Watchful Waiting

Watchful waiting is a term applied to the policy of not repairing a hernia just because it is there.  It is mainly used in the context of inguinal hernias.  The idea was just to wait and see, and only to operate if the hernia caused troublesome symptoms.

Two groups of surgeons, one in the UK and one in the USA looked at the question of whether or not to repair all inguinal hernias, or could some of them just be observed for a while.  They wanted to answer the question in a scientific manner – by carrying out a clinical trial.  Patients were randomly assigned to either have their hernia repaired or to just be observed, no operation,  and see what happened over time.

What happened?

The outcomes at two years were published in the professional medical journals –

the Annals of Surgery and the Journal of the American Medical Association (JAMA)

The findings were were remarkably similar and showed that almost one-quarter of the non-operated patients ‘converted’ to surgery over the two year study.  That is to say 25% of patients who had been assigned to the ‘no operation’(watchful waiting) group asked to have their hernia repaired because they were experiencing worsening discomfort or pain, affecting everyday activities.

Professor O’Dwyer’s group in Scotland published the long term ( 7.5 years) follow-up of these patients. His statement at the start of the discussion of this excellent study tells you all you need to know:-

“This study has confirmed previous findings that most patients with minimal symptoms from an inguinal hernia develop pain over time. Pain was the most common reason for requesting operation, followed by effect on quality of life and increase in size of the hernia. Surgical repair is recommended for medically fit patients with a painless inguinal hernia.

Most of the recent evidence suggests that inguinal hernias should be repaired in fit active individuals, as they will be become troublesome eventually.

Does ‘watchful waiting’ work for other hernias? 

Femoral hernias should always be repaired as they carry a high risk of strangulation.

Umbilical and epigastric hernias– the decision to operate should be on a case by case basis, depending on size and symptoms.

Incisional hernias are complex, with a high failure rate if not repaired correctly by an experienced surgeon.  Whether or not to repair in an individual case is a matter of judgement, and should be decided on a case by case basis.