INGUINAL HERNIA
Frequently Asked Questions
Explore our frequently asked questions (FAQs) about inguinal hernias, risk factors, treatment options and life after surgery.
About Inguinal Hernia: What is it?
A hernia is a protrusion of an organ or fatty tissue through a weak spot in the abdominal wall (the muscles or tissues comprising the abdomen) 1. An inguinal hernia is a specific type of hernia where the internal tissue (most commonly the small or large intestine) protrudes into the inguinal canal and produces a visible bulge in the groin area1.
Common symptoms of an inguinal hernia include:
- A bulge in the groin area. The bulge may become more apparent when you cough or strain. The bulge may subside when you lie down or apply slight, manual pressure1.
- A steady, aching pain radiating into the hernial area. This pain may worsen with tension and improve with manual, hernia reduction (by lying down or pressing the bulge back in) 1. These sensations can radiate into the scrotum2.
- Pain or bruising in the area of the hernia after a period of exercise1.
The size of the bulge varies between individuals but is often observed to be a few centimetres long but can be much smaller3. However, it should be noted that the size of the hernia is not always indicative of the severity of the hernia4.
Specific to infants or children, an inguinal hernia can be relatively symptom free until they cry, cough, or strain to defecate. Parents may observe a painless swelling in the groin area when this happens 1.
An inguinal hernia can also become incarcerated meaning the contents of the hernia becomes trapped (i.e. it cannot be pushed back in). Symptoms of an incarcerated hernia include more severe pain, nausea, vomiting, inability to defecate, and inability to massage the hernia back in1. Medical help should be sought immediately if this is the case.
An untreated hernia can worsen over time, leading to incarceration of the hernia (meaning it becomes trapped) and then strangulation (when blood flow is cut off from the hernial contents)1. If this happens, emergency surgery will be required. However, each individual is different, and the chances of incarceration and strangulation are quite low (estimated to be between 1% to 3% over a person’s lifetime)5. It is recommended that you consult a medical professional for the best strategy to care for your hernia.
Direct inguinal hernias occur when the abdominal contents project through a weak area of the lower abdominal wall (specifically, the posterior (back) wall of the inguinal canal)6. Direct inguinal hernias are more common in older patients7 as a result of increased abdominal pressure and thus, is sometimes referred to as an acquired hernia6.
Indirect inguinal hernias occur when the abdominal contents protrude through the internal inguinal ring and into the inguinal canal1. In males, this protrusion may descend into the scrotum1. The cause of indirect inguinal hernias is often congenital (present from birth) and thus, is sometimes referred to as a congenital hernia6.
Both direct and indirect hernias present similar symptoms and may be difficult to distinguish from symptoms alone8. However, it is not essential to differentiate between the two as the surgical repair is the same for both2.
Inguinal hernias are the most common type of hernia, accounting for over two-thirds of all adult hernias2,9 and occurring in approximately 15% of the adult population1.
Men are much more likely to develop an inguinal hernia than women, with males accounting for about 90% of all inguinal hernias2. The condition affects nearly 25% of men and less than 2% of women over their lifetime2. This is primarily due to anatomical differences between the pelvic bones of males and females10.
Inguinal hernias can occur at any age, but most commonly occur during early childhood and late adulthood11 and has the lowest occurrence during early adulthood7. More specifically, the incidence of inguinal hernias peaks at around age 5 and between the ages 70 and 80, with a steady rise in prevalence observed across both genders from early adulthood onwards2,7.
Risk Factors
Primary risk factors include being male, older age, and obesity1. Having a history of inguinal hernias may also increase a person’s risk of developing an inguinal hernia1. A build-up of abdominal pressure through strenuous heavy lifting and straining to defecate (constipation) can also cause a hernia to occur1. Previous abdominal injuries (trauma) or abdominal surgeries are also risk factors as these events can weaken the abdominal muscles1.
Smoking has long been proposed as a risk factor for inguinal hernias with strong evidence showing that it also increases the risk of recurrent inguinal hernias following surgical repair12,13. This is because smoking compromises the capacity for wound healing in the abdominal tissues12. Smoking can also increase your risk of developing COPD (chronic obstructive pulmonary disease). Patients with COPD often develop a chronic cough which will put a greater strain on the abdominal muscles and hence increase the chances of developing an inguinal hernia or impair post-surgery recovery13. However, studies are still ongoing regarding the effect of smoking on inguinal hernia development due to conflicting results in recent studies14. Regardless, the current medical advice is to stop smoking to reduce the risk of developing inguinal hernia15.
The risk of developing an inguinal hernia after lifting something heavy or performing strenuous exercise is highly dependent on your existing risk factors for the condition16. Not all people who regularly lift heavy weights will develop an inguinal hernia but if for example, you are of an older age, have had previous surgery in your groin area, or have a chronic cough, then you may be more liable to develop an inguinal hernia. The intensity and style of the exercise also has an effect on the likelihood of inguinal hernia development16.
Treatment Options
No, an inguinal hernia will not get better on its own and will most likely worsen over time. The only way to treat an inguinal hernia is through surgery1,15.
No, not all inguinal hernias require surgery, but the problem will not resolve on its own without surgery1. If you experience minimal symptoms, your doctor may suggest a strategy called “watchful waiting” where you will be required to carefully monitor your symptoms in case they worsen17. Regardless, your doctor should discuss the risks and benefits of surgery so that you may make an informed decision.
An inguinal hernia will not get better without surgery. The hernia can get larger with time and carries a risk of becoming incarcerated or strangulated although the risk is low (estimated to be between 1% to 3% over a person’s lifetime)5, 15. If your hernia becomes strangulated, emergency surgery is required and a delay in treatment can significantly affect morbidity and mortality1,5. However, each individual is different, and it is recommended that you consult a medical professional for the best strategy to care for your hernia.
The main difference between open and laparoscopic surgery is the size of the surgeon’s incision. In open hernia repair, a single long incision is made through the abdominal wall whereas in laparoscopic hernia repair, several small incisions are made on the body instead18,19. Laparoscopic surgery is sometimes referred to as ‘keyhole surgery’. Open, laparoscopic and robotic approaches have shown long-term efficacy with low recurrence rates20.
In Australia, the use of laparoscopic surgery has become increasingly popular due to its minimally invasive approach when compared with open surgery11. However, the right surgical approach for you will depend on the nature of your hernia and your surgeon’s preferences.
Hernia repair is generally a very safe procedure. In extreme cases, hernia repair surgery can lead to serious complications and can even cause death, but this is rare15. The most common complications following surgery are chronic pain and hernia recurrence. Chronic pain is reported to occur in approximately 10% of cases overall2 while hernia recurrence is highly dependent on a number of factors including the type of inguinal hernia (direct vs. indirect), treatment method (mesh vs. suture), surgical approach (laparoscopic vs. open), and surgeon experience2,7. Recurrence with mesh repair is lower compared to recurrence with suture repair (3–5% vs. 10–15%)2.
Other complications specific to hernia repair surgery include:
- accumulation of blood (haematoma) or fluid (seroma) at the site of the hernia,
- bowel obstruction (where foods and liquids can’t move through your intestines)18,
- for men, discomfort or pain in the testicle on the side where the surgery was performed,
- for men, difficulty passing urine, and
- for men, damage to the blood supply of the testicle15.
These issues are often rare but may be long-lasting without further intervention18.
General complications pertaining to any surgical operation also exist such as bleeding, allergic reactions, infection of the surgical site or mesh, and blood clots in the leg or lung15. Your doctor should discuss the risks and benefits of hernia repair surgery so that you may make an informed decision.
Things you can do to prepare for the operation and reduce complications from occurring include stopping smoking, maintaining a healthy weight, and regular exercise15.
Is the mesh used in hernia repair surgery safe?
Mesh has been used in inguinal hernia repair for over 50 years and as mesh technology advanced, so too has surgeon preference for this surgical technique11,21. The technique is tension-free meaning it does not apply increased stress on the surrounding tissues (which are already weak), and thus mesh hernia repair has been associated with less post-operative pain, faster recoveries, and a significantly lower risk of recurrence as opposed to alternative surgical approaches21,22. Compared to sutured repair where the recurrence rate is just 10–15%, mesh repair is far lower at just 3–5%2. Recurrence with mesh repair is usually associated with technical factors such as improper mesh size and missed hernias2.
However, using a mesh does carry an additional risk of mesh infection requiring hospital re‑admission. Infection rates range from 0.7–2% in laparoscopic procedures and 9–18% in open procedures18,23. Thus, primary suture repair may be recommended over mesh repair if the surgical site is contaminated2. Recent advances in mesh technology aim to lower this infection rate18.
Life After Surgery
Everyone is different and the time it takes to recover from hernia repair is dependent on existing comorbidities (e.g. obesity, COPD), type of surgical procedure, and the activities you choose to do before and after surgery (e.g. exercise, smoking habits). Pain relief and stool softener medications may be prescribed during the initial recovery period to help with pain control2. The incision(s) may be sore for two to three days after surgery and may be swollen, bruised, tender and numb. This is normal after surgery and should go away within a few weeks24. The surgeon should be contacted if there are any concerns. A regular diet is usually permitted on the day of discharge (as tolerated) and showering allowed 24 to 48 hours after discharge however, both these recommendations will be up to the surgeon’s discretion2.
Substantial recovery of the operated area can take up to 6–8 weeks to allow for sufficient tissue ingrowth into the mesh22. During this time, you are encouraged to resume regular exercise and recreational activities as soon as you feel comfortable to improve recovery outcomes, however, avoid any sports or strenuous activities to avoid hindering or worsening the recovery process15,22.
This depends greatly on your sensitivity to pain, existing comorbidities, type of surgical procedure, and nature of work that you do. Typically, office jobs that do not require much physical activity can be returned to soon after surgery. More laborious jobs that require physical activity may require a few weeks to recover, upwards of up to 6–8 weeks, to allow sufficient tissue ingrowth into the mesh22.
Can I exercise before and after a hernia repair?
Regular exercise before a hernia repair surgery can help improve post-surgery recovery, however, do not do exercises that involve heavy lifting or cause pain15. As always, ask your GP for advice before you start exercising.
Following hernia repair surgery, you are encouraged to resume regular exercise and recreational activities as soon as you feel comfortable. This should help you return to normal activities as soon as possible. However, avoid playing sports or doing strenuous exercise for at least 6 weeks to allow sufficient recovery of the operated area15,22.
Yes, a hernia can come back many years later and another surgery may be required15. The chance of hernia recurrence after surgery has been placed anywhere between 3 and 15% depending on the type of inguinal hernia (direct vs. indirect), treatment method (mesh vs. suture), surgical approach (laparoscopic vs. open), and surgeon experience2,7.
The same risk factors for developing an inguinal hernia for the first time exist for an inguinal hernia recurring. This means, while there will be some risk factors you cannot change (e.g. a chronic cough), there are steps you can take to minimise your risk of a recurrent inguinal hernia. This includes quitting smoking and maintaining a healthy weight and diet25,26.
Find a specialist
If you think you have a hernia or just want to know more about your symptoms, you can start by speaking with your regular doctor using your symptom quiz answers.
If you do have a hernia, you may need to speak with a specialist. These doctors are trained in diagnosing and treating hernias with all the available therapies.
References
- M. S. Sommers, Davis’s Diseases and Disorders: A Nursing Therapeutics Manual. Philadelphia, UNITED STATES: F. A. Davis Company, 2022. Accessed: Sep. 11, 2023. [Online]. Available: http://ebookcentral.proquest.com/lib/usyd/detail.action?docID=7153300
- M. Hammoud and J. Gerken, ‘Inguinal Hernia’, in StatPearls, Treasure Island (FL): StatPearls Publishing, 2023. Accessed: Sep. 11, 2023. [Online]. Available: http://www.ncbi.nlm.nih.gov/books/NBK513332/
- B. Anitha, K. Aravindhan, S. Sureshkumar, M. S. Ali, C. Vijayakumar, and C. Palanivel, ‘The Ideal Size of Mesh for Open Inguinal Hernia Repair: A Morphometric Study in Patients with Inguinal Hernia’, Cureus, vol. 10, no. 5, p. e2573, doi: 10.7759/cureus.2573.
- R. G. Holzheimer, ‘Inguinal Hernia: classification, diagnosis and treatment--classic, traumatic and Sportsman’s hernia’, Eur J Med Res, vol. 10, no. 3, pp. 121–134, Mar. 2005.
- A. Pastorino and A. A. Alshuqayfi, ‘Strangulated Hernia’, in StatPearls, Treasure Island (FL): StatPearls Publishing, 2023. Accessed: Sep. 12, 2023. [Online]. Available: http://www.ncbi.nlm.nih.gov/books/NBK555972/
- C. D. Procter, ‘Inguinal Anatomy’, in Textbook of Hernia, W. W. Hope, W. S. Cobb, and G. L. Adrales, Eds., Cham: Springer International Publishing, 2017, pp. 29–33. doi: 10.1007/978-3-319-43045-4_5.
- K. K. Jensen, N. A. Henriksen, and L. N. Jorgensen, ‘Inguinal Hernia Epidemiology’, in Textbook of Hernia, W. W. Hope, W. S. Cobb, and G. L. Adrales, Eds., Cham: Springer International Publishing, 2017, pp. 23–27. doi: 10.1007/978-3-319-43045-4_4.
- P. Sanjay, J. l. Fulke, I. a. Shaikh, and A. Woodward, ‘Anatomical differentiation of direct and indirect inguinal hernias: Is it worthwhile in the modern era?’, Clinical Anatomy, vol. 23, no. 7, pp. 848–850, 2010, doi: 10.1002/ca.21022.
- F. Derbel, Hernia. 2017. doi: 10.5772/66025.
- G. Amato, ‘The Pelvis: Gender-Related Differences and Impact on Visceral Protrusion Disease’, in Inguinal Hernia: Pathophysiology and Genesis of the Disease, G. Amato, Ed., Cham: Springer International Publishing, 2022, pp. 15–21. doi: 10.1007/978-3-030-95224-2_2.
- M. L. Williams, A. G. Hutchinson, D. D. Oh, and C. J. Young, ‘Trends in Australian inguinal hernia repair rates: a 15-year population study’, ANZ Journal of Surgery, vol. 90, no. 11, pp. 2242–2247, 2020, doi: 10.1111/ans.16192.
- N. A. Henriksen, K. K. Jensen, and L. N. Jorgensen, ‘The Biology of Hernia Formation’, in Textbook of Hernia, W. W. Hope, W. S. Cobb, and G. L. Adrales, Eds., Cham: Springer International Publishing, 2017, pp. 1–5. doi: 10.1007/978-3-319-43045-4_1.
- M. Landin et al., ‘The effect of tobacco use on outcomes of laparoscopic and open inguinal hernia repairs: a review of the NSQIP dataset’, Surg Endosc, vol. 31, no. 2, pp. 917–921, Feb. 2017, doi: 10.1007/s00464-016-5055-y.
- A. Hemberg, H. Holmberg, M. Norberg, and P. Nordin, ‘Tobacco use is not associated with groin hernia repair, a population-based study’, Hernia, vol. 21, no. 4, pp. 517–523, Aug. 2017, doi: 10.1007/s10029-017-1617-8.
- H. Australia, ‘Laparoscopic inguinal hernia repair (TEP)’, Dec. 20, 2022. https://www.healthdirect.gov.au/surgery/laparoscopic-inguinal-hernia-repair-tep (accessed Sep. 11, 2023).
- M. G. E. O’Rourke and T. R. O’Rourke, ‘Inguinal hernia: aetiology, diagnosis, post-repair pain and compensation’, ANZ Journal of Surgery, vol. 82, no. 4, pp. 201–206, 2012, doi: 10.1111/j.1445-2197.2011.05755.x.
- R. J. Fitzgibbons et al., ‘Watchful Waiting vs Repair of Inguinal Hernia in Minimally Symptomatic MenA Randomized Clinical Trial’, JAMA, vol. 295, no. 3, pp. 285–292, Jan. 2006, doi: 10.1001/jama.295.3.285.
- B. P. Jacob and B. Ramshaw, The SAGES Manual of Hernia Repair. New York, NY, UNITED STATES: Springer, 2012. Accessed: Sep. 12, 2023. [Online]. Available: http://ebookcentral.proquest.com/lib/usyd/detail.action?docID=1030411
- Medtronic, ‘Treatment options’. https://www.medtronic.com/au-en/c/hernia/treatment-options.html (accessed Sep. 12, 2023).
- Z. F. Williams, W. B. Hooks, and W. W. Hope, ‘Emerging Technology: Robotic Inguinal Hernia Repair’, in Textbook of Hernia, W. W. Hope, W. S. Cobb, and G. L. Adrales, Eds., Cham: Springer International Publishing, 2017, pp. 129–135. doi: 10.1007/978-3-319-43045-4_16.
- A. I. Gilbert, J. Young, and R. Azuaje, ‘Overview of Modern Surgical Techniques in Inguinal Hernia Repair’, in Textbook of Hernia, W. W. Hope, W. S. Cobb, and G. L. Adrales, Eds., Cham: Springer International Publishing, 2017, pp. 41–42. doi: 10.1007/978-3-319-43045-4_7.
- ‘Timing of return to work after hernia repair: Recommendations based on a literature review | British Columbia Medical Journal’. https://bcmj.org/articles/timing-return-work-after-hernia-repair-recommendations-based-literature-review (accessed Sep. 12, 2023).
- R. Narkhede, N. M. Shah, P. R. Dalal, C. Mangukia, and S. Dholaria, ‘Postoperative Mesh Infection—Still a Concern in Laparoscopic Era’, Indian J Surg, vol. 77, no. 4, pp. 322–326, Aug. 2015, doi: 10.1007/s12262-015-1304-x.
- Medtronic, ‘About recovery’. https://www.medtronic.com/au-en/c/hernia/about-recovery.html (accessed Sep. 12, 2023).
- J. Burcharth, H.-C. Pommergaard, T. Bisgaard, and J. Rosenberg, ‘Patient-Related Risk Factors for Recurrence After Inguinal Hernia Repair: A Systematic Review and Meta-Analysis of Observational Studies’, Surg Innov, vol. 22, no. 3, pp. 303–317, Jun. 2015, doi: 10.1177/1553350614552731.
- I. N. Haskins and M. J. Rosen, ‘Inguinal Hernia Recurrence’, in Inguinal Hernia Surgery, G. Campanelli, Ed., in Updates in Surgery. Milano: Springer Milan, 2017, pp. 151–156. doi: 10.1007/978-88-470-3947-6_15.