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'Watchful Waiting' for Inguinal Hernia Safe, But Surgery Ultimately Likely
General Surgery News

One of the ongoing debates in general surgery is whether to operate on men with asymptomatic or minimally symptomatic groin hernia, or wait.

A recent study—and one of the largest—of American men with these types of hernia demonstrated that waiting may be safe, but most patients will end up needing a repair within a decade, usually because of worsening pain. The older a man is, the more likely he is to undergo a hernia repair.

"Patients who present to their physicians to have the hernia evaluated, especially if they are elderly, should be informed that they will almost certainly come to surgery eventually," said lead author Robert J. fitzgibbons, MD, professor of surgery and chief of general surgery, Creighton University School of Medicine in Omaha, Neb.

He presented the findings at the 133rd Annual Meeting of the American Surgical Association.

The results of the study come from an updated analysis of one of the landmark, randomized trials in American hernia surgery. Between 1999 and 2004, Dr. fitzgibbons and his colleagues from five North American centers randomized 720 men with minimally symptomatic inguinal hernias to a regimen of "watchful waiting" or standard tension-free open repair.

In 2006, they reported that watchful waiting was an acceptable option (JAMA 295:285-292). One-fourth of patients who were being watched ended up needing surgery within the first two years of follow-up but surgical repair could be safely delayed until symptoms increased, the authors said.

However, questions remained about what happened to patients after the first two years of watchful waiting. Dr. fitzgibbons and his colleagues continued to track 254 men originally assigned to watchful waiting. Patients were contacted annually by mailed questionnaire, with follow-up phone and email requests to nonresponders.

Using a Kaplan–Meier estimator, investigators calculated that 68% of patients crossed over to surgery within 10 years. Nearly all patients who decided to undergo repair did so because of worsening pain, said investigators. Only 2.4% of patients (n=3) required an emergency operation.

Older men underwent surgery more often than younger patients. The estimated crossover rate to surgery 10 years after diagnosis was 79.35% in men older than age 65 years, and 62% in men younger than age 65.

The results confirmed those of another major randomized study, led by Patrick O'Dwyer, MD, professor of gastrointestinal surgery, Glasgow University in Scotland. In 2011, Dr. O'Dwyer and his colleagues reported that 72% of patients who are being "watched" undergo surgery within 7.5 years (Br J Surg 2011;98:596-599). Moreover, men who underwent surgery reported improvements in their quality of life, whereas men in the watchful waiting group had declining quality-of-life scores.

Dr. O'Dwyer and his colleagues concluded that medically fit patients with minimal symptoms should be recommended for surgical repair.

"The findings from both studies are almost identical. We now recommend repair for medically fit patients with asymptomatic inguinal hernia," said Dr. O'Dwyer in an email interview.

Guy R. Voeller, MD, FACS, professor of surgery, University of Tennessee Health Sciences Center, in Memphis, said surgeons in the United States have shifted away from the watchful waiting approach in recent years, particularly after Dr. O'Dwyer's study was published. This latest study confirms an already widespread practice, he said.

"Mostly, when patients are sent to a surgeon, they already have symptoms that justify a repair. When you do see the rare asymptomatic person, most of us say, 'you don't have to get it fixed now but I will be seeing you in the future.'"

Dr. Voeller added that surgeons and primary care doctors should take note of a patient's age when considering watchful waiting versus repair. "If you have a patient who is a little bit older, and in five years you're looking at their heart or their lungs being worse, you may want to say that now is the time to get it [the hernia] fixed."

Dr. fitzgibbons cautioned that the study focused on minimally symptomatic or asymptomatic patients who had already been referred to surgeons because of concerns about their hernia. As such, the results do not apply to the general population of patients with asymptomatic or minimally symptomatic inguinal hernias.

"The take-home message is that patients who choose to see their doctor because of concerns about their hernia will almost inevitably come to surgery," he said.

Marc M. Zaré, MD, FACS
Marc M. Zaré, MD, FACS
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Georgetown University Hospital University of North Carolina at Chapel Hill Diplomate American Board of Surgery Fellow American College of Surgeons Member Society of American Gastrointestinal & Endoscopic Surgeons Member American Society for Metabolic & Bariatric Surgery
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