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ACS

Adult Inguinal and Femoral Groin Hernia Repair

A hernia occurs when tissue bulges out through an opening in the muscles. Any part of the abdominal wall can weaken and develop a hernia, but the most common sites are the groin (inguinal), the navel (umbilical) and a previous surgical incision site. An inguinal hernia in the groin is more common in men. A femoral hernia may be at the upper leg, vaginal area or groin, and is more common in women.

Adult Inguinal and Femoral Groin Hernia Repair

Common Symptoms

  • Bulge in the groin, scrotum, or abdominal area that often increases in size with coughing or straining.
  • Mild pain or pressure at the hernia site.1
  • Numbness or irritation due to pressure on the nerves around the hernia.2
  • Sharp abdominal pain and vomiting can mean that the intestine has slipped through the hernia sac and is strangulated. This is a surgical emergency and immediate treatment is needed.

Treatment Options

Surgical Procedure

Open Hernia Repair

An incision is made near the site and the hernia is repaired with mesh or by suturing (sewing) the muscle closed.

Laparoscopic Hernia Repair

The hernia is repaired by mesh or sutures inserted through instruments placed into small incisions in the abdomen.

Nonsurgical Procedure

About 1/3 of groin hernia patients have no symptoms. Watchful waiting may be a safe option for adults who are not uncomfortable. Most men with an inguinal hernia need surgery due to increased pain with exercise, chronic constipation or urinary symptoms. 23% crossed over to surgery after 2 years and 50% after 5 years.2

Benefits and Risks of Your Operation

Benefits

An operation is the only way to repair a hernia. You can return to your normal activities and in most cases will not have further discomfort. Possible risks include—Return of the hernia; infection; injury to the bladder, blood vessels, intestines or nerves, difficulty passing urine, continued pain, and swelling of the testes or groin area.

Risks of Not Having an Operation

Your hernia may cause pain and increase in size. If your intestine becomes trapped in the hernia pouch you will have sudden pain, vomiting, and need an immediate operation.

Expectations

Before your operation—A physical examination is usually all that is needed to diagnose groin hernias.2 Evaluation may include blood work and urinalysis. Your surgeon and anesthesia provider will discuss your health history, home medications, and pain control options.

The day of your operation—You will not eat or drink for 4 hours before the operation. Most often you will take your normal medication with a sip of water. You will need someone to drive you home.

Your recovery—If you do not have complications you usually will go home the same day. You may return
to work after 1 to 2 weeks after laparoscopic or open repair, as long as you don’t do any heavy lifting.

Call your surgeon if you have:

  • Pain that will not go away
  • Pain that gets worse
  • A fever of more than 101°F or 38.3°C
  • Continuous vomiting
  • Swelling, redness, bleeding, or bad-smelling drainage from your wound site
  • Strong or continuous abdominal pain or swelling of your abdomen
  • No bowel movement by 2 to 3 days after the operation

Keeping You Informed

Who Gets Hernias?

There may be no cause for a hernia. The risk of developing an inguinal hernia is 3% for women and 27% for men.3 Inguinal hernias are 8-10 times more common in men.2 Some risk factors are:

  • Older age—muscles become weaker
  • Obesity—increased weight places
    pressure on abdominal muscle
  • Sudden twist, pulls, or strains
  • Chronic straining
  • Family history
  • Connective tissue disorders
  • Pregnancy—1 in 2,000 women develop a hernia during pregnancy.4

Other medical disorders that have symptoms similar to hernias include enlarged lymph nodes, cysts, and testicular problems such as scrotal hydrocele.

The Condition

A groin hernia occurs when the intestine bulges through the opening in the muscle in the groin area. A reducible hernia can be pushed back into the opening. When intestine or abdominal tissue fills the hernia sac and cannot be pushed back, it is called irreducible or incarcerated. A hernia is strangulated if the intestine is trapped in the hernia pouch and the blood supply to the intestine is decreased. This is a surgical emergency.6

There are two types of groin hernias:

An inguinal hernia (IH) appears as a bulge in the groin or scrotum. Inguinal hernias account for 75% of all hernias and are most common in men.2 A femoral hernia (FH) appears as a bulge in the groin, upper thigh, or labia (skin folds surrounding the vaginal opening). Femoral hernias are four times more common in women.7 They are always repaired because of a high risk of strangulation.2 Herniorraphy is the surgical repair of a hernia. Hernioplasty is the surgical repair of a hernia with mesh. 

The Procedure

Surgical Treatment

The type of operation depends on hernia size and location, and if it is a repeat hernia. Your health, age, anesthesia risk, and the surgeon’s expertise are also important. An operation is the only treatment for incarcerated/strangulated and femoral hernias.

Your hernia can be repaired either as an open or laparoscopic approach. The repair can be done by using sutures only or adding a piece of mesh.

Open Hernia Repair

The surgeon makes an incision near the hernia site and the bulging tissue is pushed back into the abdomen. Most inguinal hernia repairs use mesh to close the muscle and to decrease recurrence.2 An open repair can be done with local anesthesia.

For an open mesh repair: The hernia sac is removed. Mesh is placed over the hernia site. The placement of of mesh is the most agreed upon approach in IH repair.2 Mesh is often used for large hernia repairs and may reduce the risk that the hernia will come back. The site is closed using sutures, staples, or surgical glue.

For a suture-only repair: The hernia sac is removed. Then the tissue along the muscle edge is sewn together. This procedure is often used for strangulated or infected hernias or small defects (less than 3 cm).

Laparoscopic Hernia Repair

The surgeon will make several small punctures or incisions in the abdomen. Ports (hollow tubes) are inserted into the openings. The abdomen is inflated with carbon dioxide gas to make it easier to see the internal organs. Surgical tools and a laparoscopic light are placed into the ports. The hernia is repaired with mesh and sutured or stapled in place. The repair is done as a TransAbdominal PrePeritoneal (TAPP) procedure, which means the peritoneum (the sac that contains all of the abdominal organs) is entered, or the repair is done as a Totally ExtraPeritoneal (TEP) procedure.8

Nonsurgical Treatment

Watchful waiting is an option if you have an inguinal hernia with no symptoms.2 Hernia incarceration occurred in less than 1% of men who waited longer than 2 years to have a repair.9 Femoral hernias should always be repaired due to an increased risk of incarceration or strangulation and the risk is increased if the hernia is right-sided.10 Trusses or belts attempt to manage symptoms by applying pressure at the site however they are not recommended as they may cause complications like testicular nerve damage and incarceration.9

Common Tests

History and Physical Exam

The site is checked for a bulge. Other tests may include (see glossary):

  • Digital exam
  • Blood tests
  • Urinalysis
  • Electrocardiogram (ECG)—for patients over 45 or if high risk of heart problems
  • Ultrasound
  • Computerized tomography (CT) scan

Keeping You Informed

Open vs. Laparoscopic Incisional Repair

A laparoscopic repair of inguinal hernia may result in less pain and numbness, lower infection rate, and faster return to normal activity than open repair. When surgeons have experience with laparascopic repair, operation times, and complication rates compare to open suture repair. In follow-up after 48 months there was no difference in severe chronic pain and long-term recurrence between the types of repair.11

Repairing both sides of the hernia at the same time (bilateral repair) when done by an experienced laparoscopic surgeon has faster recovery, lower reports of chronic pain and is cost effective.12

Risks Based on the ACS Risk Calculator
Open and Laparoscopic Inguinal and Femoral Hernia Surgery from the ACS Risk Calculator—July 19, 2022

Risks

Percent for Average Patient

Keeping You Informed

Wound Infection: Infection at the area of the incision or near the organ where the surgery was performed

Open 0.4%

Laparoscopic 0.3%

Antibiotics and drainage of the wound may be needed. Smoking can increase the risk of infection.

Complications: Including surgical infections, breathing difficulties, blood clots, renal (kidney) complications, cardiac complications, and return to the operating room

Open 1.6%

Laparoscopic 1.5%

Complications related to general anesthesia and surgery may be higher in smokers, elderly and/or obese patients, and those with high blood pressure and breathing problems. Wound healing may also be decreased in smokers and those with diabetes and immune system disorders.

Pneumonia: Infection in the lungs

Open 0.1%

Laparoscopic 0.1%

Movement, deep breathing, and stopping smoking can help prevent respiratory infections.

Urinary tract infection: Infection of the bladder or kidneys

Open 0.2%

Laparoscopic 0.2%

Drinking fluids and catheter care decrease the risk of bladder infection.

Venous thrombosis: A blood clot in the legs that can travel to the lungs

Open 0.1%

Laparoscopic 0.1%

Longer surgery and bed rest increase the risk. Getting up, walking 5 to 6 times per day, and wearing support stockings reduce the risk.

Death

Less than 1%

Your surgical team is prepared for all emergency situations.

Risks from Outcomes Reported in the Last 10 years of Literature

Percent for Average Patient

Keeping You Informed

Chronic (long-term) pain

10% to 12% may have pain one year after surgery; possibly less with lapraoscopic 13

Factors contributing to chronic pain include emergency hernia repair, scrotal hernia, recurrent hernia repair, young age, female gender, perioperative pain, open hernia repair, perioperative complications, and penetrating mesh fixation.1 Pain caused by compression or tension may gradually decrease with time as a result of tissue rearrangement.14

Recurrence: A hernia can recur after the repair

All patients 1% to 17% 15

Open 4.9%

Laparoscopic 10.1%

Recurrence occurs less often when mesh is used versus non-mesh repair.16 Laparoscopic repair is recommended for recurrent hernias because the surgeon avoids previous scar tissue. There is a higher rate of recurrence in older men with laparoscopic repair.

Neuralgia: Nerve pain causing tingling or numbness

Open 10.7%

Laparoscopic 7.4%

Pressure, staples, stitches, or a trapped nerve in the surgical area can cause nerve pain. Tell your doctor if you feel severe, sharp, or tingling pain in the groin and leg immediately after your procedure; an operation may be required if the nerve is trapped.16

Seroma: A collection of clear/yellow fluid

5-25% 17

Seromas can form around the former hernia site. Removal of fluid with a sterile needle may be required.

Hematoma: a collection of blood in the wound site or scrotum

3.4% 18

Hematomas are treated with anti-inflammatory medications, elevation, and rest. Rarely blood replacement or further testing for a blood vessel injury is needed.

The ACS Surgical Risk Calculator estimates the risk of an unfavorable outcome. Data is from a large number of patients who had a surgical procedure similar to this one. If you are healthy with no health problems, your risks may be below average. If you smoke, are obese, or have other health conditions, then your risk may be higher. This information is not intended to replace the advice of a doctor or health care provider. To check your risks, go to the ACS Risk Calculator at http://riskcalculator.facs.org.

The Day of Your Procedure

Get the details you need about common procedures and know what to expect before you or a loved one has surgery.

Recovery and Discharge

Access resources and information you need to optimize your recovery from surgery.

Safe Pain Management

Your surgical team wants to help you to safely and effectively manage any pain that you may have after surgery.

Surgery FAQ

Answers to common questions surgical patients have before, during, and after a procedure.

Glossary

Advance directives: Documents signed by a competent person giving direction to health care providers about treatment choices.

Computerized tomography (CT) scan: A diagnostic test X ray and a computer to create a detailed, three-dimensional picture of your abdomen. A CT scan is commonly used to detect abnormalities or disease inside the abdomen. It is sometimes used to find a hernia not obvious during the physical exam.

Digital exam: The examiner will place their gloved index finger gently into the scrotal sac and feel up to the inguinal ring in the groin. Then the patient is asked to strain.

Electrocardiogram (ECG): Measures the rate and regularity of heartbeats and any damage to the heart.

General anesthesia: A treatment with certain medicines that puts you into a deep sleep so you do not feel pain during surgery.

Hematoma: A collection of blood that has leaked into the tissues of the skin or in an organ, resulting from cutting in surgery or the blood’s inability to form a clot.

Incarceration: The protrusion or constriction of an organ through the wall of the cavity that normally contains it.

Local anesthesia: The loss of sensation only in the area of the body where an anesthetic drug is applied or injected.

Nasogastric tube: A soft plastic tube inserted in the nose and down to the stomach which is used to empty the stomach of contents and gases to rest the bowel.

Seroma: A collection of serous (clear/yellow) fluid.

Strangulation: Part of the intestine or fat is squeezed in the hernia sac and blood supply to the tissue is cut off.

Ultrasound: Sound waves are used to determine the location of deep structures in the body. A hand roller is placed on top of clear gel and rolled across the abdomen. An ultrasound may be used to find a hernia that is not obvious during the physical exam.

Urinalysis: A visual and chemical examination of the urine, most often used to screen for urinary tract infections and kidney disease.

DISCLAIMER

The American College of Surgeons (ACS) is a scientific and educational association of surgeons that was founded in 1913 to improve the quality of care for the surgical patient by setting high standards for surgical education and practice. The ACS endeavors to provide procedure education for prospective patients and those who educate them. It is not intended to take the place of a discussion with a qualified surgeon who is familiar with your situation.  The ACS makes every effort to provide information that is accurate and timely, but makes no guarantee in this regard.

Reviewed and revised 2016, 2018 & 2022 by:
David Feliciano, MD, FACS
Mary Hawn, MD, FACS
Kathleen Heneghan, PhD, MSN, RN, FAACE
Nancy Strand, MPH, RN

References

The information provided in this report is chosen from recent articles based on relevant clinical research or trends. The research below does not represent all that is available for your surgery. Ask your doctor if he or she recommends that you read any additional research.

  1. Burcharth J, Pedersen M, Bisgaard T, et al. (2013) Nationwide prevalence of groin hernia repair. PLoS One 8(1):e54367. https://doi.org/10.1371/journal. pone.0054367
  2. HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018 Feb;22(1):1-165. doi: 10.1007/s10029-017-1668-x. Epub 2018 Jan 12. PMID: 29330835; PMCID: PMC5809582.
  3. Fitzgibbons RJ, Forse RA. Clinical practice. Groin hernias in adults. N Engl J Med. 2015;372:756–763.
  4. Buch KE, Tabrizian P, Divino CM. Management of hernias in pregnancy. J Am Coll Surg. 2008;207(4):539.
  5. Crawford P, et al. Evaluation of scrotal masses. American Family Physician. 2014;89:723. http://www.aafp.org/afp/2014/0501/p723.html. Accessed Feb. 26, 2017.
  6. Pastorino A, Alshuqayfi AA. Strangulated Hernia. [Updated 2021 Dec 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555972/
  7. Prospective evaluation of 6895 groin hernia repairs in women. Koch A, Edwards A, Haapaniemi S, etal. Br J Surg. 2005;92(12):1553.
  8. Yang XF, Liu JL. Laparoscopic repair of inguinal hernia in adults. Ann Transl Med. 2016 Oct;4(20):402. doi: 10.21037/atm.2016.10.37. PMID: 27867954; PMCID: PMC5107402.
  9. Berger D. Evidence-Based Hernia Treatment in Adults. Dtsch Arztebl Int. 2016 Mar 4;113(9):150-7; quiz 158. doi: 10.3238/arztebl.2016.0150. PMID: 26987468; PMCID: PMC4802357.
  10. Suppiah A, Gatt M, Barandiaran J, etal. (2007) Outcomes of emergency and elective femoral hernia surgery in four district general hospitals: a 4-year study. Hernia 11(6):509–512.
  11. Eklund AS, Montgomery AK, Rasmussen IC, etal. (2009) Low recurrence rate after laparoscopic (TEP) and open (Lichtenstein) inguinal hernia repair: a randomized, multicenter trial with 5-year follow-up. Ann Surg 249:33–38. https://doi.org/10.1097/SLA. 0b013e31819255d0
  12. Simons MP, Aufenacker T, Bay-Nielsen M et al (2009) European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 13:343–403. https://doi.org/10. 1007/s10029-009-0529-7
  13. Niebuhr H, Wegner F, Hukauf M, etal. What are the influencing factors for chronic pain following TAPP inguinal hernia repair: an analysis of 20,004 patients from the Herniamed Registry. Surg Endosc. 2018 Apr;32(4):1971-1983. doi: 10.1007/s00464-017-5893-2. Epub 2017 Oct 26. PMID: 29075969; PMCID: PMC5845068.
  14. Aasvang EK, Gmaehle E, Hansen J, etal. Predictive risk factors for persistent postherniotomy pain. Anesthesiology. 2010;112:957–969. doi: 10.1097/ALN.0b013e3181d31ff8.
  15. Itani K, Fitzgibbons R, Awad S et al. Management of recurrent inguinal hernias. Journal of the American College of Surgeons. 2009 Nov; 209(5):653-658. doi: 10.1016/j.jamcollsurg.2009.07.015. Epub 2009 Aug 20.
  16. Lockhart K, Dunn D, Teo S, etal. Mesh versus non-mesh for inguinal and femoral hernia repair. Cochrane Database Syst Rev. 2018 Sep 13;9(9):CD011517. doi: 10.1002/14651858.CD011517.pub2. PMID: 30209805; PMCID: PMC6513260.
  17. Dedemadi G, Sgourakis G, Radtke A, et al. Laparoscopic versus open mesh repair for recurrent inguinal hernia: a meta-analysis of outcomes. Am J Surg 2010;200:291-7.
  18. Wu J.J., Way J.A., Eslick G.D., Cox M.R. Transabdominal pre-peritoneal versus open repair for primary unilateral inquinal hernia: a meta-analysis. World J. Surg. 2018;42:1304–13011.