Recommendations and resources
1) Don’t perform repair of minimally symptomatic or asymptomatic inguinal hernias without careful consideration, particularly in patients who have significant co-morbidities.
The proportion of patients presenting with inguinal hernias who are suffering significant co-morbidities is increasing. In these populations and in the presence of multiple of co-morbidities, the importance of carefully assessing the risks and benefits of surgical intervention is vital. Studies have shown that adoption of a watch and wait approach does not heighten the risk of the patient developing more severe symptoms. In cases of minimally symptomatic and asymptomatic inguinal hernias, the patient’s prognosis and long term health may be improved by non-surgical intervention. Ongoing surgical review is required to ensure that an individual’s condition is monitored and that a re-evaluation of their surgical need is made should their symptoms increase in severity.
2) Do not use ultrasound for the further investigation of clinically apparent groin hernias. Ultrasound should not be used as a justification for repair of hernias that are not clinically apparent.
The role of ultrasound in the diagnosis and treatment of groin hernias is limited. When the clinical diagnosis of a groin hernia is uncertain, any sonographic findings should be interpreted in conjunction with clinical judgment and treated conservatively. The diagnostic accuracy of ultrasound is reduced in the absence of any clinically palpable hernia.
3) Don’t transfuse more units of blood than absolutely necessary, noting that many hospitals have developed policies on indications for transfusion with a view to minimisation.
The limited blood resources available within the health system and the lack of evidence to support transfusing more blood than required necessitate the use of appropriate guidelines. Patients should be carefully evaluated (through use of applicable guidelines) when being assessed for blood transfusions and closely monitored.
4) Do not use endoscopy for investigation in gastric band patients with symptoms of reflux.
The treatment of reflux in gastric band patients should be carefully considered. Endoscopy should not be used without consideration of alternative strategies. Reflux in gastric band patients is often related to the device. It is best managed by removal of fluid, in consultation with a Bariatric Surgeon or other appropriately qualified person.
5) Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children and young adults until after ultrasound has been considered as an option.
Although computed tomography (CT) is accurate in the evaluation of suspected appendicitis in the pediatric population, ultrasound is a good diagnostic tool that will reduce radiation exposure. Ultrasound is the preferred initial consideration for imaging examination in children and young adults. If the results of the ultrasound exam are equivocal, it may be followed by CT.