From Clinic to Recovery · First Edition
Chapter 06 — Groin Hernia Repair: Inguinal and Femoral Hernias
Dr. Tamer Rushdy Elalfy · 21 min read
In this chapter
Groin hernia repair is one of the most common operations in the world, and most patients meet the surgeon first in the outpatient clinic, often with a painless lump and a long list of questions. Does it need an operation at all? Is the mesh safe? Keyhole or open? When can I lift, pray, or go back to work? The answers have changed over the last decade: watchful waiting is now an accepted option for some men, mesh repair is the standard, and long periods of restricted activity are no longer advised. This chapter applies the five-step method to inguinal and femoral hernias, with a short section on umbilical and epigastric hernias.
Learning objectives After reading this chapter you should be able to:
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Table 6.1. Groin hernia repair at a glance.
| At a glance | |
|---|---|
| Operation | Mesh repair of the groin hernia, by keyhole (laparoscopic) or open technique |
| Anesthesia | General for keyhole repair; local, regional, or general for open repair |
| Hospital stay | Day surgery for most patients |
| Back to light work | Usually within about 1 week; guided by comfort |
| Risks every patient should hear | Bruising and swelling, chronic groin pain, recurrence, and difficulty passing urine |
| The key counseling message | “A hernia does not heal on its own, but it is rarely dangerous. Repair is safe, and you can return to normal activity as soon as you are comfortable.” |
STEP 1 Explaining the hernia and the operation
6.1 Who needs repair, and how soon
Most groin hernias slowly enlarge and become more uncomfortable, but strangulation is uncommon. For men with an inguinal hernia that causes few or no symptoms, watchful waiting is a safe option. In a randomized trial, acute incarceration occurred in about 1.8 per 1,000 patient-years, and about a quarter of men in the waiting group had chosen surgery by 2 years [1]. With longer follow-up, however, about 68 in 100 had crossed over to repair by 10 years, and about 79 in 100 of men older than 65, most often because of pain [2]. Patients who choose to wait should know that they will probably need the operation later.
Women and patients with a femoral hernia are different. Femoral hernias carry a higher risk of strangulation and should be repaired promptly; in women, a femoral hernia is easily mistaken for an inguinal one, and a keyhole approach, which allows both openings to be inspected, is preferred [3, 4]. A hernia that is hard, painful, and cannot be pushed back needs emergency assessment. Figure 6.1 summarizes the decision.
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 6.1. Deciding with the patient whether and when to repair a groin hernia.
6.2 The counseling script
Script: explaining the hernia and the operation What a hernia is. “The muscle wall of the groin has a natural weak spot. A hernia is a gap in that spot. Fat or a loop of bowel pushes through and makes the lump you can feel, especially when you stand, cough, or strain.” Why it will not go away. “A hernia does not heal by itself. It usually grows slowly and becomes more uncomfortable. Rarely, bowel can get stuck in it, which is an emergency.” The mesh. “We close the gap and cover it with a mesh, a thin, flexible surgical net. Your own tissue grows into it and makes the wall strong. It greatly reduces the chance of the hernia coming back.” How it is done. “There are two good ways. With keyhole surgery we make three small cuts and place the mesh from inside, under a general anesthetic. With open surgery we make one cut of about 6 to 8 cm in the groin, and it can be done while you are awake with a local anesthetic. Most people go home the same day.” What could change. “Sometimes we find a hernia on the other side as well, or a different type of hernia. With your agreement, we repair what we find. Rarely, a keyhole operation needs to be changed to an open one.” |
6.3 Choosing the technique
Mesh repair is recommended for adult inguinal hernias, and both the open Lichtenstein operation and the keyhole operations (totally extraperitoneal or transabdominal preperitoneal repair) are supported by strong evidence [3]. When the surgeon has the expertise, keyhole repair causes less early pain and less chronic pain, and allows a faster return to activity; open repair can be done under local anesthesia and avoids general anesthesia [3, 4]. Table 6.2 helps patients compare the two. For patients who decline mesh, a tissue repair such as the Shouldice operation is an option in experienced hands.
Table 6.2. Keyhole and open groin hernia repair compared, for use with patients.
| Keyhole repair | Open repair | |
|---|---|---|
| Cuts | Three small cuts | One cut of about 6 to 8 cm in the groin |
| Anesthesia | General | Local, regional, or general |
| Early pain and recovery | Usually less pain and a faster return | A little more pain in the first week |
| Long-term groin pain | Less common | More common, though usually mild |
| Recurrence | Similar in experienced hands | Similar in experienced hands |
| Particularly suits | Hernias on both sides, recurrence after open repair, women | Patients unfit for general anesthesia, previous lower abdominal surgery, patient preference |
Script: answering worries about mesh “Many people have read about problems with mesh used for bladder and pelvic surgery in women. That is a different product in a different part of the body. Mesh for hernias has been used safely for decades in millions of people, and international guidelines recommend it because it greatly lowers the chance of the hernia coming back. Serious mesh problems, such as infection needing removal, are rare. If you would still prefer no mesh, we can discuss a stitched repair.” |
6.4 Umbilical and epigastric hernias: what changes
The same principles apply to hernias at or above the belly button, with three differences. First, a mesh is recommended for most repairs because it lowers recurrence, and most can be repaired by an open approach with a flat mesh placed behind the muscle; keyhole repair is considered for large defects or when the risk of wound problems is high [5]. Second, a later pregnancy increases the risk of recurrence, so women who plan a pregnancy can discuss whether to delay repair if symptoms allow [6]. Third, smoking, obesity, and poorly controlled diabetes increase wound problems and recurrence, and should be addressed before a planned repair. Incisional hernias after previous surgery are often more complex and need individual planning.
STEP 2 Preparation, medicines, and recovery
6.5 Before the operation
- Anesthesia. Discuss whether local, regional, or general anesthesia suits the patient and the technique.
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Medicines and fasting. Use the standard plans for blood thinners, diabetes medicines, and weight-loss injections (Chapters 18, 22, and 23) and the fasting advice in Chapter 2.
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Smoking and weight. Stopping smoking reduces wound problems. For umbilical and incisional hernias, weight loss before surgery is often advised.
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Straining. Ask about chronic cough, constipation, and urinary symptoms. Men with prostate symptoms have a higher risk of difficulty passing urine after surgery.
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Hair. Patients should not shave the groin at home; if hair removal is needed, it is done with clippers in hospital.
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Day surgery. Confirm an adult escort and overnight support.
6.6 The day of surgery and discharge
Most patients go home the same day. Before discharge they should be walking, have pain controlled with tablets, and have passed urine. Explain that bruising often spreads into the scrotum or labia over the first few days, and that close-fitting underwear makes swelling more comfortable. Complete the personal instruction card (Appendix A) and confirm the warning signs with teach-back.
6.7 Returning to activity
Advice about rest after hernia repair has traditionally been cautious, with weeks of lifting restrictions. The evidence does not support this. International guidelines advise patients to return to normal activities as soon as they feel comfortable, and no study has shown that early activity increases recurrence [3]. In a large study of patients advised to resume activity after one day, the median time off work was 7 days, and reoperation rates were no higher than in other patients [7]. Table 6.3 and Figure 6.2 give typical times, which patients can shorten or lengthen according to comfort.
Table 6.3. Typical return to activity after groin hernia repair.
| Activity | Keyhole repair | Open repair |
|---|---|---|
| Walking | The same day | The same day |
| Showering | Day 2 | Day 2 |
| Driving | When you can do an emergency stop without pain, often 3 to 5 days | Often about 1 week |
| Light or office work | Often within 3 to 5 days | Often within 1 week |
| Prayer | From the first day, including bowing and prostration as comfort allows | From the first day; pray seated if needed |
| Sexual activity | When comfortable, often about 1 week | When comfortable, often 1 to 2 weeks |
| Sport and gym | When comfortable, often 1 to 2 weeks | Often 2 to 3 weeks |
| Heavy lifting, manual work | When comfortable, often 2 weeks | Often 2 to 4 weeks |
| Swimming | When the wounds are healed, about 2 weeks | When the wound is healed, about 2 weeks |
| Ramadan fasting | When eating normally, usually within a few days | When eating normally, usually within a few days |
| Flying | Short flights after a few days if comfortable | Short flights after about 1 week |
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 6.2. Return to activity after keyhole and open groin hernia repair, for use with patients.
STEP 3 Questions patients ask
“Is my hernia dangerous? What happens if I wait?”
For most men with a hernia that causes little trouble, waiting is safe. The risk of the hernia getting stuck is low, about 2 in 1,000 each year [1]. But most people who wait have the operation eventually, about 7 in 10 within 10 years [2]. If you are a woman, or if it is a femoral hernia, we advise repair soon.
“Is the mesh safe? I have read bad things about mesh.”
The problems you read about were mainly with mesh used in pelvic surgery for women. Hernia mesh has been used safely for decades, and guidelines recommend it because it greatly lowers the chance of the hernia coming back [3]. Serious problems with it are rare.
“Can you repair it without mesh?”
Yes, a stitched repair is possible, but the hernia is more likely to come back. If you prefer it, we will discuss it in detail.
“Keyhole or open: which is better for me?”
Both are good operations. Keyhole usually means less pain and a quicker return to activity, and it is best for hernias on both sides, for women, and for hernias that came back after open surgery. Open surgery can be done under local anesthesia. We will choose together.
“Can I stay awake?”
Open repair can usually be done under local anesthesia, with medicine to help you relax. Keyhole repair needs a general anesthetic.
“When can I lift heavy things and go back to the gym?”
As soon as you are comfortable. Lifting early does not make the hernia come back [3]. Start gently and let pain guide you.
“Will it come back?”
With a mesh repair, it comes back in a small number of people, about [X] in 100 in our unit. Smoking, heavy coughing, and straining raise the risk.
“Why is my scrotum (or groin) so bruised and swollen?”
Blood and fluid from the operation track down with gravity. It looks alarming but usually settles within 2 to 3 weeks. Firm, supportive underwear helps.
“Will it affect my sex life or fertility?”
For almost everyone, no. The tube that carries sperm runs through the area and is protected during the operation; injury is rare. A few men notice discomfort with ejaculation for a while.
“Why is the skin near my scar numb?”
Small skin nerves are stretched or divided during open surgery. The numbness usually improves over months.
“I have hernias on both sides. Can you fix both at once?”
Yes. Keyhole surgery allows both sides to be repaired through the same small cuts [3].
“Can I pray and fast normally?”
You can pray from the first day; sit if bowing or kneeling is uncomfortable. You can fast again once you are eating normally, usually within a few days.
“I have an umbilical hernia and plan to have more children. Should I wait?”
A pregnancy after repair raises the chance of the hernia coming back [6]. If your hernia is not troubling you, we can discuss repairing it after your family is complete.
STEP 4 Risks, warning signs, and consent
6.8 Material risks
Table 6.4 groups the risks into the bands of Section 1.5. Replace figures marked “unit data” with your own audit figures.
Table 6.4. Material risks of groin hernia repair. Square brackets mark figures to replace with unit data.
| Band | Risk | Typical frequency | Example wording |
|---|---|---|---|
| Common | Bruising and swelling of the groin, scrotum, or labia | Many patients, for 1 to 3 weeks | “Bruising often spreads downward. It looks worse than it is and settles.” |
| Common | Fluid swelling (seroma) at the hernia site | Common after keyhole repair of large hernias [unit data] | “A soft swelling may appear where the hernia was. It is fluid and usually goes on its own.” |
| Common | Groin pain lasting more than 3 months | About 10 to 12 in 100, usually mild and lessening [3] | “About 1 in 10 people have some groin discomfort for months. For most it is mild and fades.” |
| Less common | Difficulty passing urine after surgery | About [X] in 100; higher in older men and after general anesthesia [unit data] | “A few people cannot pass urine at first and need a tube for a short time.” |
| Less common | Recurrence of the hernia | About [X] in 100 [unit data] | “A small number of hernias come back and may need another operation.” |
| Less common | Numbness near the scar | Common after open repair; usually improves | “The skin near the scar may feel numb for months.” |
| Rare but serious | Severe chronic pain that limits daily life | Much less common than mild pain [unit data] | “Rarely, pain is severe enough to need specialist treatment.” |
| Rare but serious | Testicular problems (reduced blood supply, shrinkage) or injury to the sperm tube | Fewer than 1 in 100 [unit data] | “Rarely, the testicle on that side is affected.” |
| Rare but serious | Mesh infection needing removal; injury to bowel, bladder, or blood vessel | Fewer than 1 in 100 [unit data] | “Rarely, the mesh becomes infected, or a nearby organ is injured.” |
| Rare but serious | Blood clots; death | Very rare in healthy adults [unit data] | “For someone in your health, these are very rare.” |
If the patient chooses watchful waiting
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6.9 Consent checklist
Before the patient signs ☐ Hernia type and side confirmed, including both sides if bilateral. ☐ Options discussed: repair now, watchful waiting where suitable, mesh or tissue repair, keyhole or open. ☐ Anesthesia discussed: local, regional, or general. ☐ Possible findings: a hernia on the other side or a different type of hernia, and the patient’s wishes about repairing it. ☐ Risks from Table 6.4, with unit figures where available, including chronic pain and recurrence. ☐ Who will perform the operation, including trainee involvement under supervision. ☐ Medicines, fasting, and day-surgery arrangements confirmed. ☐ Return-to-activity advice given: guided by comfort, without fixed lifting limits. ☐ Teach-back done, and the patient guide given in the patient’s language. |
6.10 Warning signs
Table 6.5. Green, amber, and red warning signs after groin hernia repair.
| Level | Signs after hernia repair | What to do |
|---|---|---|
| Green | Groin pain that improves each day Bruising spreading into the scrotum, labia, or thigh A soft, painless swelling at the hernia site Numbness near the scar | Expected. Follow the guide and take pain medicines as advised. |
| Amber | A wound that becomes red, hot, swollen, or leaks fluid Temperature of 38 °C or more Swelling of the scrotum that keeps growing or becomes very tense Passing urine with difficulty, or only small amounts | Call the clinic or contact number the same day. |
| Red | Not able to pass urine at all for 8 hours, with a painful, full bladder Severe pain that is getting worse, or a swollen, tight tummy with vomiting Fever with shivering Chest pain, breathlessness, or a hot, swollen calf Heavy bleeding or a rapidly growing swelling | Go to the emergency department or call an ambulance now. Bring this guide. |
Key points
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STEP 5 Patient education guide
The following pages may be photocopied and given to patients. Add your unit’s name, phone numbers, and review date before use.
PATIENT GUIDE Having Your Groin Hernia Repaired For you and your family. Read it before your operation, and keep it after you go home. |
What is a groin hernia?
The muscle wall of your groin has a natural weak spot. A hernia is a gap there. Fat or a loop of bowel pushes through and makes a lump. The lump is often bigger when you stand, cough, or strain, and smaller when you lie down.
Why repair it?
A hernia does not heal on its own. It usually grows slowly and becomes more uncomfortable. Rarely, the bowel gets stuck in it, which is an emergency. The operation closes the gap.
What happens in the operation?
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The surgeon closes the gap and covers it with a mesh. This is a thin, soft net. Your body grows into it and makes the wall strong.
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Keyhole repair: 3 small cuts. You will be fully asleep.
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Open repair: 1 cut in the groin. You may be awake with numbing medicine, or asleep.
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The operation takes about 1 hour. Most people go home the same day.
Before your operation
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Stop smoking now.
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Tell us about all your medicines, including blood thinners and injections for diabetes or weight loss. Do not stop any medicine unless we tell you to.
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Follow the eating and drinking times we give you.
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Do not shave your groin. We will clip hair if needed.
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Ask an adult to take you home and stay with you for the first night.
1. Pain and pain medicines
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Your groin will be sore for a few days. Take your pain medicines regularly at first, as we told you.
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Strong pain medicines can make you sleepy and constipated. Do not drive while you take them.
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Hold a pillow against the wound when you cough or laugh.
2. Your wounds
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Keep the dressings clean and dry for 2 days.
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Bruising often spreads into the scrotum, labia, or thigh. It looks worse than it is and settles in 2 to 3 weeks.
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Firm, supportive underwear makes swelling more comfortable.
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A soft swelling where the hernia was may be fluid. It usually goes on its own.
3. Eating, drinking, and your bowels
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Eat and drink normally when you feel ready.
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Avoid constipation: drink water, eat fruit and vegetables, and walk. Straining is uncomfortable.
4. Rest, washing, and clothes
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Get up and walk from the first day.
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You can shower after 2 days. Pat the wounds dry.
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Do not soak in a bath or swim until the wounds have healed.
5. Getting back to normal
Let comfort guide you. Being active early does not make the hernia come back. Your own plan is on your card.
| Activity | Usually from |
|---|---|
| Walking | The same day |
| Showering | After 2 days |
| Prayer | From the first day. Pray sitting if bowing or kneeling hurts. |
| Driving | When you can stop suddenly without pain and are not taking strong pain medicines, often within 1 week |
| Office work or school | Often within 1 week |
| Sex | When you feel comfortable |
| Heavy lifting, sport, and gym | When comfortable, often 2 to 4 weeks. Start gently. |
| Swimming | About 2 weeks, when the wounds have healed |
| Fasting in Ramadan | When you are eating normally |
| Flying | Short flights after a few days to 1 week if you feel well. Ask us before a long flight. |
6. Follow-up
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Your follow-up appointment or phone call is on your card.
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Tell us if you have groin pain that does not settle after a few weeks.
7. Warning signs: when to get help
| Level | What you notice | What to do |
|---|---|---|
| GREEN | Pain that gets better each day; bruising in the groin, scrotum, or labia; a soft swelling; numb skin near the scar | This is normal. Keep following this guide. |
| AMBER | A red, hot, or leaking wound; temperature of 38 °C or more; swelling that keeps growing; passing only small amounts of urine | Call us today. |
| RED | Cannot pass urine at all for 8 hours; severe pain getting worse; vomiting with a swollen tummy; fever with shivering; chest pain or short of breath; a hot, swollen leg; heavy bleeding | Go to the emergency department now. Take this guide with you. |
My contacts Clinic phone: ______________________ Hours: ______________ Out of hours: ______________________ My questions: ____________________________________________________________ [Unit name] [Guide version and review date] |
References
1. Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA. 2006;295(3):285-292.
2. Fitzgibbons RJ Jr, Ramanan B, Arya S, et al. Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg. 2013;258(3):508-515.
3. HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018;22(1):1-165.
4. 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.
5. Henriksen NA, Montgomery A, Kaufmann R, et al. Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society. Br J Surg. 2020;107(3):171-190.
6. Henriksen NA, Kaufmann R, Simons MP, et al. EHS and AHS guidelines for treatment of primary ventral hernias in rare locations or special circumstances. BJS Open. 2020;4(2):342-353.
7. Bay-Nielsen M, Thomsen H, Andersen FH, et al. Convalescence after inguinal herniorrhaphy. Br J Surg. 2004;91(3):362-367.
Note: references are numbered within this chapter for the pilot. Items marked in square brackets are collected in the Author Fill-in and Verification Log.