Inguinal and umbilical hernias are two of the most common reasons a primary care patient may need referral to a general surgeon. History and physical examination are usually sufficient to make the diagnosis. Patient symptoms include pain, burning, heaviness, or aching in the groin or umbilical region. It may be worse at the end of the day or after prolonged activity. The patient may also report a bulge that often disappears in the prone position.

It is best to examine the patient standing and then lying supine. Usually, with the patient standing, a visible asymmetry is seen. This can disappear when the patient is lying flat. Physicians can also feel the bulge or impulse when the patient coughs or strains.

The surgeon’s diagnosis and subsequent treatment decisions are reliably made by the patient history and physical examination alone. The routine use of imaging, including ultrasound, in the setting of a clinically palpable inguinal or umbilical hernia is not required. This only adds unnecessary costs and treatment delay with no useful contribution to management decisions.

Choosing Wisely is a global movement for reducing unnecessary tests and treatments in health care. It tries to inspire and engage health care professionals to take the lead in reducing unnecessary tests, treatments, and procedures, and enables them with simple tools and resources that make it easier to choose wisely.

Recommendation

The Fraser Health Authority Division of General Surgeons, with the support of the Section of General Surgeons of BC, recommends avoiding the routine use of ultrasound in the evaluation of clinically apparent inguinal and umbilical hernias. We are happy to accept elective referrals without an ultrasound. If the referring physician is not confident in the diagnosis, it is okay to order an ultrasound. Also, if the physician feels an ultrasound is necessary, it can be ordered at the time of initial consultation.
—David E. Konkin, MD, FRCSC, FACS
Regional Division Head, General Surgery, FHA
Department of Surgery Head (Local), Eagle Ridge Hospital
Division Head, General Surgery, Royal Columbian Hospital & Eagle Ridge Hospital
Clinical Associate Professor, UBC

Suggested reading

Bohnen J.M.A Inguinal hernia in a 55-year-old man. CMAJ 2014;186:1010-1011. Accessed 25 June 2019. www.cmaj.ca/content/cmaj/186/13/1010.full.pdf [10].

Choosing Wisely. Society of American Gastrointestinal and Endoscopic Surgeons: Five things physicians and patients should question. 9 January 2019. Accessed 25 June 2019. www.choosingwisely.org/societies/society-of-american-gastrointestinal-and-endoscopic-surgeons [11].

Choosing Wisely Australia. Royal Australasian College of Surgeons: Tests, treatments and procedures clinicians and consumers should question. 10 May 2017. Accessed 25 June 2019. www.choosingwisely.org.au/recommendations/racs#collapse-2 [12].