Severe Mental Illness: A Contraindication to Watchful Waiting in Hernia Management?

Watchful waiting (WW) is a strategy that can be used to manage hernias whereby patients who are asymptomatic or minimally symptomatic are observed until symptoms worsen or complications develop, prompting surgical intervention. The successful implementation of a WW strategy requires patients to report changes in their clinical condition to receive timely care. Patients who have severe mental illness may defer seeking care when appropriate. This case report describes our experience treating a patient with severe mental illness who had a primary ventral hernia managed by WW. She was lost to follow-up and subsequently presented with a strangulated epigastric hernia which fistulized to the skin. The case report highlights the challenges of attempting WW in patients with severe mental illness. We suggest that poorly controlled severe mental illness should be considered a relative contraindication to WW.