Groin Hernia

A groin hernia is the protrusion of fatty tissue or part of the bowel from inside the abdomen through a weak point in the abdominal wall towards the groin. It is usually noticed as a swelling that becomes more obvious when standing, coughing or straining.

Hernias in the groin area are divided into two main groups:

• Inguinal hernia: Develops through the inguinal canal and is more common, particularly in men.
• Femoral hernia: Develops through a canal lower down, beneath the inguinal ligament. It is less common but relatively more frequent in women, and the risk of strangulation is higher.

A groin hernia can occur at any age. Although it is more common in men, it can also occur in women.

The hernia opening in the abdominal wall does not close with medicines, exercise or a support garment. A lasting anatomical repair can only be achieved with surgery. However, not every groin hernia needs to be operated on as soon as it is diagnosed. The decision on whether and when to operate is made according to the patient’s current complaints, clinical condition and the individual patient [1,2].

Most groin hernias are not an emergency. However, if the contents of the hernia become trapped and cannot return to the abdomen, “incarceration” can develop, and if the blood supply to the trapped bowel is impaired, “strangulation” can develop. Strangulation is a serious condition that requires emergency surgery.

What symptoms does a groin hernia cause?

The most common symptom is a swelling in the groin. This swelling:

• May become more obvious when standing.
• May get bigger with coughing, straining or heavy lifting.
• May get smaller or disappear completely when lying down.
• In some patients, can be gently pushed back in by hand.
• In men, may extend down into the scrotum.

The swelling may be accompanied by the following complaints:

• Pain in the groin
• A burning or stabbing sensation
• A feeling of heaviness and pressure
• Discomfort that increases after standing for a long time
• Pain during exercise
• An ache that increases with coughing or straining
• In men, discomfort spreading around the testicle

Small hernias sometimes show themselves only with pain, without causing a swelling. However, not every groin pain is caused by a hernia.

Why does a groin hernia develop?

The structure of the tissues of the abdominal wall and the natural openings in the inguinal canal play an important role in the development of a groin hernia. Some people may have an inborn predisposition; other hernias appear as a result of connective tissue weakening with age.

Factors that can increase the risk or contribute to an existing hernia becoming more obvious are:

• Male sex
• Older age
• A family history of groin hernia
• Diseases affecting the structure of connective tissue
• Smoking
• Chronic cough
• Long-term constipation and straining
• Straining when passing urine
• Previous hernia surgery on the other side of the groin
• Certain abdominal and prostate operations
• Heavy physical work

Heavy lifting on its own does not always cause a hernia. However, if there is already a weakness or a small hernia in the abdominal wall, it can make the swelling and complaints more obvious.

Is an examination enough?

In most patients, a groin hernia can be diagnosed by examination. The doctor assesses the groin area while you are standing and lying down. You may be asked to cough or strain to see whether the swelling appears.

In men, whether the swelling extends into the scrotum is assessed in particular, and in women, the possibility of a femoral hernia.

When is ultrasound needed?

If a clear hernia is found on examination, ultrasound is not needed in every patient.

Ultrasound may be requested in the following situations:

• The swelling cannot be seen during the examination
• The hernia cannot be clearly identified despite groin pain
• A small or deep-lying hernia is suspected
• The possibility of a lymph node, enlarged vein or another lump in the groin
• A femoral hernia is suspected in women
• Recurrence after surgery is suspected

Performing the ultrasound dynamically, while standing and during movements such as coughing and straining, can increase the chance of a successful diagnosis.

Is an MRI or computed tomography needed?

If a hernia is still suspected despite the examination and ultrasound results, a dynamic MRI can be used. Computed tomography can be useful particularly in emergencies, or when bowel obstruction or another abdominal disease is suspected.

Seeing a small hernia on imaging does not mean that the groin pain is necessarily caused by that hernia. Hip joint diseases, muscle and tendon strains, nerve entrapment, urinary tract problems and lymph nodes can also cause groin pain.

Should every groin hernia be operated on?

For groin hernias that cause symptoms, planned surgical repair is generally recommended. Pain, growth, limitation of daily activities or difficulty pushing the hernia back in support a decision to operate.

However, the treatment of the hernia can differ according to sex and the characteristics of the patient.

In which patients can monitoring be considered?

In male patients who have no complaints or only very mild complaints, whose daily activities are not affected and whose hernia goes back in easily, a “watchful waiting” approach may be used.

If this approach is chosen, the patient should be told:

• That the hernia may get bigger over time
• That pain may develop
• Which symptoms should prompt them to seek early medical attention
• The signs of emergency trapping

Long-term studies show that a large proportion of these men eventually have surgery because of pain or growth. In a twelve-year follow-up, about two-thirds of the men who were monitored later went on to have surgery [3].

Monitoring therefore does not make the hernia heal; it means postponing surgery until complaints develop.

Is monitoring appropriate in women?

When a hernia is found in the groin area in women who are not pregnant, long-term monitoring is generally not recommended. In women, the likelihood of a femoral hernia and the risk of emergency trapping are higher than in men.

For this reason, timely planned surgery is recommended in women and, where possible, laparo-endoscopic methods that assess both the inguinal and femoral openings in the groin together [1,2].

Some groin swellings that appear during pregnancy are not true hernias but may be widened veins of the round ligament of the womb. In pregnant women, the treatment decision should be made through a joint assessment by obstetrics and gynaecology and surgical specialists.

Is mesh used in groin hernia surgery?

Today, most adult groin hernias are repaired tension-free using a synthetic mesh.

The mesh:

• Supports the weak area in the abdominal wall over a wide surface.
• Reduces the need to stretch tissues and stitch them together.
• Lowers the risk of recurrence when used with an appropriate technique.

The type and size of the mesh and the method of placing it are determined according to the surgical technique and the patient’s characteristics.

The mesh is a foreign material and can rarely lead to infection, chronic pain, shrinkage or problems involving the surrounding tissues. However, when used in a suitable patient and with the correct technique, its benefits generally outweigh its risks [1,2].

Can the operation be done without mesh?

Operations without mesh, using the person’s own tissues, can be performed in selected patients. In current guidelines, the non-mesh method with the strongest evidence is the Shouldice repair.

A non-mesh repair may be considered in selected patients:

• Who do not want mesh to be used
• Who have suitable hernia and tissue characteristics
• In whom the use of mesh may be inadvisable because of infection
• Who have access to a surgeon experienced in this technique

A non-mesh operation is not suitable for every patient. The results depend significantly on the surgeon’s experience with it [1].

How is open groin hernia surgery performed?

In an open repair, an incision is made in the groin. The hernia sac is placed back into the abdomen and the weak area is usually reinforced with mesh.

One of the most commonly used open methods is the Lichtenstein repair.

Open surgery may be preferred:

• For some hernias on one side only
• In patients for whom general anaesthesia carries a risk
• For large hernias extending into the scrotum
• In patients who have previously had certain operations in the lower abdomen
• In situations not suitable for the keyhole method

In suitable patients and with experienced teams, an open repair can be performed under local or regional anaesthesia.

How is keyhole groin hernia surgery performed?

In keyhole surgery, the area behind the abdominal wall is reached through a few small incisions with a camera and fine surgical instruments. The contents of the hernia are put back in place and the weak area in the groin is supported from the inside with a large mesh.

There are two main laparo-endoscopic methods:

• TEP: The repair is performed in the space between the abdominal wall and the peritoneum (the lining of the abdomen), without entering the abdominal cavity.
• TAPP: The abdominal cavity is entered, then the peritoneum is opened, the hernia area is repaired and the peritoneum is closed again.

Both TEP and TAPP are effective and safe in experienced hands. Which method is used is determined according to the patient’s characteristics and the surgeon’s experience [1].

What are the advantages of keyhole surgery?

• Less pain in the early period
• A quicker return to daily activities
• A reduced risk of chronic pain
• It may offer advantages such as being able to assess both sides of the groin through the same incisions.

Keyhole repair may be preferred particularly:

• For hernias on both sides
• For hernias that recur after previous open surgery
• For groin hernias in women
• In suitable patients who want to return quickly to daily life

However, it requires general anaesthesia and has its own specific risks, such as injury to abdominal organs or blood vessels. The results depend on the surgeon’s experience in laparo-endoscopic hernia surgery.

Is robotic surgery necessary?

Groin hernia repair can also be performed using the robotic method. The basic principle of repair is similar to the keyhole TAPP method.

Robotic surgery may offer some technical advantages, but it is not necessary for every groin hernia. Current evidence does not show that the robotic method provides a clear advantage in every patient over experienced laparoscopic repair for standard, uncomplicated groin hernias.

In choosing the method, the surgeon’s experience, correct patient selection and a safe repair matter more than the technology used.

Which method is chosen for a recurrent hernia?

Generally, a method outside the previously used surgical plane is preferred:

• If the hernia was previously repaired with an open anterior approach, TEP or TAPP may be considered for the recurrence.
• If the hernia was previously repaired with TEP or TAPP, an open anterior approach may be preferred for the recurrence.

It is advisable for hernias that have recurred more than once or are accompanied by chronic pain to be assessed at experienced hernia centres [1,2].

How is emergency hernia surgery performed?

If the contents of the hernia have become trapped or the blood supply to the bowel is impaired, emergency surgery is needed.

During the operation:

• The trapped tissue is freed.
• The blood supply to the bowel is assessed.
• If part of the bowel is no longer viable, it may be removed.
• The hernia opening is repaired.

Whether mesh is used is determined according to bowel damage, infection and the degree of contamination in the operating area.

Related operationHernia Repair →Read how the operation is performed and what recovery involves →

How long do you stay in hospital?

Most uncomplicated groin hernia operations can be performed as day surgery. The patient can be discharged on the same day. In the case of older age, other illnesses, a large hernia or emergency surgery, the hospital stay may be longer.

Which complaints can be normal after the operation?

In the first days, the following may occur:

• Pain at the incision site
• Mild swelling
• Bruising
• A feeling of hardness in the groin
• In men, bruising or swelling of the scrotum
• Temporary fluid collection where the hernia was

A fluid collection at the hernia site is called a seroma. It can occur particularly after large hernias and may feel to the patient as if the hernia has come back. Most seromas shrink on their own over time; not every seroma needs to be drained with a needle.

When can I walk after the operation?

Patients can usually start walking on the day of the operation. Early movement:

• Reduces the risk of blood clots.
• Helps bowel movements to start.
• Speeds up the return to daily life.

Climbing stairs, sitting down and standing up and light daily tasks can be done as far as pain allows.

Do I need to wait 4–6 weeks before heavy lifting?

After an uncomplicated groin hernia repair, there is no strong scientific evidence supporting a strict 4–6-week ban on activity that applies to everyone.

Current guidelines support patients returning early to normal daily activities as far as pain allows [2]. Walking and light tasks can be started straight away.

Heavy lifting and intensive exercise should be increased gradually according to:

• The surgical method
• The size of the hernia
• The patient’s pain
• The physical demands of the job
• The surgeon’s assessment during the operation

Movements that cause pain or marked strain in the groin should not be forced. For large, recurrent or emergency hernias, or those extending into the scrotum, longer restrictions may be needed.

When can I return to work?

In most patients, a return to desk work or light work may be possible within a few days to 1–2 weeks.

For jobs that require heavy lifting, the time to return may be longer. There is no single mandatory period for returning to work; a personal plan should be made according to the surgical method, the level of pain and the nature of the work.

Can there be chronic pain after the operation?

Pain in the first weeks after the operation is expected. Pain that lasts longer than three months and affects daily life is regarded as chronic post-operative groin pain.

The risk of chronic pain may be higher:

• In people who had severe pain before the operation
• In younger patients
• In women
• With recurrent hernias
• In people who have severe pain in the early period after the operation

If there is burning, stabbing, numbness or pain spreading to the testicle that lasts longer than three months, assessment is needed. Treatment may include medicines, physiotherapy, nerve blocks and, in selected patients, surgical options [1,2].

Which symptoms mean I should see a doctor?

After the operation, you should contact the healthcare team in the following situations:

• Pain that keeps getting worse or does not go away despite painkillers
• High fever
• Increasing redness or pus-like discharge at the incision site
• Persistent nausea and vomiting
• Marked swelling of the abdomen
• Being unable to pass urine
• Rapidly increasing swelling or severe pain in the testicle
• Shortness of breath or one-sided swelling of the leg

1. Stabilini C, van Veenendaal N, Aasvang E, et al. Update of the International HerniaSurge Guidelines for Groin Hernia Management. BJS Open. 2023;7(5):zrad080. https://pmc.ncbi.nlm.nih.gov/articles/PMC10588975/
2. The HerniaSurge Group. International Guidelines for Groin Hernia Management. Hernia. 2018;22:1–165. https://pmc.ncbi.nlm.nih.gov/articles/PMC5809582/
3. Van den Dop LM, Sneiders D, Kleinrensink GJ, et al. Twelve-Year Outcomes of Watchful Waiting Versus Surgery of Mildly Symptomatic or Asymptomatic Inguinal Hernia in Men Aged 50 Years and Older: A Randomised Controlled Trial. eClinicalMedicine. 2023;65:102292. https://pmc.ncbi.nlm.nih.gov/articles/PMC10626166/
4. Yeow M, Aiolfi A, Lomanto D, et al. Watchful Waiting to Surgery in Men with Mildly Symptomatic or Asymptomatic Inguinal Hernia: Individual Participant Data Meta-analysis of Long-term Follow-up of Randomised Controlled Trials. Hernia. 2024;28:1909–1914. https://pubmed.ncbi.nlm.nih.gov/39046678/