Clinical Review

Inguinal hernias

BMJ 2008; 336 doi: (Published 31 January 2008) Cite this as: BMJ 2008;336:269

Watchful waiting for asymptomatic inguinal hernia

In the Clinical Review on Inguinal Hernias by Jenkins and O’Dwyer,
the authors “recommend that all medically fit patients with an inguinal
hernia should have it repaired”(1) This recommendation is made at the
end of the section dealing with hernias with minimal or no symptoms.
There is no evidence base provided for this statement. Indeed, O’Dwyer et
al. (2) showed that watchful waiting could have a role in the management
of asymptomatic hernias although curiously in that paper concluded that
all hernias should be fixed.

While recurrences have decreased with mesh repair, and are of less
concern than previously, the presence of chronic pain remains an important
adverse outcome following hernia surgery.(1,3) Jenkins and O’Dwyer state
“about 30% of patients when asked ……. report long-term pain or discomfort
at hernia repair site”. The results are different with direct questioning
in the clinic, giving a 10% chronic pain occurrence.(1) Kehlet suggests
that 5%-10% of patients have chronic pain adversely affecting their daily
lives.(3) Other sensory disturbances include hypoesthesia, and
hypoalgesia along with sexual dysfunction which can occur in about 2% of
young men.(3)

During 2007 in an NHS hernia clinic, I saw 265 patients with inguinal
hernias. As Jenkins and O’Dwyer state, about one-third was minimally or
completely asymptomatic. All were offered ‘watchful waiting’ and 67 (25%)
accepted a non-operative watchful waiting approach. There were a
surprising number who terminated the consultation immediately on hearing
of the potential consequences of having an operation.

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? Surely this is a clinical situation for which joint
decision making is appropriate. The patient decides but the surgeon
offers, rather than recommends an operation.

1. Jenkins JT, O’Dwyer PJ. Inguinal hernias. BMJ 2008; 336:269-272.

2. O’Dwyer PJ, Norrie J, Alani A, Walker A, Duffy F, Horgan P.
Observation or operation for patients with an asymptomatic inguinal
hernia. Ann Surg 2006; 244:167-73.

3. Kehlet H. Chronic pain after groin repair. Br J Surg 2008;

Competing interests:
None declared

Competing interests: No competing interests

21 February 2008
Jonathan L Meakins
Nuffield Professor of Surgery
Oxford, OX3 9DU
John Radcliffe Hospital