Hernias: 'Watchful Waiting' Proposed

Researchers Say Men Without Symptoms May Not Need Surgery

From the WebMD Archives

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.

What About Women?

The findings from the all-male study cannot be extrapolated to women, who have a more complicated clinical picture when it comes to hernias, Fitzgibbons says. Women are far more likely than men to develop a different type of groin protrusion known as a femoral hernia. These hernias can be hard to distinguish from inguinal hernias and are more likely to result in serious complications.

For this reason, a watchful-waiting approach is probably not appropriate for women in most cases, he says.

Gastrointestinal surgeon David R. Flum, MD, MPH, tells WebMD that the new study confirms what many clinicians have long suspected -- that watchful waiting is an appropriate strategy for the management of hernias that have no symptoms other than the bulging.

He says it will definitely change the way doctors counsel their patients. But it remains to be seen, he adds, if patients will embrace the watchful-waiting approach.

Flum wrote an editorial accompanying the study. He is an associate professor of medicine at the University of Washington, Seattle.

"Many patients perceive a lump in their groin as being broken, even when it doesn't cause them pain," he says. "There will always be folks who want to get rid of the bulge or who don't want to wait around for something to happen, just like there are people who want to avoid surgery unless they absolutely need it."

WebMD Health News Reviewed by Louise Chang, MD on January 17, 2006


SOURCES: Fitzgibbons, R.J., The Journal of the American Medical Association, Jan. 18, 2006; vol 295: pp 285-292. Robert J. Fitzgibbons Jr., MD, chief, division of general surgery, Creighton University, Omaha, Neb. David R. Flum, MD, MPH, associate professor, department of surgery, University of Washington, Seattle.
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