Asymptomatic inguinal hernia: does it need surgical repair? A systematic review and meta‐analysis

Abstract

Background: The aim of this review is to compare the outcomes of surgical repair versus watchful waiting in asymptomatic or minimally symptomatic inguinal hernias. Methods: Preferred reporting items for systematic reviews and meta-analyses guidelines were employed. We analysed primary outcomes: pain, quality of life, pain during daily activities and visual analogue scale (VAS that measures pain at rest and on movement) and secondary outcomes: postoperative complications and recurrence. Results: Pain and quality of life were not comparable due to differences in the parameters used in different articles. Pain interfering with normal daily activity was evaluated in one study and appears more favourable in the post-repair group respect to the watchful waiting (WW) group (5.1% versus 2.2%). VAS, measured in one study, at 6 months was more favourable in the surgery group (37% versus 44%). After 12 months the outcome was better in the control group than in the repair group (28% versus 30%). Conversion rate of the patient cohorts from watchful waiting to elective surgery was between 35.03% and 57.8%. The meta-analysis did not find significant statistical differences in the two groups examined for postoperative complications [RR = 0.95, 95% CI (0.50, 1.80), P = 0.88], as for hernia recurrence [RR = 1.01, 95% CI (0.50, 2.02), P = 0.98]. Conclusion: WW seems to be an acceptable option for the patient with asymptomatic or minimally symptomatic inguinal hernias. Delaying surgical repair until symptoms appear is safe. Acute hernia incarcerations are not particularly frequent. The incidence of chronic pain after the repair is high. Physicians must select patients carefully and explain to them the risks and benefits of surgery.

A narrative review on the non-surgical treatment of chronic postoperative inguinal pain: a challenge for both surgeon and anaesthesiologist

“…The patient assessed for a first-time hernia repair should be advised that there is a about 10-12% risk of persistent pain at three months follow-up and a 0.5-6% risk of pain affecting everyday life at one year follow-up, including sexual function [7]. The discussion should be nuanced with the evidence that for the painfree hernia there is the option of watchful waiting [36].…”

Choosing wisely: how wisely do we choose?

“…9 In this issue, we publish a study, by Clocchi et al, demonstrating the benefits a conservative approach to an asymptomatic hernia that should further help surgeons inform and reassure our patients that conservative hernia management can be used in selected circumstances. 10 This study is a systematic review and meta-analysis comparing the outcome of surgical repair versus watchful waiting in asymptomatic or minimally symptomatic inguinal hernias. This article provides us with a better understanding of the natural history of such hernias and suggests that at least 40% in the conservative group will avoid surgery.…”