Inguinal hernia repair

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 (laparoscopy). Surgery is not always needed, 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 return to normal activities again?

What causes inguinal hernias?

Inguinal hernias can occur if there is 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 after 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, and in women it contains the round ligament of the uterus that supports the uterus (womb).

In inguinal hernias, part of the peritoneum, intestine, 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: Weak point in inguinal canalInguinal hernia: Weak point in inguinal canal

Is surgery always needed if you have an inguinal hernia?

Surgery isn't always necessary. If just a little of the peritoneum protrudes 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 intestine is pinched.

When is surgery considered?

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

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

But if the hernia isn’t causing any symptoms and the intestine 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 was is covered with a synthetic mesh to strengthen the abdominal wall.
  • 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 through the abdominal wall via these cuts. In minimally invasive surgery, the area where the opening of the hernia was is always covered with synthetic mesh.

The surgery options will depend on factors like the hernia's size and exact location. General health, sex, age and other medical conditions will also play a role.

The different types of surgery each have their advantages and disadvantages: For example, you will only need a regional or local anesthetic if you have open surgery, whereas a general anesthetic is needed for laparoscopy.

What are the side effects of surgery?

Inguinal hernia operations are among the most commonly performed surgical procedures. Although complications are rare, side effects 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 permanent 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?

Adding a synthetic mesh stabilizes the abdominal wall significantly better than only closing the gap by sewing it together with neighboring connective tissue. This means that hernias are less likely to return if synthetic mesh is used: About 4 out of 100 patients who had hernia surgery without mesh had problems again – compared to only 1 out of 100 patients who had surgery with mesh.

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

It also appears that surgery with mesh doesn’t cause any more pain or inflammation than procedures that don’t use mesh.

Which is better: Open surgery or laparoscopy?

Both of these procedures are equally suitable for inguinal hernia repair in men. In both cases you can usually return home after two days at the latest. But each procedure has its pros and cons. The surgeon’s level of experience will play a major role.

Advantages of open surgery:

  • The risk of having another hernia might be lower, but studies haven’t shown for sure whether this is actually the case.
  • There is probably a lower risk of blood vessel damage, although that also hasn’t been fully proven in studies.
  • Open surgery can be performed under local or regional anesthetic.

Advantages of laparoscopy:

  • It is possible to return to work and get back to being physically active sooner – on average about four days sooner than after open surgery.
  • Infections and permanent groin pain are less likely.
  • The risk of bruising is probably lower, but this has not been clearly proven in studies.

Women are often advised not to have open surgery because of the greater risk of having another hernia later. That is why 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, both the overall success of laparoscopies and the risk of side effects and later hernias depend more on the experience of the doctors performing the operation.

Which type of laparoscopy is better?

Two laparoscopic procedures are commonly used in inguinal hernia surgery:

  • TAPP (transabdominal preperitoneal): Surgery is performed via the abdomen. The synthetic mesh is attached outside of the abdominal cavity, between the peritoneum and the abdominal wall.
  • 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 wall. 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 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 mesh implantation. Walking and 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 two to three 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. 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. Aside from that, women are more likely than men to develop another hernia.

If this happens, 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 reason for this is the scarring at the site of the first operation. Research also shows that laparoscopy has some advantages in this case: On average, it's possible to return to normal levels of activity and exertion one week sooner. Lasting pain and wound infections are less likely to occur. If laparoscopy was used to repair the first hernia, open surgery with mesh implantation is typically used the second time around.

Inguinal hernias in children

Inguinal hernias in children are usually congenital (they are born with them) or develop during their first year of life. This is because the testicles of newborn boys are often still inside the groin and move down (descend) through the inguinal canal to the scrotum later. As long as the inguinal canal is not fully closed, inguinal hernias are more likely to develop.

Inguinal hernias in children are always operated on in order to prevent the intestine from becoming trapped in the hernia opening. This is usually done under general anesthetic. Newborns may be given a regional anesthetic instead.

In children the hernia sac is closed using stitches only. Synthetic mesh is never used in children because it could increase the risk of infections and later infertility. Problems could also arise as the child grows because the mesh can’t stretch and grow with the child.

Inguinal and femoral hernias in women

Weak connective tissue or pregnancy can increase the likelihood of inguinal hernias in women. The treatment of these hernias in women is somewhat different than it is in men: Women are advised to have surgery for inguinal hernias, even if they don’t have any symptoms, because they may have an undetected femoral hernia as well. Femoral hernias are more likely to lead to complications if surgery isn’t performed. Women are also advised not to have open surgery because that is associated with a higher risk of hernia recurrence.

Femoral hernias occur below the inguinal ligament. They are most common in women over the age of 65. Because they do not cause a visible bump, they are often not noticeable at first. The first sign is often pain instead. Femoral hernias are sometimes confused with inguinal hernias, but they are more painful. The risk of complications is significantly higher with femoral hernias, so surgery is usually recommended soon after diagnosis.

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 is most important to you and talk about it with your doctor:

  • What symptoms do I have?
  • How is my 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?
  • How experienced are the surgeons who will be performing the operation?
  • When can I return to normal activities following surgery? What types of activities are possible?
  • Should I just go to a "regular" hospital or is it a good idea to have surgery at a specialized hernia center?