Should an asymptomatic inguinal (groin area) hernia be treated?

From the Guidelines

Asymptomatic inguinal hernias do not require immediate surgical intervention and can be managed with watchful waiting. This approach is particularly suitable for older adults or patients with comorbidities that increase surgical risk, as it avoids the potential complications associated with surgery 1. The key aspects to consider in the management of asymptomatic inguinal hernias include:

• Patient education on warning signs that necessitate urgent medical attention, such as pain, inability to reduce the hernia, nausea, vomiting, or skin changes over the hernia site, which could indicate incarceration or strangulation
• Regular follow-up examinations every 6-12 months to monitor for changes in the hernia's size or symptoms
• Individualized decision-making based on the patient's age, overall health status, hernia characteristics, and personal preferences after a thorough discussion of the risks and benefits of each approach
• Consideration of elective surgical repair in young, active patients, or those with physically demanding occupations to prevent future complications, even in the absence of symptoms It is essential to note that the guidelines for emergency repair of complicated abdominal wall hernias, such as those outlined in the 2017 update of the WSES guidelines 1, prioritize immediate surgical intervention in cases of suspected intestinal strangulation or other complications, but asymptomatic inguinal hernias do not fall into this category. Therefore, watchful waiting remains the recommended approach for asymptomatic inguinal hernias, with a focus on patient education, regular monitoring, and individualized decision-making regarding potential surgical intervention.

From the Research

Asymptomatic Inguinal Hernia Management

• The management of asymptomatic inguinal hernia is a topic of debate, with some studies suggesting that watchful waiting is a safe and cost-effective approach 2, 3, 4.
• A review of the literature found that the risk of incarceration is approximately 4 per 1,000 patients with a groin hernia per year, and that risk factors for incarceration include age above 60 years, femoral hernia site, and duration of signs less than 3 months 2.
• Another study found that there is no significant difference in pain scores and general health status between patients who undergo surgery and those who are managed with watchful waiting 4.
• However, a systematic review and meta-analysis found that delaying surgical repair until symptoms appear is safe, and that acute hernia incarcerations are not particularly frequent 3.
• A study also found that asymptomatic inguinal hernias can be repaired when found, with minimal increase in operation time and pain, and that this can prevent the need for another operation in almost a third of patients 5.

Surgical Repair vs. Watchful Waiting

• A review of the evidence found that both surgical repair and watchful waiting are safe options for asymptomatic inguinal hernia, but that most patients will develop symptoms over time and will require operation 4.
• A study found that the recurrence rate after tension-free mesh repair in the management of emergency groin hernias is comparable to that of elective repair 2.
• Another study found that the choice of procedure should be based on international guidelines, and that surgeons should deviate from these recommendations only in exceptional cases and for special reasons 6.
• A systematic review and meta-analysis found that watchful waiting seems to be an acceptable option for patients with asymptomatic or minimally symptomatic inguinal hernias, and that physicians must select patients carefully and explain to them the risks and benefits of surgery 3.

Patient Selection and Counseling

• A study found that patients with asymptomatic inguinal hernia should be carefully selected and counseled about the risks and benefits of surgery 3.
• Another study found that the decision to repair an asymptomatic inguinal hernia should be based on individual patient factors, including age, health status, and lifestyle 4.
• A review of the evidence found that patients with asymptomatic inguinal hernia should be informed about the potential risks and benefits of surgery, including the risk of incarceration and the potential for symptom development over time 2, 6, 3, 4.