Is watchful waiting a reasonable approach for men with minimally symptomatic inguinal hernia?

Claire Kendall; Sally Murray

doi:10.1503/cmaj.060299

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Is Watchful Waiting a valid strategy in hernia management?
Emanuele Baldassarre

Posted on: 02 May 2006

Posted on: (2 May 2006)
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Is Watchful Waiting a valid strategy in hernia management?
Emanuele Baldassarre
Dear Editor, we recently read with great interest the article proposed in jour journal [CMAJ 2006;174(9):1263-4] and previously published by Fitzgibbons RJ et al. on JAMA. [1] It explores the natural history of an untreated inguinal hernia and presents interesting results: the “pain sufficient to limit activity” is similar in both the operated as well as not operated groups; only 1.8 of 1000 patient-years presented acut...
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Dear Editor, we recently read with great interest the article proposed in jour journal [CMAJ 2006;174(9):1263-4] and previously published by Fitzgibbons RJ et al. on JAMA. [1] It explores the natural history of an untreated inguinal hernia and presents interesting results: the “pain sufficient to limit activity” is similar in both the operated as well as not operated groups; only 1.8 of 1000 patient-years presented acute hernia incarceration after 4.5-years; and the watchful waiting (WW) strategy appears acceptable when an inguinal hernia is minimally symptomatic. Nevertheless a doubt arises regarding the statistical validity of this study due to the high number (nearly 40%) of patients that crossed over from WW to surgical repair (SR) and back again. In Dr. Flum DF’s comment, he explained fairly that the key of the article is to compare two strategies and not two treatments. [2] Consequently, the intention-to- treat approach makes sense to the results of this trial. However, in our opinion, the validity of this comparison is limited by the contemporary presence of primitive and recurrent hernias. In fact this study includes 34 recurrences (9.6%) in SR group and 43 in WW one (11.8%). As documented from literature as well as from our personal experience, the recurrent and the primitive hernias are two different entities and an emergency SR of a recurrent hernia, expecially after a previous mesh positioning, has a considerable morbidity and even a slight mortality. It may represent a great challenge for a surgeon, so that in similar cases we retain that it would be difficult to accept the WW strategy proposed by the authors. [3,4]
Emanuele BALDASSARRE, MD1; Ilaria PROSPERI PORTA, MD2; Marco BARONE, MD2
1 Department of Surgery, San Pietro Hospital - Fatebenefratelli, Rome 2 Department of Clinical Sciences, University of Rome “La Sapienza” 3 Department of Anesthesiology, Regional Hospital, Aosta
REFERENCES
1. Fitzgibbons RJ, Giobbie-Hurder A, Gibbs JO et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men. JAMA. 2006;295:285-292.
2. Flum DR. The asymptomatic hernia. JAMA. 2006;295:328-329.
3. Richards SK, Vipond MN, Earnshaw JJ. Review of the management of recurrent hernias. Hernia. 2004;8:144-148.
4. Haapaniemi S, Gunnarsson U, Nordin P, Nilsson E. Reoperation after recurrent groin hernia repair. Ann Surg. 2001;234:122-126.
Conflict of Interest:
None declared
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Competing Interests: None declared.