Non operative/watchful waiting in the management of inguinal hernias

On occasion you may not wish to consider an operation to fix the hernia.
There are a number of reasons to decide to pursue a non-operative/non-surgical approach including the following
  • Other medical problems may mean that you are not really fit enough for surgery (although many groin hernias can be fixed under local anaesthetic, some abdominal, incisional or recurrent hernias may require a general anaesthetic. This is especially the case if a laparoscopic or keyhole approach is required. Medical problems such as a recent heart attack may also influence your decision to consider surgery
  • The hernia may be small and causing minimal or no symptoms (e.g. up to one third of patients with an inguinal hernia have no symptoms from the hernia)
  • It may be socially inconvenient to undergo surgery e.g. travel plans
  • Other medical issues need to take priority e.g. other surgeries such as a hip or knee replacement may need to take priority
  • Anxiety about the prospect of surgery or potential short or long-term complications of repair of the hernia

Consulting with surgeon about alternatives to surgery

Although it is reasonable to consider such an approach in specific circumstances, it is important to remember that a hernia simply not go away on it’s own. Treatments such as supports, trusses, avoiding straining or specific exercises etc sound attractive but have no impact on the actual hernia. The tear or defect in the muscle of the abdominal wall will not repair itself. Most abdominal wall hernias tend to increase in size with time. Many abdominal hernias and most inguinal/groin hernias can also be repaired under local anaesthetic which may be the best option for patients with other medical problems.

 It is reasonable to adopt a “watch and wait” approach in the following circumstances

  • The hernia is not causing any symptoms or pain
  • It is relatively small in size
  • It is not obviously getting bigger over time
  • It goes back in (reduces) easily

This approach is also called “watchful waiting”. As with most things in life, there are benefits and risks to adopting such an approach and similarly there are risks and benefits to surgical repair of the hernia. It is generally helpful to discuss these options with your surgeon before you take a decision not to undergo surgical repair. However, the risk of developing an acute problem in a small hernia that is not causing any symptoms is very low (2 per 1000 patients per year).

 

Although rare, patients who adopt a watch and wait approach should be aware of the symptoms and signs of incarceration or obstruction.

Incarcerated hernias may cause sudden or constant pain in the hernia, nausea, vomiting and abdominal distension. Incarceration means that they hernia can no longer be reduced or pushed back into place. This can lead to blockage of the intestine within the hernia. If severe, it may also cut off the blood supply to the intestine. If this occurs, it is called a strangulated hernia. This is a medical emergency and strangulation hernia requires immediate surgery. As one might expect, repairing a hernia before it becomes incarcerated or strangulated is easier, safer and has fewer short and long-term complications of surgery compared to repair of an incarcerated or strangulated hernia which can be a very major operation.

You should also re-consult your doctor if the hernia is getting bigger or you start to get discomfort in the hernia or if the hernia does not easily go back in when lying down.

What to do if you decide not to proceed with an operation

  • Avoid heavy physical activity such as heavy lifting or straining.
  • Avoid constipation.
  • A truss may provide some support. Unfortunately, however, many trusses apply pressure on the hernia with a view to keeping the hernia in place. They almost never succeed in controlling the hernia in place and not infrequently depression is applied in fact stops hernia from reducing or going back in. It is also important not to consider using a truss as a long-term solution as they sustain pressure her only can lead to inflammation and thinning of the muscles rather than helping me make the situation worse over time.

Research suggests that over time, many patients with small hernias that are not causing symptoms (who decide not to undergo surgery) will develop problems and pain in the hernia over time and many will ultimately choose to undergo planned repair of their hernias.

 

Scientific evidence supporting a watch and wait approach to managing inguinal hernias

Two important studies have addrssed the safety and wisedom of adopting a non operative approach to asymptomatic inguinal hernias. One of the these was performed in Glasgow and the second was a multi-centre study from North America.

The North American study (Fitzgibbons 2006) randomised 720 men to surgical repair or watchful waiting.

Patients were initially followed up for a period of 2 to 4.5 years although the authors subsequently reported on their longer term follow-up on the same group of patients. The main outcome measures were pain and discomfort interfering with normal activity and an assessment of their physical activity at two years after diagnosis. There were no significant differences in pain or discomfort of physical activity between the two groups after two years. 23% patients who were assigned to a watchful waiting approach crossed over to undergo surgical repair within 2 years.(usually because they complained of an increase in pain in the hernia). These patients reported a reduction in pain after their hernia was fixed.

After 2 years of follow-up, 17% of patients who were initially selected to undergo surgery decided to stay within their watchful waiting group. In total, 31% of patients in watchful waiting room had asked to undergone surgery by the end of the study (patients were followed up from a period of 2 to 4.5 years). Only one patient experienced acute hernia incarceration within two years and the second patient had incarceration and bowel obstruction after four years of follow-up in the watchful waiting group. It was estimated that the risk of having an acute problem was around 1.8 per 1000 patient years. The authors concluded that watchful waiting approach was an acceptable option for men with minimally symptomatic in one hernias. Delaying surgery until symptoms increase was safe because the risk of acute problems is very low.

The same authors reported on longer term follow-up of the same group of patients (Fitzgibbons 2013). In this study there was an additional seven years of follow-up. In total 68% of patients who had been randomised to the watchful waiting group eventually underwent surgery. The most common reason for patients deciding to ultimately undergo surgery was the development of pain. Older men (greater than 65 years) were at higher risk compared to younger men. In total three patients of the study group to undergo emergency surgery for an incarcerated hernia.

It is therefore very likely that patients who elect to undergo watchful waiting will ultimately come to surgery. In this study with a follow-up between seven and 11.5 years, nearly 70% of patients who were treated conservatively but what will ultimately underwent surgery. However it does suggest that it is a safe plan and these patients with minimally symptomatic hernias are unlikely to come to harm by not undergoing surgery immediately.

 

The Glasgow study was initially published in the same year as the North American study (O’Dwyer 2006). A total of 160 patients were randomised to repair of any hernia or adopting a watch and see policy. After 12 months of follow-up there were no significant differences between the two groups in terms of pain scores at rest or unmoving. There was a trend towards a slight improvement in quality of life in patients who underwent surgery. Within one year nearly 20% of patients with them randomised to the watch and see policy had undergone repair of the hernia, primarily because of the development of pain. Europe has concluded that repair RNA symptomatic inguinal hernia does not affect the rate of long-term chronic pain and it may have some beneficial effects in improving overall health and reducing the risk of serious morbidity.

The authors publish their longer term follow-up of the same group of patients in 2011. After a median follow-up of 7.5 years, 42 of the 160 patients in the study (26%) had died (equal numbers in the treatment – surgery and observation group. They calculated the conversion rates from a watch and wait policy and estimated these to be around 16% at one year, 54% at five years and 72% at 7.5 years. As with the American study the main reason for a conversion to surgery was pain. To patients presented with an acute hernia. In 16 patients, a new hernia on the opposite side developed.

As with the American study, the conclusion was that most patients were painless inguinal hernia will develop symptoms over time. Is therefore thought that surgical repair is the recommended treatment for medically fit patients with a painless hernia.

 

References

Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA. 200618; 295(3):285-92.

Fitzgibbons RJ Jr, Ramanan B, Arya S, et al. Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg. 2013; 258(3):508-15.

Chung L, Norrie J, O’Dwyer PJ. Long-term follow-up of patients with a painless inguinal hernia from a randomized clinical trial. Br J Surg. 2011; 98(4):596-56.

O’Dwyer PJ, Norrie J, Alani A, et al. Observation or operation for patients with an asymptomatic inguinal hernia: a randomized clinical trial. Ann Surg. 2006; 244(2):167-73.

Ilioinguinal nerve division does not reduce pain after hernia surgery

Chronic groin pain can be a troubling and on occasion disabling symptom that affects between 5-10% of patients who undergo an inguinal hernia repair. The aetiology is unclear although a number of patient and operative factors have been identified.

  • Those with other chronic pain conditions (e.g. chronic neck pain & chronic back pain) appeared to be predisposed to developing post-operative pain after hernia surgery
  • Patients who have a lot of pain prior to their surgery are at increased risk of having persistent pain following the procedure (i.e. although one can fix the hernia, it does not always fix the pain)
  • Patients who have a lot of perioperative pain are at increased risk for developing pain in the long term following surgery.
  • Although it was hoped that lightweight and partly real absorbable mesh might reduce the incidence of long-term pain, the data does not suggest that there is an overwhelming beneficial effect to these measures. Clearly advances inmates technology are not the only answer to chronic groin pain after inguinal hernia surgery.

happy patient after inguinal hernia surgery

Over the years a number of surgeons have looked at the importance of nerve entrapment as a cause for chronic groin pain following inguinal hernia surgery. In particular, there has been much speculation that entrapment of the ilioinguinal nerve may be a causative factor. A number of investigators have explored the role of elective division of the ilioinguinal nerve in an attempt to reduce the incidence of chronic groin pain after inguinal hernia surgery. Others have re-operated on patients who have chronic groin pain with a view to division of the nerve as a secondary procedure. For the most part the results have been mixed and there have been a number of calls for randomised clinical trials to assess the utility of this type of intervention.

 

A recent meta-analysis published in the June 2018 edition of the Hernia journal assessed the results of nine separate randomised controlled clinical trials comparing preservation versus planned elective division of the ilioinguinal nerve during inguinal hernia surgery.

 

The authors noted that almost 10% of patients who had preservation of the ilioinguinal nerve experienced chronic groin pain at six months after surgery. This had fallen to 4.8% at one year after surgery. Initial outcomes in the group who underwent elective division of the nerve were better with this group showing a significant reduction in groin pain at six months after surgery (relative risk (RR) 0.47, p = 0.02). Moderate and severe pain was also substantially reduced 6 months after surgery (RR 0.57, p = 0.01). However, the reduction in chronic groin pain at six months must be balanced against a significant increase in subjective groin numbness at the same time (RR 1.55, p = 0.06).

 

At 12 months after surgery, the 22 groups had merged and there were no significant differences in rates of overall groin pain in the ilioinguinal nerve preservation group versus the nerve division group (RR 0.69, p = 0.38). In addition, there was no difference between the two groups in terms of numbers complaining of moderate to severe groin pain (RR 0.99, p = 0.98). Rather surprisingly, the prevalence of groin numbness was also similar between the two groups after 12 months of surgery (RR 0.79, p =0.48) i.e. Numbness was not a major or persisting issue even for those patients who had elective division of the ilioinguinal nerve.

 

The authors concluded that although elective division of the ilioinguinal nerve may reduce the severity and frequency of chronic groin pain at six months after surgery, it has a negative impact on the sensation of numbness and the beneficial effect in terms of reducing chronic pain is not maintained out to 12 months after surgery where nerve preservation and nerve division groups showed a similar incidence of groin pain and numbness. One cannot therefore recommend elective division of the ilioinguinal nerve during elective primary groin surgery.

 

Reference

Charalambous MP, Charalambous CP (2018). Incidence of chronic groin pain following open mesh inguinal hernia repair, and effect of elective division of the ilioinguinal nerve: meta-analysis of randomized controlled trials. Hernia 22, 401–409

Inguinal hernias: A brief overview

Diagnosis

Patients often diagnose that they have a hernia as the lump or swelling is usually obvious. Your GP will usually be able to confirm the diagnosis. The lump may be more obvious when standing and coughing.

If the diagnosis isn’t obvious, investigations such as an abdominal ultrasound, CT scan or MRI may be helpful to confirm the diagnosis.

Treatment

Small hernias that are not causing any symptoms do not always require treatment. In part the decision to treat or not will depend on your symptoms from the hernia, where it is located and other factors such as your general health. A watchful waiting approach may be best for some people.

Enlarging or painful hernias usually require surgery to relieve discomfort and prevent serious complications.

There are two general types of hernia operations — open hernia repair and laparoscopic repair.

Open hernia repair

Open hernia repair (also called a tension-free mesh repair) is perhaps the most commonly performed hernia operation and can usually be done with local anesthesia and sedation or general anesthesia. An incision in made in your groin and the surgeon pushes the protruding tissue back into your abdomen. The surgeon then sews the weakened area, often reinforcing it with a synthetic mesh. The opening is then closed with stitches, staples or surgical glue.

After the surgery, you’ll be encouraged to move about as soon as possible, but it might be several weeks before you’re able to resume normal activities.

Laparoscopy

In this minimally invasive procedure, which requires general anesthesia, the surgeon operates through several small incisions in your abdomen. Gas is used to inflate your abdomen to make the internal organs easier to see.

A small tube equipped with a tiny camera (laparoscope) is inserted into one incision. Guided by the camera, the surgeon inserts tiny instruments through other incisions to repair the hernia using synthetic mesh.

Many patients who have had a keyhole or laparoscopic repair have less discomfort and scarring after surgery and perhaps, a quicker return to normal activities. However, some studies indicate that the risk of the hernia coming back is a little more likely with laparoscopic repair compared to an open tension-free repair.

Laparoscopy allows the surgeon to avoid scar tissue from an earlier hernia repair, so we usually recommend this approach for people whose hernias recur after traditional hernia surgery. It also might be a good choice for people with hernias on both sides of the body (bilateral).

Some studies indicate that a laparoscopic repair can increase the risk of complications and of recurrence. Having the procedure performed by a surgeon with extensive experience in laparoscopic hernia repairs can reduce the risks.

Open vs. Laparoscopic repair of inguinal hernias: Lap. repair may be better.

A recent study published in the March issue of Archives of Surgery 2012 suggests that patients who undergo a laparoscopic inguinal hernia repair (Total extraperitoneal inguinal hernia repair (TEP)), report higher patient satisfaction, less chronic pain and less impairment of inguinal (groin) sensation compared to those who undergo a tension-free open Lichtenstein repair.
Hernia Surgery. Two surgeons performing an operation

Mesh vs. suture repair of small umbilical hernias. Strong evidence supporting mesh repair

Although there is good evidence that large umbilical hernias should be repaired with a mesh, it is not clear how smaller hernias should be managed i.e. those with a diameter 1-4 cm. Many surgeons continue to suture repair these smaller hernias.

Chronic pain, quality of life and impact on sexual function after open tension-free mesh repair: trial comparing lightweight vs. heavyweight mesh

Research studies suggest that 3-10% of patients report postoperative pain or discomfort persisting beyond one year after hernia surgery. This can have a significant negative impact on social activities, sex life, and quality of life. As a consequence, there has been increased recent interest in the use of lightweight meshes in groin hernia repair. It is hoped that the use of lightweight meshes might lead to less discomfort and less chronic pain. However, there is a shortage of high quality evidence showing a clear benefit with the use of such lightweight meshes.

A recent Swedish study (reported Jan 2018) has addressed this issued in a multi-centre study. The authors randomized a total of 412 male patients to undergo a tension free inguinal hernia repair using either a heavyweight mesh (90 g/m2, Bard™ Flatmesh, Davol) or a lightweight mesh (28 g/m2, ULTRAPRO™, Ethicon ). It was possible to analyse results in 363 patients. There were 185 patients in the lightweight-mesh group and 178 patients in the heavyweight group. Patient characteristics including age, weight and ASA grade were similar in both groups. Patients were followed for up to 3 years.

The lead author, Martin Rutegård, MD, of Umeå (Sweden) University and his colleagues reported that there were significant differences in patient awareness of a groin lump and groin discomfort, favouring the lightweight group at one year after surgery. A total of 6% of the lightweight group reported the groin lump awareness at 1 year, vs. 18% of the heavyweight group.

 

Initial groin discomfort was reported by 18% of the lightweight group vs.28% of the heavyweight group. However, after a year, these differences between the groups became less noticeable.  No statistically significant or clinically relevant differences in groin discomfort was noted between types of mesh, with 263/288 patients (91.3%) reporting an improvement in groin pain/discomfort after 12 months follow-up, 19/288 patients (6.6%) experiencing no change, and 6/288 patients (2.1%) having worsened.

Recurrence rates were similar for both  groups (2.4%).

Patients reported significantly better quality of life from as early as 11 days after their operation. This improvement in quality of life after surgery was maintained for the duration of the study. There was no difference in quality of life between the two groups. In addition, there was no difference between the groups in their reported sexual life after surgery at 4 and 12 months subsequent to the operation.

These results suggest that the light weight mesh may be associated with a reduction in a feeling of lumpiness after hernia surgery. However, the lightweight mesh was not associated with a better long-term outcome in terms of reduced pain or discomfort. It is reassuring that the lightweight mesh was not associated with an increased risk of hernia recurrence. It is also reassuring to note that patients very quickly felt that their operations lead to a significant improvement in their quality of life, despite the small but definite risk of long term groin discomfort and groin lumpiness.

References

Chronic pain, discomfort, quality of life and impact on sex life after open inguinal hernia mesh repair: an expertise-based randomized clinical trial comparing lightweight and heavyweight mesh. Rutegård M, Gümüsçü R, Stylianidis G, et al. Hernia. 2018 Jan 20. doi: 10.1007/s10029-018-1734-z.