Overview of treatment for inguinal and femoral hernia in adults

Author:
David C Brooks, MD
Section Editor:
Michael Rosen, MD
Deputy Editor:
Wenliang Chen, MD, PhD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review
process is complete.
Literature review current through: Aug 2020. | This topic last updated: May 05, 2020.

INTRODUCTIONThe definitive treatment of all hernias, regardless of origin or type,

is surgical repair [1]. Groin hernia repair is one of the most commonly performed
operations. Over 20 million inguinal or femoral hernias are repaired every year
worldwide [2], including over 700,000 in the United States [3].

An inguinal or femoral hernia repair is performed urgently in patients who develop

complications such as acute incarceration or strangulation. For patients without a
complication, the optimal timing of repair (watchful waiting versus early repair) and
the optimal surgical technique (open versus laparoscopic) are controversial and are
the focus of this topic.

The clinical features and diagnosis of an inguinal or femoral hernia, the technical
details of performing an inguinal or femoral hernia repair, the complications of hernia
repair, and the treatment of recurrent hernias are discussed separately in other topics.
(See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in
adults" and "Open surgical repair of inguinal and femoral hernia in adults" and
"Laparoscopic inguinal and femoral hernia repair in adults" and "Overview of
complications of inguinal and femoral hernia repair" and "Recurrent inguinal and
femoral hernia".)

INDICATIONS FOR SURGICAL REPAIRThere was a time when the mere presence
of a groin hernia was a sufficient indication for surgical repair. Contemporary
practice, however, triages patients to surgery versus watchful waiting according to the
severity of symptoms and the type of hernia (inguinal versus femoral).

Complicated hernia — Patients who develop strangulation or bowel obstruction

should undergo urgent surgical repair. Surgery performed within four to six hours
from the onset of symptoms may prevent bowel loss due to one of these
complications.

Patients with an acutely incarcerated inguinal hernia but without signs of

strangulation (eg, skin changes, peritonitis) should be offered urgent surgical repair.
However, hernia reduction can be attempted in patients who wish to delay surgery. If
hernia reduction is successful, the patient should follow up with his/her surgeon
within one to two days to exclude recurrent incarceration and arrange for elective
repair. Those who fail hernia reduction should proceed urgently to surgery.
The clinical manifestations and diagnosis of incarcerated/strangulated inguinal or
femoral hernias can be found elsewhere. (See "Classification, clinical features, and
diagnosis of inguinal and femoral hernias in adults".)

Uncomplicated hernias — In patients with uncomplicated inguinal or femoral hernias,

surgical repair is intended to relieve symptoms and to prevent future complications.
The indications for surgical repair of uncomplicated hernias are less rigid than
complicated hernias and depend upon the type of hernias (inguinal versus femoral)
involved, the severity of symptoms, and patient preference. In select patients,
watchful waiting is an alternative to surgery. (See 'Asymptomatic hernia' below.)

Femoral hernia — For all patients with a newly diagnosed femoral hernia, we suggest
elective surgical repair, rather than watchful waiting, regardless of the patient's sex
and symptoms. Femoral hernias are associated with a high risk of complications, and
therefore early elective surgical repair is indicated.

Femoral hernias are associated with a higher risk of developing complications than
inguinal hernias. In one study, the rates of strangulation were 22 and 45 percent at 3
and 21 months, respectively, for femoral hernias, compared with 2.8 and 4.5 percent
for inguinal hernias [4].

Thus, early elective repair is advised for patients with a newly diagnosed femoral
hernia to avoid complications that may necessitate urgent surgery. Urgent surgery for
complicated hernias is more likely to involve bowel resection, which is associated
with a higher mortality rate. In one study, for example, bowel resection was required
in 23 percent of urgent compared with 0.6 percent of elective femoral hernia repairs,
and urgent femoral hernia repairs were associated with a 10-fold increase in mortality
[5].

For patients who have a long-standing (>3 months) femoral hernia that is
asymptomatic, surgery is preferred, but observation is a reasonable option.

Inguinal hernia — For patients with moderate-to-severe symptoms from an inguinal

hernia, surgical repair is indicated. Patients with minimal or no symptoms from an
inguinal hernia may be managed with elective surgery or watchful waiting.

The only nonsurgical therapy for groin hernia in men is a truss. A truss is a strap
similar to an athletic supporter with a metal or hard plastic plug positioned to lie over
the hernia defect. When applied appropriately, the hard disc or plug exerts pressure to
keep the hernia contents in the abdomen. Although the use of a truss may be helpful
in certain situations, we generally discourage their use because there is insufficient
evidence to prove their efficacy [6,7]. In addition, inappropriate use of a truss may
harm abdominal contents in a hernia sac or complicate subsequent surgical repair [8].

Symptomatic hernia — Patients with significant symptoms attributable to an inguinal

hernia should undergo elective surgical repair [1]. Such symptoms typically include:

●Groin pain with exertion (eg, lifting)

●Inability to perform daily activities due to pain or discomfort from the hernia
●Inability to manually reduce the hernia (ie, chronic incarceration)

Asymptomatic hernia — For patients with minimal or no symptoms from an inguinal

hernia, we suggest elective hernia repair, or watchful waiting for those who wish to
avoid surgery. The latter patients must lack hernia-related pain or discomfort limiting
usual activities or recent difficulty in reducing the hernia [9]. Patients with a
minimally symptomatic chronically incarcerated inguinal hernia can undergo watchful
waiting as they were not excluded from the trials to be discussed below.

Historically, inguinal hernias were repaired once detected, under the assumption that
complications from unrepaired hernias were common and could increase operative
morbidity. However, three randomized trials to date have compared watchful waiting
with surgical repair of inguinal hernias [10-12] and demonstrated that delaying
surgical repair in asymptomatic patients was safe, as acute complications rarely
occurred (1.8 emergency operations/1000 patient-years). However, for 38 percent of
patients at three years [12], and about 70 percent of patients at 7 to 10 years [13,14],
surgical repair was required eventually because symptoms (usually pain) gradually
increased over time. This information is particularly important when counselling
young patients. Surgical outcomes of delayed repairs were not compromised
compared with immediate surgery.

Patients with inguinal hernias managed with watchful waiting should be counseled
about modifiable risk factors, including smoking cessation, medical optimization (eg,
diabetes), and weight loss. They should be told that there is no evidence that physical
activity will result in a hernia incarceration or clinical worsening of an existing hernia
[9]. Thus, there is no compelling reason for such patients to curtail beneficial physical
activities (eg, cardiovascular or aerobic exercises) out of concern for exacerbating the
hernia. Patients who opt for watchful waiting should seek prompt surgical evaluation
if they experience new-onset pain or discomfort with certain physical activities, or if
their hernia becomes acutely incarcerated (for those whose hernias were reducible).

CONTRAINDICATIONS TO SURGICAL REPAIRInguinal or femoral hernia repair

can be performed with minimal morbidity and mortality in almost all patients,
including those who are older and/or have medical comorbidities (eg, advanced liver
disease [15,16]); most patients enjoy a rapid recovery to presurgical health shortly
after surgery. Thus, there is no contraindication to urgent repair of complicated
hernias. However, pregnant women should not have elective repair of an inguinal or
femoral hernia until at least four weeks after delivery.

For patients who cannot tolerate general anesthesia, inguinal or femoral hernias can
be repaired under local anesthesia using one of the open techniques. For patients with
an active groin infection or systemic sepsis, mesh placement is contraindicated, but
groin hernias can be repaired using nonmesh techniques when necessary. (See
"Wound infection following repair of abdominal wall hernia".)

Pregnancy — The prevalence of inguinal hernias during pregnancy is low and

estimated to be 1:2000 [17]. Elective repair of a groin hernia during pregnancy is
generally contraindicated. Expectant management during the peripartum period has
been associated with few serious hernia-related complications. In one study, seven
women with groin hernias were managed nonoperatively, and each had their hernias
repaired after delivery [18]. Although combined cesarean delivery and hernia repair
have been reported [17,19], elective hernia repair should generally be deferred for at
least four weeks postpartum to allow the lax abdominal wall to return to its baseline.

Urgent hernia repair during pregnancy may be required if the patient develops severe
discomfort or one of the complications, such as acute incarceration, strangulation, or
bowel obstruction. In one study, such complications were rare and only accounted for
<5 percent of intestinal obstructions observed during pregnancy [20].

CHOOSING A SURGICAL APPROACHWhile all surgeons perform open groin

hernia repairs, some also perform laparoscopic repairs. In general, surgeons should
choose the approach with which they are most comfortable and most experienced. For
surgeons who are equally facile with both repairs, the choice of a surgical approach
depends upon hernia and patient characteristics. The process described below and
outlined in the accompanying algorithm reflects the author's preference and should
not be regarded as the only approach (algorithm 1).

Patients precluded from laparoscopic repair — While open repair of an inguinal or

femoral hernia is feasible in almost all patients, laparoscopic repair cannot be safely
performed in certain patients due to patient or technical reasons.

Patients with prior surgery involving the preperitoneal space — Laparoscopic repair,

especially with the totally extraperitoneal (TEP) technique, requires the development
and maintenance of the preperitoneal space. Adhesions formed after previous surgery,
incision, or mesh placement could render that space inaccessible.

In a meta-analysis of seven comparative cohort studies, TEP repair in patients with

prior low abdominal surgery was associated with higher intraoperative morbidities
(odds ratio 2.85) and postoperative morbidities (multiport subgroup; odds radio 2.14)
compared with in those without prior lower abdominal surgery [21].

Thus, we perform an open hernia repair for patients who have had one or more
previous surgeries involving the preperitoneal space (eg, prostatectomy,
hysterectomy, cesarean section, or laparotomy via lower midline incision). Although
laparoscopic surgery is feasible in such patients (especially with the transabdominal
preperitoneal patch [TAPP] technique), it is technically challenging, requires a longer
operative time, and is associated with more complications than open surgery in such
patients [22,23].

Patients with complicated hernia — We repair all incarcerated or strangulated groin

hernias with an open approach to minimize the risk of bowel injury. A laparoscopic
approach is theoretically possible but difficult to perform [24-26].

Furthermore, in cases where bowel perforation has occurred due to bowel ischemia or
necrosis, the placement of mesh is contraindicated, thereby precluding a laparoscopic
repair. Open repair can be performed with or without mesh and therefore is the
preferred treatment for complicated hernias in which the risk of active infection or
contamination (from perforation) is high. (See 'Open techniques' below and "Wound
infection following repair of abdominal wall hernia".)
We also prefer to repair large scrotal hernias (>3 cm) with an open approach because
of the technical difficulty associated with managing and reducing a large hernia sac
laparoscopically [27].

Patients with ascites — In patients with ascites, we prefer an open approach to

laparoscopic approaches. In particular, the laparoscopic TAPP approach (which is
transperitoneal) should be avoided. Prior to surgery, ascites should be minimized as
much as possible with medical treatment. At the time of surgery, the hernia sac should
be left intact to avoid complications such as persistent leakage of ascitic fluid. (See
"Open surgical repair of inguinal and femoral hernia in adults" and "Laparoscopic
inguinal and femoral hernia repair in adults".)

Patients who cannot tolerate general anesthesia — Laparoscopic groin hernia repair is

typically performed under general anesthesia. Thus, patients who cannot tolerate
general anesthesia for medical reasons should undergo open repair under local or
regional anesthesia. (See 'Choice of anesthesia' below.)

Patients eligible for both open and laparoscopic repair — Patients who do not have a
history of prior preperitoneal surgery, ascites, or a complicated hernia are eligible for
both open and laparoscopic repairs of a groin hernia. The choice of the surgical
procedure then depends upon whether the hernia is primary or recurrent, unilateral or
bilateral, and femoral or inguinal.

Primary hernia — A primary, unilateral inguinal hernia can be repaired open or

laparoscopically based upon surgeon and patient preference. A primary, unilateral
femoral hernia, and all bilateral hernias (both inguinal and femoral), should be
repaired laparoscopically.

Unilateral hernia

Inguinal hernia — There is no consensus as to whether the optimal approach to

inguinal hernia repair is open or laparoscopic [28-30]. Some surgeons prefer to repair
a primary, unilateral inguinal hernia with an open technique, while others prefer a
laparoscopic approach. Although there is growing support for laparoscopic repair for
unilateral primary inguinal hernias, the total difference in outcomes remains relatively
small despite statistical significance given the large sample sizes afforded with
national registry studies [31]. Ultimately, a well-performed open inguinal hernia
repair is perfectly acceptable, and the learning curve for laparoscopic groin hernia
repair is real and can result in serious complications. Therefore, a primary, unilateral
inguinal hernia can still be repaired open or laparoscopically based upon surgeon and
patient preferences.

Because clinical outcomes are as much a function of surgeon experience as other

factors, surgeons should choose the technique that they are most experienced with and
that is best for the particular situation. Patients are best served by seeking consultation
from a well-respected surgeon who performs high-volume hernia surgery and going
with his or her recommendations.

Open and laparoscopic approaches have been directly compared, most often in
inguinal hernia repairs. In general, laparoscopic repair has been associated with less
postoperative pain and quicker recovery but longer operative time and higher
recurrence rates [25,32-44]. Laparoscopic repair could also result in serious
complications (eg, massive pelvic bleeding) that would rarely occur during open
repairs.

●The largest trial randomly assigned 1983 men with inguinal hernias to receive open
or laparoscopic mesh repair at 1 of 14 United States Veterans Affairs Medical Centers
[45]. Patients treated laparoscopically had less pain on the day of surgery and at two
weeks and returned to work one day earlier. However, they suffered more
postoperative complications (39 versus 33.4 percent), life-threatening complications
(1.1 versus 0.1 percent), and hernia recurrences (10.1 versus 4.9 percent at two years).
In subgroup analysis, the difference in recurrence rate was significant for primary
(10.1 versus 4 percent), but not recurrent, hernias (10 versus 14 percent). This trial has
been criticized for higher than average rates of recurrences in both groups due to
surgeon inexperience, as well as for a patient population that is older (average age 58)
and less healthy (only 34 percent were American Society of Anesthesiologists class I)
than the average patient who needs inguinal hernia repair.

●A subsequent trial randomly assigned 389 patients with a primary unilateral inguinal
hernia to receive either open Lichtenstein repair under local anesthesia or
laparoscopic total extraperitoneal (TEP) repair under general anesthesia [46]. Fewer
patients in the laparoscopic group reported having persistent groin pain at one year
(21 versus 33 percent). However, this difference may not be clinically relevant, as
most patients reported mild pain (described as "can be easily ignored" on the
questionnaire); only a few patients in each group (2 percent in the laparoscopic versus
3 percent in open group) reported severe pain. In addition, fewer patients in the
laparoscopic group reported having groin pain that limited their ability to perform
physical exercise (3 versus 8 percent). The recurrence rates at one year were similarly
low in both groups (1 percent laparoscopic versus 2 percent open).

●Another trial (TEPLICH) randomly assigned 416 adults with primary inguinal
hernia to laparoscopic TEP repair versus Lichtenstein open repair [47]. At both one
and three years after surgery, patient satisfaction, groin pain, and recurrence rates
were similar between the two groups. Laparoscopic TEP repair had short-term
advantages of lower morbidity and faster recovery.

●A Swedish prospective cohort study of over 20,000 patients undergoing elective

unilateral groin hernia repair between 2012 and 2015 showed that groin pain
interfering with daily activities persisted at one year after surgery in 15.2 percent of
patients, higher than previously estimated. The risk of chronic pain was lower with
TEP than with open anterior mesh (Lichtenstein) repair (adjusted odds ratio 0.84, 95%
CI 0.74-0.96), but at the price of a higher risk of recurrence requiring reoperation
(adjusted odds ratio 2.14, 95% CI 1.52-2.98) at 2.5 years [48].

●A 50,000 patient European registry (Herniamed) study compared three methods of

unilateral inguinal hernia repair using propensity-score matching [31]. Compared with
both TEP and laparoscopic transabdominal patch plasty (TAPP), open Lichtenstein
repair was associated with more postoperative complications (3.4 versus 1.7 percent
TEP; 3.8 versus 3.3 percent TAPP), reoperations (1.1 versus 0.8 percent TEP; 1.2
versus 0.9 percent TAPP), and chronic pain at rest (5.2 versus 4.3 percent TEP; 5
versus 4.5 percent TAPP) and on exertion (10.6 versus 7.7 percent TEP; 10.2 versus
7.8 percent TAPP), but not recurrence. TEP was associated with more intraoperative
complications than open Lichtenstein repair (0.9 versus 1.2 percent TEP), and TAPP
was associated with more postoperative complications than TEP (3 versus 1.7
percent). Otherwise, TEP and TAPP were comparable in all other reported outcomes.
However, the follow-up period was only one year, which may be too short to capture
all recurrences.

●A meta-analysis of 58 randomized trials compared patient-reported outcomes after

laparoscopic versus open inguinal hernia repair [49]. Laparoscopic repair was
associated with less postoperative pain from two weeks to six months (risk ratio 0.74),
six months to one year (relative risk 0.74), and after one year (relative risk 0.62).
Paraesthesia (relative risk 0.27) and patient satisfaction (relative risk 0.91) also
favored laparoscopic repair.

Femoral hernia — We prefer to repair a femoral hernia laparoscopically because of its

ease of access. Anterior femoral hernia repairs require a breach of the inguinal canal
to gain access to the femoral hernia posteriorly; posterior repairs have direct access to
the femoral hernia without going through the inguinal canal. In one study, posterior
repair of femoral hernias was associated with a lower recurrence rate than anterior
repair [5]. Posterior repairs are mostly done laparoscopically as the only open
posterior repair (Kugel) is rarely performed.

In addition, laparoscopic femoral hernia repair is also better at identifying occult

hernias [50]. In one study of 250 men undergoing laparoscopic repair of presumed
inguinal hernias, femoral hernias were detected in addition to (29) or in lieu of (4)
inguinal hernias in 33 patients (13.2 percent) [51]. Of the 33 patients with a femoral
hernia, 61 percent had undergone a previous open inguinal hernia repair, reflecting
either the failure to recognize a concomitant femoral hernia during their initial open
surgery or the interval development of a femoral hernia.

Bilateral hernias — We prefer to repair bilateral groin hernias laparoscopically

because:

●Both hernias can be repaired through the same incisions, which improves cosmesis.

●A single large piece of mesh can be used with a laparoscopic TEP repair, reducing
costs and potentially the risk of direct hernia recurrence medially [52].

●A laparoscopic approach permits exploration of the contralateral groin in patients

with symptoms suggestive but not diagnostic of a contralateral hernia [53].

Three randomized trials have independently concluded that laparoscopic compared

with open repair of bilateral inguinal hernias caused less postoperative pain, faster
recovery, and similar rates of recurrence [54-56]. The National Institute for Health
and Clinical Excellence (NICE) in the United Kingdom advocates laparoscopic repair
for patients with bilateral hernias [57].
When laparoscopic repair is not available, the alternative for patients with bilateral
hernias is bilateral open tension-free mesh repair, which can be performed as a single
operation, rather than two separate procedures [58].

Recurrent hernia — We prefer to repair a recurrent groin hernia with a laparoscopic

approach if the initial repair was open, but with an open approach if the initial repair
was laparoscopic. The rationale is that recurrent hernia repair is optimal if performed
in a previously undissected tissue plane.

Patients with prior open repair — Many surgeons feel that recurrent hernias,
particularly those that recur after an anterior mesh repair, are best addressed via a
laparoscopic technique [34,38]. As with primary repairs, a laparoscopic repair of
recurrent hernias was also associated with faster recovery, less postoperative pain, and
fewer complications [38,56,59-61]. The NICE in the United Kingdom also advocates
laparoscopic repair for recurrent hernias [57].

Patients with prior laparoscopic repair — An open repair is required for patients with
a recurrent hernia if they have had a previous laparoscopic hernia repair (usually with
mesh placement) or other surgeries involving the preperitoneal space (eg,
prostatectomy, hysterectomy, cesarean section, or laparotomy via lower midline
incision). In such patients, the preperitoneal space may be difficult to access. (See
'Patients with prior surgery involving the preperitoneal space' above.)

Special considerations

Cost effectiveness — Studies have generally found an overall cost benefit for open, as
opposed to laparoscopic, hernia repair [62-66]. Factors considered in such studies
included the cost of operating room time and equipment (especially single-use items),
length of hospital stay, and the cost of treating potential complications. Variations in
one or more of these factors (eg, by using reusable equipment) could make
laparoscopic surgery more cost-effective [62].

Female patients — Groin hernias are uncommon in females; less than 8 percent of

hernia repairs are performed in women [5,67-69]. Compared with men, women are
more likely to have femoral hernias, complicated hernias (incarceration or
strangulation), or recurrent hernias [67]. (See "Classification, clinical features, and
diagnosis of inguinal and femoral hernias in adults", section on 'Epidemiology' and
"Classification, clinical features, and diagnosis of inguinal and femoral hernias in
adults", section on 'Femoral hernia'.)

For women who have had a prior surgery involving the preperitoneal space (eg,
cesarean section or hysterectomy), an open anterior mesh repair is the best option. In
others, a laparoscopic approach is preferred because it allows identification and repair
of occult hernias (especially femoral hernias).

SURGICAL TECHNIQUESSpecific techniques of inguinal or femoral hernia repair

are briefly discussed below. Detailed information can be found in other topics. (See
"Open surgical repair of inguinal and femoral hernia in adults" and "Laparoscopic
inguinal and femoral hernia repair in adults".)
Open techniques — Open techniques approach the hernia defect anteriorly and
include tension-free mesh repairs as well as primary tissue approximation nonmesh
repairs. For patients in whom mesh placement is not contraindicated, we recommend
using a mesh repair technique to achieve a tension-free repair rather than a nonmesh
repair technique. Nonmesh repair techniques may be required for patients with active
groin infection or contamination (eg, as a result of bowel perforation from a
strangulated hernia).

Open tension-free mesh repairs — Successful hernia repair depends upon a tension-

free closure, which is typically achieved with placement of a mesh. Multiple studies
have demonstrated that tension-free mesh repair of inguinal hernias reduces
postoperative groin pain, expedites recovery, and reduces recurrence rate [1,2,27,70-
73]. Thus, the tension-free mesh techniques are most widely used and endorsed by
various hernia societies [1,28,29]. Tension-free repairs that use mesh include
Lichtenstein, plug and patch, and Kugel (preperitoneal repair). (See "Open surgical
repair of inguinal and femoral hernia in adults", section on 'Mesh versus non-mesh
repair' and "Open surgical repair of inguinal and femoral hernia in adults", section on
'Hernia repair techniques'.)

Open primary tissue approximation nonmesh repairs — Shouldice, Bassini, and

McVay repairs are open techniques that achieve primary tissue approximation without
the use of mesh [72,74-78]. Although the Shouldice repair does not incorporate mesh,
some regard it as a tension-free technique. Nonmesh repair techniques are primarily
used when mesh placement is contraindicated, such as when there is active infection
or contamination of the groin, or when the use of a mesh is cost prohibitive (eg, in
resource-limited settings). (See "Open surgical repair of inguinal and femoral hernia
in adults", section on 'Hernia repair techniques'.)

Laparoscopic techniques — Laparoscopic repairs approach the hernia defect

posteriorly. The two main techniques are totally extraperitoneal (TEP) repair and
transabdominal preperitoneal patch (TAPP) repair, both of which require the use of
mesh and are considered tension-free repairs [79]. The mesh employed for these
repairs must be of sufficient size to cover the entire preperitoneal groin space in order
to prevent recurrences. (See "Laparoscopic inguinal and femoral hernia repair in
adults", section on 'Laparoscopic repair approaches'.)

PREOPERATIVE PREPARATIONInguinal and femoral hernias can usually be

repaired with minimal morbidity and mortality. We use the following preoperative
routine to optimize patient outcomes and experience.

Confirm presence and location of hernia — The diagnosis of an inguinal or femoral

hernia is clinical for most patients. Immediately prior to surgery, the patient should be
reexamined to confirm the presence of a hernia and mark its laterality. (See
"Classification, clinical features, and diagnosis of inguinal and femoral hernias in
adults".)

Obtain informed consent — The risks and benefits of hernia repair versus watchful
waiting, including potential complications of each approach, should be reviewed with
the patient. In particular, the surgeon should inform the patient of a potential risk of
chronic groin pain or discomfort after groin hernia repair. If surgical repair is elected,
the risks and benefits of an open versus laparoscopic approach should also be
discussed with the patient. (See 'Choosing a surgical approach' above.)

Medical risk assessment — Much of the preoperative medical evaluation is directed

toward ensuring that the patient can tolerate anesthesia, especially if general
anesthesia is planned. (See "Preoperative medical evaluation of the healthy adult
patient" and "Evaluation of cardiac risk prior to noncardiac surgery" and "Evaluation
of preoperative pulmonary risk" and "Perioperative management of blood glucose in
adults with diabetes mellitus".)

Treat hernia complications if present — Patients with complicated hernias should

receive complication-specific treatment prior to hernia repair. As examples, patients
with bowel obstruction require fluid resuscitation and nasogastric decompression;
patients with bowel ischemia or perforation require antimicrobial coverage. (See
"Management of small bowel obstruction in adults" and "Overview of gastrointestinal
tract perforation", section on 'Initial management'.)

Preoperative prophylaxis — Most inguinal and femoral hernia repairs are elective

procedures performed in an outpatient setting. Thromboprophylaxis and/or
prophylactic antibiotics may be required in selected patients to prevent complications
such as venous thromboembolism (VTE) or surgical site infection (SSI).

Thromboprophylaxis — Thromboprophylaxis is administered according to the

patient's risks of developing VTE perioperatively (table 1). Patients who are young
(<40 years of age), otherwise healthy, and have no other risk factors for VTE do not
require pharmacologic thromboprophylaxis. Mechanical thromboprophylaxis may be
applied to patients undergoing general anesthesia, or at the surgeon's discretion. (See
"Prevention of venous thromboembolic disease in adult nonorthopedic surgical
patients".)

Antibiotics — For patients undergoing uncomplicated inguinal or femoral hernia

repair with planned mesh placement, we recommend administering prophylactic
antibiotics rather than no antibiotics. Patients with complicated hernias require
broader antimicrobial coverage than prophylactic antibiotics. For patients undergoing
uncomplicated inguinal or femoral hernia repair without planned mesh placement,
prophylactic antibiotics may be omitted based upon surgeon preference.

The role of prophylactic antibiotics given prior to inguinal or femoral hernia repair
remains controversial [80-85]. Uncomplicated hernia surgery is considered clean
surgery, for which prophylactic antibiotics are not indicated. Some surgeons,
however, prefer to administer antibiotics to patients undergoing hernioplasty (ie,
hernia repair with mesh) to prevent potential mesh infection [85,86]. Others omit
routine prophylactic antibiotics because the risk of SSI after groin hernia surgery is
low, and most SSIs that occur are superficial and can be easily treated with oral
antibiotics. (See "Overview of complications of inguinal and femoral hernia repair",
section on 'Superficial incisional surgical site infection'.)

A 2020 Cochrane review found that prophylactic antibiotics had little or no effect on
elective open groin hernia repair in preventing wound infections in low-infection-risk
settings but may be beneficial in preventing superficial wound infections in high-
infection-risk settings [86].

Prophylactic antibiotics should cover the usual skin flora, including aerobic gram-
positive organisms, aerobic streptococci, staphylococci, and enterococci (table 2)
[87]. To be effective, prophylactic antibiotics must be administered within one hour
before the time of incision [88,89]. (See "Antimicrobial prophylaxis for prevention of
surgical site infection in adults" and "Antimicrobial prophylaxis for prevention of
surgical site infection following gastrointestinal procedures in adults".)

Patients undergoing urgent inguinal or femoral hernia repairs should receive

antibiotics according to the complication (eg, bowel perforation, bowel ischemia, or
obstruction). For those patients, antibiotics are considered therapeutic rather than
prophylactic, and the initial coverage should be broad (table 2). Once an
intraoperative culture has been obtained, further antibiotic therapy should be guided
by microbiology data. (See "Overview of gastrointestinal tract perforation".)

Choice of anesthesia — Inguinal or femoral hernia repair can be performed using

general, neuraxial (spinal or epidural), or regional anesthesia (peripheral nerve block,
local) [90,91]. The choice of anesthesia depends upon the type and size of the hernia,
surgical approach, and patient/surgeon preferences. (See "Overview of anesthesia".)

Anesthesia for open repair — We prefer to perform open groin hernia repair with
local anesthesia, especially in patients with comorbidities (eg, advanced liver disease).

In a randomized trial of 616 patients undergoing open inguinal hernia repairs, the use
of local anesthesia resulted in less postoperative pain and nausea, a shorter recovery
room stay (3.1 versus 6.2 and 6.2 hours), and fewer unplanned overnight admissions
(3 versus 14 and 22 percent), compared with the use of regional and general
anesthesia, respectively [90]. Another randomized trial of open inguinal hernia repairs
also found that local anesthesia resulted in less postoperative pain, a shorter operating
time, and fewer overnight stays than spinal anesthesia [92].

Local anesthesia can be administered as a nerve block of the ilioinguinal and

iliohypogastric nerves, or as direct infiltration into the incision site(s). Nerve block
may be more difficult to administer but causes less soft tissue edema than direct
infiltration. Some surgeons use a combination of both nerve blocks and local
infiltration. Local anesthesia for open groin hernia repair is typically given in the
context of "monitored anesthesia care," which also provides intravenous sedatives for
patient relaxation and additional intravenous analgesics. (See "Abdominal nerve block
techniques", section on 'Ilioinguinal and iliohypogastric nerve block'.)

The main disadvantage of local anesthesia is that it may not provide adequate
anesthesia during the repair of large hernias, particularly in patients who have a loss
of abdominal domain. In such patients, general anesthesia is preferred. General
anesthesia can also be used in open hernia repair by patient or surgeon preference.

Anesthesia for laparoscopic repair — Anesthesia requirements for laparoscopic

inguinal or femoral hernia repairs vary depending upon the technique used:
●Transabdominal preperitoneal patch (TAPP) repair requires general anesthesia.

●Intraperitoneal onlay mesh (IPOM) repair requires general anesthesia.

●Totally extraperitoneal (TEP) repairs are most often performed under general
anesthesia but can also be performed under spinal or epidural anesthesia.

MORBIDITY AND MORTALITY

Mortality — The 30-day mortality rate for inguinal or femoral hernia repair is 0.1
percent after elective surgery and 2.8 to 3.1 percent after urgent surgery [67,93,94].
The mortality rate is higher when bowel resection is performed with hernia repair
[95]. Other risk factors associated with a higher mortality rate include:

●Older age – Older patients have higher mortality rates after emergency hernia
repair. In one study, the mortality rates were 1, 5, and 16 percent, respectively, for
patients who were in their seventies, eighties, and nineties [94].

●Femoral hernia – Femoral hernia repairs are associated with higher mortality than
inguinal hernia repairs [5]. In one study, the 30-day standardized mortality ratios were
higher for femoral than inguinal hernia repairs in both men (6.81 and 1.29) and
women (7.16 versus 2.82) [95].

●Women – Women have higher mortality after groin hernia repair than men [5].
However, it is not clear if female sex is an independent risk factor, as women who
require groin hernia surgeries tend to be older, have more femoral hernias, and are
more likely to require emergency operations.

●Urgent/emergency surgery.

Morbidity — Minor complications of inguinal or femoral hernia repair, including

superficial wound infection and seroma/hematoma formation, are common and easily
managed.

Serious complications include hernia recurrence and post-herniorrhaphy neuralgia.

Recurrence after either a laparoscopic or open inguinal hernia repair is rare, with a
rate generally under 4 percent. Chronic groin pain or discomfort occurs more
frequently, around 5 to 10 percent, and can be debilitating on occasion. Complications
of groin hernia repairs are discussed separately in other topics. (See "Post-
herniorrhaphy groin pain" and "Overview of complications of inguinal and femoral
hernia repair".)

SOCIETY GUIDELINE LINKSLinks to society and government-sponsored

guidelines from selected countries and regions around the world are provided
separately. (See "Society guideline links: Groin hernia in adults".)

INFORMATION FOR PATIENTSUpToDate offers two types of patient education

materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces
are written in plain language, at the 5th to 6th grade reading level, and they answer the
four or five key questions a patient might have about a given condition. These articles
are best for patients who want a general overview and who prefer short, easy-to-read
materials. Beyond the Basics patient education pieces are longer, more sophisticated,
and more detailed. These articles are written at the 10th to 12th grade reading level and
are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage
you to print or e-mail these topics to your patients. (You can also locate patient
education articles on a variety of subjects by searching on "patient info" and the
keyword(s) of interest.)

●Basics topics (see "Patient education: Inguinal and femoral (groin) hernias (The
Basics)")

SUMMARY AND RECOMMENDATIONS

●The definitive treatment of all hernias, regardless of origin or type, is surgical repair.
Inguinal/femoral hernia repair is one of the most commonly performed operations in
the world. (See 'Introduction' above.)

●Patients who develop strangulation or bowel obstruction from an inguinal or femoral

hernia should undergo urgent surgical repair. Patients with an acutely incarcerated
inguinal hernia but without signs of strangulation or obstruction also require surgery,
typically urgently. However, for those who wish to delay surgery, nonsurgical hernia
reduction can be attempted, and, if successful, elective hernia repair can be performed
at a later time. (See 'Complicated hernia' above.)

●Patients with an uncomplicated inguinal or femoral hernia may undergo surgical

repair or be managed with watchful waiting depending upon the hernia type, severity
of symptoms, and the preference of the patient, as follows:

•For patients with newly diagnosed femoral hernia, we recommend elective repair,
rather than watchful waiting, regardless of symptoms (Grade 1B). In patients with
long-standing femoral hernias (>3 months), surgery is preferred, but observation is a
reasonable option. (See 'Femoral hernia' above.)

•For patients with moderate or severe symptoms attributable to an inguinal hernia, we

recommend elective repair rather than watchful waiting (Grade 1B). (See
'Symptomatic hernia' above.)

•Patients who have an inguinal hernia but minimal or no symptoms, who wish to
avoid surgery, can be managed with watchful waiting provided that they are
appropriately counseled to seek prompt medical attention should the hernia become
acutely incarcerated or more symptomatic. Although acute complications rarely
occurred (1.8 emergency operations/1000 patient-years), about 70 percent of patients
eventually required hernia repair at 7 to 10 years due to increasing symptoms (usually
pain). Trusses are associated with negative consequences and should not be used to
manage symptoms related to inguinal hernias. (See 'Asymptomatic hernia' above.)
●The surgical approach to groin hernia repair should be the one that the surgeon is
most comfortable with and most experienced in performing. For surgeons who are
equally facile with both open and laparoscopic repairs, the choice of a surgical
approach depends upon hernia and patient characteristics as follows (algorithm 1):

•We prefer an open approach for patients with prior surgery involving the
preperitoneal space (including laparoscopic groin hernia repair, prostatectomy,
hysterectomy, cesarean section, and laparotomy via lower midline incision),
complicated inguinal hernias (infected, incarcerated, strangulated, large scrotal),
ascites, or intolerance of general anesthesia. Laparoscopic repair is relatively
contraindicated in these patients. (See 'Patients precluded from laparoscopic repair'
above.)

•A primary, unilateral inguinal hernia can be repaired open or laparoscopically based

upon surgeon and patient preferences. (See 'Inguinal hernia' above.)

•We prefer to repair a femoral hernia laparoscopically. (See 'Femoral hernia' above.)

•We prefer to repair bilateral inguinal or femoral hernias laparoscopically. (See

'Bilateral hernias' above.)

•We prefer to repair a recurrent groin hernia with a laparoscopic approach if the initial
repair was open, but with an open approach if the initial repair was laparoscopic. (See
'Recurrent hernia' above.)

●For patients with uncomplicated inguinal and femoral hernias, we recommend

performing a tension-free repair, which typically requires the use of mesh, rather than
a repair that produces tension (ie, most nonmesh primary tissue approximation repairs
except Shouldice) (Grade 1B). Nonmesh repair techniques may be required for
patients with active groin infection or contamination (eg, as a result of bowel
perforation from a strangulated hernia), or when the use of a mesh is cost prohibitive.
(See 'Surgical techniques' above.)

●For patients undergoing elective inguinal or femoral hernia repair requiring mesh
placement, we suggest using preoperative prophylactic antibiotics (Grade 2B). (See
'Antibiotics' above.)

●We prefer to perform open groin hernia repair under local anesthesia, especially in
patients with comorbidities (eg, advanced liver disease). Most laparoscopic repairs
require general anesthesia. (See 'Choice of anesthesia' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

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