Many hernias don’t need surgery!

An article published on 18 January 2006 in the Journal of the American Medical Association has studied surgery for inguinal (groin) hernias compared to “watchful waiting”:
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(For general information on hernias including how to diagnose etc go to:
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“Watchful waiting” is monitoring a patient over time to see what happens, and intervening if they get worse. Traditionally, when a hernia is diagnosed by a doctor, the patient gets referred to a surgeon for an operation, even if the hernia is not causing any symptoms or discomfort. There is a perception that they carry significant risk of strangulation or incarceration which could lead to emergency surgery.

This randomised controlled trial compared more than 700 men who had hernias. They were randomly assigned to either “watchful waiting” or a “tension-free” open hernia repair. This is the first randomised trial of its type ever carried out. The group was evaluated over two years.

The risk of incarceration was very low i.e. 1.8 per 1000 patient-years or 0.03 of the study participants. Both of the groups had very high levels of satisfaction with the care that they had i.e. “watchful waiting” or surgery. They found that the patients who didn’t have surgery were no worse off than those who did have surgery. Note that of the order of 20% of people who do have such hernia repairs, develop chronic pain following surgery for a hernia. In a patient who has an asymptomatic or minimally symptomatic hernia, this is significant information.

Effectively they found that the strategy of “watchful waiting” is safe. Even though patients may eventually undergo hernia repair, when they do the operative risks and complications are no greater than the risk of prophylactic hernia repair.

This was a population of older male veterans in veterans’ administration centres. The results can be applied to similar populations. Obviously different age groups may have potentially different outcomes. It assumes access to appropriate levels of health care such as is present in most western countries. The strategy of “watchful waiting” may not be appropriate in third world conditions.

If the results of this study are shown to be reproducible in other populations and for other hernia types, then the era of preventing hernia repair should go the way of prophylactic tonsillectomy, cholecystectomy and appendicectomy. As is mentioned in the editorial, “avoiding harm in this case is easy – it can be best accomplished by counselling and educating patients and only repairing hernias that cause symptoms”.

For more information you can contact your treating doctor or Quality Occupational Health.