Leeds ccgs Targeted Interventions Referral Form Referral for Hernia Surgery

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Leeds CCGs Targeted Interventions Referral Form
Referral for Hernia Surgery

Referral to:

(insert patient’s choice of hospital)

Patient Details:






NHS Number

Tel (home)

Tel (mobile)

Gender Ethnicity Age

Is an interpreter required Yes No

Is transport required Yes No

Referrer Details:

Referring GP

Practice Address



Practice Code

(Tick appropriate box indicating reason for referral)
 Femoral Hernia

 Female with any groin hernia

 Male with a clinically palpable inguinal hernia and pain that limits daily activity

 Male with an irreducible hernia

Clinical Notes:

Past Medical History:

Drug List:


GP Signature:


Supporting evidence
Swedish Hernia Registry data for 108,000 hernia repairs during 1992-2004. Ann Surg 2007;245:656-660
Patient reported outcomes http://www.hscic.gov.uk/catalogue/PUB10899 Accessed July 2013
Observation or Operation for Patients with an Asymptomatic Inguinal Hernia O'Dwyer et al. Ann Surg 2006;244:167-173. American study JAMA 2006;295:285-292
Fitzgibbons RJ Jr et al Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA. 2006 Jan 18;295(3):285-92.
Laparosopic surgery for inguinal repair http://publications.nice.org.uk/laparoscopic-surgery-for-inguinal-hernia-repair-ta83 accessed July 2013
Laparoscopic Repair of Inguinal Hernias http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140939/ accessed July 2013
Sevonius D, Gunnarsson U, Nordin P, et al. Repeated groin hernia recurrences. Ann Surg. 2009;249:516-518

Review Date: April 2016

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