Surgery often avoidable for men with hernias
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Men who experience few or no symptoms from an inguinal hernia do not require immediate surgery; instead, they can be safely followed and treated if symptoms worsen, new research shows.
If this approach catches on with surgeons throughout the US, it could markedly reduce the number of hernia repairs performed.
Inguinal hernias, the most common type, occur in the groin when tissue that normally resides in the abdomen pushes through a weak area in the abdominal wall. This bulging mass of tissue, which may contain intestine, can cause pain, but usually can be pushed back into the abdomen without difficulty. In some cases, however, it may become stuck, a potentially life-threatening complication called incarceration.
Out of fear that incarceration and other problems may occur, “surgeons are generally taught that all hernias should be repaired at diagnosis,” lead author Dr. Robert J. Fitzgibbons, from Creighton University in Omaha, Nebraska told Reuters Health.
“Our study questioned this conventional wisdom, he explained, “and found that a ‘watchful waiting’ approach can be safely applied to men with minimal symptoms. I suspect that 50 percent of patients with hernias could keep them for the rest of their lives and never have a problem.”
One of the key findings “was that there didn’t appear to be any penalty for waiting to perform surgery,” Fitzgibbons said. “The concern had been that waiting could lead to worse hernias that are more difficult to repair and associated with greater complications. But in our study, the complication rate for patients having initial surgery and those having delayed surgery was exactly the same.”
The study, which is reported in this week’s Journal of the American Medical Association, involved 720 men with inguinal hernias that caused minimal symptoms who were randomly assigned to receive immediate surgery or watchful waiting. With the latter approach, subjects were seen after 6 months and then annually to determine if hernia symptoms worsened, an indication for surgery.
At 2-year follow-up, the rate of pain limiting activities in each group was comparable, hovering around 3.5 percent. Likewise, both groups showed a similar improvement in the physical component of a standard health survey.
Twenty-three percent of patients assigned to watchful waiting ultimately moved to the surgery group, typically due to an increase in hernia-related pain. As noted, these patients were not at heightened risk for surgical complications compared with men who had their hernias repaired immediately.
One patient in the watchful waiting group developed incarceration within 2 years. In addition, another patient in the group had incarceration with intestinal blockage at 4 years.
Fitzgibbons believes the new findings will lead many surgeons to “discuss nonoperative options with their hernia patients.” He said that for legal reasons, surgeons may have been reluctant to adopt a watchful waiting approach in the past. “But now there is good scientific evidence that it’s a reasonable strategy and that takes the medicolegal burden away.”
“If the results of this study are reproduced in other populations and for other types of hernia, then the era of preventive hernia repair should go the way of prophylactic tonsillectomy, (gallbladder removal), and appendectomy,” Dr. David R. Flum, from the University of Washington in Seattle, comments in a related editorial.
SOURCE: Journal of the American Medical Association, January 18, 2006.
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