Who’s trusting in a truss?

Abstract

Dear Sir, The British Hernia Society guidelines advice regarding the primary care management of inguinal hernias is that Hernia trusses should not be routinely used [1]. This is, however, a level D recommendation with most of the limited evidence for trusses in hernia management over 20 years old. This precedes many innovations in hernia repair such as the widespread use of the tension-free mesh repair and laparoscopic surgery. The advancement of surgical and anesthetic technique has led to fewer patients being considered ‘‘unfit’’ for either anesthetic or surgical reasons to undergo repair. Despite the widespread belief that the role of the truss is obsolete, hernia trusses continue to be produced and used in large numbers. In 1991, Goldman [2] received communication from two hernia truss suppliers E Sallis Ltd and Ellis, Son and Paramore Ltd, and estimated that total UK annual truss sales were approximately 40,000. Sallis have since bought Ellis, Son and Paramore. Recent personal communication with Sallis suggests that about 13,000 trusses continue to be supplied to the UK annually. Hernia trusses remain available on prescription. We sent freedom of information requests to establish the number of inguinal hernia trusses dispensed in the UK annually. In Scotland, 286 inguinal hernia trusses were dispensed in 2012, a fall from 927 in 1994. In Northern Ireland, 300 were dispensed in 2012, down from 452 in 1999. In England, inguinal hernia truss dispensing fell from 10,214 in 2003 to 4,304 in 2012. These figures may, however, be an underestimation of hernia truss use with the advent of the internet and the ability for UK customers to shop internationally with ease. As the British Hernia Society guidelines state the evidence base surrounding inguinal hernia truss use is limited. The two largest retrospective studies of truss wearer’s experience show mixed results, 53/85 patients in one study finding partial or complete relief of symptoms [3], while Law [4] found that 33/52 found the truss uncomfortable and it failed to control the hernia in 36/52 cases. A review of trusses in inguinal hernia management by Cheek et al. [5] concluded that ‘‘considering the frequency of use of trusses and the evidence for high incidence of inguinal hernia, the paucity of relevant research in this area is disconcerting’’. Given the significant number of inguinal hernia trusses still being used in the UK, the question of who is trusting in a truss remains unanswered. Perhaps an even more important question remains, are they trusting with good reason?