OBJECTIVES: Hernia repair is one of the most commonly performed surgical procedures. Hernia societies encourage surgical decisions based on up-to-date evidence-based guidelines rather than surgical intuition. The objective was to identify whether surgical guidelines and protocols for hernia repair can reduce costs and improve patient outcomes, and whether they are followed. METHODS: Comprehensive literature search to identify publications on hernia repair guidelines and summarise their impact on cost and patient outcomes. RESULTS: A Dutch study that compared inguinal hernia repair outcomes before and after evidence-based guidelines were introduced showed a significant reduction in hernia recurrence when guidelines were followed. A Spanish study of emergency ventral hernia repairs found that the proportion of patients treated after introduction of a protocol was significantly lower for mortality following bowel resection and the incidence of severe complications was reduced (excluding femoral hernia) versus pre-protocol. Introduction of a protocol for inguinal hernia repair in a UK general hospital improved patient outcomes to a level comparable with a specialist hernia centre. The authors also reported potentially large cost savings by increasing the proportion of ambulatory patients and those that received local anaesthesia. The Royal College of Surgeons noted that ambulatory operations are recommended for 80% of groin hernia repairs but found that only 67% were ambulatory, ranging from 32–100% across UK healthcare providers. Another UK study looked at the uptake of NICE guidelines for several procedures, including laparoscopic repair of inguinal hernia, and reported that although Hospital Episode Statistics suggested 96% compliance, a detailed audit of healthcare trusts showed only 65% compliance. CONCLUSIONS: The following of protocols and guidelines for hernia repair has been shown to improve patient outcomes and reduce costs but the degree of uptake is variable. This suggests that there is scope for greater protocol/guideline adherence and resultant cost savings in hernia repair