Watchful waiting may be appropriate for some inguinal hernia patients

As long as they remain under the watchful eyes of their primary care physicians, men who have an inguinal hernia (a weakening of the abdominal wall that bulges into the groin area) may postpone surgical repair unless the condition causes symptoms that interfere with their usual activities.

This recommendation is the primary finding from the first study of its kind to compare outcomes for men with an inguinal hernia who immediately underwent surgery to men who were followed regularly by their primary care physicians for a minimum of 2 years.

The study was published in the January 18 issue of the Journal of the American Medical Association. The study was coordinated by the American College of Surgeons and supported by a grant from the Agency for Healthcare Research and Quality, an arm of the Department of Health and Human Services that seeks to improve the quality, safety, efficiency, and effectiveness of health care in the United States.

"The most important message is that it is probably safe to observe a hernia," Robert J. Fitzgibbons, Jr., MD, FACS, Harry E. Stuckenhoff Professor of Surgery from Creighton University, Omaha, NE, and a principal author of the study said. "Surgeons have been taught and are still being taught that all inguinal hernias should be repaired at diagnosis to prevent the complication of something getting caught in that hernia and becoming strangulated, in other words losing its blood supply and becoming gangrenous. What this study would suggest is that it is reasonable to simply observe a totally asymptomatic hernia," he explained.

The study found that pain or discomfort serious enough to interfere with usual activities occurred with equal frequency in the 2 groups of men: those who were observed without repair, and those who underwent surgery. Among 364 men who were watched, 5.1% developed pain that limited their daily activities over the course of 2 to 4.5 years after a diagnosis of inguinal hernia. Among 356 men who had immediate surgery, 2.2% developed pain that interfered with their lives. This difference was not statistically significant.

Men in both groups had similar physical functioning scores. There was no statistically significant difference in physical function after 2 years.

The study also found that a hernia accident was extremely rare. Only 2 watchful waiting patients (0.06%) experienced a hernia accident during the follow-up period which ranged from 2 to 4.5 years.

Dr. Fitzgibbons cautioned that men who choose to delay surgery should be under the care of a physician and see a physician once a year. He also emphasized that any increase in pain that hinders routine activities or rapid enlargement of a bulge in the groin area should be assessed immediately by a physician. "A hernia is a life-long situation if you're going to observe it, so patients need to be vigilant. However, the incidence of major complications in this study was so low after 2 to 4 years in men who did not have symptoms, it's reasonable to assume that there won't be too many problems in the future," he said.

An inguinal hernia is a hole in the outer layer of the abdominal wall that allows the inner lining of the abdominal cavity to protrude and form a sac extending into the groin or the scrotum. It results from strain on the abdominal muscles that have been weakened by age or by congenital factors. It may occur after lifting heavy objects; sudden twists, pulls, or muscle strains; marked gains in weight; chronic constipation; or repeated attacks of coughing.

The only curative treatment for an inguinal hernia is to surgically repair it. The most common method of surgery and the procedure used in the study is the tension-free mesh technique, which involves inserting a piece of mesh to cover the defect in the abdominal wall without sewing together the surrounding muscles.

The study included 720 men who were diagnosed with and treated for an inguinal hernia between January 1999 and December 2004 at 5 community or academic medical centers across the US and Canada. Men in both groups were followed for 2 to 4.5 years. Men in the observation group were examined by study surgeons 6 months after diagnosis and every year thereafter. Men in the surgery group were followed at 3 and 6 months immediately after diagnosis and every year thereafter. The men were evaluated for any changes in the degree of pain caused by the hernia or a change in the baseline physical component score (PCS) of the Medical Outcomes Study Short-Form-36 Version 2 survey, a quality-of-live measuring tool with only 36 questions that provides a generic profile of health and well-being.

Rather than move quickly to perform surgery, many primary care physicians and patients choose to observe a hernia on their own even though the surgical literature up to now has not supported that option, Dr. Fitzgibbons said. "They just say, 'If it isn't a bother, don't worry about it.' This study would suggest that it is safe enough to do that."

Other participants in the multi-center study of inguinal hernia patients included Olga Jonasson, MD, FACS, Chicago IL; Leigh H. Neumayer, MD, FACS, Salt Lake City, UT; Jeffrey S. T. Barkun, MD, FACS, Montreal, Quebec; James L. Hoehn, MD, FACS, Marshfield, WI; George A. Sarosi, Jr., MD, FACS; William C. Syme, MD, FACS; Jon S. Thompson, MD, FACS, Omaha, NE; and seven other researchers from five institutions.

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