Repair of minimally symptomatic inguinal hernia
Best Practice Guidance
Summary
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.
This guidance applies to adults aged 19 years and over.
Recommendation
Minimally symptomatic inguinal hernia can be managed safely with watchful waiting after assessment. Conservative management should therefore be considered in appropriately selected patients. In women, all suspected groin hernias should be urgent referrals.
Rationale for recommendation
Repair of minimally symptomatic inguinal hernia is a high cost and high frequency operation. A randomised control trial determined that watchful waiting was a safe and reasonable option for minimally symptomatic hernias. Up to one third of hernias give patients only mild pain that does not interfere with work or leisure activities.
The risks/potential harm of delaying surgery (which is a frequently cited reason for repair) are rare. The incidence of hernia accident (i.e. acute hernia incarceration with bowel obstruction, strangulation of intraabdominal contents, or both) is very low (1.8 per 1’000 patients) and even in elderly, whom are at greater risk, the rate is 0⋅11% in patients aged over 65 years. Patients who develop symptoms have no greater risk of operative complications than those undergoing hernia repair for minimally symptomatic hernia. The rate of complications is similar for those undergo surgery for minimally symptomatic hernia and those who have surgery as a result of an increase in symptoms whilst under watchful waiting. The risks are infection, bleeding, perforation, and long-lasting significant pain after surgery as well as risks associated with sedation/anaesthetic. Although it is a generally safe and effective operation, procedures should be delayed where appropriate to avoid these associated risks.
In a male randomised clinical trial for two-year watchful waiting, for the instances that treatment escalated to surgery, the most common reason cited was increased hernia-related pain. The hernia repair can be safely delayed until increased pain or discomfort. Pain interfering with activities increased 5.1% for watchful waiting and 2.2% for surgical repair over this same time. The is confirmed by another trial looking at pain at 12 months that did not find statistically different values between surgery and watchful waiting groups. Those who had increased pain crossed over to have surgery where necessary. 23% of patients crossed over from watchful waiting to surgery within two years. Pain was decreased in both groups at two years.
Results of several randomised controlled and clinical trials agreed with these findings. It is safe to manage minimally symptomatic inguinal hernia with watchful waiting. Outcomes, pain and post-operative complications remained similar to hernia repair for minimally symptomatic hernia.
Patient information
Information for Patients
Surgery (an operation) to repair an inguinal hernia should only be carried out for a very few clinical reasons. Medical evidence tells us that even if your hernia causes you mild symptoms, it is safe to monitor this. Most people will never go on to need an operation.
About the condition
An inguinal hernia is a bulging of part of your bowel through into your groin. People may see or feel a lump under the skin, which may be a bit uncomfortable and may disappear on lying down. This bulge is caused by a weakening of the wall of your abdomen and tends to affect men more often than women. The majority cause either no, or only very mild symptoms, such as occasional groin discomfort.
Very few people will go on to develop serious problems with their inguinal hernia that will require an emergency operation. These problems include blockage of the bowel or very intense pain. It is important that patients seek medical help if they notice sudden changes.
What are the BENEFITS of the operation?
The operation may reduce the likelihood of the hernia causing serious symptoms, or the bowel becoming blocked.
What are the RISKS?
Surgery carries some risks and may not always prevent some serious symptoms from occurring. The risks of inguinal hernia surgery include infection, bleeding, pain and how the anaesthetic may affect you. There is also a risk of damage to the bowel and that the hernia may come back again in the future. Medical evidence shows that there is no significant difference in the number of people suffering pain after having surgery compared to those who didn’t have surgery.
What are the ALTERNATIVES?
You can monitor any changes in the symptoms of your hernia. These changes may include increased pain, not being able to push the bulge back in, or vomiting and constipation. If these occur then you should urgently speak to a doctor. Your doctor will be able to offer more advice on managing the symptoms of the hernia.
What if you do NOTHING?
You will avoid an operation and the risks of an operation. If you do nothing there is a very small risk that you will go on to develop serious problems associated with the hernia that will require an emergency operation at a later date. But most inguinal hernias do not need an operation.
Coding
Code Script
WHEN LEFT(der.Spell_Dominant_Procedure,4) in ('T201','T202','T203','T204','T208','T209’)
AND der.Spell_Primary_Diagnosis like 'K40[29]%’
AND isnull(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date) between 19 and 120
AND APCS.Admission_Method not like ('2%’)
THEN '2B_hernia_repair'
Code Definitions
Procedure codes (OPCS)
T201 Primary repair of inguinal hernia using insert of natural material
T202 Primary repair of inguinal hernia using insert of prosthetic material
T203 Primary repair of inguinal hernia using sutures
T204 Primary repair of inguinal hernia and reduction of sliding hernia
T208 Other specified primary repair of inguinal hernia
T209 Unspecified primary repair of inguinal hernia
T211 Repair of recurrent inguinal hernia using insert of natural material
T212 Repair of recurrent inguinal hernia using insert of prosthetic material
T213 Repair of recurrent inguinal hernia using sutures
T214 Removal of prosthetic material from previous repair of inguinal hernia
T218 Other specified repair of recurrent inguinal hernia
T219 Unspecified repair of recurrent inguinal hernia
Diagnosis codes (ICD)
K402 Bilateral inguinal hernia, without obstruction or gangrene
K409 Unilateral or unspecified inguinal hernia, without obstruction or gangrene
Exclusions
apcs.der_diagnosis_all not like '%C[0-9][0-9]%' and apcs.der_diagnosis_all not like '%D0%' and apcs.der_diagnosis_all not like '%D3[789]%' and apcs.der_diagnosis_all not like '%D4[012345678]%’
This code captures code in the ranges C00-C99, D00-D09 and D37-D48.
Age range: the codes use the following age ranges 0-18 for children and 19-120
for adults.
— Private Appointment Exclusion
AND apcs.Administrative_Category<>’02’
References
- 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
How up to date is this information?
Last revised December 2023
Changes
December 2023 - Coding updated. August 2022 - Coding updated
