Hernia Debate 17 May 2007 Surgery-OMMC JGGuerra, MD HCruz, MD HBalucating, MD JMalabanan, MD MASunaz, MD EVelasquez, MD

Hernia: Natural History Groin hernia is one of the most common worldwide afflictions of adults, especially men 500, ,000 herniorrhaphies annualy most common surgical operation performed by general surgeons

The natural history of an untreated inguinal hernia is poorly understood with almost no modern data available. This is because of the commonly held opinion that all inguinal hernias should be repaired when diagnosed to prevent the complications of intestinal obstruction and/or strangulation of incarcerated contents.

It is high time to discuss whether delaying surgical intervention is a safe option for asymptomatic groin hernia case.

Premise Is watchful waiting a safe option for asymptomatic IIH patients? YES

Arguments 1.Low risk of developing symptoms of incarceration and pain 2.Watchful waiting is Cost effective 3.Watchful waiting has comparable quality adjusted life years with elective surgery 4.No postoperative morbidity

Literature Review Fitzgibbons, RJ. ACS Spring Convention 2006: The Role of Watchful Waiting for Inguinal Hernias – 8633 patients – Risk of major complications:<3% – Yearly risk of % – Lifetime risk: 18 yo (0.272), 75 yo (0.034)

To summarize, despite popular wisdom to the contrary, it may be that patients with inguinal hernias can safely delay surgical treatment in favor of careful watchful waiting (WW) as the method of management for their hernia

Stroupe, KT et al. Tension-free repair versus watchful waiting for men with asymptomatic or minimally symptomatic inguinal hernias: a cost-effectiveness analysis. – cost-effectiveness analysis of a randomized controlled trial at six community and academic centers. – 724 men randomized, 641 were available for the economic analysis: 317 were randomized to TFR and 324 were randomized to watchful waiting

– TFR patients had $1,831 higher mean costs than WW patients CONCLUSION: At 2 years, WW was a cost- effective treatment option for men with minimal or no hernia symptoms.

Fitzgibbon, RJ et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. – compare pain and the physical component score (PCS) – RCT: 720 men (364 watchful waiting, 356 surgical repair) followed up for 2 to 4.5 years

– RESULTS: Primary intention-to-treat outcomes were similar at 2 years for watchful waiting vs surgical repair: pain limiting activities (5.1% vs 2.2%, respectively) 1/363 (0.0027%) in WW had incarceration CONCLUSIONS: Watchful waiting is an acceptable option for men with minimally symptomatic inguinal hernias. Delaying surgical repair until symptoms increase is safe because acute hernia incarcerations occur rarely

OMMC Databank: Groin Hernia 2006 – Elective: 141 – Emergency: 25 (17.7%) 12 adults (8.5%) 13 pediatrics (9.2%) Risk for Incarceration: 8.5%

Management Options BENEFIT RISK for Complication COSTAVAILABILITY Watchful Waiting (Observation) Surgical Complication MorbidityMortality <0.5%*0√ 00 0 Hernia Surgery 3-5%5% 3% 65% ^(postoperatve pain) 20K√ *Fitzgibbon et al ^Rutkow et al

Summary These data provide evidence that in patients the indication for operative treatment of inguinal hernias should depend upon symptoms and suffering. There is no reason to operate on asymptomatic patients because of a presumed risk of strangulation.

Thank You

References 1.Fitzgibbons, RJ. The Role of Watchful Waiting for Inguinal Hernias. ACS Spring Convention Fitzgibbon, RJ et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. Department of Surgery, Creighton University, Omaha, Neb, USA. 3.Rutkow IM, Robbins AW. Groin Hernia. In Cameron JL., ed. Current Surgical Therapy. St. Louis: Mosby Co. 1995; Stroupe, KT et al. Tension-free repair versus watchful waiting for men with asymptomatic or minimally symptomatic inguinal hernias: a cost-effectiveness analysis. Cooperative Studies Program Coordinating Center, Edward Hines Jr VA Hospital, 5th Avenue and Roosevelt Road, Hines, IL 60141, USA.