What are the risks of not getting hernia surgery and what non-pharmacological options are available for management?

Risks of Not Getting Hernia Surgery and Non-Pharmacological Management Options

Symptomatic hernias should be surgically repaired, as watchful waiting carries significant risks of complications including incarceration, strangulation, intestinal obstruction, and perforation, which can be life-threatening. 1

Risks of Not Getting Hernia Surgery

Potential Complications

• Incarceration: When hernia contents become trapped and cannot be reduced
• Strangulation: When blood supply to herniated tissue is compromised, leading to tissue death
  • Strangulation requires immediate surgical intervention, with delayed treatment beyond 24 hours significantly increasing mortality 1
• Intestinal obstruction: Blockage of intestinal contents
• Perforation: Rupture of herniated organs
• Skin complications: Including ulceration, necrosis, or rupture of the hernia sac
  • Non-operative management of hernias with skin complications results in mortality rates of 60-88% 1

Risk Factors for Complications

• Female gender increases risk of hernia incarceration/strangulation 2
• Femoral hernias have higher risk of complications 2
• History of hospitalization related to groin hernia 2
• Larger hernia defects (≥3 cm) are associated with higher complication rates 3

Watchful Waiting Considerations

• Asymptomatic or minimally symptomatic male inguinal hernia patients may be managed with watchful waiting as their risk of hernia-related emergencies is relatively low 2
• However, the majority of these individuals will eventually require surgery 2
• For older patients (≥65 years), watchful waiting may be reasonable due to the low risk of life-threatening complications, but this must be balanced against potential increased surgical risk if emergency repair becomes necessary 4

Non-Pharmacological Management Options

Conservative Management

1. Activity Modification

   • Avoiding heavy lifting and strenuous activities that increase intra-abdominal pressure
   • Resuming normal activities without restrictions as soon as comfortable after repair 2

2. Weight Management

   • Obesity is associated with higher post-operative complications 3
   • Weight reduction is recommended before elective surgery (aim for BMI <40 kg/m²) 1

3. Smoking Cessation

   • Smoking history is independently associated with post-operative complications 3
   • Smoking cessation is recommended before elective surgery 1

4. Hernia Support Devices

   • Trusses or binders may provide temporary symptom relief but do not treat the underlying condition
   • Not recommended as definitive management for symptomatic hernias

Special Populations

Pregnant Women

• Watchful waiting is suggested as groin swelling most often consists of self-limited round ligament varicosities 2
• Emergency repair is indicated if incarceration or strangulation occurs 1
• For symptomatic hernias, elective repair may be considered 1
• Asymptomatic hernias should be managed after childbirth 1

Cirrhotic Patients

• Optimization of ascites control before repair is recommended 1
• Multidisciplinary team discussion is essential 1
• Risk factors for mortality include emergency surgery, Child-Pugh-Turcotte class C, ASA score ≥3, and MELD score ≥20 1

Older Patients

• General anesthesia is suggested over regional anesthesia in patients aged 65 and older as it might be associated with fewer complications 2
• Understanding frailty is important in determining the best management approach 4

When Surgery Is Necessary

Indications for Emergency Surgery

• Incarceration (if manual reduction unsuccessful)
• Strangulation
• Intestinal obstruction
• Perforation
• Skin ulceration/necrosis

Surgical Approaches

• Mesh repair is recommended as first choice, either by open procedure or laparo-endoscopic technique 2
• Lichtenstein technique using polypropylene mesh is considered the gold standard for inguinal hernia repair 1
• Laparoscopic approach may be considered for stable patients without signs of strangulation or peritonitis 1
• Open repair is typically recommended for hemodynamically unstable patients 1

Caveats and Pitfalls

1. Misdiagnosis

   • Femoral hernias in women are often missed; laparo-endoscopic repair is suggested to decrease this risk 2

2. Delaying Treatment

   • Delaying treatment of strangulated hernias beyond 24 hours significantly increases mortality 1

3. Ignoring Comorbidities

   • Diabetes control (HbA1C <7%) is important before elective surgery 1
   • Cirrhotic patients require special consideration 1

4. Post-Surgical Recovery

   • Progressive core strengthening focusing on transverse abdominis muscle is recommended 1
   • Avoiding exercises that strain the rectus abdominis for the first 3-6 months post-surgery 1
   • Adequate protein intake and hydration are essential to support tissue repair 1

In conclusion, while watchful waiting may be appropriate for select patients with asymptomatic hernias, the risks of complications from untreated symptomatic hernias are significant and can be life-threatening. Non-pharmacological management options should focus on risk factor modification and appropriate patient selection for either conservative management or timely surgical intervention.