Articles comparing surgery with watchful waiting

British Medical Journal Clinical Review This summary has been recommended by one of our site visitors as it includes medical views which are not biased towards surgery.

If it's partly broken should you fix it? Article recommended by one of our site visitors as a very clear and helpful guide for those contemplating surgery.

Turaga K, Fitzgibbons RJ, Puri V. Inguinal hernias: should we repair? Surg Clin N Am 88 (2008) 127-138. Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska, USA.

A review paper comparing the incidence of complications in groups of untreated hernia patients compared with those treated by hernia repair surgery. Includes a discussion of historical data from a time before hernia repair surgery became routine, and contemporary data from two recently completed clinical trials comparing watchful waiting with routine repair.

van den Heuvel B, Dwars BJ, Klassen DR, Bonjer HJ. Is surgical repair of an asymptomatic groin hernia appropriate? A review.

Does delaying repair of an asymptomatic hernia have a penalty? Thompson JS, Gibbs JO, Reda DJ, McCarthy M Jr, Wei Y, Giobbie-Hurder A, Fitzgibbons RJ Jr. Am J Surg. 2008 Jan;195(1):89-93. University of Nebraska, Nebraska Medical Center, Omaha, Nebraska, USA.

Patients undergoing hernia repair surgery immediately after diagnosis were compared with those those repair was delayed. No significant difference between them was found in terms of operative time, surgical complications, recurrence rates, and satisfaction with outcome.

Mizrahi H, Parker MC. Management of asymptomatic inguinal hernia: a systematic review of the evidence.

Sarosi GA, Wei Y, Gibbs JO, Reda DJ, McCarthy M, Fitzgibbons RJ, Barkun JS. A clinician's guide to patient selection for watchful waiting management of inguinal hernia

Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. Fitzgibbons RJ Jr, Giobbie-Hurder A et al. JAMA. 2006 Jan 18;295(3):285-92. Department of Surgery, Creighton University, Omaha, Nebraska, USA.

This was the first published randomised clinical trial which looked at the safety of not operating on patients with a minimally symptomatic hernia. 720 men from 5 North American centres were followed up for 2 to 4.5 years after being assigned to watchful waiting or surgery. Pain and discomfort interfering with usual activities was compared between the two groups. There was very little difference between them, and the researchers concluded patients should understand that, if they can live with it, they don't have to have their hernia fixed.

More comments from this researcher

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Observation or operation for patients with an asymptomatic inguinal hernia: a randomized clinical trial. O'Dwyer PJ, Norrie J, Alani A, Walker A, Duffy F, Horgan P. Ann Surg. 2006 Aug;244(2):167-73. University Department of Surgery, Western Infirmary, Glasgow, UK.

Many patients with an inguinal hernia have no symptoms or discomfort. On the other hand hernia repair surgery often brings long-term chronic pain and hernias recurr in 5-10 per cent of cases.

Comment in the British Medical Journal, 21 February 2008, by Professor Jonathan L Meakins, Nuffield Professor of Surgery, John Radcliffe Hospital, Oxford

Professor Meakins comments "Why would someone with an asymptomatic inguinal hernia trade that state for a chance to have chronic pain, hypoesthesia or any degree of sexual dysfunction?"

"Is surgery needed?" More comments published in the British Medical Journal

Tension-free repair versus watchful waiting for men with asymptomatic or minimally symptomatic inguinal hernias: a cost-effectiveness analysis. Stroupe KT, Manheim LM et al. J Am Coll Surg. 2006 Oct;203(4):458-68.Cooperative Studies Program Coordinating Center, Edward Hines Jr VA Hospital, Illinois, USA

This article reports on a study comparing the treatment costs of hernia patients treated with surgery compared with those using watchful waiting over a three-year period. At 2 years, surgery patients cost their health-care providers an average of 1,831 dollars more than watchful waiting patients. For each additional quality-adjusted life-year the cost for surgery patients was 59,065 dollars.

Articles on the side effects of hernia repair surgery

Pain and functional impairment one year after inguinal herniorrhaphy: a nationwide questionnaire study. Bay-Nielsen M, Perkins F M, Kehlet H for the Danish Hernia Database. Ann Surg 2001; 233: 1-7.

One year after surgery, 29% of patients surveyed were still suffering persistent post-operative pain. Younger patients were worst affected. The problem equally affected all types of hernia and surgical technique.

Pain and functional impairment 6 years after inguinal herniorrhaphy.Aasvang EK, Bay-Nielsen M, Kehlet H. Section of Surgical Pathophysiology, The Juliane Marie Centre, 4074, Rigshospitalet, 2100, Copenhagen, Denmark. Hernia. 2006 Aug;10(4):316-21. Epub 2006 May 19.

In a follow-up six years after the previous study, 16 per cent of the patients who replied had had a recurrence of their hernia followed by further surgery. Of the remaining 210 patients, 34 per cent were still suffering persistent pain in the area of their hernia.

Dr Brian Camazine: Testicular atrophy following hernia repair - a case report.

This is one of the rarer complications of hernia repair surgery, but nevertheless affects 0.5 per cent of cases after the first operation and up to 5 per cent of cases if the hernia recurs and requires further surgery.

Open mesh versus laparoscopic mesh repair of inguinal hernia. Neumayer L, Giobbie-Hurder A, Jonasson O et al. N Engl J Med 2004; 350: 1819-1827.

After surgical mesh repair, 15% or more hernia cases are reported to have a recurrence, and postoperative pain and disability are frequent, especially after a second repair operation. Comparing the statistics of open surgery with laparoscopic technique, this study found that a hernia recurrence was twice as likely after a laparoscopic repair. The rate of complications was also significantly higher.

Chronic pain after open mesh and sutured repair of direct inguinal hernia in young males. Bay-Nielsen M, Nilsson E, Nordin P et al. Br J Surg 2004; 91: 1372-1376.

Chronic pain following hernia repair was thought to occur in about 10-15% of patients. This study analysed 2,612 individuals from the Danish and Swedish database of hernia patients treated with surgery. Of those who responded, 23 per cent reported that they had experienced chronic pain within the previous month. At 37-48 months after surgery this rate dropped to 18 per cent with no overall difference between the different types of repair operation. Pain was more common in patients under 40 years of age. Four per cent of patients described the pain as moderate to severe and frequent or constant. Of all the patients with pain, 10.7 per cent said is was worse than before surgery and 56.6 per cent said that it interfered with their social activities.

Effects of training and supervision on recurrence rates after inguinal hernia repair. Robson A J, Wallace C G, Sharma A K et al. Br J Surg 2004; 91: 774-777.

Owing to its low mortality risk, inguinal hernia repair surgery is considered an appropriate operation for trainee surgeons. This Scottish survey of 4406 cases compared outcomes of hernia repairs carried out by experienced surgeons and unsupervised trainees. Hernia recurrence rates were similar for consultants, senior trainees and supervised junior trainees. Hernia recurrence rates were unacceptably high after repairs carried out by unsupervised junior trainees.

Pain from primary inguinal hernia and the effect of repair on pain. Page B, Paterson C, Young D, O'Dwyer P J. Br J Surg 2002; 89: 1315-1318.

Inguinal hernia repair is one of the most common general surgical operations. Up to one-third of all patients undergoing hernia repair have a painless hernia that has little or no effect on work or leisure activities. In contrast, one year after a hernia repair operation 3 to 6% of patients will have severe pain and more than 30% will have mild pain. This pain persists for many years and has a significant effect on daily activity. The aim of this study was to quantify patients' pain from an inguinal hernia with and without surgery. Overall, without surgery 27% recorded no pain at rest from the hernia and 54% had mild pain only on movement. One year after surgery 25% had no pain at rest but only 22% had no pain on movement. Patients who had no pain at rest before the operation had significant pain scores at rest one year after.

Cooperative hernia study. Pain in the postrepair patient. Cunningham J, Temple WJ, Mitchell P, Nixon JA, Preshaw RM, Hagen NA. Ann Surg. 1996 Nov;224(5):598-602. Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.

Postoperative pain after hernia repair appears to be more disabling than two other recognized after-effects of surgery: hernia recurrence and testicular atrophy.

Factors associated with postoperative complications and hernia recurrence for patients undergoing inguinal hernia repair: a report from the VA Cooperative Hernia Study Group. Matthews RD, Anthony T, Kim LT, Wang J, Fitzgibbons RJ Jr, Giobbie-Hurder A, Reda DJ, Itani KM, Neumayer LA. Am J Surg. 2007 Nov;194(5):611-7. George E. Wahlen Salt Lake City VA Health Care System and University of Utah Department of Surgery, VAMC-112, 500 Foothill Dr, Salt Lake City, UT 84148, USA.

Regardless of technique, scrotal and recurrent hernias were associated with a greater risk of complications and younger patients had more long-term pain. Predictors of recurrence vary based on surgical technique.

Chronic sequelae of common elective groin hernia repair. Loos MJA, Roumen RMH. Hernia (2007) 11:169–173. Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands.

1,766 men responded to a questionnaire concerning frequency and intensity of pain, presence of bulge, numbness, and functional impairment after inguinal hernia surgery. After a follow-up period of three years 40.2 per cent of patients reported some degree of pain. 1.9 per cent experienced severe pain. Almost one-fourth reported numbness which correlated significantly with pain. One-fifth of the patients felt functionally impaired in their work or leisure activities.

Risk factors for long-term pain after hernia surgery. Fränneby U, Sandblom G, Nordin P, Nyrén O, Gunnarsson U. Ann Surg. 2006 Aug;244(2):212-9. Department of Surgery, Södersjukhuset, Stockholm, Sweden.

2,456 patients responded to a questionnaire 2-3 years after undergoing hernia surgery. 31% per cent reported that they still had pain to some extent. In 6 per cent, the pain interfered with daily activities.

Foreign body reaction to meshes used for the repair of abdominal wall hernias. Klinge U, Klosterhalfen B, Müller M, Schumpelick V. Eur J Surg. 1999 Jul;165(7):665-73. Department of Surgery, IZKF-Biomat, The University of Technology, Aachen, Germany.

Inflammation around materials used to repair hernias persists for many years. This study showed evidence of long term wound complications as a result of persistent foreign body reactions.

A Review of Chronic Pain After Inguinal Herniorrhaphy. Poobalan AS, Bruce J, Cairns W et al. Clin. J. Pain 2003; 19(1):48-54 University of Aberdeen Medical School and Aberdeen Royal Infirmary, Aberdeen, Scotland.

The authors reviewed all studies of postoperative pain after inguinal hernia repair, published between 1987 and 2000, with a minimum follow-up period of 3 months. The frequency of chronic pain after inguinal hernia repair was found to be as high as 54%. Chronic pain was reported less often after laparoscopic and mesh repairs.

Chronic pain and quality of life following open inguinal hernia repair. Poobalan AS, Bruce J, King PM, Chambers WA, Krukowski ZH, Smith WC. Br J Surg. 2001 Aug;88(8):1122-6. Department of Public Health, University of Aberdeen, Scotland.

30 per cent of patients who completed a questionnaire after open inguinal hernia repair reported persistent pain for three months or more after surgery.

Outcome of patients with severe chronic pain following repair of groin hernia. Courtney CA, Duffy K, Serpell MG, O'Dwyer PJ. Br J Surg. 2002 Oct;89(10):1310-4. University Department of Surgery, Western Infirmary, Glasgow G11 6NT, UK.

Chronic pain persists in most patients who report severe or very severe pain at 3 months after hernia repair, and has a significant effect on the patients' daily activities and quality of life.

Novel Mechanisms and Treatment of Chronic Pain. Flatters S. King's College, University of London website.

Persistent postoperative pain following thoracotomy and inguinal hernia repair occurs in up to 60% of patients and is reported to persist for 3-30 months. 25% of these patients will rate their pain as severe. Persistent postoperative pain has been estimated to affect over 60,000 patients per year in the US from inguinal hernia repair surgery alone. It is unclear whether the pain is due to the skin incision, inflammation, muscle damage or nerve damage.

Quality of elective inguinal hernia repair at Hadassah Hebrew University Hospital, Jerusalem, Israel. Tal Yemini Biber, Patient Survey.

Adult patients one and five years after hernia repair procedure. One year post procedure 43% reported some level of pain or discomfort. Of them 30% reported pain above the level 5 (on a scale of 1 – 10). Five years after the procedure 40% of the patients reported some level of pain or discomfort. Of them 45% reported pain above level 5 (on a scale of 1 -10). Reoccurrence of the hernia was observed in 3% one year after the procedure and in 4% five years after the procedure. Post-op infections: the rate at one month post-op was 11%.

Mesh repair issues

Article by Dr Kevin Petersen, a surgeon who has many times removed mesh placed by other surgeons, because of chronic pain. There is thought to be a lower rate of hernia recurrence after mesh repairs. According to this surgeon, this is not true.

Open mesh versus laparoscopic mesh repair of inguinal hernia. Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R Jr et al. N Engl J Med. 2004 Apr 29;350(18):1819-27. Veterans Affairs Medical Center and the Department of Surgery, University of Utah, Salt Lake City, USA.

After surgical mesh repair, 15% or more hernia cases are reported to have a recurrence, and postoperative pain and disability are frequent, especially after a second repair operation. Comparing the statistics of open surgery with laparoscopic technique, this study found that a hernia recurrence was twice as likely after a laparoscopic repair. The rate of complications was also significantly higher.

The effects of mesh bioprosthesis on the spermatic cord structures: a preliminary report in a canine model. Uzzo RG, Lemack GE, Morrissey KP, Goldstein M. J Urol. 1999 Apr;161(4):1344-9. Department of Urology, The New York Hospital-Cornell Medical College, New York 10021, USA.

In this test, half of the testicles had gross abnormalities after mesh repair, versus none in the control and Shouldice (non-mesh) dogs. There was a marked soft tissue foreign body reaction traumatic neuroma after mesh repair suggesting nerve entrapment in the fibrotic mesh. This may account for chronic post-operative pain seen in a proportion of patients. Marlex [TM] mesh may have a damaging effect on spermatic cord structure and function.

Post-operative hernia infections Hernia Infections Pathophysiology - Diagnosis - Treatment - Prevention. Maximo Deysine (editor). ISBN: 978-0-8247-4612-4 (hardback) 978-0-203-91320-8 (electronic). Informa Healthcare, USA, 2003

Approximately 700,000 inguinal hernia repairs are performed yearly in the United States and about 85% of these are mesh repairs. The reported infection rate is 1-3 per cent for inguinal hernias. In terms of human suffering and cost, the impact of wound infection in the presence of mesh is significant. The prosthetic materials, bathed in nutritious body fluids, become fertile grounds for bacterial colonization. Mesh technology changes the wound biology by exponentially increasing the amount of foreign material left in the wound. Infected mesh converts a simple ambulatory surgical procedure into a protracted and complex clinical situation requiring further surgery and may be associated with long-term disability. Approximately 14,000 individuals per year require further surgical treatment because of infection.

Three-year results of a randomized clinical trial of lightweight or standard polypropylene mesh in Lichtenstein repair of primary inguinal hernia. Bringman S, Wollert S, Osterberg J et al. Br J Surg. 2006 Sep;93(9):1056-9. Karolinska Institutet, Stockholm, Sweden.

Hernia repair surgery with mesh has become the standard technique in inguinal hernia surgery. However there is concern about mesh-induced problems such as groin pain and infertility. Polypropylene, the material most commonly used for mesh, is associated with a strong foreign-body reaction and can cause potentially harmful side-effects including chronic inflammation and decreased elasticity of the abdominal wall.

Late-onset deep mesh infection after inguinal hernia repair. Delikoukos S, Tzovaras G, Liakou P et al. Hernia. 2007 Feb;11(1):15-7. Department of Surgery, Larissa University Hospital, Greece

Between 1998 and 2005, 954 men had hernia repair surgery using polypropylene mesh. Five patients (0.35 per cent) developed a mesh infection 2 to 4.5 years after the surgery. All the patients had been given antibiotics to prevent infection at the time of the surgery. None of them had a prior history of wound infection. The patients were re-operated and the meshes were removed. Pus was found in three patients and Staphylococcus aureus was isolated in one. From these results it appears that late-onset deep-seated mesh infection is an important complication which has been rarely reported. Its true incidence is yet to be established.

Can we be sure that the meshes do improve the recurrence rates? Klinge, U, Krones CJ. Hernia 2005;9:1–2 Surgical Department of the RWTH Aachen, Germany.

In 2003 the results of Flum et al. cast clouds over the rising enthusiasm for mesh repair. In a database with more than 10,000 patients observed for more than 15 years the rate of hernia recurrence following incisional versus mesh implantation repair was compared. In contrast to grandiose expectations, both groups showed a linear rise of the accumulating rate of re-operations, which was simply delayed for 2 years in the mesh group.

Have outcomes of incisional hernia repair improved with time? A population-based analysis. Flum DR, Horvath K, Koepsell T. Ann Surg 2003;237:129–135 Robert Wood Johnson Clinical Scholars Program, Seattle, USA

In a study on more than 10,000 people, the 5-year hernia recurrence rate was 23.8 per cent after the first reoperation, 35.3% after the second, and 38.7% after the third. The expectation that these figures would have improved in recent years since the use of mesh became prevalent, is not confirmed. To read this article online, copy and paste this link into a search engine such as Google and then click on the search result. In this very comprehensive articles about meshes, mesh expert Dr Ramshaw emphasises the need for further development of biomeshes. He reminds us that some of the traditional synthetic hernia meshes were initially designed and tested for the textile industry and what may be a good material for household furniture may not necessarily be ideal for human abdominal wall reconstruction.

Risk Factors for Long-term Pain After Hernia Surgery. Fränneby U, Sandblom G, Nordin P et al. Ann Surg 2006;244(2):212-219. Department of Surgery, Södersjukhuset, Stockholm, Sweden (a multi-centre study).

In response to a questionnaire about pain three years after hernia surgery, 31% out of a total of 3,000 patients who received the questionnaire, reported some degree of pain. In 144 cases (6%), the pain interfered with daily life. Younger age, a high level of pain before the operation, and occurrence of postoperative complications were found to significantly and independently predict the likelihood of experiencing long-term post-operative pain.

Chart showing prevalence of residual pain by age

Chart showing prevalence of residual pain by technique of repair

Forthcoming trials

 Inguinal Hernia Management: Operation or Observation? A randomised controlled multicentre trial. Wijsmuller AR Department of General Surgery, Erasmus University Medical Centre, Rotterdam.

Pain and quality of life will be compared in 800 men assigned either to hernia repair surgery or to watchful waiting.