This guidance is produced by The Academy of Medical Royal Colleges (the Academy) as part of the Evidence-based interventions programme. It is based on recommendations from the Expert Advisory Committee and the National Institute for Health and Care Excellence (NICE).

All guidance has been reviewed by the Birmingham and Solihull & Sandwell and West Birmingham CCGs’ Treatment Policy Clinical Development Groups (TPCDG). This was reviewed to establish if existing CCG policies were already in place which covered the proposed intervention / treatment in question.

Where there was no current CCG policy for the area in question, the NHSEI policy has been implemented in full into the CCG’s Clinical Treatment Policy portfolio.

Where there was a current CCG policy for the area in question, then the existing CCG policy has been reviewed by the TPCDG considering the NHSEI EBI policy rationale and evidence base.  A decision has then been taken by TPCDG based on the review as to the most appropriate policy for implementation by taking into account the healthcare needs of our local population.

The aims of the Evidence Based Interventions programme is to ensure the quality and safety of patient care by, freeing up valuable resources such as time so that more effective interventions can be carried out, reducing harm or the risk of harm to patients, helping clinicians maintain professional practice, creating headroom for innovation, and maximising value and avoiding waste.

What is bariatric surgery?

Bariatric surgery is a group of surgical procedures: restrictive; malabsorptive and combined procedures. The procedures may be used to promote weight loss for people who are considered obese.

Obesity is defined as a Body Mass Index (BMI) of 30kg/m2 or more. These surgical procedures are usually performed by keyhole surgery (laparoscopically), which means patients spend a shorter time in hospital and the recovery time is quicker.

  • Restrictive procedures help to limit the amount of food the stomach can hold.
  • Malabsorptive procedures shorten or bypass a section of the intestine to reduce the amount of food intake.
  • Combined procedures use elements of restriction and malabsorption to aid weight loss.

Surgical mesh:

Mesh is a screen like material used during an operation to provide extra support to weak ordamaged tissue or bone. There are three types of surgical mesh:

  1. Standard Surgical Synthetic. Mesh made from synthetic or manmade materials which will or will not absorb in the body
  2. Biological Mesh made from animal or human tissues
  3. Biosynthetic Mesh made from a combination of animal, human or synthetic tissues.

Surgical mesh is most commonly used to repair different types of hernias.

Hernia:

A hernia occurs when an internal part of a body pushes through a part of a weakened muscle or the surrounding tissue wall. This results in a lump or swelling which may or may not be painful. They mainly occur in the abdominal wall which holds the large and small intestines.

Treatment:

Hernias cannot be treated with medication and often need an operation. Hernia repair surgery is carried out using surgery to put the hernia back in its place. During this operation a mesh may be fixed to the muscle or tissue to strengthen it and repair the hernia.

Eligibility criteria:

Due to the limited quality of evidence of clinical effectiveness, the use of biological orbiosynthetic mesh in standard hernia repair is Not Routinely Commissioned.

Biological or biosynthetic mesh in hernia repair may only be used in the following clinicalcircumstances following a review by a specialist complex abdominal wallrepair multidisciplinary team:

  • The first hernia repair surgery with synthetic surgical mesh did not work and the wound has not healed

OR

  • The use of synthetic mesh would not be clinically appropriate for that individual patient,e.g. the mesh would need to be placed directly against the patient’s bowel.

This means, for patients who DO NOT meet the above criteria, the patient’s NHS commissioning organisation (CCG), who is responsible for buying healthcare services on behalf of patients, will only fund the treatment if an Individual Funding Request (IFR) application has shown exceptional clinical need and the CCG supports this.

Advice and further guidance:

Non-cosmetic body contouring surgery is an operation to remove loose and saggy skin folds after weight loss from certain areas of the body which are causing medical problems. This type of operation helps patients to prevent further or future illnesses.

There are a number of surgical interventions which can be described as body contouring procedures:

Full abdominoplasty

Also known as a ‘tummy tuck’, a full abdominoplasty involves making openings from hip to hip and around the belly button to remove extra skin and fat. Some tissues and muscles are also tightened before the skin is repositioned and sewn up. This procedure will leave a circular scar around the belly button and a long scar along the bikini line.

Mini abdominoplasty

A mini tummy tuck involves making a horizontal cut along the bikini line to remove a block of skin and fat from the lower tummy. Sometimes the muscles will also be tightened. This procedure will leave a smaller scar along the bikini line.

Extended abdominoplasty

An extended abdominoplasty involves a full ‘tummy tuck’, with the additional removal of extra skin and fat from the thighs and back at the same time.

Endoscopic abdominoplasty

Endoscopic abdominoplasty is a procedure carried out if only the muscles of the abdominal wall need to be tightened. A small cut near the bikini line, or around the belly button is made to insert special surgical tools to tighten the muscles. As skin is not removed during this procedure, liposuction can also be carried out at the same time.

Apronectomy (Panniculectomy)

An Apronectomy removes the large excess of skin and fat hanging down over the pubic area which looks like an ‘apron of skin’. This extra skin can affect normal activities such as walking and may lead to serious medical problems such as skin inflammation or infection under the flap.

Brachioplasty

Brachioplasty, also known as an arm lift, removes and tightens loose skin and excess fat in the upper arm. A long cut is made between the elbow and armpit to remove sections of the skin and fat. The remaining skin and tissue are lifted and sewn up.

Thighplasty

Thighplasty, also known as a bum and/or thigh lift, involves removing the ‘extra’ loose and saggy skin around the bottom and thighs. Liposuction may also be performed during this procedure to tighten the bottom and thighs.

Liposuction

Liposuction is an operation using a suction technique to remove fat from certain areas of the body which haven’t responded to exercise and diet.

Evidence review:

The clinical evidence reviewed showed the benefit to patients in certain clinical circumstances where excess skin is causing problems with daily life activities or ongoing skin infections which have not improved after six months of treatment.

Eligibility criteria:

Non-cosmetic body contouring is a restricted procedure and the removal of excess skin will only be funded if the patient:

  • Is 18 years old or over at the time of application and has lost at least 50% of their original excess weight and maintained their weight for at least two years

AND

  • The patient has skin folds which are affecting their ability to carry out activities of everyday life such as sleeping, eating, walking

OR

  • The patient has recurrent skin infections in the skin folds which have not improved after six months of treatment.

This means the patient’s NHS commissioning organisation (CCG), who is responsible for buying healthcare services on behalf of patients, will only fund the treatment if the patient meets the eligibility criteria above, or if an Individual Funding Request (IFR) application has shown exceptional clinical need and the CCG supports this.

Advice and further guidance:

What is a hernia?

A hernia is when an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall.

A hernia usually develops between the chest and hips. In many cases, it causes no or very few symptoms, although the patient may notice a swelling or lump in the tummy (abdomen) or groin. The lump can often be pushed back in or disappears when laid down. Coughing or straining may make the lump appear.

Umbilical hernias happen when fatty tissue or a part of the bowel pokes through the abdomen near the belly button (navel). This type of hernia can occur in babies if the opening in the tummy through which the umbilical cord passes doesn't seal properly after birth and over time, can heal by itself.

Adults can also be affected, possibly as a result of repeated strain on the abdomen and are more likely to need surgery to fix it.

A para-umbilical hernia is different to an umbilical hernia in that these hernias may become very large. They are more common in adults (especially women who have had more than one pregnancy), than children and happens because of a defect in the linea alba, which is the tendon-like tissue that lines the wall of the tummy.

An incisional hernia is where tissue pokes through a surgical wound in the tummy that hasn't fully healed.

Treatment

Advances in surgery and post-operative care have meant that clinical research has been done to look at the benefits to the patient of the different surgical approaches and which is the best is the safest.

The types of surgical repairs have included:

  • Laparoscopic approach - during keyhole surgery, the surgeon usually makes three small incisions in your abdomen instead of a single larger incision.
  • ‘Open repair’ approach- the surgeon makes a single cut (incision). This incision is usually about 6 to 8cm long.

However, the evidence currently available shows that laparoscopic surgery, where clinically appropriate, is preferable due to the significantly reduced rates of surgical site infection and should be the preferred choice.

Patient eligibility criteria

This policy is for the management of umbilical, para-umbilical and incisional hernias in adult patients.

Strangulated umbilical, para-umbilical or incisional hernias should proceed to the most clinically appropriate surgery in a timely manner

For non-urgent procedures, the patient must be diagnosed with a *symptomatic umbilical, para-umbilical or incisional hernia

The patient should be reviewed by the surgical clinician and in a shared decision-making process with the patient; a decision should be reached as to the most clinically effective method of surgery for the individual patient (either laparoscopic or open surgery).

* For the purposes of this policy, symptomatic hernia is defined described as 'debilitating pain which impacts on activities of daily living, e.g. walking; sleeping; working.’

This means (for patients who DO NOT meet the above criteria) the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG.

Advice and guidance

  • For more information, search for ‘hernia’ at www.nhs.uk 
  • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.

This guidance is produced by The Academy of Medical Royal Colleges (the Academy) as part of the Evidence-based interventions programme. It is based on recommendations from the Expert Advisory Committee and the National Institute for Health and Care Excellence (NICE).

All guidance has been reviewed by the Birmingham and Solihull & Sandwell and West Birmingham CCGs’ Treatment Policy Clinical Development Groups (TPCDG). This was reviewed to establish if existing CCG policies were already in place which covered the proposed intervention / treatment in question.

Where there was no current CCG policy for the area in question, the NHSEI policy has been implemented in full into the CCG’s Clinical Treatment Policy portfolio.

Where there was a current CCG policy for the area in question, then the existing CCG policy has been reviewed by the TPCDG considering the NHSEI EBI policy rationale and evidence base.  A decision has then been taken by TPCDG based on the review as to the most appropriate policy for implementation by taking into account the healthcare needs of our local population.

The aims of the Evidence Based Interventions programme is to ensure the quality and safety of patient care by, freeing up valuable resources such as time so that more effective interventions can be carried out, reducing harm or the risk of harm to patients, helping clinicians maintain professional practice, creating headroom for innovation, and maximising value and avoiding waste.