Long-term follow-up in asymptomatic or oligosymptomatic inguinal hernias: watchful or watchless waiting?

Abstract

Background: Watchful waiting (WW) for inguinal hernia has been established as a safe strategy for selected patients. However, this approach relies on regular long-term follow-up and adherence rates to WW are poorly characterized.

Methods: A retrospective cohort study was performed including patients with inguinal hernia enrolled in a WW surveillance protocol between May 2013 and May 2026. Follow-up visits were scheduled every 6 months during the first year and annually thereafter. Demographic, clinical, and long-term adherence to surveillance protocols were analyzed Patients who were lost to follow-up were contacted via a structured questionnaire to update their clinical status and identify causes for discontinuing protocol.

Results: A total of 400 patients were included in the WW protocol. Overall follow-up adherence was low, with 240 patients (60.0%) failing to maintain scheduled surveillance at the end of this study. Kaplan-Meier analysis demonstrated a progressive drop out of the protocol over time. Younger age was an independent factor associated with follow-up discontinuation. Patients younger than 30 years demonstrated the highest rate of surveillance discontinuation (92.9%), compared with 63.6% among patients aged 30-50 years and 56.4% among patients older than 50 years (p = 0.015). Seventy-seven (32%) responded to the survey; the most frequent causes for discontinuation were the absence of symptoms and the lack of awareness of recommended follow-up intervals (36% and 27%, respectively). Eleven patients (14.1%) had an elective hernia repair at another institution. No emergency surgery was identified among patients who remained under institutional follow-up or among those successfully contacted after surveillance discontinuation.

Conclusions: Watchful waiting appears to remain an acceptable management strategy for selected patients with asymptomatic or oligosymptomatic inguinal hernia. However, long-term adherence to surveillance beyond 2 years is low, posing a significant limitation to sustained WW management.