Surgery can sometimes be avoided for men with hernias

Men with hernia who have minimal or no symptoms and who had surgery delayed had similar levels of pain and discomfort that limited their activities after 2 years compared to men who had surgical repair, according to a study in the January 18 issue of JAMA: The Journal of the American Medical Association.

Many men with an inguinal hernia (the most common type of hernia, occurring near the groin) are asymptomatic or minimally symptomatic, according to background information in the article. These men and their physicians sometimes delay hernia repair until emergence of pain or discomfort. Surgical repair, while generally safe and effective, carries long-term risks of hernia recurrence, pain, and discomfort. The natural history of an untreated inguinal hernia is not known. Whether delaying surgery and "watchful waiting" is a good option has not been critically tested.

Robert J. Fitzgibbons, Jr., M.D., of Creighton University, Omaha, Neb., and colleagues compared pain, physical function, and other outcomes in men with asymptomatic or minimally symptomatic inguinal hernias who were randomly assigned to a strategy of watchful waiting or surgical repair. The randomized trial, conducted January 1, 1999, through December 31, 2004, included 720 men (364 watchful waiting, 356 surgical repair) who were followed up for 2 to 4.5 years. Watchful-waiting patients were followed up at 6 months and annually and watched for hernia symptoms; surgical repair patients received standard open tension-free hernia repair and were followed up at 3 and 6 months and annually.

At 2 years, intention-to-treat analyses showed that pain interfering with activities developed in similar proportions in both groups (5.1 percent for watchful waiting vs. 2.2 percent for surgical repair; difference 2.86 percent). Average 2-year measurements of pain and discomfort as determined with the physical component score (PCS) were not significantly different from baseline: watchful-waiting patients improved by 0.29 points (of 100) and surgical repair patients improved by 0.13 points (difference, 0.16). Twenty-three percent of patients assigned to watchful waiting crossed over to receive surgical repair (increase in hernia-related pain was the most common reason offered); 17 percent assigned to receive repair crossed over to watchful waiting. Self-reported pain in watchful-waiting patients crossing over to operation improved after repair. Occurrence of post-operative hernia-related complications was similar in patients who received repair as assigned and in watchful-waiting patients who crossed over. Hernia complications in the watchful waiting patients were uncommon (rate of 1.8 per 1000 patient-years).

"A strategy of watchful waiting is a safe and acceptable option for men with asymptomatic or minimally symptomatic inguinal hernias. Acute hernia incarcerations occur rarely, and patients who develop symptoms have no greater risk of operative complications than those undergoing prophylactic hernia repair," the authors conclude.