Digestive Disorders Health Center

Hernias: 'Watchful Waiting' Proposed

Jan. 17, 2006 - More than half a million hernia surgeries are performed in the U.S. each year, but a new study shows that many may be unnecessary.

Researchers concluded that "watchful waiting" is an acceptable alternative to surgery in men with inguinal hernias who have few or no symptoms. The findings from the long-awaited study are expected to have a major impact on the clinical management of hernias that cause little pain or discomfort.

An inguinal hernia happens when part of the intestine protrudes through a small opening in the abdominal muscle wall. There can be a noticeable bulge in the groin.

The findings are published in the Jan. 17 issue of The Journal of the American Medical Association.

"The thinking has been that even hernias that don't cause symptoms should be surgically repaired because they become harder to fix with time and waiting would result in more complications" researcher Robert J. Fitzgibbons Jr., MD, tells WebMD. "But that is not what we found at all."

Delaying Surgery

While surgery is the only treatment and cure for hernias of the groin, it is not without risks. It is estimated that about one in 10 people who have hernia surgeries in the U.S. develop chronic pain as a result of the surgery itself.

Because of this, some doctors now recommend delaying hernia repair or forgoing surgery altogether in male patients who have minimal or no symptoms. But this approach also carries potential risks, the most serious of which is a rare but potentially fatal complication in which the hernia becomes dangerously trapped, leading to a blockage in the intestines or lack of blood supply to the herniated tissues.

Risks vs. Benefits

In an effort to better understand the risks and benefits of watchful waiting vs. surgery, Fitzgibbons and colleagues randomly assigned 720 men with inguinal hernias to one approach or the other.

The men had minimal symptoms, and, depending on when they entered the study, they were followed for at least two years -- and some up to 4.5 years -- between 1999 and 2004.

After two years of follow-up, the incidence of pain severe enough to interfere with activities was similar in both patient groups.

Serious hernia-related complications in the watchful-waiting group were very rare, occurring at a rate of about one-fifth of a percent per year, Fitzgibbons says.

At two years, 23% of the patients assigned to watchful waiting had opted for surgical repair of their hernia, most often due to increasing hernia-related pain.

But surgical complication rates were similar in patients operated on early and those treated with surgery later after hernia symptoms increased.

"There did not appear to be a penalty for delaying surgery," says Fitzgibbons, who is chief of the division of general surgery at Creighton University in Omaha, Neb.