What is an inguinal hernia?
An inguinal hernia—medically known as an inguinal hernia—is the most common type of hernia. About 75–80% of all hernias involve the inguinal canal, which is why inguinal hernia repair is one of the most common surgical procedures.
The inguinal canal runs diagonally through the abdominal wall. In men, it contains the spermatic cord with blood vessels and nerves; in women, it contains a ligament that supports the uterus. If the abdominal wall weakens, a gap (hernia orifice) forms through which parts of the intestine or other abdominal organs can protrude. This bulge is usually palpable and sometimes visible.
Typical symptoms include pain or a feeling of pressure in the groin area, especially when lifting heavy objects, straining, or coughing. In many cases, an inguinal hernia remains harmless at first and causes only mild symptoms.
However, it becomes dangerous if sections of the intestine become trapped and their blood supply is cut off. This constitutes an acute medical emergency that requires immediate treatment.
Since an inguinal hernia does not resolve on its own, doctors generally recommend surgery. Various open and minimally invasive procedures are available to permanently repair the hernia and prevent complications.
Typical signs that help patients recognize an inguinal hernia include swelling in the groin area, pain in the groin, or a feeling of pressure in the abdomen when coughing or lifting heavy objects.
Procedure & Methods of Inguinal Hernia Surgery: Inguinal Hernia Repair – Open Surgery & Minimally Invasive Procedures
Inguinal hernias are almost always treated surgically. The goal of any inguinal hernia surgery is to permanently close the hernial opening in the abdominal wall, return the hernial contents to the abdominal cavity, and stabilize the area.
This minimally invasive inguinal hernia surgery is performed through three small skin incisions. For patients, this means smaller scars, fewer complications, and a quicker return to daily life shortly after surgery.
The choice of surgical procedure depends on several factors—such as the type, location, and size of the inguinal hernia, the patient’s age, and any existing comorbidities. Therefore, the doctor and patient decide together on the most appropriate method.
There are essentially two procedures available:
- Suture technique: The hernia opening is closed using the patient’s own tissue and sutures.
- Surgery with a synthetic mesh: A mesh stabilizes the abdominal wall and reduces the risk of a recurrent hernia.
Both methods can be performed either as open surgery with an incision or as minimally invasive (laparoscopic or endoscopic) inguinal hernia surgery.
Today, most inguinal hernia surgeries worldwide are performed using a synthetic mesh. In practice, three established surgical procedures are primarily used:
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Open surgery without mesh – Shouldice inguinal hernia repair
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Open surgery with mesh – Lichtenstein inguinal hernia repair
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Minimally invasive surgical techniques with mesh – TEP (total extraperitoneal repair) and TAPP (transabdominal preperitoneal repair)
Open Inguinal Hernia Surgery: Shouldice & Lichtenstein Methods – When Is Surgery Performed for an Inguinal Hernia?
Canadian surgeon Edward Earle Shouldice developed the inguinal hernia repair procedure in 1944. Until the introduction of surgical techniques using synthetic mesh, this was the gold standard in hernia surgery.
The Shouldice inguinal hernia repair is a conventional, non-minimally invasive surgical method. In this procedure, surgeons close the hernia defect using the patient’s own tissue.
The Shouldice procedure is performed as follows: The surgeon makes a transverse skin incision approximately 5 to 8 centimeters long above the inguinal ligament. Through this incision, the surgeon exposes the hernial sac that has formed as a result of the inguinal hernia.
The surgeon then opens the hernial sac and examines the intestines inside to treat them if necessary. He then returns them to their original positions within the abdominal cavity. The surgeon then removes the hernial sac and closes the peritoneum with a suture.
He then makes a transverse incision in the fascia transversalis and mobilizes it.
The surgeon stabilizes the inguinal region by suturing the inguinal ligament to the transversus fascia. The transversus fascia is the adjacent connective tissue that lines the inner surface of the abdominal wall. For safety, this suture is applied in several rows.
The Shouldice inguinal hernia repair is considered the best suturing technique and has a comparatively low recurrence rate (hernia reoccurrence).
This type of surgery is primarily used for smaller inguinal hernias and for young patients without a high-risk profile.
The Shouldice inguinal hernia repair is typically performed under general anesthesia. However, one of the advantages of this surgical method is that the procedure can also be performed under spinal anesthesia or local anesthesia.
In addition, doctors do not need to use any synthetic material during this inguinal hernia surgery.
However, patients must take it easy for a long time after this open inguinal hernia surgery. It takes about two months before they are allowed to resume strenuous activities or exercise.
The Lichtenstein inguinal hernia repair was developed in 1984 by the American surgeon Irving Lester Lichtenstein and is now one of the most commonly used surgical procedures for inguinal hernias worldwide.
The open Lichtenstein inguinal hernia repair is particularly suitable for patients with a medium-sized or large inguinal hernia. It is also used when a hernia recurs (recurrent hernia).
Unlike the Shouldice procedure, doctors always use a mesh in this procedure to permanently close the opening in the abdominal wall. This reduces the risk of the hernia recurring after the procedure.
Many patients recover quickly: They can resume light activities just days after the procedure. After about six weeks, heavy physical work or sports are usually possible again. This means that severe pain or prolonged rest are significantly less common after this surgery than with suture techniques.
The procedure at a glance:
- The surgeon makes a transverse skin incision approximately 5–8 cm long above the inguinal ligament. He then exposes the hernial sac and opens it.
- The contents of the hernia sac (e.g., sections of the intestine) are returned to the abdominal cavity. The hernia sac is then removed, and the peritoneum is sutured closed.
- In the next step, the surgeon covers the hernial ring with a thin polypropylene mesh. This is sutured to the abdominal wall muscles and the inguinal ligament, providing long-term stabilization of the abdominal wall.
The Lichtenstein method is particularly suitable for:
- older patients,
- people with medium-sized or large inguinal hernias,
- patients with a recurrent inguinal hernia.
One advantage is that the surgery can be performed under spinal anesthesia or local anesthesia—general anesthesia is not absolutely necessary. In addition, the recurrence rate (the hernia returning) is low.
For patients, the Lichtenstein procedure means they recover more quickly than with the Shouldice method. Moderate physical activity is possible again after only a short time, which is why the procedure is now considered the standard of care in many hospitals.
Minimally Invasive Inguinal Hernia Surgery: Three Small Skin Incisions & Modern Mesh Techniques
Minimally invasive inguinal hernia surgery does not involve a large skin incision, but rather three small incisions in the area around the navel. Through these access points, surgeons insert an endoscope and surgical instruments to reposition the hernia contents back into the abdominal cavity.
These procedures are also known as keyhole surgery. For patients, this means fewer scars, a lower risk of severe pain, and a faster recovery just a few days after the procedure.
In all minimally invasive methods, a synthetic mesh is placed between the peritoneum and the abdominal wall to permanently stabilize the hernia site. This reduces the risk of a recurrent inguinal hernia.
The two most important procedures are:
- TAPP (Transabdominal Preperitoneal Repair)
- TEP (Total Extraperitoneal Patch Repair)
Both techniques are performed under general anesthesia and are particularly suitable when a hernia must be operated on, e.g., in cases of symptoms, incarceration, or a concomitant femoral hernia. These methods are also suitable for patients with a recurrent hernia following open surgery.
One advantage: Patients are able to get up and perform light activities shortly after surgery. After about six weeks, sports and heavy physical work are generally possible again.
In TAPP surgery, the surgeon makes three small incisions in the area around the navel and the mid-abdomen.
The surgeon then inserts a special needle, inflates the abdomen with carbon dioxide, and pushes the intestines aside—this creates space and a clear view for the procedure.
The peritoneum is carefully incised, the hernial sac is exposed, and the hernial contents are returned to the abdominal cavity.
The surgeon then advances a synthetic mesh to the site of the hernia and places it preperitoneally between the peritoneum and the abdominal wall.
The mesh is secured, and the incision in the peritoneum is closed. This prevents the intestine from coming into direct contact with the mesh.
TAPP is particularly suitable for bilateral inguinal hernias because both sides can be treated in a single procedure. It is also a proven method for recurrent inguinal hernias following open surgery.
In TEP hernia surgery, the abdominal cavity is not opened. Instead, surgeons operate in the preperitoneal space in front of the abdominal wall. This reduces the risk of injuring internal organs such as the intestines.
A balloon is inserted through a small incision below the navel and inflated with air to create space for the procedure.
Carbon dioxide is then injected to separate the layers of the abdominal wall and peritoneum, giving the surgeon a clear view.
Through two additional small skin incisions, the surgeon inserts a camera and instruments.
The hernial sac is exposed, and the hernial contents are carefully returned to the abdominal cavity.
A synthetic mesh is placed over the hernial ring. It usually stabilizes itself due to the natural pressure in the abdominal cavity, so that additional fixation is often not necessary.
TEP is particularly suitable for patients with recurrent inguinal hernias and is considered a minimally invasive procedure, as it results in less pain after surgery and allows patients to recover more quickly.
As with any inguinal hernia surgery, there are potential risks and complications associated with the procedure. These include postoperative bleeding, infections, or temporary symptoms such as numbness, severe pain, or nausea and vomiting.
In most cases, recovery proceeds without complications. Many patients are mobile again just a few days after surgery. After about six weeks, sports or heavy physical work are usually possible again.
An inguinal hernia usually occurs suddenly and does not resolve on its own. For this reason, it is almost always treated surgically. If left untreated, it can enlarge or become incarcerated—an acute medical emergency.
Which specialists treat inguinal hernias? Diagnosis & Specialists
An inguinal hernia should always be evaluated by a doctor and usually requires surgery. The diagnosis is typically made by an experienced visceral surgeon, though sometimes by a general surgeon specializing in hernias.
Hernia surgery is a subspecialty of visceral surgery and deals with the treatment of all types of hernias—not only inguinal hernias, but also umbilical and femoral hernias. Specialists in this field can reliably diagnose an inguinal hernia through a physical examination and ultrasound. Typical signs include swelling in the groin area, pain in the groin, or a feeling of pressure in the abdomen when coughing or lifting heavy objects.
Certified hernia centers are particularly recommended. These centers employ specialists with extensive experience who perform hundreds of inguinal hernia surgeries each year. Clinics and departments receive this certification only if they meet specific quality criteria, such as:
- many years of experience and specialized training in hernia surgery,
- standardized procedures for inguinal hernia surgery,
- modern surgical methods (open and minimally invasive procedures),
- comprehensive follow-up care and counseling.
For patients, this means high-quality care, lower complication rates, and a better prognosis after surgery.
