When is surgery required for an inguinal hernia?
A diagnosis of an inguinal hernia usually raises an immediate question: does it need to be operated on?
Surgery is the treatment that repairs the defect in the abdominal wall causing the hernia, but the discovery of a hernia does not necessarily mean that surgery is required straight away. In some patients, there are clear reasons to consider repair; in others, particularly where symptoms are minimal, it may be reasonable to monitor the condition.
International guidelines recommend surgical treatment for symptomatic inguinal hernias and accept a watch-and-wait approach for certain men with asymptomatic or minimally symptomatic hernias. The decision therefore depends on more than just the mere presence of a hernia.
As Dr Jorge Martín Gil, head of the Abdominal Wall Unit at the Publio Cordón Memorial Hospital, explains: ‘Diagnosing a hernia and deciding that it needs to be operated on are two related issues, but they are not exactly the same. The indication depends on the symptoms, how the hernia is progressing and the circumstances of each patient.”
This distinction is important because it allows surgery to be approached on a case-by-case basis: neither operating automatically upon any diagnosis, nor waiting without assessing what might happen over time.
What makes it advisable to have surgery for an inguinal hernia?
Symptoms are one of the main factors influencing the decision to have surgery.
The most obvious is pain, although an inguinal hernia does not always present as severe pain. It can cause a feeling of heaviness, tightness or pressure in the groin; discomfort when walking, standing for long periods, exercising, coughing or straining; or simply a lump that becomes more noticeable by the end of the day.
Rather than the mere presence of a symptom, what matters is how it develops and to what extent it affects the person’s life.
Dr Martín Gil emphasises precisely this point: ‘We do not simply assess whether the hernia is painful or how large it is. We are interested in knowing whether the discomfort is increasing, whether it occurs with increasingly minor exertion, or whether the patient is beginning to restrict activities that they previously carried out without difficulty’.
A hernia that gradually forces a person to give up sport, alters their work activities or causes increasingly frequent discomfort does not present the same situation as one that is barely noticeable and remains stable.
Nor is there a specific size at which all hernias must be operated on. Anatomy matters, but it must be interpreted in conjunction with the symptoms, the physical examination and the patient’s overall condition.
Hence, for the specialist, the decision to operate is a broader clinical judgement: “Surgery makes sense when we expect that repairing the hernia will provide the patient with a benefit that justifies the procedure. That decision should not be based on a single piece of information, but on the overall assessment.”
Would you like more information about inguinal hernias and your treatment options?
If the hernia isn’t painful, can you wait?
In certain patients, yes. An inguinal hernia occurs because there is a weak spot in the abdominal wall through which abdominal tissue protrudes. In adults, this defect does not usually disappear spontaneously. Therefore, keeping a hernia under observation does not mean that it will heal on its own, but rather that there may not be sufficient reason to operate at that stage.
The strategy known as ‘watchful waiting’ has mainly been studied in men with asymptomatic inguinal hernias or those with minimal symptoms. In this group, it can be a safe option when the patient has been properly assessed and is aware of the changes that should prompt them to seek further consultation.
Here, Dr Martín Gil points out, it is important to understand exactly what ‘waiting’ really means: ‘Monitoring a hernia does not mean forgetting about it. It means that, at that moment, we may not have sufficient grounds for surgery, but we know which symptoms or changes would make it advisable to reassess the need for surgery’.
This clarification avoids two extremes: thinking that every hernia must be operated on immediately, or assuming that, if it causes little discomfort, it can be ignored indefinitely.
Could a hernia that does not require surgery today need it later on?
Yes, and this is one of the issues that should be explained from the outset. Studies with long-term follow-up show that a considerable proportion of men initially placed under watch end up undergoing surgery as the years go by.
A meta-analysis published in 2024, which pooled the long-term follow-up data from three randomised clinical trials, found that approximately 29 per cent of men initially managed by watchful waiting had undergone surgery within one year, around 52 per cent within five years, and 71 per cent within ten years. The most common reason was increased pain.
This does not mean that waiting was the wrong decision. It means that the clinical situation can change.
Dr Martín Gil sums it up in a way that is particularly helpful for patients: ‘Just because there is no clear indication for surgery today does not mean that decision has to remain in place forever. If the hernia changes or begins to cause significant symptoms, the balance between waiting and intervening may also shift.’
Monitoring and surgery are not necessarily opposing or definitive decisions. In some patients, they represent different stages of the same process.
What changes should prompt a follow-up consultation?
Increased pain is the most common reason why people initially placed under surveillance end up opting for surgery. But it is not the only significant change.
It is also advisable to seek a further assessment if the discomfort occurs more frequently, if the hernia begins to restrict activities that could previously be carried out normally, or if the behaviour of the lump changes from what is usual.
Many hernias are reducible, meaning they shrink when the patient lies down or their contents return to the abdomen either spontaneously or through gentle manipulation. This is a factor the surgeon takes into account, although it does not in itself determine the need for surgery.
As Dr Martín Gil points out: ‘The patient should not necessarily wait until they are in severe pain. If the hernia starts to affect their daily life, changes from how it was before, or raises concerns about its progression, it is a good time to have it reassessed.’
In some cases, a clinical examination is sufficient. In others, it may be useful to carry out imaging tests to confirm the diagnosis or gain a better understanding of the hernia’s anatomy.
If surgery is required, what role does laparoscopic surgery play?
Once the need for surgery has been established, a second important decision arises: how to repair the hernia.
Currently, there are open approaches and minimally invasive techniques. Among the latter, laparoscopic surgery for inguinal hernias plays a prominent role, allowing the repair to be carried out via small incisions, using a camera and specific surgical equipment.
The two most commonly used laparoscopic techniques are known as TEP and TAPP. Both allow access to the region where the defect is located and enable the placement of wall reinforcement from a posterior approach, although they reach this space via different anatomical routes. The choice between the two depends on the characteristics of the hernia, the patient’s medical history and the experience of the surgical team.
It is not necessary for the patient to be aware of all the technical details in advance. The important thing is to understand that, when a hernia requires repair, the choice of approach forms part of the surgical indication itself.
As Dr Martín Gil explains: ‘Once we have decided that a hernia requires surgery, the next question is what is the best way to repair it in that particular patient. Not all hernias are the same, and there is no single technique that should be applied automatically to all cases.’
Laparoscopic surgery is particularly relevant because recent evidence has demonstrated advantages in certain patients. The updated HerniaSurge international guidelines state that, when performed by surgeons with specific expertise, laparoendoscopic techniques are associated with less post-operative pain and a lower incidence of chronic pain, as well as a faster recovery, whilst maintaining comparable results in terms of recurrence compared with the standard open repair.
For this reason, the guidelines currently recommend a laparoendoscopic approach for many patients with a primary unilateral inguinal hernia where sufficient experience and the necessary resources are available, although certain characteristics of the patient or the hernia itself may make an open repair preferable.
For Dr Martín Gil, this individualised approach is essential: “Laparoscopy offers us a very useful approach to inguinal hernia surgery and, when properly indicated, can promote a faster recovery and reduce the post-operative impact. But its main value lies in using it on the right patient and with a correctly performed technique’.
The Abdominal Wall Unit at the Publio Cordón Memorial Hospital offers both open surgery and minimally invasive techniques, employing various laparoscopic approaches, including TEP and TAPP, and selecting the approach based on the type of defect and the characteristics of each patient.
This specific article will explain in greater depth the differences between TEP and TAPP, for which patients they may be particularly useful, and what the recovery is like, without straying from the main question here: when is surgery warranted?
Is the recommendation the same for men and women?
No.
This distinction is particularly important because the evidence supporting watchful waiting stems primarily from studies conducted on men with asymptomatic or minimally symptomatic inguinal hernias.
In a woman with a lump or hernia in the groin area, particular consideration should be given to the possibility of a femoral or crural hernia, which occurs in an area very close to the inguinal region and can be difficult to distinguish by physical examination alone.
A femoral hernia carries a higher risk of incarceration and strangulation. For this reason, international guidelines recommend a different approach to inguinal hernias in women and do not permit the watch-and-wait strategy studied in men to be simply applied to them.
Dr Martín Gil emphasises this difference: ‘We should not treat the absence of pain as a general rule for deciding that a wait-and-see approach is appropriate. In a woman, for example, we must pay particular attention to the possibility of a femoral hernia, because its behaviour and risk of complications are different.’
When does an inguinal hernia become a medical emergency?
Most inguinal hernias can be assessed and, where appropriate, treated by elective surgery. There is, however, one exception: when the hernia’s contents become acutely trapped and cannot be pushed back into the abdomen.
If, in addition, the blood supply to the trapped tissue is compromised, strangulation may occur, requiring urgent surgical intervention.
Dr Martín Gil explains why this change necessitates a different approach: ‘What concerns us most is that the hernia’s contents become trapped and their blood supply may be compromised. At that point, we are no longer faced with the decision of when to schedule surgery, but with a potential medical emergency’.
Sudden, severe pain – particularly if the lump becomes hard, very painful or can no longer be pushed back in – requires immediate medical assessment. The onset of nausea, vomiting, abdominal distension or significant changes in bowel movements raises concerns about a possible complication.
So, when is the best time to have surgery?
There is no single date, age or hernia size that can be applied as a rule to everyone.
When significant symptoms are present, and these are progressing or beginning to restrict normal activity, elective repair becomes the most sensible option. On the other hand, certain men with asymptomatic or minimally symptomatic hernias may initially be monitored if they have been properly selected and informed.
General health, other medical conditions, anaesthetic and surgical risks, the patient’s activity level and personal preferences must also be taken into account.
Therefore, seeing a surgeon does not necessarily mean leaving the consultation with a date set for surgery. The assessment also helps to determine whether it is still reasonable to wait and, when surgery is indicated, to choose between the various surgical options, including laparoscopic surgery.
For Dr Jorge Martín Gil, both decisions form part of the same process: ‘First, we must determine whether that patient needs surgery and what the appropriate time is. When the answer is yes, then we can decide which approach offers the best balance between effectiveness, safety and recovery for their specific case.’
This is the principle on which the Abdominal Wall Unit at the Publio Cordón Memorial Hospital is organised: first establishing a precise indication and then selecting the most appropriate approach. The Unit itself incorporates minimally invasive and laparoscopic techniques such as TEP and TAPP into its range of treatment options.
For anyone who has just been diagnosed, this may be the most useful piece of advice: an inguinal hernia should not be operated on simply because it is there, but nor is it advisable to decide to wait just because it is causing little discomfort at present. And, when the time comes for surgery, the method used must also be tailored to the individual.
Informative medical content
This content is for general information purposes only and has been prepared solely for informational purposes. It is not a substitute for an individual medical assessment and should not be used to establish a diagnosis or decide on a course of treatment.
The decision to operate on an inguinal hernia and the choice between an open or minimally invasive approach depend on the symptoms, the characteristics of the hernia, its progression and the clinical condition of each patient. If you experience new symptoms, a worsening of symptoms or have any concerns about your condition, you should consult a qualified healthcare professional. Symptoms consistent with an acute complication require urgent medical assessment.
The information in this article is provided for general awareness and does not replace an individualised medical assessment.
