No you're not obligated to operate on this type of hernia. Watchful waiting is an acceptable alternative. JAMA 295:285-292. Most will eventually have surgery, but emergencies are rare.

In infancy period , the answer to your question, respect to urgent condition, is yes.

I agree with Dan, not all hernias need to be repaired and in your patient weighing the risks and benefits and how its impacting on his quality of life are key.  His hernia is asymptomatic and a repair has a 3-5% chance of causing chronic pain amongst other potential morbidity.  As Dan said, most will eventually come to surgery and one hopes that he will not fall into the small percentage of patients who need a repair as an emergency.

 i think ,  if the patient has hard job, you may perform hernia repair.

Both therapeutic options are valid.

However patients on watchful waiting have a 68% chance to get operated in the future because of the hernia becoming symptomatic. This risk is even greater for older patients. [Ann Surg. 2013 Sep;258(3):508-15]

A watchful waiting strategy also seems to increasing the risk for an emergency hernia repair by an adjusted odds ratio  [OR]: 1.59, 95% confidence interval [CI]: 1.03-2.47 [Ann R Coll Surg Engl. 2014 Jul;96(5):343-7].

For these patients the strangulation risk is 0.55% at 4 years of follow-up. [Arch Surg. 2012 Mar;147(3):277-81]

It seems that, even for older patients, a programmed surgical repair for asymptomatic hernias is more logical. There are very few patients that are unfit for a mesh hernioplasty under local anesthesia. On the other hand I wouldn't force an old, frail, completely asymptomatic patient to have a hernia repair if he was thoughtful of an operation.

In the end it all depends on the patient's general condition, comorbidities, and his willingness to get operated.

Hernia is due to a defect and till it is repaired the patient  will be at risk of a complication. Hence yes all hernias will need a repair sometime

Yes, the question is timing of surgery. Best to do before complication occurs or before his overall health becomes a limitation to surgery. All the best!

I too agree that if the patient is fit for surgery all hernias should be operated, although many literature advocates wait and watch policy. Why to wait for the complication to occur?? "The rationale for surgery in inguinal hernia is treatment of current or future symptoms, and not to prevent incarceration". [EAES Consensus Development Conference on endoscopic repair of groin hernias. Surg Endosc 27:3505–19.] 

Yes I think patients should be operated on as soon as possible. In doing so because we can  protect side effects due to a incarcerated  hernia i.e.; testicular, bowel, appendix necrosis due to compression, torsion of ovary.

There is no need for new fantasies about it.  

For each surgeon to be able to fully answer your question, dr Andresen, he/she must acquire a realistic view on his/her personal results.

All surgeons are not equal: 

By some surgeons the risk for prolonged postoperative pain will be significantly lower than 10%, while by others that risk will by far exceed 15%.   

Recent studies showed that monitoring patients, instead of them having immediate elective suregery, did not raise the risk of a strangulated hernia...... So probably a policy of "watchful waiting" could be adopted when the hernia is painless, not growing,without complications and when the patient does not demand the repair.......

In non-emergency primary hernias, the risk of having a complication due to surgery is bigger than the risk of having a strangulation.

Therefore, we shouldn't operate to minimize the risk of strangulation, we should operate patients to get rid of the irritation and embarrassment that the hernias (sooner or later will) incur.

"Watchful waiting" is a term adapted for scientific follow-up, not for routine clinical practice. How many doctors out here would refuse an operation for an asymptomatic hernia, and then follow that patients with regular return visits? And for how long...? We don't need to be "watchful"; the patient will come back if/when symptoms become more bothersome.

In my practice, I will operate on any one with a symptomatic hernia, particularly in young working age group people. In older patients if indirect hernia, I will operate as even though the risk of strangulation is not very high, if it occurs, the patients are at a very high risk of problems after a general anaesthesia and if gut resection becomes necessary. As in older patients with co morbidities I would operate under LA in my Walk In Walk Out Hernia clinic that I set up about 8 years ago, first in the NHS. I have not regretted to date. 

Failure and Chronic pain I feel is avoidable if proper care is taken during surgery and every nerve is carefully seen and guarded. I have been lucky so far in that I have not had any recurrences and only one patient with chronic pain in over 15 years. 

Elderly patients with direct Inguinal hernia, if no symptoms, I do not touch them unless patient demands it. 

I completely agree with Bengt Novik  that "Watchful waiting" is a term adapted for scientific follow-up, not for "routine clinical practice". The term "watchful waiting" is not practical or possible in many underdeveloped or developing countries because of ignorance, socioeconomic status and  lack of resources  and so it should not be universalized.  

Watchfull waiting is a synonym for "active surveillance" and indicates a treatment option in some clinical situation such as prostate cancer ( see Campbell-Walsh Urology) and its role has not been limited in some strange scientific research and could be accomplished in every reliable clinical settings. However up to my knowledge, its role in hernias (especially inguinal) has not been documented.

The most important aspect of the question is: what is an asymptomatic hernia?

Normally a patient having a surgical consultation for a groin hernia has at least minor symproms related to it. In many studies completely asymptomatic patients are grouped with those presenting minor symptoms. Practically it is important to understand if the hernia poses a problem for the patient's everyday habits to thenpoint where he seeks a surgical solution (with its probable complications).

As for watchfull watching which is the equivalent of active surveillance i fail to understand why it's not applicable in clinical practice. By all means it is a treatment option and a term used by 49 articles indexed in PUBMED as well as the ACS for asymptomatic or minimaly symptomatic inguinal hernias.

In current practice a patient that has a groin hernia and chooses not to be operated has it noted in his medical history and normally has his hernia checked at each physical examination practiced by his GP, surgeon or during hospitalisation.

http://www.acssurgerynews.com/single-view/watchful-waiting-doesn-t-pay-for-asymptomatic-inguinal-hernias/a128817982383712bb691ec239057a28.html

If patient has no pain maybe we can think about evry month control and if pain appears than we can think about repair in local anenetesia.

I enjoyed reading the discussions

Watchful waiting is a complete misnomer! Who is watching ? 

What are we waiting for - a complication?

If a patient comes with a hernia he/she  should offered surgery. The  type of anaesthesia etc are details depending on the patient.Local anaesthesia is a good option for small hernias. It seems that age is being portrayed as  a barrier for surgery. This is not acceptable in the modern era. The risk of  complication does not depend on the age.

If the patient does not want surgery then we must ensure that he/she is seen regularly

A direct hernia after the age of 60 years doesn't require surgery-Ref Nyhus.As for the stangulation  incidence is about 10-15% and 85 to 80% are not going to have it, the surgery has to be evaluated against other symptoms the patient could be having!. I have operated on a 75 year old doctor because he was getting pain and so many of my patients went to their graves with intact hernias, due to other comorbidities.

In the modern era, I think, the treatment of inguinal hernia is in local anaeshesia and in day surgery, then to arrive the protesis has revolutinated this operation. The patients are satisfied as return at work briefly time, are satisfied of aesthetic results, therefore only the patient don't want the operation we must control periodically

By the way if all hernias need surgery I want attach the file below. In 2002 we have get  analized the effectiveness of local anesthesia for inguinal hernia's surgery.

It depends on your evaluation as a surgeon. However, if a patient wants his/her hernia operated, it has to be done.

Interesting discussion, the words "the end" on the hernia surgery will never be written.

In the literature, each of us can find articles to support their ideas. Is for this reason that the experience still has a vital role, I think.

When I was a young surgeon and prosthetic surgery hernia was at the beginning, I worked all patients with hernia I saw. Young people with small  asymptomatichernias, elderly people with large symptomatic herniations,  women with small or large femoral hernia or inguinal hernias. Then, one day a young man of 19 years old operated on for asymptomatic inguinal hernia (Gilbert I), within three months after the procedure, began to suffer inguinal neuralgia and told me that since he had been operated on, his discomfort was significant enough to prevent him from normal daily activities, which did not happen before the surgery. Since then, bearing in mind that the complication rate of the inguinal hernia patients is less than 2/1000 patients-year (follow-up of 4 years) and the rate of post-herniorrafiy  neuralgia  is about 11% two years after surgery, I work only symptomatic hernias  (unless in the case of femoral hernias), and have adopted a policy of Watchful Waiting that  was never given any particular problems in a personal series of more than 1000 procedures.

Complications have more risk than surgery therefore it should be operated

Elderly patients most probably have direct inguinal hernia...which has less chances of complications...as in this patient the hernia is asymptomatic and small so it can be managed by just waitful watching but the patient must be told about the complications...this is what we are doing in our setup

Would never operate on an old man with an asymptomatic inguinal hernia. 

i enjoid the discussion very much.

small hernias tend to obstruct more than big hernias as far as the neck size is concerned, and this elderly man meight get worse (medically) with time when his hernia got a complication. I think surgery would help him much when it is elective rather than emergency

First of all it is a very pleasing discussion.

All patients must be evaluated by oneself. Surgeon must be avoid of surgical complications and co-morbids. Also during follow up period surgeon must be alert of non operative complications such as incarceration, intestinal obstruction. The behaviour of surgeon must be surgical art to decide whether perform surgery or not.

Yes. All hernias are a mechanical defect that need to be repaired as early as possible. We will recommend mesh free and tension free open repair in all cases to avoid dangers of a foreign body. Pl. visit www.desarda.com

It's necessary to tailor the treatment recommendation for the individual patient. I will offer watchful waiting to patients with small asymptomatic or minimally symptomatic hernias with two caveats: 1. The patient must understand the symptoms of incarceration/strangulation and the potential need for an emergent operation if that occurs; and 2. If the patient notices the hernia enlarging, I ask them to return to clinic to be reevaluated, as a large inguinal-scrotal hernia is more challenging to operatively repair (laparoscopically or open).

Likewise, depends on the individual. Younger active patients are ultimately very likely to have surgery but if asymptomatic I give them the necessary information to make the decision and leave it up to them. Older less active patients with asymptomatic hernias can often be managed conservatively

In eldry friable patient Each one should assess individually .for wide neck direct asymptmatic inguinal hernia its acceptable to follow up the patient without surgery .

It should be done electively better than to be done in emergency situations.

Maybe important to distinguish the elderly but fit and active patient from the elderly with multiple co morbidities

There is no such thing as asymptomatic hernia. almost all patients will tell you they get twinges of pain which they can bear. So the answer is all hernia should be operated. They can be done under LA or GA and age is NO bar.