title: Watchful waiting in incisional hernia: is it safe?
abstract: BACKGROUND
  Incisional hernia (IH) is among the most common postoperative complications after abdominal surgery. Operative treatment (OT) using mesh is the treatment of choice. A strategy of watchful waiting (WW) might be a considered in some patients. This retrospective study compares the outcomes of WW and OT.
  
  
  METHODS
  All patients presenting with IH in an academic surgery department between January 2004 and December 2009 were analyzed according to whether they were treated by WW or OT. Crossovers between both groups were also analyzed. Patient characteristics, information about the initial abdominal operative procedure, symptoms at presentation, and characteristics of the hernia were collected retrospectively. In case of OT, postoperative complications were analyzed.
  
  
  RESULTS
  In total, 255 patients were included; 151 (59%) in the OT group and 104 (41%) in WW group. The median follow-up was 68 months (interquartile range [IQR], 52-93). The reasons for WW were the absence of symptoms in 34 patients (33%), comorbidities in 24 (23%), and obesity in 23 (22%). During follow-up, 34 patients (33%) crossed over from WW to OT. Eight of the crossovers (24%) were emergency repairs owing to incarceration at a median of 1 month (IQR, 1-5) after the start of WW. The incidence of unexpected intraoperative intestinal perforation was greater in the crossover group (13%) compared with the OT group (2%; P = .002). Postoperative fistulas were seen in 7% of patients who crossed over from WW to OT versus 0% in primary OT (P = .002). Postoperatively, 3 patients died, 2 of whom were treated operatively after belonging initially to the WW group.
  
  
  CONCLUSIONS
  WW for IH leads to high crossover rates with significantly greater incidence of intraoperative perforations, fistulas, and mortality, than in the OT group, particularly in patients who require emergency repair of IH owing to incarceration.
authors.affiliation: Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands. Electronic address: j.verhelst@erasmusmc.nl.
authors.forename: Joost
authors.initials: J
authors.lastname: Verhelst
authors.affiliation: Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.
authors.forename: Lucas
authors.initials: L
authors.lastname: Timmermans
authors.affiliation: Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.
authors.forename: Maurits
authors.initials: M
authors.lastname: van de Velde
authors.affiliation: Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.
authors.forename: An
authors.initials: A
authors.lastname: Jairam
authors.affiliation: Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.
authors.forename: Konstantinos A
authors.initials: KA
authors.lastname: Vakalopoulos
authors.affiliation: Department of Neuroscience, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.
authors.forename: Johannes
authors.initials: J
authors.lastname: Jeekel
authors.affiliation: Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.
authors.forename: Johan F
authors.initials: JF
authors.lastname: Lange
mesh_terms: D000005:Abdomen / Q000601:surgery; D000328:Adult; D000368:Aged; D004638:Emergency Treatment; D005260:Female; D046449:Hernia, Abdominal / Q000209:etiology* / Q000601:surgery / Q000628:therapy*; D059685:Herniorrhaphy; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology* / Q000601:surgery / Q000628:therapy*; D012189:Retrospective Studies; D012307:Risk Factors; D013526:Surgical Mesh; D016019:Survival Analysis; D016896:Treatment Outcome; D057832:Watchful Waiting / Q000379:methods*