Every year around 20 million people worldwide undergo surgery to repair an inguinal hernia, revealing just how common inguinal hernias are. An inguinal hernia occurs when tissue in your abdomen, usually part of your bowel, pushes outwards through a weakness in the abdominal muscle wall in your groin area.
Here we’ll take a look at some of the most common questions and concerns that I hear about inguinal hernias as a Consultant Hepato-Pancreato-Biliary and Laparoscopic Surgeon, covering everything from risk factors to treatment.
Do inguinal hernias only occur in men?
No, anyone can develop an inguinal hernia, both men and women. However, they are far more common in men — the lifetime risk of developing an inguinal hernia if you’re a man is 27-42%, while it is only 3.5-8% if you’re a woman. The reason for this difference comes down to anatomy.
An inguinal hernia occurs when tissue in your abdomen pushes through a passage in your abdominal wall called the inguinal canal. Any weakness in your abdominal wall, therefore, increases your risk of an inguinal hernia. In men, more structures pass through the inguinal canal, specifically, the spermatic cord, which connects to the testes, making this area of the abdominal wall more prone to weakness.
At what age do inguinal hernias most commonly occur?
Inguinal hernias are more common as you get older as wear and tear weakens your abdominal wall. In adults, the age group most affected by inguinal hernias are those aged over 65 years.
What are the main risk factors for developing an inguinal hernia?
Common risk factors for developing an inguinal hernia include being overweight, male and older, as well as having a family history of inguinal hernias ie close relatives who have had one.
Older men with benign prostate hyperplasia (BPH) are also more likely to develop an inguinal hernia. This is because BPH prevents the bladder from emptying properly, causing more frequent urination and straining when urinating — this can weaken your groin muscles.
Previous injury or surgery (eg prostate surgery) in or around your groin also increases your risk as this can weaken your abdominal wall. Similarly, certain medical conditions, such as connective tissue disorders, can also weaken your abdominal wall and increase your chances of developing an inguinal hernia.
Does being a smoker increase your risk of an inguinal hernia?
Yes, if you are a long-term smoker. This is because smoking increases your risk of developing COPD (chronic obstructive pulmonary disease), which causes a chronic (long-term) cough. This puts a greater strain on your abdominal and groin muscles.
Does heavy lifting or strenuous exercise cause inguinal hernias?
Whether or not you develop an inguinal hernia after lifting something heavy or performing strenuous exercise depends on your overall risk for the condition. Not all people who regularly lift heavy weights will develop an inguinal hernia but if you have several of the risk factors for the condition, this is more likely to happen. For example if inguinal hernias run in your family, you have had previous surgery in your groin area, or you have COPD, BPH or another condition that puts strain on or weakens your abdominal wall.
Does constipation cause inguinal hernias?
If you have chronic constipation ie constipation lasting for several months or more, you’re more likely to develop an inguinal hernia. This is because constipation forces you to strain more when you open your bowels, which puts greater pressure on your abdominal wall and groin muscles.
What are the main symptoms of an inguinal hernia?
The most common symptoms of an inguinal hernia are a noticeable bulge in your groin area and pain. You may find it uncomfortable to sit, stand or engage in certain activities that put greater strain on your abdomen or groin. However, it is important to note that not all inguinal hernias cause pain or discomfort at first.
Do inguinal hernias get better on their own?
No, inguinal hernias do not get better on their own. In fact, they’re likely to get worse over time as the affected area of your abdominal wall becomes weaker.
How do inguinal hernias progress?
Inguinal hernias usually start off as an initial bulge that occurs when part of your bowel pushes out through a weakness in your abdominal wall. In most cases, the bulge will get larger over time.
In some cases, an inguinal hernia may progress to an incarcerated hernia, where the protruding bowel becomes trapped but still has a healthy blood supply.
If the blood supply to the trapped part of your bowel is cut off, this tissue will become gangrenous and die. This is called a strangulated hernia and is a medical emergency — emergency surgery is needed.
Surgery to repair an inguinal hernia is usually recommended to avoid it becoming incarcerated or strangulated. The size of your hernia doesn’t determine how likely it is to become strangulated or how likely you are to have symptoms — small inguinal hernias are just as likely as large inguinal hernias to cause pain or become strangulated.
Do inguinal hernias always need to be treated?
Inguinal hernias do not get better on their own and can only be resolved with hernia repair surgery. If your inguinal hernia is not causing you any pain or discomfort, you may not want to undergo surgery as every surgery comes with risks. However, if your inguinal hernia is causing you pain or discomfort, you may choose to have surgery now. In either case, your doctor will discuss the risks and benefits of surgery with you so you can make an informed decision.
In general, surgery is usually recommended rather than taking a “watchful waiting” approach. This recommendation is based on studies that show over time, patients with inguinal hernias who opt to “wait and see” increasingly end up needing surgery. The chances of complications after hernia repair surgery are lower if the surgery is elective, rather than emergency surgery. Hernia repair surgery can be open or keyhole (laparoscopic).
What is the difference between keyhole and open hernia repair surgery?
Open hernia repair surgery and keyhole (laparoscopic) hernia repair surgery are both used to place the protruding tissue back into your abdomen and repair the weakness in your abdominal wall. The weakness in the abdominal wall is usually repaired by sewing in a piece of flat mesh to help strengthen the muscle wall.
Open surgery involves making a single, large cut into your groin to carry out the repair. In contrast, keyhole surgery, which has been performed since the 1990s, involves making several smaller cuts on your abdomen to repair the hernia.
During keyhole surgery, a thin telescope-like tube with a camera and a light on the end (laparoscope) is passed into your abdomen via one small cut so your surgeon can see inside your body. Small surgical instruments are then passed through the other small cuts so your hernia can be repaired.
Which is better, keyhole or open hernia repair surgery?
According to the UK’s National Institute of Health and Care Excellence, both keyhole and open hernia repair surgery are equally as effective in treating inguinal hernias and overall have similar rates of complications. However, there is some evidence that keyhole surgery comes with lower risks of persistent pain and numbness compared with open surgery. The main difference between the two is the recovery time, with keyhole surgery usually allowing a quicker return to normal activities.
In some cases, such as if you have an inguinal hernia on both sides of your body (bilateral inguinal hernia), keyhole surgery is recommended to avoid having two large cuts on either side of your groin. If your inguinal hernia has recurred and you previously had open surgery, you may also be recommended keyhole surgery to avoid cutting through the same area of tissue.
In either case, open or keyhole surgery, a major factor in determining the success of your procedure will be how experienced your surgeon is in the chosen technique.
Is the mesh used in hernia repair surgery safe?
The controversy around the safety of using mesh in surgeries came to light in 2017 but is not related to hernia repair surgery. It was revealed that thousands of women who had vaginal mesh implanted to treat pelvic floor problems and/or bladder incontinence went on to develop severe complications due to the mesh eroding. This included chronic pain, infections and sexual dysfunction. In these cases, the use of mesh was found to be inappropriate for this procedure.
The use of mesh in hernia repair surgery is, however, recommended and considered safe based on current data and evidence. In these cases, the mesh is placed flat against the weakness in the abdominal wall to repair it and help reinforce the abdominal wall.
How long does it take to recover from inguinal hernia repair surgery?
Inguinal hernia repair surgery is usually a day case, so you can return home on the same day as your surgery. However, you will need to avoid any strenuous activity for at least six weeks. At around six to eight weeks after hernia repair surgery, you can gradually introduce weight-bearing activities. Whether or not you can return to work at this point will depend on how physical your job is. If you aren’t sure, speak to your surgeon or doctor. It’s important to give your body enough time to heal to reduce the risk of your inguinal hernia recurring.
Recovery from keyhole inguinal hernia repair surgery is usually faster — you may be able to drive after a week. However, you should always speak to your surgeon or doctor to avoid injuring yourself before your body has had the chance to heal properly.
Can an inguinal hernia come back after treatment?
Yes, inguinal hernias can come back after treatment. Although hernia repair surgery is effective, your abdominal wall is still not going to be as strong as it was before your inguinal hernia developed. Another reason that you may develop another inguinal hernia in the future is that several of the major risk factors are not ones that you can change eg your sex, age and genetics.
How can I reduce my risk of developing another inguinal hernia?
Although there are several risk factors for inguinal hernias that you can’t change, there are several that you can control. You can reduce the risk of your inguinal hernia recurring by quitting smoking, losing any excess weight and maintaining a healthy weight, following a healthy diet rich in fibre and staying active to avoid constipation. Make sure to take any prescribed medication to treat conditions that increase your risk of an inguinal hernia eg medication for BPH.
Mr Dhanwant Gomez is a Consultant Hepato-Pancreato-Biliary and Laparoscopic Surgeon at Spire Nottingham Hospital and Nottingham University Hospitals NHS Trust, specialising in hernia surgery, complex liver surgery, pancreatic and biliary surgery, gallbladder and gallstone removal, and neuroendocrine tumours. He holds a postgraduate MD for his research into liver regeneration. He is also an Honorary Associate Professor for the University of Nottingham where he is actively involved in national clinical research trials and research into medical devices in liver surgery.