What should be the management policy for asymptomatic inguinal hernias?

Elective surgical repair was the general policy for the treatment of asymptomatic and minimally symptomatic inguinal hernias, based on reducing the risks of possible future bowel obstruction or visceral strangulation. Two randomised controlled trials in 2006 suggested that an alternative policy of "watchful waiting" was safe and appropriate. As a result, some health authorities in the UK withdrew funding for elective surgical repair for asymptomatic hernias in 2010. The long-term follow-up results of these two trials, however, showed high rates of surgery in the watchful waiting arms due to the development of symptoms. Two recent studies have called the watchful waiting policy into question on the basis of cost-effectiveness, quality of life and mortality data. The current article shows the results of an Official Information Act request of the New Zealand Ministry of Health and the 20 District Health Boards on their current policies for the management of such hernias. The results show a range of policies, with two District Health Boards employing watchful waiting, seven with policies or health pathways that can restrict or deny access to treatment, and all District Health Boards required to comply with Ministry of Health performance indicators. It is concluded that, at least with some District Health Boards, patients with asymptomatic and minimally symptomatic inguinal hernias are given a lower priority for surgical treatment than they might merit on clinical grounds. Further research is needed to formulate appropriate policy for the management of this common disorder, and should perhaps be extended to cover other similarly common conditions.