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Asymptomatic hernia repair. Would you fix it.....why?

Author:Lengyel J.
on 13 Aug, 2007

Last edited by: Lengyel J. on 12 Oct, 2007
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Asymptomatic groin hernias
 
Fast Facts
·       Prevalence 1.7% all ages. OR 4% over age 45
·       Lifetime risk 30% men 3% women
·       Most common operation General Surgery
·       90% of hernias present with pain over a ten year period
·       30% will become incarcerated at 10 years
·       ONLY 5% will require an emergency operation for “strangulation” which is defined on surgical grounds as a decision to treat on the basis of acute pain.
Galleos et al BJS 1991 quoted a bowel resection rate for these hernias of 1/439.
·        
 
 
 
Argument for repair
  • 9/10 will eventually cause pain
  • Risk of complications is small but not insignificant. 5% will require an emergency repair and 30-day mortality in the acute scenario is 3%
  • 2 studies of note are
o      RCT Fizgibbons et al ( American paper JAMA 2006 )
724 pts
After f/u 5 years of watchful waiting ¼ required a repair for pain.
Argument: why not 
 
o      RCT O’Dwyer Ann Surg 2006 ( UK)
160 men. 20% eventually required an operation in 2 years
repair of asymptomatic patients did not lead to chronic pain
  • Watch and wait policy never cures, but delays the inevitable that most do develop symptoms or serious complications
 
 
Argument against repair
  • Cost of repairing all hernias under the NHS when only 5% will eventuall require repair for a serious complication of it
  • Mortality for elective repair is 0.15%, and for emergencies 3%. However the patients who have emergency repair are arguably more likely to have never been candidates for elective repair.
  • Chronic pain post op is 30% overall. In 11% it will interfer with daily living
  • 2 Studies quoted above can be used as a counter argument that the rate of complication is low and emergency surgery can be performed safely with only 1/3000 ever requiring a bowel resection
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