would recheck after 6 months. If a patient had failed to lose weight they would be discharged.
6. Losing weight will not resolve a hernia or reduce it in size – however it might reduce symptom burden and will certainly reduce surgical risks and risks of recurrence of the hernia post-operatively.
7. Patients should be encouraged to stop smoking prior to hernia repair as this significantly increases the risk of post-operative wound infection and failure. This is especially important in large abdominal hernia repairs.
8. A clinically obvious hernia does not need an USS to confirm it. It is a clinical diagnosis.
9. We have developed a “Groin Pain” pathway in collaboration with Radiology, General Surgery and the MSK service. This will be a useful guide for those patients presenting with groin pain with no clinically obvious hernia or history of a lump. You will see that these patients should be directed down an MSK pathway first without requesting a scan
10. There is a “Hernia Referral Checklist” on the PRESS portal. Please use this form when referring patients with a hernia. It gives a useful summary of the referral criteria.