Lancashire Clinical Commissioning Groups (CCGs)
Policies for the Commissioning of Healthcare
Hernia (abdominal) Surgery in Adults Policy
1 Introduction
1.1 This document is part of a suite of policies that the CCG uses to drive its commissioning of healthcare. Each policy in that suite is a separate public document in its own right but will be applied with reference to other policies in that suite.
1.2 This policy is based on the CCGs Statement of Principles for Commissioning of Healthcare (version in force on the date on which this policy is adopted).
2 Policy
2.1 The case for watchful waiting in men with minimally symptomatic inguinal hernia is strong1,2 ; the case for watchful waiting in minimally symptomatic ventral, umbilical, incisional and epigastric hernia is less strong because it has been little researched, although there are examples of good studies3,4. In the absence of criteria 2.1.1 to 2.1.8 inclusive, the patient should be instructed how to look for signs of strangulation and what to do about it, and watchful waiting should be employed.
Even when 2.1.4 to 2.1.7 are present, patients who are either heavily comorbid or who do not wish surgery may not be referred for surgical assessment, but rather a “watchful wait” in the community be adopted, with appropriate safeguards in place.
All femoral hernias should always be referred, watchful waiting is not appropriate.
All groin hernias in females should be referred without delay as they are likely to be femoral and at greater risk of strangulation.
The CCG will commission a referral to secondary care and the subsequent surgical management of a hernia in the following circumstances:
2.1.1 A strangulated or obstructed hernia of any type. (N.B Patients with suspected strangulated or obstructed hernias require emergency referral.)
OR
2.1.2 Femoral hernias in all patients due to the increased risk of incarceration and strangulation.
OR
2.1.3 All groin hernias in females, as it can be difficult to differentiate between a femoral and an inguinal hernia, and due to the increased risk of incarceration and strangulation.
OR
2.1.4 Inguino-scrotal hernias
OR
2.1.5 The hernia is irreducible or only partially reducible
OR
2.1.6 The hernia is increasing in size month on month.
OR
2.1.7 The hernia is symptomatic, i.e. causes functional impairment (defined as pain, disability or physical discomfort that is directly attributable to the hernia), symptoms present all or most of the time. The symptoms prevent usual activities or significantly disrupt the sleep pattern, and are not primarily related to activities which could be avoided without detriment to health.
OR
2.1.8 The patient has had bariatric surgery and there is a hernia at the port site
2.2 The CCG will not commission the surgical management of inguinal, ventral, incisional, umbilical, parastomal or Spigelian hernias in the following circumstances:
2.2.1 They are asymptomatic.
OR
2.2.2 They are minimally symptomatic, i.e. whose symptoms do not cause functional impairment (defined as pain, disability or physical discomfort that is directly attributable to the hernia) all or most of the time. The symptoms do not prevent usual activities, or significantly disrupt the sleep pattern, or are related to activities which could be avoided without detriment to health.
3 Scope and definitions
3.1 This policy applies to adults aged 19 and over.
3.2 The term hernia means an interruption in a layer of tissue which allows underlying structures, or parts of organs, such as bowels, to protrude through. In lay terms, a hernia is a bulge in the tummy or groin.
The types of hernia
Ventral literally means at the front of the body, but the term is imprecise and used for different types of hernia in different countries.
Abdominal includes not only the abdomen (tummy), but also groin hernias as it is abdominal muscle weakness that allows the underlying abdominal tissue (e.g. bowel) to poke through.
Groin hernias includes inguinal and femoral hernias, depending in which structure in the groin is affected.
Umbilical hernias are those in which tissue bulges through a weakness in or around the umbilicus (belly button).
Epigastric hernias occur in the upper abdomen.
Incisional hernias occur along scars of previous surgery.
Parastomal hernia occur around a stoma (e.g. colostomy).
Spigelian hernias are rare. They occur in the midline of the (usually lower) abdomen.
Note – hiatus and diaphragmatic hernias are internal and not within the scope of this policy.
Also note - Divarication of recti also causes a “bulge in the tummy” but is not a hernia and there is no risk of strangulation. It is in the scope of the Cosmetic Procedures Policy and is not routinely funded.
3.3 The CCG recognises that a patient may have certain features, such as
- having a hernia;
- wishing to have surgery for their hernia;
- being advised that they are clinically suitable for the surgical repair of a hernia, and
- being distressed by their hernia; and by the fact that that they may not meet the criteria specified in this commissioning policy.
Such features place the patient within the group to whom this policy applies and do not make them exceptions to it.
4 Appropriate Healthcare
4.1 The purpose of surgery to repair a hernia is normally to either treat the pain and associated symptoms of the hernia, or to reduce the risk of complications from the hernia, including strangulation or obstruction of the bowel.
4.2 The following policy criteria rely on the principle of appropriateness:
- The criteria in 2.2 relating to the management of asymptomatic or minimally symptomatic hernias, as the CCG considers the alternative management approach of watchful waiting is usually more appropriate than surgical intervention.
5 Effective Healthcare
5.1 The CCG does not call into question the effectiveness of the surgical management of hernias and therefore this policy does not rely on the Principle of Effectiveness. Nevertheless if a patient is considered exceptional in relation to the principles on which the policy does rely, the CCG may consider whether the purpose of the treatment is likely to be achieved in this patient without undue adverse effects before confirming a decision to provide funding.
6 Cost Effectiveness
6.1 The CCG does not call into question the cost-effectiveness of the surgical management of hernias and therefore this policy does not rely on the Principle of Cost-Effectiveness. Nevertheless if a patient is considered exceptional in relation to the principles on which the policy does rely, the CCG may consider whether the treatment is likely to be Cost Effective in this patient before confirming a decision to provide funding.
7 Ethics
7.1 The CCG does not call into question the ethics of the surgical management of hernias and therefore this policy does not rely on the Principle of Ethics. Nevertheless if a patient is considered exceptional in relation to the principles on which the policy does rely, the CCG may consider whether the treatment is likely to raise ethical concerns in this patient before confirming a decision to provide funding.
8 Affordability
8.1 The CCG does not call into question the affordability of the surgical management of hernias and therefore this policy does not rely on the Principle of Affordability. Nevertheless if a patient is considered exceptional in relation to the principles on which the policy does rely, the CCG may consider whether the treatment is likely to be affordable in this patient before confirming a decision to provide funding.
9 Exceptions
9.1 The CCG will consider exceptions to this policy in accordance with the Policy for Considering Applications for Exceptionality to Commissioning Policies.
9.2 In the event of inconsistency, this policy will take precedence over any non-mandatory NICE guidance in driving decisions of this CCG. A circumstance in which a patient satisfies NICE guidance but does not satisfy the criteria in this policy does not amount to exceptionality.
10 Force
10.1 This policy remains in force until it is superseded by a revised policy or by mandatory NICE guidance relating to this intervention, or to alternative treatments for the same condition.
10.2 In the event of NICE guidance referenced in this policy being superseded by new NICE guidance, then:
- If the new NICE guidance has mandatory status, then that NICE guidance will supersede this policy with effect from the date on which it becomes mandatory.
- If the new NICE guidance does not have mandatory status, then the CCG will aspire to review and update this policy accordingly. However, until the CCG adopts a revised policy, this policy will remain in force and any references in it to NICE guidance will remain valid as far as the decisions of this CCG are concerned.
11 References
- Evidence-Based Interventions List 2. Academy of Medical Royal Colleges. November 2020
- INCA Trialists Collaboration. Operation compared to watchful waiting in elderly male inguinal hernia patients – A review and data analysis. J Am Coll Surgeons. February 2011.
- Kokotovic D, Sjølander H, Gögenur I, Helgstrand F. Watchful waiting as a treatment strategy for patients with a ventral hernia appears to be safe. Hernia. 2016 Apr;20(2):281-7. doi: 10.1007/s10029-016-1464-z. Epub 2016 Feb 2. PMID: 26838293. https://pubmed.ncbi.nlm.nih.gov/26838293/
- Lauscher, Johannes & Loh, J & Rieck, S & Buhr, H & Ritz, J. (2012). Long-term follow-up after incisional hernia repair: Are there only benefits for symptomatic patients?. Hernia : the journal of hernias and abdominal wall surgery. 17. 10.1007/s10029-012-0955-9.
Date of adoption
Date for review
OPCS & ICD codes
The codes applicable to this policy are:
OPCS codes
T198, T210, T202, T203, T204, T208, T209, T211, T212, T213, T214, T219, T221, T222, T 223, T228, T229, T232, T233, T234, T241, T242, T243, T244, T248, T249, T251,T252, T253, T258, T259, T261, T262, T263, T264, T269, T271,T272, T273, T278, T279, T971, T972, T978, T079, T981, T982, T983, T988, T989
ICD codes
A415, A419, C152, C155, C172, C181, C182, C183, C187, C20X, C541, C786, D172, D175, D176, E669, F171, G588, H409, I10X, I249, I489, I850, J180, J181, J449, J984, K049, K400, K402, K403, K404, K409, K410, K412, K413, K414, K419, K420, K421, K429, K430, K431, K432, K433, K434, K435, K436, K437, K439, K440, K441, K449, K450, K458, K460, K469, K500, K514, K550, K559, K565, KK566, K632, K659, K660, K703, K709, K800, K801, K811, K851, K913, K914, L089, L905, M2555, M429, M6218, M653, N179, N183, N185, N40X, N430, N433, N508, N509, N948, O908, O996, R103, R104, R521, S3651, S7200, T409, T810, T813, T814, T818, T855, T856, T857, T858, Z432, Z433, Z466, Z488