Loading...
In 2006, two randomized trials suggested that observation without surgery is a valid alternative to immediate surgery in men with inguinal hernias (NEJM JW Gen Med Sep 15 2006 and Ann Surg 2006; 244:167; NEJM JW Gen Med Feb 15 2006 and JAMA 2006; 295:285). In this new trial, researchers in the Netherlands randomized 496 men (age, ≥50) with asymptomatic or mildly symptomatic inguinal hernias to undergo elective surgery or watchful waiting.
At baseline, mean pain score on a scale of 0 of 3 (representing no, mild, moderate, or severe pain) was 0.5. During average follow-up of about 3 years, mean pain scores changed minimally in both groups, with a small difference of 0.2 to 0.3 points (favoring surgery) throughout follow-up. On secondary endpoints for physical function and quality of life, a few small (and probably clinically unimportant) differences also favored surgery. Among watchful waiting patients, 35% crossed over to elective surgery, and 2.3% (6 patients) required emergency surgery for incarceration or strangulation — but none required bowel resection.
de Goede B et al. Watchful waiting versus surgery of mildly symptomatic or asymptomatic inguinal hernia in men aged 50 years and older: A randomized controlled trial. Ann Surg 2018 Jan; 267:42. (http://dx.doi.org/10.1097/SLA.0000000000002243)
Comment
This trial, like its predecessors, suggests that observation without surgery is reasonable for men with asymptomatic or mildly symptomatic inguinal hernias: During several years of follow-up, only a small proportion required emergency surgery. But what about longer follow-up? The authors of the two 2006 trials mentioned above eventually published longer-term follow-up data; at 7 to 10 years, about two thirds of observed men had crossed over to elective surgery, and 2% required emergency surgery (Ann Surg 2013; 258:508 and Br J Surg 2011; 98:596). Still, the bottom line is that observation is a reasonable strategy; patients always can opt for elective surgery if discomfort worsens.