Reviewed on : 12 Nov 2024

Reviewed by : Lucy Dyde IFR Support Manager Coventry & Warwickshire CCG

Expires : 12 Nov 2026

1. Category: Prior Approval

Prior approval from the Integrated Care Board (ICB) will be required before any treatment proceeds in secondary care unless an alternative contract arrangement has been agreed with the ICB that does not necessitate the requirement of prior approval before treatment

2. Indication

• Inguinal (groin) Hernia
• Umbilical and Para-umbilical Hernia
• Incisional Hernia
• Femoral Hernia

3. Eligibility Criteria

Inguinal Hernia Repair

In women, all suspected groin hernias should be urgent referrals

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

Minimally symptomatic inguinal hernia can be managed safely with watchful waiting after assessment

Conservative management should therefore be considered in appropriately selected patients

For asymptomatic or minimally symptomatic inguinal hernias not covered by any exclusions stated in this policy, a watchful waiting approach should be taken. This should include reassurance and the provision of information on the signs and symptoms requiring treatment

Surgical treatment will only be approved where a patient meets ONE OR MORE of the following:

• Symptomatic i.e. symptoms are such that they cause significant functional impairment;
• The hernia is difficult or impossible to reduce (i.e. history of incarceration or real difficulty reducing the hernia confirmed by ultrasound)
• It is an inguino-scrotal hernia;
• The hernia increases in size month on month;
• Patients with suspected strangulated or obstructed inguinal hernia should be referred as an emergency
• All inguinal hernias in children (<18 years) should be referred to a paediatric provider
• All inguinal hernias in women should be urgent referrals

Umbilical and Para-umbilical Hernia Repair

• Surgical treatment will only be approved where a patient meets ONE OR MORE of the following:
• There is significant risk of incarceration or strangulation of the bowel;
• Pain/discomfort that causes significant functional impairment;
• Increase in size month on month

Incisional Hernia

Surgical treatment will only be approved where a patient meets the following:

• There is significant risk of incarceration or strangulation OR
• The patient is experiencing pain/discomfort that causes significant functional impairment AND
• Appropriate conservative management has been attempted first e.g., weight reduction where appropriate

Femoral Hernia

All suspected femoral hernias should be referred to secondary care due to the increased risk of incarceration or strangulation. Surgical treatment for adults to be supported subject to policy criteria

For patients who DO NOT meet the eligibility criteria, the ICB will only consider funding the treatment if an Individual Funding Request (IFR) detailing the patient’s clinical presentation is submitted to the ICB

4. Guidance/References

Laparoscopic surgery for inguinal hernia repair: https://www.nice.org.uk/guidance/ta83

Acadamy of Medical Royal Colleges: Repair of minimally symptomatic inguinal hernia – EBI (aomrc.org.uk)

Royal College of Surgeons and British Hernia Society (2016)Commissioning Guide: Groin Hernia.

Malik HT, Marti J, Darzi A, Mossialos E. Savings from reducing low-value general surgical interventions. Br J Surg. 2018 Jan;105(1):13-25. doi:10.1002/bjs.10719. Epub 2017 Nov 8.Review. PubMed PMID: 29114846.

Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, Dunlop DD, Reda DJ, McCarthy M Jr et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA 2006; 295: 285 – 292.

O’Dwyer PJ, Norrie J, Alani A, Walker A, Duffy F, Horgan P. Observation or operation for patients with an asymptomatic inguinal hernia: a randomized clinical trial. Ann Surg 2006; 244: 167 – 173.

Fitzgibbons RJ Jr, Ramanan B, Arya S, Turner SA, Li X, Gibbs JO et al. Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg 2013; 258: 508 – 515