Is surgical repair of an asymptomatic groin hernia appropriate? A review

Abstract

Purpose Groin herniorrhaphy is the most common operation performed by general surgeons. Annually, more than 20 million groin hernias are repaired worldwide. The general approach towards groin hernias is surgical repair regardless of the presence of symptoms. The rationale to recommend surgery for asymptomatic groin hernias is prevention of visceral strangulation. The goal of this review is to evaluate the appropriateness of surgery in patients with asymptomatic groin hernias. Methods The review was based on an extensive literature search of Pubmed, Medline and the Cochrane Library. Results The risk of incarceration is approximately 4 per 1,000 patients with a groin hernia per year. Risk factors for incarceration are age above 60 years, femoral hernia site and duration of signs less than 3 months. Morbidity and mortality rates of emergency groin hernia repair are higher in patients who are older than 49 years, have a delay between onset of symptoms and surgery of more than 12 h, have a femoral hernia, have nonviable bowel and have an ASA-class of 3 or 4. The recurrence rate after tension-free mesh repair in the management of emergency groin hernias is comparable to that of elective repair. There is no diVerence in pain and quality of life after elective repair compared to watchful waiting. There is no advantage in cost-eVectiveness of elective repair compared to watchful waiting. ConclusionWatchful waiting for asymptomatic groin hernias is a safe and cost-eVective modality in patients who are under 50 years old, have an ASA class of 1 or 2, an inguinal hernia, and a duration of signs of more than 3 months.

The pitfalls of inguinal herniorrhaphy: Surgeon volume matters

“…With an estimated 800,000 groin hernia repairs performed in the United States each year and a projected cost of $15 to $20 per minute in the operating room, the potential for large cost savings exists with improved operative efficiency for inguinal hernia repairs. 1,19 Further potential cost savings exists with decreasing the number of reoperations for hernia recurrence. Although the absolute risk reduction of reoperation between high-volume and low-volume surgeons is only 0.4% (1.6% reoperation rate for high-volume surgeons vs 2% for low-volume surgeons), the large number of inguinal hernia repairs performed annually in the United States makes this number clinically meaningful.…”

“…WITH APPROXIMATELY 800,000 GROIN HERNIA REPAIRS performed in the United States each year, inguinal herniorrhaphy accounts for 10À15% of all general surgical procedures, making it one of the most common operations performed by general surgeons. 1,2 Hernia recurrence also continues to be a clinical problem, with 13% of all groin hernia repairs being performed for a recurrent hernia. 3 As a result, inguinal hernia surgery is a multibillion dollar industry that results in a substantial amount of health care use.…”

Totally extraperitoneal (TEP) endoscopic hernia repair in elderly patients

“…Although a safe strategy, and the risk of incarceration being low with an estimated incidence of 5 per 1000 patients per year [9,31], approximately 50 % of the patients will require surgery within 5 years due to progression of their complaints. Since elective surgery is accompanied by less morbidity and mortality than emergency procedures [7,8,32], and the life expectancy in this relatively healthy cohort with a median age of 74 years is well over five years [33], this selection of elderly patients gains from elective inguinal hernia surgery [34] In conclusion, for a selected group of elderly patients with inguinal hernia, TEP is associated with a very low overall risk of complications and a good functional outcome.…”

“…However, 54 % of the patients in whom a watchful waiting policy was initially adhered to, require repair within 5 years due to worsening of complaints, mainly pain [7,8]. A watchful waiting policy is also accompanied by a small risk (2.5 %) of incarceration [8], which is a condition associated with substantial morbidity and even mortality [9][10][11].…”

Dynamic inguinal ultrasound: a diagnostic tool for hernia surgeons

“…Baukje van den Heuvel in her literature review on the appropriateness of an operational approach for an asymptomatic groin hernia came to the conclusion that watchful waiting was a safe and cost-effective modality in patients who were under 50 years, had an ASA class of 1 or 2, an inguinal hernia and duration of signs of more than 3 months [5].…”