Royal Australasian College of Surgeons: tests, treatments and procedures clinicians and consumers should question

Released recommendations

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.

Supporting evidence

  • Fitzgibbons RJ, Giobbie-Hurder A, Gibbs JO, Dunlop DD, Reda DJ, McCarthy M, et al. Watchful Waiting vs Repair of Inguinal Hernia in Minimally Symptomatic Men. JAMA 2006;295(3):285-92.
  • Turaga K, Fitzgibbons RJ, Puri V. Inguinal Hernias: Should We Repair? Surgical Clinics of North America 2008;88(1):127–38. 
  • Mayer F, Lechner M, Adolf D, Öfner D, Köhler G, Fortelny R, et al. Is the age of >65 years a risk factor for endoscopic treatment of primary inguinal hernia? Analysis of 24,571 patients from the Herniamed Registry. Surgical Endoscopy 2016;30(1):296-306. 

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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.

Supporting evidence

  • O’Rourke MGE, O’Rourke TR. Inguinal hernia: Aetiology, diagnosis, post-repair pain and compensation. ANZ Journal of Surgery 2012;82(4):201–6.
  • Robinson A, Light D, Nice C. Meta-analysis of sonography in the diagnosis of inguinal hernias. Journal of Ultrasound in Medicine 2013;32(2):339-46.

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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.

Supporting evidence

  • Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, et al. Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med 2012;157(1):49-58.
  • Goodnough LT, Shieh L, Hadhazy E, Cheng N, Khari P, Maggio P. Improved blood utilization using real-time clinical decision support. Transfusion 2014;54(5):1358-65. 

Clinician resources


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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.

Supporting evidence

  • Burton PR, Brown W, Laurie C, Lee M, Korin A, Anderson M, Hebbard G, O’Brien PE. Outcomes, satiety, and adverse upper gastrointestinal symptoms following laparoscopic adjustable gastric banding. Obesity Surgery 2011;21(5):574-81.
  • Hamdan K, Somers S, Chand M. Management of late postoperative complications of bariatric surgery. Br J Surg 2011;98(10):1345-55. 

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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.

Supporting evidence

  • Wan MJ, et al. Acute appendicitis in young children: cost-effectiveness of US versus CT in diagnosis-a Markov decision analytic model. Radiology 2009;250(2):378-86.
  •  Doria AS, et al. US or CT for diagnosis of appendicitis in children? A meta-analysis. Radiology 2006;241(1):83-94.
  • Krishnamoorthi R, et al. Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. Radiology 2011;259(1):231-9.

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Computed tomography scanning is expensive, exposes the patient to radiation and offers no useful information that would improve initial management. CT scanning may be appropriate in patients with focal neurologic findings, a history of trauma or chronic ear disease.

Sudden hearing loss is distinct from progressive loss and chronic ear disease. Sudden sensorineural hearing loss (SSHL) can be described as at least 30dB sensorineural hearing loss (SNHL) in at least three consecutive frequencies within a three-day period.

Supporting evidence

  • Stachler RJ, Chandrasekhar SS, Archer SM, et al. Clinical practice guideline: Sudden hearing loss. Otolaryngol Head Neck Surg 2012;146(IS):S1-35.
  • Tarshish Y, Leschinski A, Kenna M. Pediatric sudden sensorineural hearing loss: Diagnosed causes and response to intervention. International Journal of Pediatric Otorhinolaryngology 2013;77(4):553–9.

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Oral antibiotics have significant adverse effects and do not provide adequate coverage of the bacteria that cause most episodes; in contrast, topically administered products do provide coverage for these organisms. Avoidance of oral antibiotics can reduce the spread of antibiotic resistance and the risk of opportunistic infections.

A discharge is uncomplicated when it is not associated with any other symptom, for example fever, pain or swelling of the ear canal.

Supporting evidence

  • Goldblatt EL, Dohar J, Nozza RJ, et al. Topical ofloxacin versus systemic amoxicillin/clavulanate in purulent otorrhea in children with tympanostomy tubes. Int J Pediatr Otorhinolaryngol 1998;46:91-101.
  • Rosenfeld RM, Schwartz SR, Pynnonen MA, et al. Clinical Practice Guideline: Tympanostomy tubes in children. Otolaryngol Head Neck Surg 2013;149(IS): S1-35.

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Oral antibiotics have significant adverse effects and do not provide adequate coverage of the bacteria that cause most episodes; in contrast, topically administered products do provide coverage for these organisms. Avoidance of oral antibiotics can reduce the spread of antibiotic resistance and the risk of opportunistic infections.

Supporting evidence

  • Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical practice guideline: Acute otitis externa. Otolaryngol Head Neck Surg 2014;150(IS):S1-24.
  • Wipperman J. Otitis externa. Primary Care: Clinics in Office Practice 2014;41:1–9.

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Imaging of the paranasal sinuses, including plain film radiography, computed tomography (CT) and magnetic resonance imaging (MRI) is unnecessary in patients who meet the clinical diagnostic criteria for uncomplicated acute rhinosinusitis. Acute rhinosinusitis is defined as up to four weeks of purulent nasal drainage (anterior, posterior or both) accompanied by nasal obstruction, facial pain-pressure-fullness or both. Imaging is costly and exposes patients to radiation. Imaging may be appropriate in patients with a complication of acute rhinosinusitis, patients with comorbidities that predispose them to complications and patients in whom an alternative diagnosis is suspected.

Supporting evidence

  • Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg 2015;152(2S):S1-39.
  • Ebell MH, McKay B, Guilbault R, et al. Diagnosis of acute rhinosinusitis in primary care: a systematic review of test accuracy. British Journal of General Practice 2016;66(650):e612-32.

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Examination of the larynx with mirror or fibre optic scope is the primary method for evaluating patients with hoarseness. Imaging is unnecessary in most patients and is both costly and has potential for radiation exposure. After laryngoscopy, evidence supports the use of imaging to further evaluate 1) vocal fold paralysis, or 2) a mass or lesion of the larynx.

It is essential to have the larynx examined by a specialist if the hoarseness has not resolved within 4 weeks.

Supporting evidence

  • Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg 2009;141:S1-31.
  • Mau T. Diagnostic evaluation and management of hoarseness. Medical Clinics of North America 2010;94(5):945–60.

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RACS collaborated with General Surgeons Australia (GSA) and the Australian Society of Otolaryngology Head and Neck Surgery (ASOHNS) respectively on the development of lists for Choosing Wisely Australia. Each organisation worked closely with key members including the Sustainability in Healthcare Committee and Professional Development and Standards Board (RACS), and the Boards of Directors (GSA and ASOHNS) to develop the lists of tests/treatments/procedures for general surgery, and head and neck surgery.

Last reviewed 10 May 2017

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