Inguinal hernia

Summarizing advice from Choosing Wisely Canada on minimally symptomatic inguinal hernias in adults, Bohnen re-emphasizes that management may include “watchful waiting for up to two years.”¹ Bohnen cites a randomized trial² that reported a control group of 364 patients with hernia followed without intervention for two years. These investigators now report the long-term results of their trial,³ and although the majority of those on long-term follow-up elected to have surgery, the researchers still counsel that watchful waiting for up to 11.5 years is a reasonable and safe strategy. Other Canadian surgeons have also acknowledged that watchful waiting without a time limit is an appropriate strategy for asymptomatic groin hernias.⁴

The author presents estimates of the death rate from elective surgery for inguinal hernia (0.2%, range 0.0%–1.8%) and the death rate from emergency intervention for incarceration/strangulation (4%) but fails to emphasize that the yearly rate of irreducibility associated with a nonoperative approach in such trials is only 0.4%.⁵ This means that if 1000 people with a small, minimally symptomatic hernia have elective surgery, 2, or maybe as many as 18, will die from complications. If 1000 such people elect for watchful waiting, 4 will experience an irreducible hernia per year, or 40 after 10 years. Of the 40 experiencing irreducibility, 4% are at risk of dying from emergency surgery, or 1.6 per 1000 people per 10 years. Looks like a distinct advantage for watchful waiting if death from intervention is your main worry.

Also, Bohnen’s summary discusses a 55-year-old man: he fails to consider that mortality and complications may increase in seniors.