Inguinal Hernias — Watch or Repair?

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December 28, 2006

Inguinal Hernias — Watch or Repair?

  1. Thomas L. Schwenk, MD

Three studies suggest that the choice can safely be left to patients in most cases.

  1. Thomas L. Schwenk, MD

The issue of whether to repair or watch minimally symptomatic inguinal hernias arises frequently in primary care practice. Three studies published during the past year support the idea that watchful waiting (WW) is a reasonable alternative to surgery.

In a multicenter North American trial, 724 men (mean age, 58) were randomized to WW or tension-free open hernia repair. About 20% of subjects in each group eventually crossed over to the other group. In analyses based on either initial assignment or eventual treatment, no significant differences were seen in pain or physical activity during 2 years of follow-up. Two WW patients suffered incarcerations that required surgery (Journal Watch Jan 31 2006).

In a Scottish study, 160 men (age, ≥55) with asymptomatic inguinal hernias were randomized to the same treatment options as those in the first study. Roughly 20% of WW patients crossed over to surgery. In intent-to-treat analyses, there was no difference in pain between the two groups at 1 year of follow-up, although the surgery group had a borderline-significant improvement in general health status. One WW patient required emergency surgery, and one surgery patient suffered a fatal postoperative complication (Journal Watch Aug 29 2006).

Finally, Swedish researchers used a national registry to assess the prevalence of pain following inguinal hernia surgery, through questionnaires sent to almost 3000 patients who had undergone hernia surgery 3 years previously. Thirty-one percent of respondents reported at least some pain at the surgery site during the previous week, and 6% of respondents said the pain interfered substantially with their daily activities (Journal Watch Aug 29 2006).

Taken together, these results support the approach of many physicians who discuss with patients the alternatives of having surgery immediately or waiting to see whether the hernia becomes bothersome. Patients can choose based on personal factors (such as convenience, concerns about surgery and postoperative recovery, work, and cost). One additional factor to consider is that patients who initially wait and then choose surgery later seem to do well.

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