Summary of intervention

Watchful waiting is a safe option for people with minimally symptomatic inguinal hernias. Delaying and not doing surgical repair unless symptoms increase is acceptable because acute hernia incarcerations occur rarely. Many people with an inguinal hernia are asymptomatic or minimally symptomatic and may never need surgery.

 

This guidance applies to adults aged 19 years and over.

 

Number of interventions 2018/19

54,764

 

Recommendation

Minimally symptomatic inguinal hernia can be managed safely with watchful waiting after assessment. Conservative management should therefore be considered in appropriately selected patients. In women, all suspected groin hernias should be urgent referrals.

 

Rationale for Recommendation

Repair of minimally symptomatic inguinal hernia is a high cost and high frequency operation. A randomised control trial determined that watchful waiting was a safe and reasonable option for minimally symptomatic hernias. Up to one third of hernias give patients only mild pain that does not interfere with work or leisure activities.

 

The risks/potential harm of delaying surgery (which is a frequently cited reason for repair) are rare. The incidence of hernia accident (i.e. acute hernia incarceration with bowel obstruction, strangulation of intraabdominal contents, or both) is very low (1.8 per 1’000 patients) and even in elderly, whom are at greater risk, the rate is 0⋅11% in patients aged over 65 years. Patients who develop symptoms have no greater risk of operative complications than those undergoing hernia repair for minimally symptomatic hernia. The rate of complications is similar for those undergo surgery for minimally symptomatic hernia and those who have surgery as a result of an increase in symptoms whilst under watchful waiting. The risks are infection, bleeding, perforation, and long-lasting significant pain after surgery as well as risks associated with sedation/anaesthetic. Although it is a generally safe and effective operation, procedures should be delayed where appropriate to avoid these associated risks.

 

In a male randomised clinical trial for two-year watchful waiting, for the instances that treatment escalated to surgery, the most common reason cited was increased hernia-related pain. The hernia repair can be safely delayed until increased pain or discomfort. Pain interfering with activities increased 5.1% for watchful waiting and 2.2% for surgical repair over this same time. The is confirmed by another trial looking at pain at 12 months that did not find statistically different values between surgery and watchful waiting groups. Those who had increased pain crossed over to have surgery where necessary. 23% of patients crossed over from watchful waiting to surgery within two years. Pain was decreased in both groups at two years.

 

Results of several randomised controlled and clinical trials agreed with these findings. It is safe to manage minimally symptomatic inguinal hernia with watchful waiting. Outcomes, pain and post-operative complications remained similar to hernia repair for minimally symptomatic hernia.

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