Watchful waiting is safe for men with asymptomatic inguinal hernias, but data from randomized trials suggest that most men will ultimately undergo surgery, primarily because of pain. Watchful waiting is not recommended in women, given their higher prevalence of femoral hernias. Read the new Clinical Practice review on this topic.
The lifetime risk of development of a groin hernia has been estimated at 27% for men and 3% for women.
- Describe the epidemiology of and risk factors for groin hernia.
Inguinal hernias are more common on the right side than on the left and are 10 times more common in men than in women. Among adults, the annual frequency of groin hernia repair was found to increase consistently with age, from 0.25% at 18 years of age to 4.2% at 75 to 80 years of age. Femoral hernias account for fewer than 5% of groin hernias; however, 35 to 40% of femoral hernias are not diagnosed until the patient presents with strangulation or bowel obstruction, and mortality is higher in association with emergency repair than with elective repair. Femoral hernias are more common in women than in men, but a woman with a groin mass is still 5 times more likely to have an inguinal hernia than a femoral hernia. A major risk factor for a groin hernia is a family history of groin hernias, which is associated with up to eight times the risk.
- How are hernias diagnosed?
Inguinal hernias are diagnosed by means of a physical examination disclosing a visible bulge or an easily palpable mass on straining with an examining finger in the external ring. Differentiating an indirect from a direct inguinal hernia is unnecessary, because it does not affect treatment. It is not always possible to differentiate an inguinal hernia from a more worrisome femoral hernia during physical examination.
Imaging studies are required only in cases in which there are typical symptoms in the absence of physical findings, to rule out an occult hernia or other condition. Ultrasonography is relatively inexpensive and avoids the use of radiation, but its accuracy is operator-dependent. Computed tomography and magnetic resonance imaging (MRI) are alternatives; MRI provides the best anatomic detail and has the highest sensitivity and specificity.
Morning Report Questions
Q: How should an asymptomatic or minimally symptomatic groin hernia be managed?
A: Regardless of the type of hernia, symptomatic patients should be offered repair to improve quality of life. However, the results of two randomized trials comparing prompt repair with a strategy of watchful waiting for asymptomatic or minimally symptomatic inguinal hernias have argued against routine repair. One of these, a single-center randomized trial from the United Kingdom involving 160 patients, showed no significant difference between groups in pain scores and a minimal difference in scores on the 36-Item Short Form Health Survey at 1 year. In a larger multicenter trial from North
America, there was no significant difference at 2 years in pain or quality of life between the group that underwent surgery and the group that did not. In both studies, approximately one quarter of patients assigned to watchful waiting crossed over to surgery, primarily because of increasing pain; the delay did not affect the frequency of operative complications. Both studies have recently been updated with longer-term follow-up data. The estimated frequency of crossover to surgery from the watchful-waiting group was 72% by 7.5 years in the U.K. trial and 68% by 10 years in the North American trial; most crossovers to surgery were a result of increasing pain.
The logical conclusion is that watchful waiting is safe but only delays the inevitable surgery. Because the patients in both studies had presented to their physicians with concerns about their hernias, the results may not be generalizable to the larger group of patients with asymptomatic hernias and no concerns. Another important caveat is that these results apply only to inguinal hernias and not to femoral hernias, because of the higher risks of serious complications with the latter.
Q: How do laparoscopic herniorrhaphy and open surgical repair compare?
A: Laparoscopic herniorrhaphy results in less pain initially, an earlier return to normal activities, and easier repair of recurrent hernias that have previously undergone open repair, and it allows treatment of bilateral hernias through the same skin incisions. The risks of common surgical complications are similar for laparoscopic and open repair; complications include wound seroma or hematoma (approximately
7 to 8% risk), wound infection (approximately 1% risk), testicular complications (approximately 0.7% risk), and complications related to the mesh — for example, contraction, erosion, and infection.
However, laparoscopic repair is associated with a small risk life-threatening vascular or visceral injury (0.9 and 1.8 per 1000 procedures, respectively). Whereas laparoscopic repair requires general anesthesia, open repair can be performed under local anesthesia; the possibility of using local anesthesia is a particular advantage in older patients who require repair and have serious coexisting medical conditions. Laparoscopic herniorrhaphy is more expensive, but the costs of the procedure may be offset by an earlier return to daily function and work.