Annals of Surgery Journal Club

Interactive resource for surgery residents and surgeons to discuss and critically evaluate articles published in Annals of Surgery selected by a monthly guest expert who will review an article each month, offer questions and respond to reader's comments.

Thursday, April 3, 2014

April, 2014 Journal Club
Moderator: Dr. Mary Hawn


The study population for this current study is a subset of 264 (69%) of the 366 patients in the watchful waiting group from the original study that agreed to participate in a registry.  The main finding is that while watchful waiting remains a safe strategy with a very low rate of subsequent presentation for an incarcerated hernia, most hernias became increasingly symptomatic ultimately leading to elective repair.  Nearly 70% of patients in the watchful waiting arm crossed over to repair during the 10 year follow-up period.  In Cox proportional hazards analysis, age greater than 65 was the single factor identified with cross over.  The cross over rate for men greater than 65 was 79% versus 62% for men younger than 65.  Thus while watchful waiting is safe, most men, especially older men will ultimately elect to undergo repair of their inguinal hernia.   


The findings in this study are useful for shared decision making with men about whether and when to get their inguinal hernia fixed. 


While the authors do not specifiy why they chose to dichotomize the age variable at 65 years, it cannot be overlooked that two major policies go into effect in the United States at this age:  eligibility for (1) retirement with social security benefits and (2) Medicare healthcare benefits.



1.  Based on the observation of the association between age >65 and crossover to surgery, do you think that age is the determinant of whether men will chose to have their hernia repair, or perhaps is the time available for recovery an important variable? 


2.  When discussing management strategies with patients, should we focus on their employment status, disability coverage and activity level in determining the optimal time for elective hernia repair?


3.  This study did not report on outcomes of surgery for those men that underwent delayed hernia repair compared with their counterparts that underwent immediate hernia repair.  What could the effects of delayed hernia repair have on ultimate hernia outcomes?


Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers. This article can be accessed for free.