24 Jun 2023 When should hernia repair be performed?

Should every hernia be operated on? Can it be delayed? When should surgery be performed? The answers to these questions are here…

A famous quote from William Shakespeare’s play Hamlet that you all know: “To be or not to be, that is the question.” It is one of the most famous examples of the dichotomies present in the universe, such as black and white, night and day, and good and bad. In the case of hernia disease, there is a debated and inconclusive dichotomy: Should every hernia be operated on? Or should we wait? Or should we not perform surgery at all? In short, the wait-and-watch dilemma. I will try to clarify this dilemma.

Inguinal Hernias

The most important symptoms of inguinal hernias are a bulging that comes out and goes in, sometimes accompanied by pain, sometimes just a burning sensation. They can be larger over time. It can manifest itself only with pain without swelling. This needs to be examined carefully, but it is not the subject of this article. In men with inguinal hernias that do not cause any or only minimal complaints, studies have shown that about 1/3 of patients undergo surgery within 3 years due to pain and getting larger. This rate increases to 70% in a 10-year follow-up. The most significant determinant leading the patients to undergo surgery in these studies is pain! I emphasized the word “men” specifically. Inguinal hernias in women require a separate approach. Although inguinal hernias are less common in women compared to men, due to the differences in groin anatomy and hernia location, it is best to operate without delay!

First of all, I want to point out that 75% of incarcerations (strangulations) in inguinal hernias occur in the first 6 months of life. It is more common in infants. Incarceration of inguinal hernias in adults is not that common. Therefore, there is no need to panic thinking that it will strangulate. However, in the elderly (65 years and older or 65+), the incidence of strangulation is around 2-3%, leading to serious problems and even a risk of death. Additionally, the common systemic chronic diseases in the elderly such as heart, lung, or kidney diseases further complicate this situation. Warning for the 65+ age group: Planned and prepared inguinal hernia surgery can be performed safely!

Different approaches to the timing of surgery can be applied between young individuals and those 65+ in inguinal hernia surgery. In young individuals, it can be observed. It should be remembered that hernia surgery is performed to improve the quality of life. Surgery can be performed when there is pain, hernia enlargement, activity restriction, and when it negatively affects the quality of life. In individuals aged 65+, inguinal hernias tend to grow faster due to tissue weakening associated with age. Repairing large hernias that have descended into the testicles and cannot be reduced is more difficult. Therefore, early planned surgery in the 65+ improves the quality of life and reduces the occurrence of possible complications.

One of the most important problems of inguinal hernia surgery is recurrence (the hernia coming back), and the second is chronic pain. The use of mesh in hernia repair has significantly reduced the rate of recurrences, but it is still relatively high. The rate of chronic pain after inguinal hernia surgery is also high, around 15-20%, and being young is a risk factor for chronic pain. However, the claim that waiting can be done in young patients to avoid chronic pain risk contradicts the finding mentioned in the above paragraph, which states that most patients eventually have to undergo surgery after waiting. Therefore, it should be adopted for the surgeon to discuss the details with the patient and assist the patient in making their own decision.

My recommendation for inguinal hernias is not to wait for 65+, but to perform surgery immediately or within 2 years in younger individuals. However, early hernia surgery is beneficial for both the patient and the surgeon!

Primary Abdominal Wall Hernias

Primary hernias of the abdominal wall, such as umbilical, epigastric, and Spigelian hernias, can also enlarge over time and cause pain. It is beneficial to undergo surgery while healthy. Chronic diseases of the heart, lungs, and kidneys that may occur with advancing age can complicate these surgeries. Especially for small hernias of this type, can be repaired with local anesthesia and suture techniques but when they become larger, mesh techniques and laparoscopic techniques come into play, making the procedures even more complex. Beyond this, cost should be the last thing to consider, but as the complexity of the surgery increases, the cost also increases significantly.

Incisional Hernias

Incisional hernias are a different topic, and the approach mentioned above does not apply to them. Incisional hernias tend to grow over time, and this happens quickly. The repair of large incisional hernias involves difficulties, requiring extensive surgery and a larger mesh. Almost all incisional hernias should be repaired without delay. The only exception can be if the patient has a short life expectancy.

Surgery is the only treatment for inguinal and abdominal wall hernias. Surgery yields satisfactory results when performed early and by experienced surgeons/centers.