1. Is Non-operative Treatment of Inguinal Hernias a Reasonable Option?
Lloyd C Smith MD.

2. No Disclosures

3. Inguinal Hernia Repair
Annually 20 million repairs worldwide
In Canada 80,000 repairs per year
Lifetime risk for a male is 1:4
The risk of a hernia increases with age

4. Indications for Surgery
Pain
Up to a third of patients are asymptomatic
Avoidance of complications
Incidence of incarceration approx 7%

5. Argument Against Surgery
Pain and suffering from the surgery
Risk of complications from the surgery
Chronic Pain

6. Fitzgibbons et al. JAMA 2006 Multicenter trial involving 720 patients Followed for a minimum of 2 years Outcomes 1) pain and discomfort at 2 years 2) complications, functional status satisfaction with care

7. Pain at Two Years Post op.
Physical component score of the SF36

10. Results at Two Years Pain similar : surgery 2.2%, WW 5.1%
Both groups were improved over baseline
23% of WW crossed over to Surgery
2 patients from the WW group had surgery for acute incarceration (1.8/1000 patient years)
A strategy of watchful waiting is a safe and acceptable option.

11. Annals of Surgery 2011

13. Conclusion
Readily identifiable patient characteristics can predict those patients with minimally symptomatic hernias that are likely to “fail”

14. Annals of Surgery 2013
Followed 254 men from the original study
Followed for an additional 7 years (9-11.5)
At the end of the first study 31% had surgery.

15. Results. The cumulative surgical rate was 68% By Age:
>65 had a 79% conversion
<65 had a 62% conversion

17. Conclusion
Men with minimally symptomatic hernias should be counselled that although WW is a reasonable and safe strategy, symptoms will likely progress and an operation will be needed eventually.

18. Review of Cochrane, Pubmed, Medline
Overall risk of incarceration 4/1000.
Risk of incarceration higher for age>60, femoral, or <3mos duration.
Morbidity and mortality higher in age>49, nonviable bowel and ASA 3or4

19. Results
Morbidity and Mortality
Emergency % %
Elective % %

20. Suggested Algorythm

21. Summary Inguinal hernia is an extremely common problem.
Approximately one third of hernias are asymptomatic.
Most patients will ultimately end up having surgery.
Surgery does not result in an increase in chronic pain.
The exact incidence of incarceration and strangulation is unknown.
The morbidity and mortality increase significantly in the emergency situation.
Watchful waiting may be most appropriate for younger, healthier patients.

22. Is Non-operative Treatment of Inguinal Hernias a Reasonable Option?
Lloyd C Smith MD.

23. Pain