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 type of hernia, specifically a visceral rupture in the groin area. More specifically, an inguinal hernia occurs when a weak spot or gap in the abdominal wall appears 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 for 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: An inguinal 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 (reducible hernia), but the abdominal wall gap 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 various causes and risk factors that promote an inguinal hernia. Basically, the hernia results from an imbalance between the load (intra-abdominal pressure) and the strength of the abdominal wall in the groin area. The following are some important factors:

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

• Male gender: Men have an approximately nine times higher risk than women. The inguinal canal is wider in men due to the spermatic cord, which makes a rupture more likely. The lifetime risk is about 27% for men and about 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 decrease, which makes ruptures more common.

• Increased intra-abdominal pressure: Situations or chronic conditions that increase pressure in the abdominal cavity promote the development of a rupture. These include heavy lifting and carrying (e.g., during physical work or intensive strength training), frequent pressing (e.g., during bowel movements or lifting weights), chronic coughing (from smoking, COPD, asthma) and severe sneezing, as well as prostate enlargement (which causes pressing during urination).
  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. Intense physical activity, abrupt twisting, jumping, or violent shooting movements (e.g., in soccer) put stress 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 non-specific symptoms. Many affected individuals initially report a pulling or pressing sensation in the groin – hence the expression “first pull”.

This pulling occurs especially with abdominal pressure, i.e., when lifting heavy objects, coughing, sneezing, or pressing. Initially, the feeling may be intermittent and subside again at rest. Not infrequently, it is initially misinterpreted as a muscle strain or overexertion.

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 bulge is often small and soft. In men, if the rupture canal is large enough, it can extend into the scrotum (so-called 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: An inguinal hernia does not have to be associated with severe pain. In many cases, there is initially only mild pulling pain or a feeling of pressure in the groin, which is especially noticeable during movement, coughing, or prolonged standing.

Some affected individuals also have burning or abnormal sensations in the area. If the rupture becomes larger, the pain may increase. Pain can also radiate to neighboring regions – in men, for example, to the testicles, in women to the thighs.

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 inguinal hernias – especially smaller ones – initially cause no symptoms at all. They are discovered accidentally by the doctor or only noticed when the bulge becomes clearly visible.

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

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

Many patients – especially men – unfortunately wait too long before going to the doctor. Early diagnosis is important 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.

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

Summary of symptoms: It usually starts with a vague pulling sensation, followed by a small bulge. Over weeks to months, this lump in the groin can increase in size. Pain is often pulling and load-dependent, 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 (about 90%). In them, both indirect hernias (the congenital form along the inguinal canal) and direct hernias are common, with indirect hernias being about twice as common as direct ones.
  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, observation may be possible initially (see section on therapy). However, most men develop symptoms over time. Men are also more likely 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 about 3%). But if a woman has swelling in the groin area, special caution is advised.
  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 lump, as the hernia may remain smaller or more hidden in them. Younger women (e.g., after pregnancies) 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 an inguinal hernia is usually made by a thorough clinical examination. The doctor will examine the patient both standing and lying down. The following steps are common:

1. Inspection and palpation: First, the groin region is inspected for visible bulges. Then, the doctor systematically palpates the groin, often by having the patient cough or press 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 hernia contents can be pushed back. A reducible hernia – in which the bulge 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 a similar swelling. These include enlarged lymph nodes in the groin (lymphomas or infections), hydrocele in the testicle. varicose veins in the testicles (varicocele) or a testicular tumor .
   These are differentiated by targeted palpation and, if necessary, an ultrasound examination. In the case of unclear swellings, the doctor will also consider such differential diagnoses and carry out appropriate checks.

5. Imaging procedures: In many cases, the clinical examination is already sufficient to make the diagnosis of inguinal hernia. However, if there are doubts (e.g., very small hernia, severely 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 shows a gap in the abdominal wall and, if necessary, protruding intestinal loops or fatty tissue. An experienced examiner can also assess the size of the rupture and determine whether parts are trapped.
   Ultrasound is painless and can be repeated as often as required and is often sufficient. In rare cases, especially in the case of very unclear findings or recurrent hernias, an MRI (magnetic resonance imaging) or CT scan may be performed.
   These provide cross-sectional images on which even the smallest hernias become visible. They are also used if a patient continues to have pain, but no rupture can be found sonographically – sometimes the MRI only shows a so-called “occult hernia” (hidden rupture).

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, there is a tendency to do imaging early or to consider a diagnostic laparoscopy (endoscopy) to clarify the situation. The latter especially if symptoms are severe.

 

As a rule, the diagnosis of inguinal hernia is therefore a clinical visual and palpation diagnosis, supported by ultrasound. Once the diagnosis has been made, the further procedure is 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 therapy for an inguinal hernia is surgical repair of the rupture 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, there are differences in the timing of the operation depending on the patient’s situation. Not every inguinal hernia needs to be operated on immediately, but ultimately most hernias are surgically treated 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 especially true for male patients with a small, asymptomatic, first-diagnosed hernia. Patients with a small, asymptomatic, newly diagnosed hernia may be considered.
  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 closely monitored (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 determine 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 OP indication are: pain, palpable increase in size, restriction in everyday life (e.g. uncertainty 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 a period of observation. The goal of the operation is to close and reinforce the rupture gap so that the intestines remain safely in the abdominal cavity.

 

Overview of surgical procedures

Various surgical methods have been developed in hernia surgery in recent decades. Basically, a 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 widely used open technique. Through a small incision in the groin (usually 5–8 cm long), the hernia sac is located, moved back into the abdominal cavity, and the rupture orifice is covered from the outside with a synthetic 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 an enlarged 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 faster than with open procedures.
  In particular, chronic nerve pain occurs less frequently because the nerves of the groin are protected under vision and not irritated by tension. TAPP requires general anesthesia and some special equipment as well as experience 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 getting into the free abdominal cavity. Advantage: No contact with the intestines, therefore potentially even lower risk of internal injuries or 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 if a very gentle procedure is desired. Many surgeons decide situationally between TAPP and TEP – 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. For the patient, the results 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 extending into the scrotum (scrotal hernias) or emergency incarcerated hernias are also often operated on openly, as intestinal parts may also have to be resected. On the other hand, bilateral hernias and all hernias in women are considered ideal for laparoscopic repair.

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 Center Berlin in Kreuzberg) that specialize in the treatment of inguinal and abdominal wall hernias. There, modern minimally invasive techniques such as TAPP are preferably used, often also 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 employed or wants to get fit again quickly will find the opportunity to receive gentle treatment in such centers – on an outpatient basis, with minimal downtime. The centers often also participate 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 (here with plaster and staples, a few days postoperatively) are only a few millimeters in size. Such keyhole surgeries lead to 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 . Often mild pain relievers are sufficient, and after a few days you are largely pain-free. This also allows for faster mobilization: you can get up and walk on the same day of 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 inguinal hernia operations are even performed on an outpatient basis. The trend towards outpatient treatment of these operations is also increasing in Germany, which is more convenient for patients.

Cosmetic benefits: The scars with TAPP are usually barely visible. Typically, there is a mini-incision at the navel (which often disappears in a skin fold) 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 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, the recurrence is better done openly (Lichtenstein). This strategy ensures the best results and lowest complication rates.

High success rates: The success rate of the TAPP method is excellent. In specialized centers, the recurrence rate (return of the rupture) 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 go through the operation without 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. Severely overweight people (BMI > ~30) can be technically more difficult to operate on, as the peritoneum and posterior wall are more difficult to reach with a lot of fat – the surgeon must weigh this carefully.

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

After an inguinal hernia operation – whether open or minimally invasive – a short rehabilitation and healing phase follows. Thanks to the tension-free mesh techniques, this usually proceeds quickly and with a high success rate today.

Hospitalization: As mentioned, many procedures can be performed on an outpatient basis. If a hospital stay is necessary (e.g., due to pre-existing conditions or lack of domestic care), it is usually 1–3 days that you spend in the 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 because they often recover faster 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 tablets for a few days after laparoscopic surgery and are then pain-free. After open surgery, it can take a little longer, but even here 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, sutures (if not self-dissolving) are removed after approx. 7–10 days. Showering is often allowed after 2 days; wait with bathing until the wounds are completely closed.

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

You are allowed and should move to get your circulation and digestion going – only strong abdominal pressure should be avoided at first. Full physical capacity is usually restored 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 allow sports even after 14 days, especially after the minimally invasive method, if wound healing has proceeded without problems. Nevertheless, it is often advised not to lift anything heavier than 10 kg for about 4–6 weeks to give the mesh and tissue enough time to heal stably – these recommendations may vary and will be discussed individually.

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 an 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 below 1–3% (depending on the study and follow-up period). For comparison: Previously, without meshes, relapse rates were over 10%. Today, relapses are rare and usually due to specific factors (very large hernias, wound infection, premature stress, 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. Here, registry data show that, on average, just over 10% of patients continue to experience pain that can affect their quality of life.

However, this number takes into account all degrees of pain and all techniques. These are often mild abnormal sensations or numbness that do not cause severe impairment. Fortunately, truly severe chronic pain (e.g., neuropathic pain from nerve injury) is much less common – estimates are usually around 2–5% of patients, depending on the surgical procedure and definition.

The laparoscopic methods tend to show lower rates of chronic pain than open ones. Through continuous improvements (gentler techniques, early physiotherapy, pain therapy), efforts are being made to further reduce 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, inguinal hernia surgery is very safe. Serious complications (e.g., injury to the intestine or blood vessels, secondary bleeding, infection) are rare and are well below 1–2% risk, especially with elective (planned) surgery.

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

The greatest risk exists if you do not have surgery at all and incarceration occurs – because then, in an emergency, intestinal parts can occur and, in the worst case, life-threatening situations can arise. The 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 below that. Herniamed data also show what still needs to be worked on: e.g., the chronic pain mentioned >10%. Through such data collections, surgeons can further improve their techniques and update guidelines in an evidence-based manner.

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.

From the first pull to the surgery, it doesn’t have to be a long way if you take the right steps. The prognosis is excellent, and the vast majority of patients are subsequently happy to have opted for surgery in good time – for a symptom-free, active life without a fracture.

 

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 for 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 Klinik) – Patient Information (2022) – Mentions lifetime risk: Men 27%, women 3%; Incidence increases with age. (Generally known statistics, 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, status 2020) – German guideline (S1) confirms international recommendations: Use of meshes, operate early in women, expectant open approach possible in asymptomatic men, otherwise TEP/TAPP preferred. (Quintessence reflected in sources 3 and 5).