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Page 2 of 6 McBee et al. Mini-invasive Surg 2021;5:18 https://dx.doi.org/10.20517/2574-1225.2021.08

INTRODUCTION
Groin hernias are a very common problem with presentation ranging from patients who are completely
asymptomatic to those with the life-threatening complication of strangulation or bowel obstruction,
referred to as a hernia accident. Over 1.6 million hernias are diagnosed each year in the United States alone,
[1]
of which 500,000 are surgically repaired . Of the groin hernias in the United States, 96% are classified as
[2]
inguinal hernias and 4% are femoral . Men are significantly more likely to develop a groin hernia than
[1]
women; the lifetime risk of is 27% for men and 3% for women . Two-thirds of patients will present with a
painful bulge in the groin and diagnosis is made primarily through history and physical examination with
imaging rarely required . Up to one third of inguinal hernia patients present asymptomatically without
[3]
[4]
pain or other factors that lead to impairment of daily functioning .
Management of inguinal hernias has evolved over time to improve quality of life and limit safety risk to the
patient. Historically, it was recommended that all patients presenting with an inguinal hernia have it
repaired surgically at the time of diagnosis due to the prevailing belief that the risk of a hernia accident
(bowel obstruction and/or strangulation) was significantly high enough to contraindicate watchful waiting
(WW). However, more recent evidence of WW has emerged that has shown that WW is a safe and
acceptable alternative to surgical repair for asymptomatic or minimally symptomatic inguinal hernia
patients. Avoiding operative repair in asymptomatic patients through a WW approach precludes any
potential development of pain related to the operation as well as the other standard risks associated with
major surgery (e.g., hemorrhage, infection, and recurrence). Post-herniorrhaphy groin pain has now come
to the forefront of issues facing groin hernia surgeons as some studies suggest that as many as 15% of
patients experience post-herniorrhaphy inguinal groin pain that affects their daily lives 6 months after the
operation .
[5]

To date, three major clinical trials from North America, the United Kingdom and the Netherlands have
investigated outcomes after randomization of patients presenting with asymptomatic or minimally
symptomatic inguinal hernias to a WW approach vs. routine elective surgical repair . While all completed
[6-8]
trials support WW as a viable and safe approach for some patients in the initial treatment of inguinal hernia
management, long-term follow-up has found that most (approximately 70%) of patients who elect to forego
hernia repair will eventually be treated surgically due to worsening pain or lifestyle limitations from
progression of symptoms. The purpose of this article is to provide an overview of the current status of
watchful waiting as an option for initial inguinal hernia management and review the clinical evidence from
randomized controlled trials that led to the adaptation of WW as an acceptable alternative to an operative
approach.

WATCHFUL WAITING
The risks and benefits of WW as an approach for inguinal hernia management in patients who are
asymptomatic or mildly symptomatic were investigated in three randomized controlled trials from North
America, the UK, and the Netherlands. Asymptomatic or minimally symptomatic patients were defined as
those patients whose hernia-related discomfort did not limit activities of daily living and who did not
exhibit difficulty in manually reducing the hernia . An important distinction is necessary to recognize in
[6]
the optimal management of hernias between men and women. Currently, the approach of WW is only an
appropriate strategy for men because women are significantly more likely to develop femoral hernias, which
are more prone to strangulation . It is difficult to distinguish inguinal hernias from femoral hernias, so
[9]
surgical repair is recommended for all nonpregnant women with groin hernias . Pregnant women with a
[10]
groin bulge which appears to be a hernia should be imaged with ultrasound to rule out round ligament
[10]
varicosities, a common cause of a groin bulge in a pregnant female, before surgery is considered .