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Watchful-Waiting

"A stitch in time saves nine" - relearning old lessons.

You may have come across the term 'watchful waiting' in your research on hernias or been told about it by your doctor. So what does this term actually mean and why is it used when talking about a strategy for dealing with a hernia?

What is Watchful-Waiting?

'Watchful-Waiting' is the process of doing nothing but monitoring your inguinal hernia and trying to mitigate the condition. Diet,  weight-loss, smoking and healthy lifestyle changes are all recommended elements of this strategy. We would suggest that our compression underwear is also an important factor in self-managing your condition. 

We have had conversations with our customers who have followed this regime wearing our briefs and a small number have reduced or eliminated their Inguinal hernia. However, these are a very small minority and followed a strict regime of Pilates, Yoga, dietary changes etc. The common trait is that they were proactive, single-minded and committed customers and unlikely to sit back and wait for their condition to worsen.

At first glance watchful waiting seems attractive. For the health provider, the key aspect is that as a treatment strategy it appears cheap - very cheap. But Inguinal hernias tend to worsen rather than stay benign. In a 2014 study patients that switched from elective surgery to watchful waiting were 59% more likely to require emergency surgery 1 with all its associated costs.

Watchful waiting is considered an alternative to surgery, particularly for mild asymptomatic hernias where the pain is absent. This is actually mainstream policy (at least in the UK and many other western countries). This doctrine was endorsed in a flawed 2009 McKinsey report to the Department of Health that failed to model patient outcomes over time and focused on the initial savings. Watchful waiting is contrary to the Royal College of Surgeons and NICE advice where surgery is recommended for nearly all occurrences of Inguinal Hernia. 

Many Clinical Commissioning Groups (CCGs) in the UK are making short-term financial savings by deferring surgery choices - in effect rationing services for surgery that is deemed 'low-clinical value'. Unfortunately, this up-front 'saving' can be undone by the small percentage of hernias that become strangulated and become expensive medical emergencies. These costs could have been wholly eliminated by planned elective surgery. Ironically, hernia surgery is considered to have some of the highest post-operative benefits when rated by patients compared with other surgery types2,3  which is contrary to the low-clinical value argument of watchful waiting.

In addition, the hidden costs of an inactive work-force of peak-earning middle-aged men with debilitating hernias are also ignored.
If you are unfortunate enough to have 'watchful waiting' suggested for your hernia you may want to consider private hernia surgery.

When is it not a suitable course of action?

If your hernia is painful or impacting your work or quality of life then a course of 'waiting' for improvement will have little benefit and will probably make your condition worse over time. In a study of 700 patients, 90% reported increased pain with time over a period of 10 years on watchful waiting 4.  You may also be giving up surgical options in the future if you are unlucky to get another condition that affects your ability to have anaesthesia. 

More evidence of the dubious benefits of Watchful-Waiting

A recent article in Annals of Surgery (September 2013 - Volume 258 - Issue 3 - p 508–515) describes a long-term trial of men with Inguinal Hernias. Of the 254 men who consented to a period of watchful waiting, just 32% had requested surgery in the follow-up period of 7 years (younger men fared better than older men at managing their hernias).  This is despite the small risks of complications from strangulated hernias and peritonitis which often encourage patients to elect for surgery.

The conclusion drawn from the study was :

"Men who present to their physicians because of an inguinal hernia even when minimally symptomatic should be counselled that although watchful-waiting (WW) is a reasonable and safe strategy, symptoms will likely progress and an operation will be needed eventually"

(Our emphasis in bold).

Another independent study in the same Annals of Surgery medical journal from 2018 also shows the benefits of early surgery. It concluded:

"Some 528 men were included and followed for 24 months; 99/262 men in the watchful waiting group had a hernia repair.
Overall pain/discomfort score was lower in the early repair group: mean score 0.35 versus 0.58 in the watchful waiting group" 5


(Our emphasis in bold).

References
1 - Hwang, M.J., et al., Unintended consequences of policy change to watchful waiting for asymptomatic inguinal hernias. Ann R Coll Surg Engl,
     2014. 96(5): p. 343-7.

2 - BBC Radio 4 'Inside Health' 31st January 2017 - Consultant Surgeon Jonothan Earnshaw, Cheltenham General Hospital 

3 - 'Hernia Surgery is Cost Effective' - British Medical Journal  (BMJ 2013;346:f3498) 

4 - Chung, L., J. Norrie, and P.J. O'Dwyer, Long-term follow-up of patients with a painless inguinal hernia from a randomized clinical trial.
      Br J Surg, 2011. 98 (4): p. 596-9.

5 - De Goede et al ' Watchful Waiting Versus Surgery of Mildly Symptomatic or Asymptomatic Inguinal Hernia in Men Aged 50 Years and Older: A
     Randomized Controlled Trial'  
  Ann Surg. 2018 Jan;267(1):42-49. doi: 10.1097/SLA.0000000000002243.