Alani, Ahmed M
Management of asymptomatic inguinal hernias.
MD thesis, University of Glasgow.
Full text available as:
Hernia surgery remains one of the most common operations carried out by general surgeons worldwide with more than 800,000 repairs performed in the USA alone in 2003. Advancement in surgical technique has meant fewer recurrences are now encountered with figures dropping to less than 2% using the laparoscopic approach. Yet despite the progress achieved in securing the repair, post operative pain remains an issue with many authors reporting figures of 30% in patients following groin hernia repair 1,2, 3% of patients report sever pain that limits their daily activities and renders them off work.
Many patients with inguinal hernia have very little in the way of symptoms and even some of them are asymptomatic, having noticed their hernia by accident or by their general practitioner.
In order to clarify two issues (the first being the incidence of acute hernia presentation, its management and subsequent outcome, while the second was the management of patients with an asymptomatic inguinal hernia) 4 studies were carried out: The first study was a prospective observational study looking at all patients presenting to our unit with an acute hernia, the aim of the study was to prospectively assess the presentation and management of acute hernias in light of recent changes in hernia management.
Data on all patients admitted with an acute hernia between 2001 and 2004 was collected prospectively. During the 3 year study period 91 patients were admitted with an acute hernia. 46 had a previous medical assessment either as an acute admission (12) at a surgical clinic (22) or by a General Practitioner (12). Eighteen had been declared unfit for operation at that assessment, 10 were ASA4, 5 ASA3 and 3 ASA2. Eleven patients were on the waiting list for operation 3 of whom had a previous acute hospital admission. For 30 patients this hospital admission was the first indication that they had a hernia while the remainder refused operation or did not seek medical advice. Five patients died, 2 while being assessed for operation and 3 postoperatively, 3 were ASA4 while 2 were ASA3. The number of patients undergoing operation for an acute hernia amounted to 8.4% (80 of 952) of all hernia operations carried-out during the study period.
This study concluded that despite advances in hernia surgery there was still room for improvement, to ensure that all suitable patients presenting with an acute hernia receive an operation during their acute hospital admission.
The second study was a prospective study of all patients presenting with subacute bowel obstruction in one teaching hospital between 2003 and 2004. The aim of the study was to identify the most frequent causes of strangulation in patients presenting with small bowel obstruction.
During the study one hundred and sixty-one patients with symptoms and signs of small bowel obstruction were admitted. Eighty-nine were confirmed with contrast studies. The male: female ratio was 1:1.6. The aetiology of obstruction was hernia in 29 (18%), adhesions in 97 patients (60.2%), and miscellaneous in 35 (21.8%) Operative procedures were performed on 74 patients (46%), 31 of them (42%) with adhesions, 25 (34%) with hernias and 18 (24%) due to other causes. Strangulated bowel occurred in 15 patients (9.3%); 12 had hernias whilst three had adhesions (P < 0.0001). Of the strangulated hernias, ten were femoral, one was inguinal and one was paraumbilical.
Our conclusion was that whilst adhesions are the most common cause of small bowel obstruction, femoral and not inguinal hernias remain the most frequent cause of strangulation.
The third and main study was a prospective randomized trial comparing surgery and no intervention for asymptomatic inguinal hernias. The aim of the study was to compare operation with a wait and see policy in patients with an asymptomatic hernia.
160 male patients 55 years or older were randomly assigned to observation or operation. Patients were assessed clinically and sent questionnaires at 6 months and 1 year. The primary endpoint was pain and general health status at 12 months; other outcome measures included costs to the health service and the rate of operation for a new symptom or complication.
At 12 months there were no significant differences between the randomised groups of observation or operation, in visual analogue pain scores at rest, 3.7mm versus 5.2mm (P=0.34), or on moving, 7.6mm versus 5.7mm (P=0.39). Also the number of patients who recorded pain on moving 29 versus 24 (P=0.31), and the number taking regular analgesia, 9 versus 17, (P=0.14) was similar. At 6 months there were significant improvements in most of the dimensions of the SF-36 for the operation group, while at 12 months although the trend remained the same the differences were only significant for change in health (P=0.039). The rate of crossover from observation to operation was 23 patients at a median follow-up of 574 days, this was higher than predicted. The observation group also suffered 3 serious hernia related adverse events compared to none in the operation group.
Finally a sub study was generated from the non randomised patients within the asymptomatic trial. The aim here was to assess the outcome of patients opting for no surgery in terms of need for surgery and outcome.
There were 72 patients (58 opting for observation and 14 wanting an operation), 13 patients (22.4%) in the observation group became symptomatic and required an operation, 9 patients had died at the time of data analysis, all of which were due to co morbid illnesses.
The final 2 studies concluded that repair of an asymptomatic inguinal hernia did not affect the rate of long-term chronic pain and might be beneficial to patients in improving overall health and reducing potentially serious morbidity.
Actions (login required)