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
Fitzgibbons RJ. Open versus watchful waiting: An update. Slides from presentation given at the American College of Surgeons Spring Meeting 2004.
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
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
See the full article in pdf format
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.
Inguinal Hernias. Jenkins JT and O’Dwyer PJ. British Medical Journal 2008;336;269-272. University Department of Surgery, Western Infirmary, Glasgow, UK.
A review article discussing clinical assessment, treatment options and complications in relation to inguinal hernias.
in the British Medical Journal, 21 February 2008, by Professor Jonathan
L Meakins, Nuffield Professor of Surgery, John Radcliffe Hospital,
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
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.
New Research Questions Need For Some Common Surgeries. By Amy Dockser Marcus, Staff Reporter of The Wall Street Journal.
This article discusses the growing number of studies which show that
patients who don't get surgery often fare just as well, if not better,
than those who do.
Articles on the side effects of hernia repair surgery
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
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
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.
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:
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.
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:
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.
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.
associated with postoperative complications and hernia recurrence for
patients undergoing inguinal hernia repair: a report from the VA
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
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.
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
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.
patients with severe chronic pain following repair of groin hernia.
Courtney CA, Duffy K, Serpell MG, O'Dwyer PJ. Br J Surg. 2002
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%.
Missouri Hernia Institute Patient Education for Inguinal Hernia Repair An open and honest summary of the facts.
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.
Article from the Missouri Center for Advanced Techniques in Surgery
Chronic pain or discomfort occurs in up to 43 per cent of cases where
open surgery is used. This figure is reduced to 24 per cent by the
laparoscopic ("keyhole surgery") technique.
Chronic mesh syndrome and other medical articles relating to persistent postoperative pain Capital Hernia Center
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
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
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
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
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.
This article suggests that some hernias are wrongly diagnosed and discusses the use of prolotherapy for hernia symptoms