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 area [1].

 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 pressure [1].
• 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 scrotum [2].
• Pain or bruising in the area of the hernia after a period of exercise [1].

The size of the bulge varies between individuals but is often observed to be a few centimetres long but can be much smaller [3]. However, it should be noted that the size of the hernia is not always indicative of the severity of the hernia [4].

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 in [1]. 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 patients [7] as a result of increased abdominal pressure and thus, is sometimes referred to as an acquired hernia [6].

Indirect inguinal hernias occur when the abdominal contents protrude through the internal inguinal ring and into the inguinal canal [1]. In males, this protrusion may descend into the scrotum [1]. The cause of indirect inguinal hernias is often congenital (present from birth) and thus, is sometimes referred to as a congenital hernia [6].

Both direct and indirect hernias present similar symptoms and may be difficult to distinguish from symptoms alone [8]. However, it is not essential to differentiate between the two as the surgical repair is the same for both [2].

Inguinal hernias are the most common type of hernia, accounting for over two-thirds of all adult hernias [2], [9] and occurring in approximately 15% of the adult population [1].

Men are much more likely to develop an inguinal hernia than women, with males accounting for about 90% of all inguinal hernias [2]. The condition affects nearly 25% of men and less than 2% of women over their lifetime [2]. This is primarily due to anatomical differences between the pelvic bones of males and females [10].

Inguinal hernias can occur at any age, but most commonly occur during early childhood and late adulthood [11] and has the lowest occurrence during early adulthood [7]. 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 onwards [2], [7].

Primary risk factors include being male, older age, and obesity [1]. Having a history of inguinal hernias may also increase a person’s risk of developing an inguinal hernia [1]. A build-up of abdominal pressure through strenuous heavy lifting and straining to defecate (constipation) can also cause a hernia to occur [1]. Previous abdominal injuries (trauma) or abdominal surgeries are also risk factors as these events can weaken the abdominal muscles [1].

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 repair [12], [13]. This is because smoking compromises the capacity for wound healing in the abdominal tissues [12]. 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 recovery [13]. However, studies are still ongoing regarding the effect of smoking on inguinal hernia development due to conflicting results in recent studies [14]. Regardless, the current medical advice is to stop smoking to reduce the risk of developing inguinal hernia [15].

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 condition [16]. 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 development [16].

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 surgery [1], [15].

No, not all inguinal hernias require surgery, but the problem will not resolve on its own without surgery [1]. 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 worsen [17]. 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 mortality [1], [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 instead [18], [19]. Laparoscopic surgery is sometimes referred to as ‘keyhole surgery’. Open, laparoscopic and robotic approaches have shown long-term efficacy with low recurrence rates [20].

In Australia, the use of laparoscopic surgery has become increasingly popular due to its minimally invasive approach when compared with open surgery [11]. 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 rare [15]. The most common complications following surgery are chronic pain and hernia recurrence. Chronic pain is reported to occur in approximately 10% of cases overall [2] 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 experience [2], [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 testicle [15].

These issues are often rare but may be long-lasting without further intervention [18].

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 lung [15]. 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 exercise [15].

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 technique [11], [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 approaches [21], [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 hernias [2].

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 procedures [18], [23]. Thus, primary suture repair may be recommended over mesh repair if the surgical site is contaminated [2]. Recent advances in mesh technology aim to lower this infection rate [18].