Inguinal hernia

It usually presents as a lump in the groin that appears or becomes more prominent with exertion and may subside when lying down. Some hernias cause very little discomfort and can be monitored, whilst others require surgical repair due to their symptoms or characteristics.

What is an inguinal hernia?

An inguinal hernia occurs when abdominal fat or, occasionally, a section of the intestine protrudes through a weak spot in the abdominal wall in the groin area. This usually results in a bulge that becomes more prominent when standing, coughing or straining, and which may diminish or disappear when lying down.

When the contents of the hernia return to the abdomen spontaneously or through a gentle medical manoeuvre, it is referred to as a reducible hernia. This characteristic helps to assess its behaviour and to distinguish between a stable condition and one that requires more urgent attention.

There are two main anatomical types. An indirect inguinal hernia follows a natural pathway in the inguinal region that forms during development and which, in some people, remains an area of reduced strength. A direct inguinal hernia occurs through an area of the abdominal wall that weakens over time.

This distinction is important for the surgeon, but for the person with a hernia, it is usually more useful to know whether it causes symptoms, whether it can be reduced, whether it affects one or both groins, and which type of repair is most appropriate.

It is also important to distinguish it from a femoral or crural hernia, which forms very close by but through a different anatomical channel. This distinction is particularly important in women because, proportionally, femoral hernias are more common than in men and are more likely to become strangulated. For this reason, the international HerniaSurge guidelines on the treatment of inguinal hernias recommend paying particular attention to them both during diagnosis and when selecting a surgical procedure.

Symptoms of an inguinal hernia

The most characteristic sign is a lump in the groin which may become more visible when standing, coughing, bending over or straining. In some people it is virtually painless; in others it causes a sensation of heaviness, pressure, tightness or pain, particularly at the end of the day or after certain activities.

In men, larger hernias may descend into the scrotum. The size of the hernia, however, does not in itself predict how much discomfort it will cause: a small hernia may be painful, whilst a larger one may produce few symptoms.

The progression of the symptoms and their impact on walking, working, exercising or carrying out everyday activities are important factors when deciding on treatment.

When an inguinal hernia requires urgent attention

A hernia that usually slips back into the abdomen but suddenly becomes fixed and cannot be reduced requires urgent medical assessment, particularly if pain develops.

The 2023 HerniaSurge international update uses the term ‘acutely irreducible hernia’ to describe this situation. The reason for the urgency is that the trapped tissue may become compressed and, in certain circumstances, lose part of its blood supply.

When the blood supply to the hernia’s contents is compromised, this is referred to as strangulation. Severe or progressive pain, nausea or vomiting, abdominal distension or noticeable changes in the skin covering the lump raise concerns about this complication.

If there are no signs to suggest strangulation, the medical team may attempt to reduce the hernia using a carefully performed manoeuvre. If this is unsuccessful or there are signs of reduced blood supply, the updated HerniaSurge guidelines recommend urgent surgery.

Causes and risk factors for inguinal hernias

An inguinal hernia is not usually caused by a single factor. Its development reflects a combination of the anatomy of the region, the strength of the tissues forming the abdominal wall, and the changes these tissues undergo over the course of a person’s life.

Being male, age, family history and a previous hernia in the other groin are associated with an increased risk. Certain characteristics of the connective tissue — the tissue that provides strength and support to the abdominal wall — and some previous procedures, such as prostate surgery, may also play a role, as outlined in the international HerniaSurge guidelines.

In some indirect hernias, there is also an anatomical predisposition present from embryonic development. This does not mean that the hernia has to appear during childhood: this vulnerable area may become clinically apparent many years later.

Can lifting heavy weights cause an inguinal hernia?

Intense exertion can cause a hernia that was beginning to develop to become visible for the first time or to start causing discomfort, as it temporarily increases the pressure inside the abdomen.

The explanation, however, is usually more complex than a single instance of exertion. The 2025 review on inguinal hernias published in *Nature Reviews Disease Primers* describes an interaction between biological predisposition, characteristics of connective tissue and mechanical factors.

Therefore, noticing a lump after lifting a heavy object does not necessarily mean that this exertion is the sole cause of the hernia.

What other conditions or circumstances can cause similar symptoms?

Not every lump or pain in the groin is caused by an inguinal hernia. When the examination does not reveal an obvious hernia, the aim is to identify which structure is actually causing the symptoms.

A femoral hernia is one of the conditions of particular interest to recognise. Swollen lymph nodes, lipomas — benign accumulations of fat — and certain lesions in the scrotal region or the spermatic cord can also cause lumps.

When pain is the predominant symptom and there is no characteristic lump, muscles and tendons in the region, the hip joint or other musculoskeletal causes may be involved. In these situations, imaging tests are used to answer a specific clinical question, not simply to ‘look for a hernia’.

Treatment of an inguinal hernia

Treatment depends primarily on the symptoms caused by the hernia, its characteristics and the individual’s circumstances. The aim is to relieve any discomfort, prevent complications and repair the weak spot in the abdominal wall when the benefits of surgery outweigh the risks.

An established hernia cannot be closed using medication, exercise or a support belt. The only way to permanently repair the anatomical defect is through surgery. However, having a hernia does not necessarily mean that surgery is required straight away.

Watchful waiting in some men with few or no symptoms

In certain men with a hernia that produces no symptoms or causes minimal discomfort, a watch-and-wait approach may initially be considered.

For this option to be appropriate, the hernia must be easily reducible into the abdomen, must not significantly limit daily activities, and must not have characteristics that would warrant earlier surgery.

Watchful waiting does not mean ignoring the hernia. It involves monitoring how it behaves, seeking advice if symptoms change, and reconsidering surgery if pain develops, limitations increase, or the hernia no longer reduces normally.

In the INCA trial, which involved 12 years’ follow-up and was conducted among men aged 50 or over, a significant proportion of those who began with watchful waiting eventually underwent surgery, mainly because symptoms developed or worsened.

These results help to illustrate that watchful waiting can be a safe option in carefully selected patients, but it often postpones surgery rather than avoiding it altogether.

In non-pregnant women, the approach is usually different, due to the greater significance of femoral hernias and the higher risk of them becoming strangulated. For this reason, the international HerniaSurge guidelines generally favour elective repair once the diagnosis has been established.

What options are available when deciding to have surgery

When surgery is indicated, there are two main ways of accessing the hernia. One is open surgery, which involves an incision directly over the groin.

The other is laparoscopic surgery, which uses several small incisions and a camera to repair the hernia from the inside of the abdominal wall. In most adults, both open and laparoscopic surgery use a surgical mesh to reinforce the weakened area.

There is no single operation that is best for all hernias. The choice depends on whether it affects one or both sides, whether the patient has had previous surgery, the size and anatomy of the hernia, the patient’s previous operations, the most suitable type of anaesthesia, and the team’s experience with each technique.

What is a mesh used for?

Surgical mesh is a thin prosthesis designed to reinforce the area of the abdominal wall through which the hernia has developed. Rather than closing the defect by subjecting the tissues themselves to excessive tension, the mesh covers a wider area and provides support whilst the tissues heal around it.

For most adults requiring surgery, the 2023 HerniaSurge international update recommends mesh repair. Overall, this type of repair reduces the risk of the hernia recurring compared with techniques using sutures alone, whilst the use of mesh does not in itself imply a higher overall risk of chronic pain.

Not all meshes have the same characteristics, nor are they placed in the same way. The outcome depends both on the material and on where it is positioned, how it adapts to the anatomy, and the technique used to implant it.

Laparoscopic inguinal hernia surgery: TEP and TAPP

Laparoscopic surgery allows the hernia to be repaired via small incisions. A camera is inserted through one of these incisions, enabling the surgeon to work whilst viewing the inguinal region from the inside of the abdominal wall.

The two most commonly used laparoscopic techniques for repairing an inguinal hernia are known as TEP and TAPP.

TEP — totally extraperitoneal repair — is performed by creating a working space between the abdominal wall and the peritoneum, the thin membrane lining the inside of the abdominal cavity. In this way, the surgeon reaches the hernia site without deliberately entering the cavity containing the abdominal organs and places the mesh in a deep layer of the wall.

TAPP – transabdominal preperitoneal repair – begins by entering the abdominal cavity via laparoscopy. From there, the surgeon carefully opens the peritoneum to reach the space behind the hernia site, places the mesh and closes the peritoneum over it.

In both techniques, therefore, the aim is very similar: to repair the hernia from the inside of the abdominal wall and to place a wide mesh in a deep position. The main difference lies in the route used to reach that area.

For the patient, knowing which of the two acronyms will be used is usually less important than understanding why the surgical team considers that technique suitable for their hernia and what experience they have in performing it.

TEP and TAPP offer broadly comparable results when performed correctly. The choice between them depends mainly on the patient’s anatomy, surgical history and the surgeon’s experience.

What advantages can laparoscopic surgery offer?

When performed by a team with specific expertise, laparoscopic surgery may be associated with a faster recovery, less pain after the operation and a lower risk of persistent groin pain than the Lichtenstein open repair.

For this reason, the 2023 HerniaSurge update favours a laparoscopic or laparoendoscopic approach for many primary unilateral inguinal hernias where the necessary expertise and resources are available.

Laparoscopy can be particularly useful in certain situations. In a bilateral hernia, for example, it allows both sides to be repaired using the same small incisions.

It can also offer advantages when a hernia recurs after a previous open repair, as it allows access to the region from a different site to the one that has already been operated on. In women, it also offers the possibility of examining both the inguinal and femoral regions from the inside, which facilitates the identification of a possible femoral hernia.

These advantages do not mean that laparoscopy is necessarily the most suitable option for everyone.

When might open surgery be preferable?

In open surgery, the surgeon accesses the hernia via an incision made directly in the groin. The best-studied open mesh technique is the Lichtenstein repair. In this procedure, the hernia contents are returned to their correct position and a mesh is placed to reinforce the inguinal wall.

It remains a gold-standard technique and may be particularly suitable in certain circumstances. These include a history of previous pelvic or prostate surgery, certain very large hernias extending into the scrotum, or situations where it is preferable to perform the procedure under local anaesthesia.

Open surgery can be performed under local, regional or general anaesthesia, depending on the individual case. Laparoscopic TEP and TAPP repairs are usually carried out under general anaesthesia.

Therefore, the choice between laparoscopic and open surgery should not be framed in terms of which is ‘better’ in absolute terms. The most useful question is which offers the best balance between safety, recovery and the risk of recurrence for that specific hernia and that specific individual.

Mesh-free repair

Although mesh repair is the recommended option for most adults, there are selected patients for whom a repair using only the patient’s own tissues may be considered.

When opting for a mesh-free technique, the 2023 HerniaSurge update considers the Shouldice technique to be the alternative with the strongest scientific evidence.

This operation reconstructs and reinforces the inguinal wall using several suture lines, without implanting a prosthesis. Its outcome depends particularly on rigorous technical execution and the surgeon’s experience.

It should not be interpreted as an automatically simpler or safer alternative simply because it does not use mesh. The decision requires appropriate patient selection and a clear explanation of the advantages and limitations of both options.

Hernias on both sides

When inguinal hernias are present on both sides, laparoscopic surgery can repair both via the same abdominal incisions.

For this reason, the international HerniaSurge guidelines favour laparoscopic repair of primary bilateral hernias when the team has the necessary experience and resources.

When a hernia reoccurs

A hernia that reappears after surgery is known as a recurrent hernia. In such cases, it is particularly important to know how the initial operation was performed. Wherever possible, surgeons will attempt to access the hernia via a different route to avoid working on the same scarred tissue again.

Thus, where the first repair was performed via an open approach through the groin, a laparoscopic approach from the inner surface of the abdominal wall may be particularly appropriate. If the first operation was carried out using TEP or TAPP, an open repair is often considered.

This principle is set out in the international HerniaSurge guidelines. Recurrences following multiple operations require a highly individualised approach and specific expertise in abdominal wall surgery.

Persistent pain after surgery

It is normal to experience some discomfort during the first few days or weeks after an operation. However, it is a different matter if the pain persists for months and begins to limit your daily activities.

Clinical guidelines use the term ‘chronic post-operative inguinal pain’ to describe at least moderate pain related to the operation that affects normal activities and lasts for more than three months.

There may be various causes. These may include scarring, irritation of one of the nerves in the area, a recurrence of the hernia, certain aspects of the repair, or even a musculoskeletal cause unrelated to the operation.

Therefore, persistent pain does not automatically mean there is a problem with the mesh. When the discomfort is significant, the aim is to identify its cause before deciding on treatment.

The 2023 HerniaSurge update recommends a structured assessment of these cases and, where they are complex, evaluation by teams with specific expertise in post-hernia surgery pain.

Progression and prognosis of an inguinal hernia

An established inguinal hernia does not usually close spontaneously. Its course, however, varies: some remain virtually unchanged for years, whilst others gradually increase in size or begin to cause discomfort.

In men selected for watchful waiting, the progression of symptoms is one of the most useful factors in deciding when to reconsider surgery. An increase in pain or in limitations on daily activities is the main reason why many patients initially placed under watchful waiting eventually opt for surgery, as shown by the 12-year follow-up of the INCA trial.

When a planned repair is carried out using a carefully chosen and correctly performed technique, the outcome is usually favourable. The aim of the operation is not only to close the defect, but also to enable the patient to resume their usual activities with as little pain as possible and to reduce the risk of the hernia recurring.

As with any surgery, complications may arise, including haematoma, seroma — a temporary build-up of fluid —, infection, temporary difficulty urinating, recurrence or persistent pain.

The specific risk depends on the individual, the characteristics of the hernia and the procedure used.

Reducing the risk of an inguinal hernia

There is no proven way to prevent all inguinal hernias. Anatomy, age, sex, family history and the characteristics of connective tissue play an important role and are not factors that can be modified.

The 2025 review in *Nature Reviews Disease Primers* on inguinal hernias describes their origin precisely as the result of a complex interaction between biological predisposition and mechanical factors.

Maintaining good physical fitness and properly treating conditions that cause persistent coughing or problems such as constipation may be beneficial to general health, but should not be presented as a guarantee of hernia prevention.

Nor is there any basis for a general recommendation that a healthy person should avoid strength training for fear of developing a hernia. Once a hernia is present, activities can be adapted according to the level of discomfort until the most appropriate strategy is decided upon with a specialist.

Living with an inguinal hernia

Having an inguinal hernia does not necessarily mean you have to stop exercising or completely change your daily routine. If the hernia is being monitored, you can maintain an active lifestyle as long as the activities you undertake do not cause significant pain or prevent the hernia from reducing itself.

When a particular exercise, load or movement repeatedly causes discomfort, it is sensible to adapt it until a further assessment can be carried out. Activity should be adjusted according to your symptoms, not based on the assumption that any exertion will necessarily make the hernia worse.

Following an uncomplicated inguinal hernia repair, the international HerniaSurge guidelines recommend an active and progressive recovery. In general, normal activities can be resumed as and when they feel comfortable, without systematically imposing prolonged restrictions.

The pace of recovery is not the same for everyone. A large hernia extending into the scrotum, a hernia that has previously been operated on, or a more complex repair may require specific guidance.

A return to work also depends on the type of job. A sedentary job and one that involves heavy physical labour do not have the same requirements; therefore, the return to work is tailored to the patient’s progress and the nature of the operation.

Preguntas frecuentes

Does an inguinal hernia always need to be operated on?

Not necessarily at the time of diagnosis. In certain men with an asymptomatic hernia or one causing minimal discomfort, watchful waiting may be considered. Where there is significant pain, limitation of activities or certain characteristics of the hernia, surgical repair is usually the appropriate option. In women, the approach is usually more interventionist, given the need to take particular account of the possibility of a femoral hernia.

Can an inguinal hernia go away on its own?

It does not usually close up on its own. The lump may disappear when you lie down because its contents return to the abdomen, but the weak spot in the wall through which the hernia appears still remains.

What does it mean for a hernia to be strangulated?

This means that the tissue trapped inside the hernia is no longer receiving its normal blood supply. It is a complication that requires urgent attention. A hernia that suddenly becomes fixed and painful must be assessed without delay, particularly if it is accompanied by vomiting or abdominal distension.

Is it better to treat an inguinal hernia by laparoscopy or by open surgery?

It depends on the hernia and the individual. Laparoscopic surgery — primarily using the TEP and TAPP techniques — is usually associated with a quicker recovery and a lower risk of persistent pain when performed by an experienced team. However, there are situations in which an open repair may be more appropriate. Anatomy, previous operations and the surgeon’s experience all play a part in the decision.

What is the difference between TEP and TAPP?

These are two types of laparoscopic surgery for inguinal hernias. In TEP — totally extraperitoneal repair — the hernia is accessed without deliberately entering the abdominal cavity. In TAPP (transabdominal preperitoneal repair), the abdomen is first entered and, from there, the space where the mesh is placed is accessed. Both methods offer comparable results when correctly indicated and performed.

Do all inguinal hernia operations involve the use of a mesh?

No, although mesh repair is recommended for most adults as it reduces the risk of the hernia recurring. In carefully selected patients, a mesh-free repair may be considered; of these techniques, the Shouldice procedure currently has the strongest scientific evidence to support it.

Can the mesh cause pain?

Persistent pain following a hernia operation can have various causes and should not automatically be attributed to the mesh. Factors such as nerves in the area, scarring, a recurrence or other local problems may be involved. When the pain persists and limits your activity, you need a specific assessment.

Medical information for general guidance

An inguinal hernia is a common condition, but having a hernia does not in itself determine when or how it should be operated on. The diagnosis can usually be made through a clinical examination, and treatment is tailored to the individual based on their symptoms, the characteristics of the hernia and their personal circumstances. When repair is indicated, there are various options — open and laparoscopic — and the choice of technique forms part of an individualised surgical decision.

At the Publio Cordón Memorial Hospital, we believe it is important for medical information to be accurate, understandable and useful in guiding each person through their care journey. Our specialists devote part of their work to explaining conditions, tests and treatment options in an accessible way, helping patients and their families to better understand each stage and to participate with greater confidence in decisions about their health. This commitment to knowledge and public outreach is also part of our commitment to research and scientific dissemination.

This information outlines the general principles of diagnosis and treatment and is not a substitute for an individual assessment. A hernia that suddenly becomes irreducible, cannot be pushed back into place and begins to cause pain — particularly if accompanied by vomiting, abdominal distension or a general worsening of symptoms — requires urgent assessment.