Inguinal (groin) hernias in men

Photo of an older man in a hospital bed talking to a doctor (PantherMedia / monkeybusiness) Inguinal (groin) hernia surgery is one of the most common surgical procedures in Germany. Surgery for an inguinal hernia can be either open or minimally invasive (laparoscopic). It is not always necessary, though.

Inguinal hernias often don't cause any severe symptoms, and can be treated quite effectively with surgery. But there are still a few issues to consider: When is surgery not needed? What risks are involved? And which is better: open or minimally invasive surgery (laparoscopy)? How soon after surgery can I start putting pressure on that part of my body again?

What causes inguinal hernias?

Inguinal hernias can occur if there's a weak point in the inguinal canal in the front abdominal wall. This canal runs diagonally from the hip bone down to the pubic bone, connecting the abdomen with the groin area. It forms a hollow space through which boys’ testicles can move from the abdominal cavity down to the cooler environment of the scrotum afr they are born. Once the testicles have reached their final position, the canal gradually closes. It contains nerves, blood vessels and lymphatic vessels. In men, it also holds the spermatic cord.

Inguinal hernias occur when part of the peritoneum, bowel, or fat tissue protrudes through a gap in the abdominal wall. The peritoneum is the membrane that lines the abdominal cavity and (completely or partly) encloses most of the organs in the abdomen. This type of hernia is more common in men because they have a wider inguinal canal than women do. Weak connective tissue can also increase the likelihood of having an inguinal hernia. Contrary to popular belief, there is no proven link between lifting or carrying heavy loads and getting inguinal hernias.

 

Illustration: Inguinal hernia: The weak point in the inguinal canalInguinal hernia: The weak point in the inguinal canal

Is surgery always needed if you have an inguinal hernia?

Surgery isn't always necessary. If just a little of the peritoneum bulges through the opening of the hernia and it doesn’t cause any problems, surgery isn’t needed at first. It may be a good idea for old or very ill people to avoid surgery due to the associated risks. But only if the risk of the hernia causing complications isn’t too high. That risk will depend on things like the size and exact position of the hernia.

Studies have looked into what happens in men who have inguinal hernias with no symptoms if they don't have surgery right way. They have shown that waiting to have surgery until the first symptoms arise, such as pain, doesn't have any disadvantages. The study participants didn’t have a higher risk of complications either. About half of the men decided to have surgery within five years, usually because the hernia started causing pain.

It is important to see a doctor as soon as any symptoms arise. Immediate medical attention is needed if you have severe pain, fever or nausea. These could be signs that the bowel is being pinched.

When is surgery considered?

Most men decide to have surgery if their hernia is painful or simply becomes bothersome. The hernia may grow larger over time, and even slide down into the scrotum in rare cases.

Another reason to have surgery is to avoid possible complications: When the bowel pushes through the opening, it may be pinched or become twisted. Although that rarely happens, it can have serious consequences such as bowel obstruction (a blocked bowel). If the trapped part of the bowel doesn’t get enough blood, the tissue may die. Then immediate surgery is needed.

If the hernia isn’t causing any symptoms and the bowel isn’t pinched, you can wait a few weeks or months and see what happens. Sometimes surgery isn't needed at all.

What are the different types of surgery?

During surgery, the hernia sac is moved back into the abdomen together with its contents. The gap in the abdominal wall is then closed off. It can also be reinforced with tissue from another part of the body or with a fine synthetic mesh.

There are three main types of surgery:

  • Open surgery without mesh: Surgery is performed from outside the body through quite a long cut, and the gap is sewn together with neighboring connective tissue.
  • Open surgery with mesh: The area where the gap used to be is covered with a synthetic mesh to strengthen the abdominal wall.
  • Minimally invasive surgery (also known as keyhole or laparoscopic surgery): Three small incisions are usually made in the skin (5 to 10 mm long). A camera and surgical instruments can then be inserted into the abdomen or as far as the abdominal wall through these cuts. In minimally invasive surgery, the area where the opening of the hernia used to be is always covered with synthetic mesh afterwards.

The surgery options will depend on factors like the size and exact location of the hernia. The person's general health, age and other medical conditions may also play a role. All three surgical approaches have advantages and disadvantages.

What are the side effects of surgery?

Inguinal hernia operations are among the most commonly performed surgical procedures in Germany. Complications are rare, but side effects such as pain or inflammation are possible. And anesthetics are always associated with risks.

Pain resulting from surgery in the groin area usually goes away within a few days. But about 10 out of 100 people have long-term pain following surgery. This may be caused by nerve damage or reactions to the synthetic mesh.

Fewer than 1 out of 100 people have more serious complications after surgery. These include damage to blood vessels, the spermatic cord or the nerves inside the inguinal canal. Pain or poor blood circulation in the testicles, poor wound healing and inflammation may also arise.

Which is better: Mesh or no mesh?

In hernia surgery, the opening of the hernia is sewn together with neighboring connective tissue to stabilize the area. Adding a synthetic mesh stabilizes the abdominal wall somewhat better. This means that hernias are less likely to return if synthetic mesh is used: About 4 out of 100 patients who have hernia surgery without mesh have problems again – compared to only 2 out of 100 patients who have surgery with mesh. But mesh isn't always needed.

The risk of having another hernia will also depend on the surgical technique used and how experienced the surgeon is. Research has shown that certain mesh-free techniques can prevent further hernias just as well as surgery with mesh can.

Because surgery that uses mesh provides greater stability, you can return to normal activities sooner after the operation. But if no mesh is used, it is important to wait up to two months before doing more strenuous physical activities or sports. The tissue needs time to grow back together and become more stable.

Surgery with mesh probably doesn’t cause any more pain or inflammation than procedures that don’t use mesh. But the risk of damaging blood vessels and organs is somewhat lower.

Which is better: Open surgery or laparoscopy?

Both of these procedures are equally suitable for inguinal hernia repair in men. But laparoscopic surgery is more commonly recommended because it has a few advantages. In both cases you can usually return home after two days at the latest. It's often possible to go home on the same day as the surgery, too.

Advantages of laparoscopic (minimally invasive) surgery:

  • You can return to work and get back to being physically active sooner – on average about four days sooner than after open surgery.
  • There's a lower risk of infections, abnormal sensations and long-term groin pain.
  • The risk of bruising is probably somewhat lower.

Advantages of open surgery:

  • The risk of damage to blood vessels is probably somewhat lower.
  • It can be performed under local or regional anesthetic.

The risk of having another hernia is equally low for both procedures.

Women are advised not to have open surgery because it increases the risk of having another hernia later. As a result, women who have inguinal and femoral hernias usually have laparoscopic surgery with the use of a mesh.

It is harder for surgeons to learn how to perform laparoscopic surgery compared to open surgery. Because of this, the overall success of laparoscopic surgery and the risk of side effects and later hernias depend more on how experienced the surgeon is. To find out how much experience different hospitals in Germany have with a certain type of surgery, you can read their hospital quality reports.

Which type of laparoscopic surgery is better?

Two laparoscopic procedures are commonly used in inguinal hernia surgery:

  • TAPP (transabdominal preperitoneal): Surgery is performed via the abdomen. To do so, small cuts have to be made in the abdominal wall. The synthetic mesh is then attached between the peritoneum and the abdominal muscles.
  • TEP (totally extraperitoneal): Surgery is performed on the abdominal wall only. This means that the surgical instruments are not inserted as deeply as they are in TAPP. The synthetic mesh is then attached between the peritoneum and the abdominal muscles. TEP surgery is the more complex approach and more difficult to learn.

Studies have shown no differences between the two procedures, though: Pain, side effects, and recurrences were equally common, and it took about the same amount of time for people who had the procedures to get back to work.

What do I need to know after having surgery?

You can return to physical activity very soon after having hernia surgery with the use of mesh. Walking and gentle physiotherapy exercises are already possible just a few hours later. The type and intensity of exercise should be chosen based on how you feel and how you are coping with the exertion. It is better to avoid lifting heavy objects in the first 2 to 3 weeks.

What can you do if the hernia comes back?

The risk of having another hernia will vary from person to person, and will also depend on the surgical procedure used. About 1 to 5 out of 100 people develop another inguinal hernia after having surgery to repair a previous hernia. Surgery without synthetic mesh is associated with a higher risk of recurrence.

If the hernia returns, it is possible to have surgery again. The surgical options are then determined by which approach was used the first time:

  • If open surgery was performed the first time round, laparoscopy is used the next time. One of the reasons for this is that there is now scar tissue in the part of the body that was operated on. What's more, you're also more likely to be able to return to normal activities after about one week if you have laparoscopic surgery. And the risk of long-term pain and wound infections is lower than it is after open surgery.
  • If the first operation was laparoscopic, the new hernia is usually treated using open surgery with mesh because of the scarring.

What questions could help when considering the treatment options?

Decisions for or against a specific treatment must be made on an individual basis. The following questions may help you to figure out what's most important to you and talk about it with your doctor:

  • What symptoms do I have?
  • How is my inguinal hernia likely to develop?
  • What is the risk of complications?
  • Should I avoid certain movements or activities?
  • Is it possible to not have surgery (at least at first)?
  • What are the pros and cons of the different surgical procedures?
  • When can I return to normal levels of activity following surgery? What types of activities are possible?
  • How experienced are the surgeons who will be performing the operation?
  • Should I just go to a "regular" hospital or would it make sense for me to have surgery at a specialized hernia center?