From the first pull to surgery: the path of a hernia explained

Special attention is paid to the modern minimally invasive TAP method (transabdominal patch plasty) and to treatment in Berlin, particularly at the VenaZiel Hernia Centre in Berlin-Kreuzberg, which specializes in gentle procedures.

In addition, equal consideration is given to men and women, different patient groups (athletes, older people, professionals, etc.) are addressed and current statistics on surgical results and success rates are presented.

What is a hernia? – Definition and background

An inguinal hernia is a form of hernia, i.e. a hernia in the groin area. More precisely, an inguinal hernia occurs when a weak point or gap occurs in the abdominal wall in the inguinal canal and internal tissue protrudes through this opening.

The peritoneum often bulges outwards, sometimes pushing intestinal loops or fatty tissue outwards with it.

Externally, those affected often notice a bulge in the groin area – especially when standing, pressing or coughing, this protrusion becomes visible and palpable.

In common parlance, the term “hernia” is used, although it is not a bone that is affected, but the connective tissue of the abdominal wall.

There is an anatomical explanation for why the inguinal region is susceptible: in men, the inguinal canal leads the spermatic cord (vas deferens and blood vessels) towards the testicles; in women, a retaining ligament of the uterus runs there.

This passage represents a natural weak point in the abdominal wall. In men, during embryonic development, the testicles migrate from the abdominal cavity through the inguinal canal into the scrotum – the resulting connection leaves a potential gap throughout life.

Direct inguinal hernias usually occur in a weak point in the posterior wall of the inguinal canal, indirect hernias run along the internal pathway (vaginal process) and can extend into the scrotum (so-called scrotal hernia).

In women, the inguinal hernia is less common and often more difficult to recognize – it is often actually a femoral hernia, which occurs below the inguinal ligament (see section below).

Important: A hernia does not heal on its own. Once such an opening has formed, it remains and can enlarge over time. In many cases, the prolapsed tissue can initially be pushed back (repositionable hernia), but the gap in the abdominal wall remains.

A hernia is therefore not a temporary strain, but an anatomical gap that can usually only be closed permanently by surgery.

Causes and risk factors of a hernia

There are many causes and risk factors that promote an inguinal hernia. Basically, the hernia results from an imbalance between the load (internal abdominal pressure) and the strength of the abdominal wall in the groin area. Here are some important factors:

• Congenital connective tissue weakness: A genetic weakness of the connective tissue is often the cause. In some people, the tissue is naturally less stable, which favors hernias. A familial predisposition (positive family history) clearly increases the likelihood of a hernia.

• Male gender: Men have a roughly nine times higher risk than women. The inguinal canal is wider in men due to the spermatic cord, which makes a hernia more likely. The lifetime risk is around 27% for men and around 3% for women . Women are less frequently affected, but when they are, it is often due to other types of hernia (see below).

• Age: Inguinal hernias can occur at any age – from infancy to old age. However, the incidence (frequency of new cases) increases with age. In old age, the strength and elasticity of the tissue decreases, making hernias more frequent.

• Increased intra-abdominal pressure: Situations or chronic conditions that increase the pressure in the abdominal cavity promote the development of a hernia. These include heavy lifting and carrying (e.g. during physical work or intensive weight training), frequent straining (e.g. during bowel movements or lifting weights), chronic coughing (smoking, COPD, asthma) and severe sneezing, as well as prostate enlargement (which causes straining when urinating).
  Pregnant women also have increased pressure due to the growing abdomen, which can rarely lead to inguinal hernias.
  Being overweight (obesity) is often cited as a risk factor as it increases the pressure – however, studies show that being underweight (very low BMI) can also be a risk factor, possibly because there is less protective fat padding to support the groin area.

• Physical stress in athletes: Athletes in particular can be affected. Intensive physical activities, abrupt turning, jumping or violent kicking movements (e.g. in soccer) put strain on the groin region.
  It is not uncommon for athletes to initially be diagnosed with a “soft groin” (sports groin) – a syndrome with groin pain without a palpable hernia.
  This overloading of the tendons and muscles in the region can lead to minor injuries and promote the development of a real hernia.
  Athletes should therefore take repeated groin pain seriously and have it checked by a doctor to see if it is due to an incipient hernia.

• Previous operations and scars: Patients who have already had a hernia operation can develop a recurrent hernia (a new hernia in the same place) years later.
  Other abdominal operations in the vicinity (e.g. prostate surgery, vascular surgery) can also change the anatomy and promote subsequent hernias.

In addition to the points mentioned, there are special forms: A direct load on the groin (e.g. a kick or impact, such as during sport or an accident) can acutely manifest an existing latent hernia, but is rarely the sole cause.
Overall, it is often an interplay – an existing tissue weakness meets a situation with increased pressure, resulting in the fracture.

Statistics: In Germany, Austria and Switzerland, an estimated 300,000 hernia operations are performed each year – no other general surgical procedure is performed as frequently.

This high number illustrates how common inguinal hernias are, but also that they are routine operations (more on this in the section on therapy).

Symptoms – from the first pulling to swelling

Early signs: An inguinal hernia often begins with unspecific symptoms. Many sufferers initially report a pulling or pressing sensation in the groin – hence the term “first pull”.

This pulling sensation occurs in particular when the abdomen is pressed, i.e. when lifting heavy objects, coughing, sneezing or pressing. Initially, the feeling may be intermittent and subside again when at rest. It is not uncommon for it to be misinterpreted as muscle strain or overexertion at first.

Swelling/bump: Typically, a protrusion (bump) develops in the groin region over time.

This swelling is a sure sign of a hernia, especially if it becomes more prominent when coughing or pressing and may disappear again when lying down.

Initially, the protrusion is often small and soft. In men, if the hernia canal is large enough, it can extend into the scrotum (so-called testicular hernia or scrotal hernia).

In women, a protrusion into the labia majora may occasionally occur (labial hernia), but often remains discreet. The swelling is often reducible, i.e. it can be pushed back into the abdomen by hand or while lying down. Many patients experience temporary relief as a result.

Pain: A hernia does not necessarily have to be accompanied by severe pain. In many cases, there is initially only slight pulling pain or a feeling of pressure in the groin, which is particularly noticeable when moving, coughing or standing for long periods.

Some sufferers also experience burning or discomfort in the area. The pain can increase as the hernia gets bigger. Pain can also radiate to neighboring regions – in men to the testicles, for example, and in women to the thigh.

Chronic groin pain without a recognizable protrusion can – as mentioned – indicate an athlete’s groin (overuse syndrome), although this can also develop into a genuine hernia.

No symptoms? Some hernias – especially smaller ones – do not cause any symptoms at first. They are discovered by chance by the doctor or only noticed when the protrusion becomes clearly visible.

A hernia can remain asymptomatic for a long time, especially in older or less active people. However, most patients develop symptoms over time, even if the hernia was initially silent.

Therefore, even painless or small bumps in the groin should be taken seriously and checked out by a doctor.

Unfortunately, many patients – especially men – wait too long to go to the doctor. Early diagnosis is important in order to avoid complications.

Warning signals (emergency): It becomes dangerous if there is severe, sudden pain in the groin, accompanied by nausea or vomiting and the protrusion is hard, tense and can no longer be pushed back.

This indicates an incarceration – i.e. a piece of intestine or tissue is trapped in the hernia and the blood supply is cut off. An incarcerated hernia is a surgical emergency, as the affected piece of intestine can die within a short time, leading to intestinal obstruction and peritonitis.

If such symptoms occur, surgery must be performed immediately – do not hesitate to call the emergency doctor. Fortunately, acute incarceration only occurs in a small proportion of inguinal hernias; however, the risk is higher in femoral hernias – these become incarcerated in up to 30% of cases.

Summary of symptoms: It usually begins with a vague pulling sensation followed by a small protrusion. Over weeks to months, this bump in the groin can increase in size. Pain is often pulling and dependent on exertion, but may be absent.

If you notice such signs – especially a new swelling in the groin area – have yourself checked by a doctor, even if there is no severe pain (yet).

Different aspects for men and women

An inguinal hernia affects men and women differently and can manifest itself differently, which is why gender-specific aspects are important:

• Men: Men make up the vast majority of inguinal hernia patients (around 90%). Both indirect hernias (the congenital form along the inguinal canal) and direct hernias are common in men, with indirect hernias being approximately twice as common as direct hernias.
  Men often notice a swelling that can extend into the scrotum.
  Important: In men, a minimally symptomatic inguinal hernia does not always require immediate surgery – under certain circumstances it can be observed initially (see section on therapy). However, most men develop symptoms over time. Men also tend to wait until the pain gets worse.
  Education is important here: the earlier a hernia is diagnosed and, if necessary, treated, the lower the risk of complications.

• Women: Women are much less frequently affected by inguinal hernias (lifetime risk approx. 3 % ). However, if a woman has a swelling in the groin area, special care is required.
  On the one hand, femoral hernias are relatively more common in women – these are located slightly lower (at the base of the thigh) and can clinically resemble an inguinal hernia.
  Secondly, femoral hernias in particular tend to incarcerate frequently (incarceration in up to 30 %) . For this reason, the rule of thumb is that women should always have a hernia operated on as soon as possible, even if it does not cause any symptoms.
  It is often not possible to distinguish clinically between an inguinal and a femoral hernia.
  For this reason, experts recommend that women with hernias should always be advised to undergo surgery soon – the risk of a hidden femoral hernia is too great.
  Women often notice pain rather than a clear bulge, as the hernia can remain smaller or more hidden in them. Younger women (e.g. after pregnancy) can also be affected.
  It is important that doctors take a close look at women with groin problems and, if in doubt, operate early to prevent incarceration.

• Children: For the sake of completeness, it should be mentioned that inguinal hernias also occur in children (especially boys), usually congenital due to an open canal.
  Surgery is practically always performed on children, as the hernia does not grow closed on its own and the risk of incarceration is particularly high in infants.
  For this article, however, the focus is on adult patients (women and men).

Diagnosis: How is a hernia diagnosed?

The diagnosis of a hernia is usually made through a thorough clinical examination. The doctor will examine the patient both standing up and lying down. The following steps are common:

1. Inspection and palpation: First, the groin region is examined (inspection) for visible protrusions. The doctor then palpates the groin systematically (palpation), often by the patient coughing or pressing to push out a possible hernia sac.
   The examiner often places a finger on the inguinal canal (in men also leading into the scrotum) to feel an impulse that presses against the finger when coughing – a classic sign of a hernia.
   The examination is carried out on both sides, as around 10-15% of cases involve bilateral inguinal hernias (sometimes simultaneously).

2. Reposition test: The doctor checks whether the contents of the hernia can be pushed back. A reducible hernia – where the protrusion can be gently pushed back into the abdominal cavity – is usually not acutely incarcerated.
   If this is not successful (irreducible fracture), caution is advised, as this may indicate adhesions or incipient incarceration.

3. Examination of the genitals: In men in particular, the testicles and inguinal canal are palpated to determine whether the hernia sac extends there (scrotal hernia).
   In women, the labia region is palpated, as there may be a rare labial hernia here.

4. Exclusion of other causes: Some diseases can cause similar swelling. These include enlarged lymph nodes in the groin (lymphomas or infections), a hernia in the testicles (hydrocele) varicose veins in the testicles (varicocele) or a testicular tumor .
   These are differentiated by specific palpation and, if necessary, an ultrasound examination. If the swelling is unclear, the doctor will also consider such differential diagnoses and carry out appropriate checks.

5. Imaging procedures: In many cases, the clinical examination is sufficient to make a diagnosis of inguinal hernia. However, if there is any doubt (e.g. very small hernia, very overweight patient, only pain without palpable findings), imaging methods are used.
   Ultrasound (sonography) is the most common method: The groin region can be examined with a high-resolution transducer while standing or lying down.
   This reveals a gap in the abdominal wall and any protruding intestinal loops or fatty tissue. An experienced examiner can also assess the size of the hernia and determine whether any parts are trapped.
   Ultrasound is painless and can be repeated at will and is often sufficient. In rare cases, particularly in the case of very unclear findings or recurrent hernias, an MRI (magnetic resonance imaging) or CT scan can be performed.
   These provide cross-sectional images that reveal even the smallest hernias. They are also used if a patient continues to have pain but no hernia can be found sonographically – sometimes only the MRI shows a so-called “occult hernia” (hidden hernia).

6. Clinical examination in women: As mentioned above, in women it is not possible to distinguish with certainty by palpation whether it is an inguinal or femoral hernia.
   Therefore, if there is a suspicion, it is more likely that imaging will be performed early on or a diagnostic laparoscopy (endoscopy) will be considered to clarify the situation. The latter especially if symptoms are severe.

As a rule, the diagnosis of an inguinal hernia is therefore a clinical visual and palpation diagnosis, supported by ultrasound. As soon as the diagnosis has been made, the next steps are discussed.

Important for the patient to know: Every palpable hernia should at least be assessed by a doctor, even if there is no acute pain.

This allows you to plan together whether an operation is necessary and when the best time for it is.

Therapy: Does every hernia need an operation?

The standard treatment for an inguinal hernia is surgical repair of the hernia gap. Since – as already mentioned – the hernia does not disappear on its own, surgery is the only definitive solution to close the abdominal wall.

However, the timing of the operation varies depending on the patient’s situation. Not every hernia needs to be operated on immediately, but ultimately most hernias are treated surgically sooner or later. Let’s take a look at the decision factors:

• Watchful waiting (wait-and-see observation): In certain cases, an initially conservative approach may be chosen – i.e. no surgery for the time being, but regular check-ups.
  This is particularly suitable for male patients with a small, asymptomatic, initially diagnosed hernia.
  Studies have shown that watchful waiting is safe for small inguinal hernias without symptoms, as the risk of sudden incarceration is relatively low at such early stages.
  However, the prerequisite is that the patient is monitored closely (e.g. every 6 months or earlier if there is a change) and is ready for surgery at any time if symptoms occur. An examination is often recommended every 6-12 weeks to check for progression (increase in size).
  Older patients in particular, or patients with severe pre-existing conditions, for whom surgery would carry a higher risk, can be observed initially – provided the fracture is small and symptom-free.
  Important: The concept of waiting does not apply to women (where surgery is always recommended, see above) and not to large or symptomatic hernias in men.
  And: On average, most initially asymptomatic men develop pain or enlargement within a few years, which then leads to surgery. Watchful waiting is therefore usually only a temporary solution, not a permanent therapy.

• When to operate? Symptomatic hernias (i.e. those that cause discomfort) should generally be operated on promptly. Reasons for an indication for surgery are Pain, noticeable increase in size, restriction in everyday life (e.g. insecurity when lifting), or simply the patient’s desire to solve the problem.
  Progressive hernias – i.e. if the hernia becomes significantly larger over time – should also be operated on, as an increase in size can make the operation more complicated and a larger hernia rarely becomes smaller again.
  Bilateral hernias (simultaneous left and right) are usually also operated on, especially because a laparoscopic procedure can treat both sides under anesthesia (advantage of the minimally invasive procedure).
  Recurrent hernias (new hernias in the same place) are usually operated on as soon as they are diagnosed – there is not much discussion here, as a new hernia usually causes some discomfort and there is a risk that it will rupture further.
  And of course: every incarcerated hernia is an acute surgical case (emergency) – you don’t wait and see.

To summarize: The vast majority of inguinal hernias are operated on, either immediately or after an observation phase. The aim of the operation is to close and reinforce the hernia gap so that the intestines remain safely in the abdominal cavity again.

Overview of surgical procedures

Various surgical methods have been developed in hernia surgery over the last few decades. A basic distinction is made between open procedures and minimally invasive (laparoscopic) procedures.

Modern guidelines generally call for a mesh-based procedure, i.e. the use of a plastic mesh to reinforce the abdominal wall is almost always recommended in adults (exception: very small hernias or if a mesh is absolutely rejected).

The most important procedures are

• Open surgery with mesh – Lichtenstein method: This is the most common open technique. The hernia sac is accessed via a small incision in the groin (usually 5-8 cm long), moved back into the abdominal cavity and the hernial orifice is covered from the outside with a plastic mesh and sutured to the connective tissue layer.
  Lichtenstein surgery is currently recommended in guidelines as the best open procedure, as the recurrence rates are significantly lower than with old suture techniques (such as Bassini or Shouldice) and comparable to laparoscopic methods.
  Advantages: It can be performed under local or spinal anesthesia (no general anesthesia required), which makes it useful for older or high-risk patients.
  Disadvantage: Slightly larger incision, slightly higher risk of wound healing disorders and – importantly – slightly higher rate of chronic pain compared to endoscopic techniques (more on this later).
  The Lichtenstein method is well suited for unilateral hernias in men when keyhole surgery is not available or the surgeon is not experienced in this procedure and for cases with contraindications to laparoscopy (see below).

• Minimally invasive surgery – TAPP method: TAPP stands for TransAbdominal Preperitoneal Patchplasty. This is a laparoscopic (“keyhole”) operation via the abdominal cavity.
  Under general anesthesia, three small incisions are usually made – one near the navel for the camera and two in the lower abdomen for fine instruments.
  The surgeon prepares the hernia site from the inside via these accesses and places a mesh in the so-called preperitoneal space (between the peritoneum and abdominal wall muscles), which covers the gap from the inside.
  The mesh is either fixed in place with a few staples or adhesive or simply held in place by the internal abdominal pressure (self-adhesive).
  TAPP has the advantage that both groins can be treated in one session (in the case of bilateral hernias) and that undiagnosed hernias on the opposite side can also be detected and repaired, as both groin areas can be viewed.
  Modern camera optics allow a magnified view, which increases precision. The procedure leaves only tiny scars, usually 5-12 mm long. The pain after the operation is typically less and subsides more quickly than with open surgery.
  Chronic nerve pain in particular occurs less frequently, as the nerves in the groin are spared under visualization and are not irritated by tension. TAPP requires general anesthesia and some special equipment and experience on the part of the surgeon. In experienced hands, however, it is extremely safe and effective.
  Studies and guidelines now see laparo-endoscopic techniques (TAPP or TEP) as the treatment of choice for most inguinal hernias – particularly in men with a first hernia, bilateral hernias and recurrent hernias (if the previous operation was open).

• Minimally invasive – TEP method: TEP stands for total extraperitoneal patchplasty. This method is similar to TAPP, with the difference that the abdominal cavity is not opened.
  The instruments are inserted into the layers of the abdominal wall and the procedure is performed completely outside the peritoneum (extraperitoneal).
  The mesh is also applied from the inside, but without entering the free abdominal cavity. Advantage: No contact with the intestines, thus potentially even lower risk of internal injuries or adhesions (adhesions).
  Disadvantage: Technically somewhat more demanding, as the space is narrower and the overview somewhat more difficult, especially with very large hernias or pre-operated abdomens.
  TEP is particularly suitable for patients without previous surgery in the lower abdomen and when a very gentle procedure is desired. Many surgeons decide between TAPP and TEP depending on the situation – both methods have excellent results in experienced hands.

• Special situations – e.g. robot-assisted surgery: Some centers (including Berlin) now use robotic systems (e.g. daVinci robots) for hernia operations.
  In principle, surgery is also minimally invasive, but with robotic instruments that the surgeon controls from a console.
  This can increase precision, but is cost-intensive. The results for the patient are similar to conventional laparoscopy.

• No nets? Historically, there were classic suture procedures (Shouldice, Bassini) in which the hernia gap was sutured only with the body’s own tissue, without mesh.
  Today, these are only used in exceptional cases – for example for very small hernias in young patients, when absolutely no foreign material is desired, or in certain infectious situations.
  The recurrence rates (relapse rates) are significantly higher with suture procedures (sometimes over 10 %), which is why modern guidelines advise against them.
  A mesh-free procedure should only be chosen if a mesh is exceptionally not available or is rejected by the patient.

Contraindications and choice of procedure: The choice of method depends on various factors: Size and type of fracture, age and concomitant diseases of the patient, as well as experience and equipment of the treating surgeon.

There are cases in which open surgery is preferable, e.g. if the patient cannot tolerate general anesthesia (then Lichtenstein under local anesthesia), or in the case of complicated previous operations in the abdomen (where adhesions could make laparoscopy difficult).

Large hernias that extend into the scrotum (scrotal hernias) or emergency incarcerated hernias are also often operated on openly, as parts of the intestine may also have to be resected. On the other hand, bilateral hernias and all hernias in women are considered ideal for laparoscopic treatment.

Severe pain before the operation is also an argument in favor of minimally invasive surgery, as this has been shown to reduce the likelihood of pre-operative pain turning into chronic post-operative pain.

Ultimately, an experienced hernia surgeon should select the optimal procedure in consultation with the informed patient.

Treatment in Berlin – Specialized hernia centers: In a major city like Berlin, there are certified hernia centers (e.g. the VenaZiel Hernia Centre Berlin in Kreuzberg) that specialize in the treatment of inguinal and abdominal wall hernias. Modern minimally invasive techniques such as TAPP are preferred there, often on an outpatient basis.

Specialization brings routine, from which patients benefit: shorter operating times, standardized procedures and a high level of expertise in the individual choice of procedure.

Anyone who is working or wants to get fit again quickly can receive gentle treatment at such centers – on an outpatient basis, with minimal downtime. The centers often also take part in quality assurance programs such as Herniamed (see below) so that results are continuously monitored.

Focus on the minimally invasive TAP method: advantages of keyhole surgery

The TAP method (usually referred to as TAPP in the context of inguinal hernias) deserves special mention, as it offers many patients considerable advantages.

Surgical wounds after minimally invasive inguinal hernia surgery (TAPP method). The three small incisions (shown here with plaster and staple, a few days postoperatively) are only a few millimetres in size. Such keyhole operations result in less pain and almost invisible scars.

Less pain and faster recovery: the tiny incisions cause much less trauma to the surrounding tissue than a larger incision.

Patients often report significantly less post-operative pain after laparoscopic hernia surgery . Mild painkillers are often sufficient, and after a few days you are largely pain-free. This also enables faster mobilization: you can get up and walk on the same day as the operation.

Many of these procedures are performed on an outpatient basis – about a third of patients in such programs can go home the same day.

In Northern Europe, up to 90% of hernia operations are performed on an outpatient basis. The trend towards outpatient surgery is also increasing in Germany, which is more convenient for patients.

Cosmetic benefits: The scars from TAPP are usually barely visible. Typically, there is a mini incision on the navel (which often disappears into a fold of skin) and two small stitches in the lower abdomen.

In the example shown above, there are only 3 small scars of 2.9 mm each, which look like pinheads – here the operation was performed in a specialized clinic with extra-fine instruments.

After just a few weeks, these scars are pale and inconspicuous. This is a pleasant side effect, especially for young, active patients or athletes.

Reduced risk of chronic pain: A feared complication after inguinal hernia surgery is the occurrence of chronic groin pain (groin pain syndrome) due to scar tension or nerve irritation.

Studies have shown that laparoscopic procedures have a lower rate of such persistent pain than open procedures.

Severe chronic pain in particular is less frequent, as certain nerves (ilioinguinal nerve, iliohypogastric nerve) are spared during the endoscopic technique or can be cut prophylactically to avoid neuroma formation.

If a patient already has severe pain in the fracture area before the operation, experts tend to recommend minimally invasive surgery, as this reduces the risk of this pain becoming chronic.

Bilateral treatment and recurrences: As mentioned, bilateral inguinal hernias can be repaired in one session with TAPP – a great advantage as the patient only has to undergo one anesthetic and one recovery process instead of two separate operations.

In the case of repeat hernias (recurrences), it is generally the case that if the first operation was open, the next one should be performed laparoscopically, as this allows the surgeon to operate on uninjured tissue.

The other way around: If the first operation was minimally invasive, it is better to open the recurrence (Lichtenstein). This strategy ensures the best results and the lowest complication rates.

High success rates: The success rate of the TAPP method is excellent. In specialized centers, the recurrence rate (recurrence of the fracture) is in the low single-digit percentage range.

For example, a recent registry analysis (Herniamed data from over 1,000 patient pairs) showed that the relapse rate after one year was only 0.6-1.8%.

Modern meshes and techniques have therefore greatly increased healing rates. Complications are also rare: Most patients undergo the operation without any major problems.

Of course, as with any operation, complications can occur (see next section), but overall laparoscopic hernia surgery is a very safe procedure.

Restrictions: Not every patient is an ideal candidate for TAPP/TEP. Heavily overweight people (BMI > ~30) can be technically more difficult to operate on, as the peritoneum and posterior wall are more difficult to reach if there is a lot of fat – the surgeon must make a careful assessment here.

In the new method with extra-thin instruments mentioned above, for example, only patients with a normal physique could be operated on because the instruments are shorter.

Patients with certain pre-existing conditions (severe heart/lung diseases that make general anesthesia risky) or coagulation disorders are also more likely to require open procedures under local anesthesia.

Despite these few exceptions, it can be said that for most patients – whether young or old, athletes or pensioners, men or women – the minimally invasive TAP method offers considerable advantages.

After the operation: healing phase and prognosis

Inguinal hernia surgery – whether open or minimally invasive – is followed by a short rehabilitation and healing phase. Thanks to tension-free mesh techniques, this is usually quick and has a high success rate.

Hospitalization: As mentioned, many procedures can be performed on an outpatient basis. If an inpatient stay is necessary (e.g. due to pre-existing conditions or lack of care at home), the patient usually spends 1-3 days in hospital.

However, the trend is clearly towards outpatient treatment – modern centers discharge the majority of patients on the day of surgery or after one night of monitoring. Patients appreciate this as they often recover more quickly at home.

Pain and wound healing: Immediately after the operation, there is naturally pain in the wound area, but this can be well controlled with painkillers.

Many patients only need pills for a few days after laparoscopic surgery and are then pain-free. After open surgery, it may take a little longer, but here too the pain is usually moderate.

Temporary numbness or slight swelling in the groin area postoperatively is frequently reported, which is normal and gradually disappears.

The small skin incisions heal in ~10-14 days, stitches (if not self-dissolving) are removed after approx. 7-10 days. Showering is often permitted after 2 days; bathing is delayed until the wounds are completely closed.

Everyday life and exertion: Fortunately, patients can be active again very quickly. Light activities, walking, climbing stairs are usually possible immediately or the next day.

You can and should exercise to get your circulation and digestion going – you should only avoid strong abdominal pressure at first. As a rule, full physical resilience is regained after about 2-3 weeks.

This means that patients can lift, exercise and work again without restriction after approx. 3 weeks, provided they are pain-free.

In some cases, doctors even allow exercise after 14 days, especially after the minimally invasive method, if the wound has healed without any problems. Nevertheless, it is often advised not to lift anything heavier than 10 kg for approx. 4-6 weeks to give the mesh and tissue enough time to heal stably – these recommendations can vary and are discussed on an individual basis.

Office work can often be resumed after 1-2 weeks, depending on how you feel.

Prospects of success and long-term results: The prognosis after inguinal hernia surgery is excellent. The vast majority of patients are completely cured and have no long-term complaints.

Modern mesh operations have recurrence rates of less than 1-3% (depending on the study and follow-up period). In comparison: in the past, without meshes, recurrence rates were over 10 %. Today, recurrences are rare and usually due to special factors (very large fractures, wound infection, early loading or, rarely, material failure).

If a fracture occurs again, it can be successfully operated on again as described above, often using a different procedure (change of method).

One of the biggest challenges is chronic pain after hernia surgery. Registry data shows that, on average, just over 10% of patients continue to experience pain, which can affect their quality of life.

However, this figure takes into account all degrees of pain and all techniques. It is often a case of slight discomfort or numbness that is not severely debilitating. Truly severe chronic pain (e.g. neuropathic pain due to nerve injury) is fortunately much rarer – estimates are usually 2-5% of patients, depending on the surgical procedure and definition.

Laparoscopic methods tend to show lower rates of chronic pain than open methods. Continuous improvements (gentler techniques, early physiotherapy, pain therapy) are aimed at further reducing this rate.

It is important that patients are aware of this: Some numbness at the scar or in the upper thigh is common and can take months to normalize – this is not synonymous with damage, but is usually the result of the severing of small cutaneous nerves and often subsides.

Complications: In general, hernia surgery is very safe. Serious complications (e.g. injury to the bowel or blood vessels, secondary bleeding, infection) are rare and the risk is far below 1-2%, especially in the case of elective (planned) surgery.

Wound infections occur slightly more frequently in open surgery than in endoscopic surgery, but are rare thanks to antibiotic prophylaxis. However, large registries show that the overall complication rate is low and the mortality rate (lethality) for elective hernia surgery is close to 0.

The greatest risk is if you don’t operate at all and an incarceration occurs – in an emergency this can lead to partial bowel movements and, in the worst case, to life-threatening situations. Scheduled surgery, on the other hand, is very safe.

Quality assurance and hernia register: In Germany, there is an Internet-based hernia register, Herniamed, in which over 700,000 hernia operations have been documented since 2009.

This register helps to monitor quality and record complications or recurrences in order to learn from them. For example, we know that the average recurrence rate across all clinics is still around 10% – but this includes many complex cases and various techniques.

The best centers are significantly lower. Herniamed data also shows what still needs to be worked on: e.g. the chronic pain mentioned >10 % . By collecting such data, surgeons can further improve their techniques and update guidelines based on evidence.

The latest international guideline (HerniaSurge 2018) has already been commented on by German experts and emphasizes the advantages of laparo-endoscopic procedures as the first choice in most cases.

Conclusion

A hernia is initially no reason to panic, but in the long term it can usually only be repaired by surgery.

From the first pulling in the groin to the final healing, patients ideally go through an orderly process: early diagnosis, evaluation of the urgency and then – in the vast majority of cases – minimally invasive surgery, which is nowadays performed routinely, safely and with excellent chances of success.

Men and women, young and old, athletes and the less active: everyone can be affected and everyone can benefit from modern therapy methods.

Inform yourself, have yourself examined early if in doubt and entrust yourself to an experienced hernia surgeon or a hernia center for the procedure.

Thanks to procedures such as the TAP/TAPP method, it is often possible to go through life pain-free again shortly after the operation, with barely visible scars and the good feeling that “the hernia is gone”.

Above all, it is important not to take a hernia lightly – even if it seems harmless at first, it can get worse.

If you take the right steps, it doesn’t have to be a long way from the first pull to the operation. The prognosis is excellent, and the vast majority of patients are glad in retrospect that they opted for surgery in time – for a pain-free, active life without a hernia.

Sources

1. ORF.at – New surgical method for inguinal hernias (2025) – Report on a minimally invasive TAP technique developed in Klagenfurt with halved access sizes, less pain and 2.9 mm small scars.
2. Spiegel Online – Inguinal hernia: Surgery is usually unavoidable (2016) – Article with expert interviews (Dr. Lorenz, Dr. Reinpold) on the dangers of untreated hernias, 27% vs. 3% lifetime risk, risk factors and surgical options.
3. Webop.de – Pape-Köhler et al: Perioperative management – inguinal hernia repair (Lichtenstein), updated 15.07.2024 – Surgical e-learning module with current guideline recommendations (e.g. mandatory mesh, laparoscopic procedures as the first choice, Lichtenstein as the best open procedure).
4. Herniamed.de – Patient information from the Herniamed quality assurance study (as of 2021) – Background on hernias in Germany ( >350,000 operations annually), average recurrence rate >10%, chronic pain >10%.
5. NetDoktor.at – Inguinal hernia: diagnosis, treatment and prognosis – Patient guide (as of 2020) with emphasis: Always operate on women (femoral hernia risk ~30% incarceration), wait and see if men are asymptomatic, always operate on children.
6. VKKD Clinics Blog – New data on inguinal hernia surgery (Herniamed registry analysis) (July 2025) – Study with >1,000 patients: Recurrence rate after 1 year with lap. Hernia repair only 0.6 % (slit mesh) vs. 1.8 % (without slit), no differences in chronic pain or complications.
7. Kaernten.ORF.at – Health: New method promises less pain – Interview with Dr. Andreas Grün: TAP access routes halved, significantly less trauma, 1/3 of patients can be treated in day clinics (outpatient) thanks to low-pain method.
8. Hernia surgery Tübingen (Loretto Clinic) – Patient information (2022) – Mentioned Lifetime risk: men 27%, women 3%; incidence increases with age. (Generally known statistic, cited in many guidelines, among others).
9. German Hernia Society (DHG) – Expert statement by Dr. W. Reinpold (quoted in Spiegel) – Underlines genetic connective tissue weakness as a common cause, recommends rapid surgery after diagnosis, exceptions only in individual cases in young asymptomatic men under control.
10. AWMF guideline S1 Inguinal hernia, hydrocele (AWMF no. 043/001, as of 2020) – German guideline (S1) confirms international recommendations: Use of meshes, operate early in women, in men asymptomatic wait-and-see keeping open possible, otherwise TEP/TAPP preferred. (Quintessence reflected in sources 3 and 5).