Retrospective studies3,5,7 of the temporal duration and the natural history of inguinal hernias, as well as operative complication rates, have shown conflicting results.
70- and 80-year olds have greater risk. A Turkish study5 of patients needing emergent surgical repair found morbidity to be significantly related to American Society of Anesthesiologists (ASA) class, with mortality rates of 3% and 14% for ASA class III and IV patients, respectively. This was a retrospective chart review that analyzed factors responsible for unfavorable outcomes; it found increased complications in hernia patients who had coexisting disease, hernias of longer duration, as well as higher ASA class. This study5 and another retrospective study6 found the need for emergent repair peaked for patients 70 to 80 years of age.
longer history of herniation may more postop complications. The Spanish retrospective review3 of emergent surgical repair of incarcerated hernias (noted earlier) reported a 3.4% postoperative mortality rate. All deaths were among patients over 65 years of age and ASA class III or IV. This review also found more postoperative complications and a higher mortality for hernias present for more than 10 years.
Another study raises questions. A retrospective study from Israel8 also showed that patients who underwent emergency repair were older, had a longer history of herniation than those undergoing elective repair, and had higher ASA scores. However, a case-control study7 and a chart review9 found that the risk of strangulation was higher for hernias of shorter duration.
We found no studies addressing potential exacerbating conditions of inguinal hernia, such as chronic cough, bladder outlet obstruction with straining, constipation, obesity, or bilateral hernias.
Recommendations from others
All the textbooks and guidelines we identified acknowledge that many patients forego operation and remain minimally symptomatic for long periods of time, and that operations themselves have risks and complications.10–12 The avoidable risks of strangulation and emergent operation lead most experts to favor operative treatment.
In ACS Surgery: Principles & Practice 2007,10 the authors lament the difficulty of obtaining accurate studies of the natural history of inguinal hernia because surgeons have been taught that it is best to operate at diagnosis, making it hard to find an adequate population to study. The authors acknowledge that while many primary care physicians advise their patients to delay operations if the hernia is minimally asymptomatic, they do not share this belief.
The American College of Physicians’ PIER: The Physicians’ Information and Education Resource11 recommends assessing the hernia and the patient on a case-by-case basis. They recommend deferring an operation for poor-risk patients with minimal symptoms if the hernia is easily reducible and is unquestionably an inguinal hernia, if there are no past episodes of obstruction, and if the risks of untreated hernia are fully understood by the patient. Sabiston Textbook of Surgery makes virtually the same points and recommendations.12