Battle of the Bulge: Surgical Management of Inguinal Hernias
As a surgeon that specializes in the treatment of hernias, I see a tremendous amount of patients every year with inguinal hernias. Despite this being one of the most common surgical problems treated annually in the United States and worldwide, there are still many unanswered questions about the treatment of these common conditions.
Inguinal hernias occur with a prevalence of 1.3% for all ages. This gives men a lifetime risk of forming an inguinal hernia of 27%. Women are not as commonly afflicted with inguinal hernias and have a 3% lifetime risk of hernia formation. 1 While roughly 30% of the population will go on to develop a hernia at some point in their life, not all will be repaired; in the United States there are greater than 800,000 inguinal hernia repairs performed annually. 2
There are a variety of approaches to inguinal hernia repair. The traditional open tension-free approach involved the reduction of hernia contents followed by recreation of the floor of the inguinal canal utilizing a piece of synthetic mesh. Laparoscopic approaches to inguinal hernia repair have also been developed. Similar to the open approach, hernia contents are reduced and mesh is employed to cover the hernia defect and reduce the risk of hernia recurrence. Both approaches have their risks and benefits, and certain patients may be better served by one approach compared to the other. The laparoscopic approach tends to be associated with faster recovery and earlier return to normal activities compared to the open approach.
One of the most common questions I am asked during clinic is whether or not the patient’s hernia needs to be fixed at all. Certainly patients with symptomatic inguinal hernias should still undergo repair as their pain and discomfort is likely to resolve following surgery. But what should be done about patients with asymptomatic hernias? Historically, the surgical approach to inguinal hernias was that all of them should be fixed as they present a risk of incarceration, strangulation, and possibly bowel necrosis. Recent research has refuted this long-held surgical belief. In a randomized controlled trial of 720 men with minimally symptomatic or asymptomic inguinal hernias, half of the patients were randomized to undergo an open inguinal hernia repair while the other half were made to live with their hernia. 3 Over the course of the next two years, acute incarceration happened at a rate of 0.3.
While it is safe to live with an inguinal hernia, 23% of patients crossed over to the surgery group as their hernias became symptomatic. The group of patients living with their hernias were then followed for an additional 7 years, and at 10 years, the rate of crossover went up to 68%. 4 Patients greater than age 65 crossed over at a higher rate compared to their younger counterparts (79% vs 62%).
So what should we do about the bulge? If patients are symptomatic then they should undergo repair. Asymptomatic patients should meet with a surgeon to discuss their risk of developing symptoms with time and to decide if an operation makes sense for them when comparing their own personal risks vs. the benefits.
For more information
The UW Health Comprehensive Hernia Center sees patients with all types of inguinal and ventral hernias and provides specialized hernia care. As of August 17, 2015, the UW Health Comprehensive Hernia Center is located at UW Health at The American Center, 4602 Eastpark Boulevard on Madison’s far east side. To refer a patient call (608) 440-6363.
1 Jenkins JT, et. al. BMJ, 336:269-72, 2008
2 Rutkow IM. Surg Clin N Am, 83:1045-51, 2003
3 Fitzgibbons RJ, et al. JAMA, 295:285-292, 2006
4 Fitzgibbons RJ, et al. Ann Surg, 258:508-15, 2013