What is the recommended management for an asymptomatic hernia found on physical exam?

Management of Asymptomatic Hernia Found on Physical Examination

For asymptomatic abdominal wall hernias, watchful waiting is an appropriate management strategy, with surgical repair reserved for patients who develop symptoms or have specific risk factors.

Initial Assessment and Management Decision

• Watchful waiting is a safe and appropriate option for asymptomatic hernias, particularly in patients under 50 years old with ASA class 1 or 2 1
• The risk of incarceration in asymptomatic hernias is relatively low at approximately 4 per 1,000 patients per year 1
• Patients with asymptomatic hernias should be educated to recognize symptoms of hernia incarceration or strangulation, which would necessitate prompt surgical evaluation 2

Risk Stratification for Watchful Waiting

Favorable candidates for watchful waiting:

• Patients under 50 years of age 1
• ASA class 1 or 2 patients 1
• Inguinal hernia (versus femoral) 1
• Duration of hernia presence more than 3 months 1

Patients who should consider surgical repair despite being asymptomatic:

• Patients over 60 years (higher risk of incarceration) 1
• Femoral hernias (higher risk of incarceration) 1
• Patients planning peritoneal dialysis 2
• Large hernia defects with risk of progression 2

Long-Term Outcomes of Watchful Waiting

• Long-term studies show that many patients initially managed with watchful waiting will eventually require surgery:

  • 64.2% cumulative crossover rate to surgery after 12 years of follow-up 3
  • Higher crossover rates in mildly symptomatic patients (71.7%) compared to completely asymptomatic patients (60.4%) 3
  • Median time to crossover was 6.0 years for asymptomatic patients versus 2.0 years for mildly symptomatic patients 3

• The risk of acute incarceration without strangulation is approximately 0.3% within 2 years 4

• The frequency of acute incarceration with bowel obstruction is approximately 1.8 per 1000 patient-years over 4.5 years of follow-up 4

• In a 12-year follow-up study, incarceration occurred in 3.9% of patients in the watchful waiting group 3

Special Considerations

• For patients with asymptomatic abdominal wall hernias and severe kidney enlargement (such as in ADPKD), nonsurgical management should be strongly considered due to increased risk for complications associated with repair and potential hernia recurrence 2
• Patient regret has been reported to be higher in watchful waiting groups (37.7%) compared to surgical repair groups (18.0%) in long-term follow-up 3
• Pain and discomfort scores tend to be higher in watchful waiting groups compared to surgical repair groups over time 3, 5

Monitoring During Watchful Waiting

• Regular follow-up examinations are recommended at 6 months initially and then annually 4
• Patients should be instructed to seek immediate medical attention if they develop:
  • Acute pain at the hernia site 2
  • Irreducibility of the hernia 2
  • Signs of bowel obstruction (nausea, vomiting, abdominal distention) 2
  • Systemic inflammatory response syndrome (SIRS) 2

When to Consider Surgical Intervention

• Development of pain or discomfort at the hernia site 4, 5
• Increase in hernia size 6
• Difficulty in reducing the hernia 2
• Patient preference after being fully informed of risks and benefits 3

Conclusion

Watchful waiting is an appropriate initial management strategy for asymptomatic hernias, especially in younger patients with inguinal hernias. However, patients should be informed that there is a high likelihood of eventually requiring surgery as most patients (64.2%) will cross over to surgical repair within 12 years. The decision should be based on patient factors, hernia characteristics, and informed patient preference after discussion of the risks and benefits.