Watchful waiting vs. early repair for asymptomatic and mildly symptomatic inguinal hernia - silent hernia, loud debate: a qualitative systematic review.

AIM: More than one-third of inguinal hernias are asymptomatic, and performing surgery in the absence or presence of mild symptoms remains a point of concern for many surgeons. This study aims to evaluate whether watchful waiting (WW) is a viable management strategy for asymptomatic and mildly symptomatic inguinal hernias by comparing its outcomes to early surgical repair. To broaden the scope of existing evidence, we included both recent randomized controlled trials and observational studies.

MATERIAL AND

METHODS

PubMed, Cochrane Central, and EMBASE were searched for studies comparing early repair and WW in patients with asymptomatic or mildly symptomatic inguinal hernias. The primary outcomes assessed were the rate of crossover from WW to surgery, reasons for crossover, and the presence of pain in both groups. Secondary outcomes included quality of life (QoL) and hernia recurrence. A Kaplan-Meier failure function curve was constructed to estimate time from study enrollment to crossover.

RESULTS

Among 619 screened studies, 12 met the inclusion criteria, covering 1,755 patients (748 (42.6%) in early surgical intervention and 1,007 [57.4%] in the WW). Among WW patients, 477 (27.1%) eventually crossed over to surgery, with crossover rates ranging from 6.1% (Patti 2014) to 75.4% (Chung 2011). Approximately 50% of WW patients required surgery within five years. The most reported reason for crossover was pain (65%), followed by impaired quality of life (16%), bowel-related symptoms such as incarceration or strangulation (8.5%), hernia volume progression (3%), and other or unspecified causes (7.5%). Pain was the most consistent patient-specific predictor of crossover to surgery.

CONCLUSION

WW appears to be a viable and safe approach with low complications rates for patients with asymptomatic inguinal hernias. However, long-term data show that approximately 50% of patients cross over to surgery within five years, and this proportion exceeds 96% by 12 years. Ultimately, the decision between WW and early surgical intervention should be guided by shared decision-making, considering patient values, symptom burden, comorbidities, and life expectancy.