Outcomes/Effectiveness Research

Delaying surgery and watchful waiting for inguinal hernias is safe in men with minimal symptoms

Many men with an inguinal hernia, in which part of the intestine protrudes through a weak point in the groin, have minimal symptoms. Delaying surgery in favor of watchful waiting until they suffer from pain or discomfort is safe in these cases because acute hernia incarcerations (when an abdominal organ cannot be reduced back into the abdomen) occur rarely, notes Robert J. Fitzgibbons Jr., M.D., of Creighton University.

Researchers, supported in part by the Agency for Healthcare Research and Quality (HS09860), randomized 720 men with minimally symptomatic inguinal hernias to 2 groups: 364 men to watchful waiting and 356 to receive standard open tension-free surgical repair with mesh. They examined pain and discomfort that interfered with usual activities 2 years later and change in the physical component score (PCS) of the SF-36 quality of life measure from baseline to 2 years. Men in the watchful waiting group were followed up at 6 months and annually and watched for hernia symptoms. Surgery patients were followed up at 3 and 6 months and annually. Similar proportions of men in both groups had pain sufficient to limit usual activities at 2 years (5.1 percent vs. 2.2 percent), and their levels of physical functioning were similar (PCS improvement over baseline, 0.29 points vs. 0.13 points).

Twenty-three percent of men assigned to watchful waiting crossed over to surgery, mostly due to hernia-related pain; 17 men assigned to receive surgery crossed over to watchful waiting. Men who had surgery after they developed symptoms had no greater risk of operative complications than those undergoing prophylactic hernia repair.

Hernia accidents were extremely uncommon (1.8 per 1,000 patient years). Because the risk of a hernia accident increases with the length of time the hernia is present and because accidents are more common in elderly individuals, a longer followup period is needed. To this end, a registry has been set up to continue to follow the patients indefinitely.

More details are in "Watchful waiting vs repair of inguinal hernia in minimally symptomatic men," by Dr. Fitzgibbons Jr., Anita Giobbie-Hurder, M.S., James O. Gibbs, Ph.D., and others, in the January 18, 2006, Journal of the American Medical Association 295(3), pp. 285-292.

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