A question commonly asked by patients with hernias, particularly when they are not in pain, is ‘does my groin hernia need to be treated?’
Unfortunately, for those hoping that their hernia will go away without surgical repair, guidance provided by the Royal College of Surgeons and British Hernia Society makes clear that doing nothing is generally only appropriate for patients who have other serious medical conditions and whose hernias do not cause any symptoms. The guidance states that although hernias are not usually serious, simply observing a hernia during a ‘watchful waiting’ period is unlikely to prevent the need for surgery. Generally, such periods of conservative management tend to merely constitute an interval in which surgery is delayed, as the majority of patients will eventually require surgery.
In a report published in June 2018, the Royal College of Surgeons and British Hernia Society discuss the risks associated with conservative management and delaying surgery. They state that when treatment is delayed, patients may have to endure ‘severe and debilitating pain’, which can be highly distressing and can reduce quality of life. They also highlight that the majority of hernias gradually get larger and more uncomfortable, making later operations more complicated and often resulting in poorer outcomes for patients. Furthermore, a delay in surgery can increase the risk of strangulation, which occurs when the hernia becomes trapped in the abdominal wall, threatening blood supply to the tissue. Symptoms include a lump that does not go away, accompanied by nausea, fever or pain, which requires emergency surgery and if not treated in a timely manner is potentially life threatening. Such emergency intervention is more complicated than standard repair with a slower and more difficult recovery and is also associated with a mortality rate that is seven times higher than elective operations.
To reinforce the importance and effectiveness of early surgical intervention, the report points to a study published in 2014 which revealed that patients undergoing a ‘watchful waiting’ approach were 59% more likely to require an emergency repair and were at an increased risk of mortality compared with patients undergoing elective repair.
Given that the report stresses that the only curative treatment for groin hernias is surgical intervention, and that delaying surgery can put patients at unnecessary risk of serious complications, including death, it is concerning that in this same report, the Royal College of Surgeons and British Hernia Society published their findings that Clinical Commissioning Groups (CCGs) are restricting patients from accessing appropriate treatment for groin hernias. They suggest that prohibitive and ‘potentially dangerous criteria’, such as requiring patients to prove their pain and discomfort, a history of hernia incarceration or evidence of the hernia increasing in size from month to month, have been implemented in an attempt to reduce spending.
In light of the evidence that early surgical intervention helps to reduce avoidable morbidity and mortality, it comes as no surprise that the report recommends that access to treatment for hernias is based on clinical assessment and informed discussion between clinician and patient rather than CCGs making the decision.
Emma McCheyne, a senior associate in Penningtons Manches’ clinical negligence team comments: “When surgery is recommended for treatment of a hernia, the risk of a delay is significant. Patients should be given clear advice of warning signs to look out for and when to seek further urgent medical advice. In any individual case, a clinician needs to make a decision upon diagnosis of a hernia of the suitability of the patient for surgery and risks of any delay. Unfortunately, we do receive enquiries from patients who believe they have experienced a delay in their hernia management and surgery, which has resulted in much more significant surgery as well as poor outcomes in terms of longer-term complications.
“If you or a friend or family member have concerns about the management and / or treatment of hernias – or indeed the management of any other surgical procedure, please contact our specialist surgical team on freephone 0800 328 9545 for advice.”