An inguinal hernia is a hernia in the groin area in which abdominal contents bulge outwards through a weak point in the abdominal wall.
This typically leads to a palpable protrusion in the groin area, which is particularly noticeable when coughing, pressing or lifting heavy loads.
In many cases, pulling pain or a feeling of pressure occurs, which can intensify during the course of the day. Inguinal hernias are one of the most common surgical conditions: Around one in four men will suffer an inguinal hernia in the course of their life, and in 70-year-old men the probability is even around 50% . Women are affected much less frequently – there is only about one woman with an inguinal hernia for every 34 men – which is due to anatomical differences in the inguinal canal.
Although a hernia in itself is often not immediately dangerous, without treatment there is always a risk of intestinal loops becoming trapped and blood flow being cut off.
In such an emergency (incarceration), an intestinal obstruction or even the death of intestinal tissue can occur within a few hours, which is life-threatening if left untreated.
The following therefore applies: if severe pain, nausea or vomiting occur with an existing inguinal hernia, immediate medical help is required. In most cases, however, an inguinal hernia is initially mild and can be treated well.
This article explains the causes and risk factors of inguinal hernia – including the role of lifestyle, diet, exercise and genetic predisposition – and presents modern minimally invasive treatment methods.
Special aspects for athletes and elderly patients are also highlighted. All information is scientifically sound and backed up with sources.
Causes and risk factors of a hernia
An inguinal hernia is caused by a weak point in the tissue of the abdominal wall in the area of the inguinal canal. The inguinal canal is a natural gap in the abdominal wall through which the spermatic cord runs in men (a ligament of the uterus in women).
Normally, this area is stabilized by muscles, ligaments and tight connective tissue. However, increased pressure in the abdominal cavity can lead to fibers giving way at a weak tissue point and the peritoneum bulging outwards like a sac (hernia sac).
Parts of the abdominal organs – usually a loop of intestine – can protrude from the abdominal cavity through this hernial orifice. The pressure in the abdomen rises sharply for a short time, for example during heavy lifting, pressing or even violent coughing and sneezing.
It is usually the combination of several factors that leads to a hernia. Doctors consider the most important risk factors for an inguinal hernia to be
- Older age: With increasing age, connective tissue loses elasticity and firmness. Older people (especially men) therefore have a higher risk of hernias. For example, the probability of a hernia in a 70-year-old man increases to up to 50 % .
- Male gender: Around 90 % of all hernias occur in men . The inguinal canal is a naturally weak point in men, as this is where the spermatic cord passes through.
In women, the anatomy is more stable and an inguinal hernia is more common below the inguinal ligament than a femoral hernia. - Genetic predisposition: Congenital connective tissue weakness or a family history of hernias significantly increase the risk.
If there is a family history of hernias, the personal risk can increase up to eightfold, indicating a hereditary component.
Certain genetic connective tissue diseases (e.g. collagenoses, Marfan or Ehlers-Danlos syndrome) also favor hernias. In infants and children, inguinal hernias are often congenital, for example due to an incompletely closed inguinal canal (indirect hernia). - Increased intra-abdominal pressure: Anything that chronically increases the pressure in the abdominal cavity can promote a hernia. Classic factors are chronic coughing (e.g. in COPD), frequent heavy straining during bowel movements due to chronic constipation enlargement of the prostate (pressing when urinating) and pregnancy .
Ascites (abdominal fluid) caused by diseases can also expand the abdominal wall from the inside.
Interestingly, heavy lifting has long been considered a typical trigger, but studies show that physically hard-working people are no more likely to suffer a hernia than less stressed people . Lifting itself generates high pressure in the short term, but does not appear to open an intact inguinal canal on its own.
However, heavy lifting is likely to make an existing, as yet unnoticed hernia visible – for example, when a previously small gap suddenly appears. In any case, you should bend your knees properly when lifting and tense your abdominal muscles to minimize the strain on the groin. - Overweight and lack of exercise: Excessive body weight can increase the risk of hernias, as fat accumulation in the abdominal cavity increases the pressure on the abdominal wall.
At the same time, a lack of exercise weakens the muscles that support the abdominal wall. A healthy lifestyle with a normalized body weight counteracts this.
However, in some studies, very overweight people do not have significantly more inguinal hernias than people of normal weight – in some cases, a slightly lower risk of hernia is even discussed, as fat pads in the groin fill the canal.
Nevertheless, obesity is considered a risk factor, particularly for other types of hernia such as abdominal wall hernias and because obesity makes surgical treatment more difficult. - Smoking: Nicotine consumption promotes chronic coughing and damages the blood supply to the connective tissue. Smokers have more frequent hernias and also a higher risk of healing disorders after hernia operations.
- Previous operations and injuries: Any damage to the abdominal wall, for example due to previous operations (incisional hernias) or injuries, can promote a hernia.
Surgical scars on the lower abdomen in particular are weak points. If wound infections occur after abdominal surgery, the risk of a subsequent hernia is significantly increased. - Medication: Long-term treatment with drugs containing cortisone (glucocorticoids) can weaken the connective tissue and make hernias more likely.
Link between lifestyle and hernias: The factors mentioned show that diet, exercise and lifestyle habits play an important role.
This means that the risk of hernia can be reduced to a certain extent through a healthy lifestyle: A balanced, high-fiber diet prevents constipation and prevents straining during bowel movements – an important contribution to avoiding chronically increased abdominal pressure.
A normal body weight also helps to reduce the permanent strain on the abdominal wall. Regular physical exercise and moderate training can strengthen the abdominal and core muscles, which gives the abdominal wall additional support.
In modern hernia surgery, a holistic approach is increasingly being propagated that emphasizes the health of the trunk and abdominal muscles (core health).
As part of the “Abdominal Core Health” concept, the American Hernia Society recommends optimizing the core muscles preventively through targeted training, physiotherapy and nutrition in order to prevent hernias or to survive them better.
However, prevention also has its limits: If someone has a congenital tissue weakness or an existing hernia gap, a hernia cannot always be prevented by training or diet alone.
Once a hernial orifice has formed, it does not heal by itself, as the tissue that has leaked out keeps the gap open. For this reason, conservative measures can only reduce risk factors, but cannot replace a necessary operation.
Treatment: from open surgery to minimally invasive hernia surgery
An inguinal hernia does not heal spontaneously, but must be treated surgically if symptoms occur or there is a risk of complications.
The aim of the operation is to move the hernia sac back into the abdominal cavity and permanently close the hernia gap in the abdominal wall. Hernia surgery has developed considerably over the last few decades.
Whereas open surgical techniques with larger incisions were mainly used in the past, various gentle, minimally invasive procedures are now available.
Open surgery (conventional technique): In classic open hernia surgery, an incision is made in the groin region to expose and push back the hernia sac. The gap in the abdominal wall is then closed.
Since the 1980s, the tension-free technique with mesh has become established: a synthetic mesh implant (usually made of propylene plastic) is placed over the fracture site and fixed in place with sutures.
This mesh reinforces the weakened area and distributes the intra-abdominal pressure widely, thus largely preventing a new hernia.
The introduction of the mesh technique revolutionized hernia treatment – the recurrence rate fell from double-digit percentages to only around 1-5% .
The most common open method is the Lichtenstein operation, in which a flat mesh is placed on the hernia gap in the groin without tension.
Alternatively, there are traditional suturing methods without mesh, such as the Shouldice technique, which, however, places greater demands on the tissue and is now usually only used in specialist clinics or in young patients without connective tissue weakness.
One advantage of open surgery is that it can be performed under local anesthesia – relevant for older or previously ill patients who do not want to run the risk of general anesthesia.
However, open surgery requires a larger incision and thus potentially longer healing time and initially causes more wound pain.
Minimally invasive procedures (keyhole surgery): Increasingly, inguinal hernias are being repaired laparoscopically or endoscopically.
The procedure is performed through small incisions of approx. 5-10 mm, through which a tiny video camera and instruments are inserted. This allows the surgeon to reach the hernia site from the inside without having to cut through the outer layers extensively.
There are two common techniques: TAPP (transabdominal preperitoneal plasty), in which surgery is performed via the abdominal cavity, and TEP (total extraperitoneal plasty), in which the procedure is performed completely outside the peritoneum in the so-called preperitoneal space .
In both cases, a mesh is inserted in a similar way to an open procedure, but from the inside of the abdomen to close the hernia gap. The advantages of minimally invasive methods are that they are gentler on the patient as the incisions are smaller and less soft tissue is cut through.
As a result, there is less pain and the recovery time is shorter . Patients are usually mobile again within a few days and can often resume their normal everyday activities after just one to two weeks . Bilateral inguinal hernias can also be treated in one session without having to make two separate incisions.
However, the laparoscopic technique requires general anesthesia and is technically more demanding; it is mainly performed by experienced hernia surgeons.
Not every hernia is suitable for this: Very large or complicated hernias, e.g. long untreated hernias with large hernia sacs or hernias with many previous operations, sometimes require further open surgery.
Robot-assisted hernia surgery: A more recent extension of the keyhole technique is the use of surgical robots. Here, the surgeon does not guide the instruments directly with his hands, but controls mechanical robotic arms from a console.
The robot (e.g. the daVinci system) enables high-precision movements and a 3D HD view inside the body. The robot can offer particular advantages in complex hernias, as its flexible instruments can reach areas that are difficult to access with rigid laparoscopic instruments.
Robotic surgery is becoming more widespread worldwide – young surgeons are increasingly learning this technique as standard. For patients, the robot-assisted method offers similar advantages to conventional laparoscopy: small incisions, little pain and rapid recovery.
In addition, better visualization with the robot allows for extremely precise dissection, which can theoretically further reduce the risk of complications. However, robotic technology is very expensive and operations often take longer than laparoscopic or open procedures. Studies show that the safety and success rate of robotics are comparable to the other methods.
In individual cases, even particularly difficult fractures that would otherwise have been operated on openly were successfully repaired using minimally invasive techniques.
Overall: Robot-assisted hernia repair is a powerful tool, but is not yet available in all hospitals. Experts recommend weighing up its use critically and not just operating out of enthusiasm for new technology when a simpler procedure would suffice.
In specialized centers, the entire spectrum is ideally available today – from open to endoscopic to robotic methods – so that the optimal therapy can be selected individually.
Network or no network?
New developments: The introduction of permanent plastic meshes has drastically reduced the recurrence rate and has since become the standard in hernia surgery.
However, mesh implants are not free of disadvantages. A small proportion of patients develop chronic groin pain after the operation (in around 10% of cases) – often due to irritation of nerves or scarring in the area of the mesh.
Nets can also become infected or grow together with surrounding organs (e.g. bowel or bladder), which can lead to complications. Although these problems rarely occur, they are very stressful for those affected.
Researchers and surgeons are therefore looking for improvements:
- Resorbable (non-permanent) meshes: New mesh materials that are gradually broken down by the body are intended to reduce the foreign material in the long term.
Such bioresorbable meshes trigger a controlled inflammatory reaction that leads to the strengthening of the body’s own connective tissue and scarring in order to close the fracture.
Initial studies show that modern absorbable meshes achieve similarly low recurrence rates to conventional meshes in selected patients. However, in contaminated wound areas (e.g. bowel operations with a risk of infection), the recurrence rate with absorbable meshes may be somewhat higher, meaning that permanent meshes are still often preferred here. - Mesh-free techniques (suture techniques): “No mesh” repairs have recently experienced something of a renaissance . Especially for inguinal and umbilical hernias, pure suture procedures are increasingly being used again in specialized centers, especially when patients do not want a plastic implant.
A well-known example is the Shouldice operation, which was developed back in 1940 and in which the posterior wall of the inguinal canal is firmly sutured in layers.
Newer modifications such as the Desarda method also rely on the body’s own tissue (here a strip of the outer abdominal wall aponeurosis is used as reinforcement).
Mesh-free procedures completely avoid implant-related complications; however, the risk of rupture is usually somewhat higher and the procedure requires a great deal of experience on the part of the surgeon.
However, many patients accept a potentially increased risk of recurrence in order to avoid having foreign material in their bodies. - Refined mesh positioning: To counteract problems with intra-abdominal mesh, some techniques place the mesh outside the peritoneum (extraperitoneally) where it has no direct contact with the bowel or organs.
This is the case with TEP/TAPP procedures and is also used for incisional hernias to avoid adhesions. - Improved surgical technique: A key to avoiding complications is careful surgical technique. Surgeons today pay attention to nerve protection (if necessary, targeted transection of small pain nerves to prevent chronic pain), exact mesh size (current studies suggest: less overlap = less pain) and fixation-free meshes (self-adhesive meshes or tissue adhesives instead of sutures or staples) to minimize tissue irritation.
Hernia in athletes
Athletes are particularly affected by groin hernias and groin-related pain. Sports involving explosive twisting movements, sprints or heavy weight training put a lot of strain on the groin region.
The term “athlete’s groin” or “soft groin” is often used in this context to describe painful groin syndromes in athletes without a real hernia sac being present.
These are muscular or tendinous overloads in the area of the abdominal wall attachments (also known as athletic pubalgia), which can cause similar symptoms to a hernia, but are treated differently (usually conservatively with physiotherapy).
It is important to distinguish such a functional sports hernia from a true hernia. In the latter case, an examination or ultrasound typically reveals a hernial orifice through which abdominal contents escape.
Causes in athletes: In men, chronic groin pain is often caused by a classic inguinal hernia, which may initially be small and inconspicuous.
Typical triggering factors are intensive training sessions, heavy weight lifting and sudden changes of direction that suddenly increase abdominal pressure.
Although, as mentioned above, heavy lifting alone has not been proven to be the main cause, in combination with a possible weak point (genetic predisposition or previous injury), it can lead to a fracture in athletes.
Genetic factors also play a role here: some athletes have inherently weaker connective tissue and are more prone to hernias.
Furthermore, intensive sport with insufficient recovery time favors micro-injuries at the attachment points of the abdominal muscles – the so-called posterior wall of the inguinal canal can become “worn out” and weakened without a hernia sac developing immediately. This is probably a preliminary stage that can eventually develop into a real hernia.
Treatment and special requirements: For competitive athletes, the focus is not only on safe hernia treatment but also on rapid rehabilitation.
Modern minimally invasive techniques meet this need: Laparoscopic procedures (TAPP/TEP) often allow a return to training after about 14 days, provided the wound heals normally.
Due to the reduced tissue trauma, athletes heal faster and can quickly return to physical activity. Some specialized sports clinics have also developed the “minimal repair” procedure (by Dr. Ulrike Muschaweck, among others), which does not require any mesh at all and only sutures the weakened fascia.
This technique is used in particular for athletes with a soft groin or very small hernias in order to preserve the natural tissue structure as much as possible.
Studies show comparable success to mesh procedures, but a high level of expertise is required here. The advantage for athletes: no foreign material that could theoretically impair mobility or, in rare cases, cause chronic discomfort.
If a mesh is required, surgeons often use lightweight, small meshes in athletes that provide sufficient stabilization but cause as little stiffness as possible.
Rehabilitation: Regardless of the surgical procedure, a short rest period applies for athletes.
It is usually recommended to refrain from heavy exertion for around 1-2 weeks and in particular to avoid weight training or intensive core training.
However, light exercise is recommended early on – walks or easy cycling – to promote blood circulation. After two weeks, training can be resumed cautiously, starting with low intensity and focusing on technique.
Full contact and competitive sports as well as heavy strength training should only be resumed after clearance by the attending physician, usually after a few weeks.
Interestingly, there is no conclusive scientific evidence as to whether very early full weight-bearing increases the risk of recurrence – however, many experts recommend a gradual increase in weight-bearing out of caution. Sports physicians advise athletes to take pain in the groin area seriously and have it examined at an early stage.
Anyone who continues to train despite groin pain risks further damage and an extension of their downtime. However, with adequate therapy and rehabilitation, most sports groins and hernias can be successfully repaired so that full athletic ability can be restored.
Inguinal hernia at an advanced age
An inguinal hernia is also a special situation for older patients. On the one hand, the incidence of hernias increases significantly with age – up to half of men over the age of 75 are affected.
On the other hand, the benefits and risks of surgery in the elderly must be weighed up particularly carefully, as there are more concomitant diseases (cardiovascular, lung, etc.) as people get older and their ability to cope with stress may be reduced.
As a general rule, an inguinal hernia that does not cause any symptoms can initially be observed conservatively (watchful waiting), especially in older or frail patients. Studies have shown that watchful waiting is a safe option for asymptomatic or minimally symptomatic inguinal hernias, as the risk of acute complications (incarceration) is relatively low.
Each year, only around 2-3% of untreated inguinal hernias lead to incarceration. This means that many older patients can manage for a long time without surgery as long as the hernia remains small and does not cause pain.
However, the hernia does not “disappear” of course – it often increases slowly, and symptoms do develop over time in most people affected.
A long-term study over 12 years found that around 64% of men over the age of 50 who were initially observed with only a slight hernia eventually underwent surgery because they developed symptoms or the hernia became larger.
Watchful waiting therefore often only delays an operation instead of avoiding it permanently.
It is important that patients are closely monitored during this time and seek medical help immediately if the situation worsens (e.g. sudden pain – an indication of entrapment).
For older people with symptoms caused by the hernia (pain, restricted movement) or a progressive hernia, a planned operation makes perfect sense, provided their state of health allows the procedure. Electrosurgery is generally safe – the mortality rate for planned hernia surgery is extremely low .
However, studies show that the general risk of surgery is slightly higher in older people and complications can occur slightly more frequently than in younger people.
Emergency surgery for incarcerated hernias is particularly risky in old age, which is why a hernia should ideally be operated on in a stable condition before an emergency occurs.
Treatment approaches for the elderly: Modern hernia surgery offers customized solutions for older patients.
If the patient is fit, a minimally invasive procedure under general anesthesia can be performed in the same way as for younger patients – according to studies, patients over 70 also benefit from the lower stress and faster recovery of the keyhole method.
Many patients are mobile and independent again after just a few days. However, if severe heart or lung conditions are present, general anesthesia can be problematic.
In such cases, open surgery under local anesthesia is often used as an alternative. For example, an inguinal hernia can be repaired under local anesthesia using the Lichtenstein procedure, which is a gentle alternative.
The success rates of the operation are also high in older age; however, there are indications that very elderly men (>75-80 years) have slightly higher recurrence rates, as their tissue is weaker overall.
Surgeons report that over 10% of older hernia patients develop a new hernia (in the same or a different location) within a few years.
Although this risk is reduced by the use of meshes, the natural ageing of the tissue cannot be stopped completely.
Postoperative aspects: Careful care is important after a hernia operation in old age. Older patients usually recover somewhat more slowly.
This is where concepts such as “fast-track” surgery come into play, which includes optimized pain therapy, early mobilization and respiratory therapy to prevent complications such as pneumonia.
Seniors can often get up and walk around carefully on the day of the operation or shortly afterwards. Many return to their original status within two weeks, provided there are no complications.
However, lifting and carrying loads of more than 5 kg should be avoided for the first 4-6 weeks in order not to jeopardize the fresh suture. In some cases, a hernia belt is prescribed for older people or those in need of care if surgery is not performed.
Such special hernia bands can temporarily prevent the hernia from protruding and alleviate discomfort, but are not a permanent solution – the hernia remains present and can enlarge if the abdominal pressure decreases.
Finally, individual assessment is crucial for older patients: a sprightly 70-year-old with a painful hernia is usually treated surgically today so that he can quickly be pain-free and active again.
On the other hand, in an 85-year-old multimorbid patient with a small, asymptomatic fracture, it is better to do without and just observe.
The informed decision is best made jointly by the patient, family doctor and surgeon, taking quality of life and risks into account.
Future outlook: New research and therapeutic approaches
For over 100 years, the treatment of inguinal hernias has consisted almost exclusively of surgical procedures. Could there be a medical treatment for hernias in the future?
In fact, the latest research provides surprising approaches: At the beginning of 2025, a team of researchers from the USA reported a breakthrough in hernia research.
For the first time, an existing inguinal hernia was successfully reversed in experiments on mice using medication – without the need for surgery.
The scientists had discovered that a certain molecular signaling pathway is overactive in inguinal hernias: The estrogen receptor-α (ERα) in connective tissue cells of the groin appears to drive the formation of scarred, weak tissue, which ultimately leads to the hernia.
Using the already known drug fulvestrant – an oestrogen receptor blocker that is actually used to treat breast cancer – they injected male mice with the active ingredient and thus stopped the breakage-promoting signals.
The amazing thing: In treated animals, existing hernias shrank and the tissue healed, comparable to a post-operative state . At the same time, the researchers found exactly the same overactive cell markers in the tissue of human hernia patients.
This raises the hope that one day high-risk patients (e.g. very old or seriously ill men) could be treated with a drug that stabilizes or heals the fracture . Of course, this development is still in its infancy – so far it is based on test results in mice and tissue analyses in humans.
However, the identification of a specific molecular mechanism (ERα signaling pathway) is an important step. If it is possible to specifically influence this in humans, it would be a revolution in hernia treatment.
In addition to such pharmacological approaches, a lot is also happening in other areas: artificial intelligence and machine learning are finding their way into surgery.
Thousands of hernia cases are recorded in databases in order to find patterns for optimal results. Researchers are developing AI models to individually predict the risk of hernia complications or recurrences.
An algorithm fed with patient data could, for example, calculate whether patient X is very likely to need surgery in the next few years or whether patient Y will manage without surgery thanks to certain factors.
Future technology is also conceivable for the operation itself: automated suturing robots or 3D-printed, precisely fitting meshes are the subject of current research.
Another field is the holistic care of hernia patients – as described above, one moves away from isolated “hole plugging” and considers abdominal core health as a whole.
Interdisciplinary teams of surgeons, physiotherapists and nutritionists work together to provide optimal care for patients before and after hernia operations, to strengthen the core muscles and to tackle accompanying problems such as back pain or pelvic floor weakness.
This approach can significantly improve quality of life and may even prevent recurrent hernias by stabilizing the entire trunk.
Conclusion: Inguinal hernia is a widespread condition that can be treated very well with modern medicine. Thanks to minimally invasive techniques, most patients can now quickly return to their everyday life or sport.
Special patient groups – from competitive athletes to senior citizens – benefit from individually adapted therapy concepts, ranging from high-tech robotics to conservative wait-and-see approaches. It remains important to pay attention to the body’s warning signals: A protrusion or persistent pain in the groin should be clarified by a doctor in order to initiate the right treatment at an early stage.
With a sound knowledge of causes, risk factors and modern therapies, patients can make informed decisions.
Hernia surgery in 2025 combines high-tech and holistic care – and future research findings may even open up completely new, non-surgical approaches to hernia therapy. Until then, however, surgery remains the most effective and only way to heal a hernia.
References
- Gödel, C. et al. What causes an inguinal hernia? – netdoktor.de (2022)
- Hutterer, C. et al. Athlete’s groin, inguinal hernia and femoral hernia, Dt. Z. Sportmedizin (2020)
- McCartney, J. et al. New Approaches, Trends Are Emerging in Hernia Repair, ACS Bulletin (2023)
- Huerta, S. et al. Open, Laparoscopic, and Robotic Inguinal Hernia Repair: Systematic Review, J. Clin. Med (2025)
- Northwestern Univ. et al. Drug reverses groin hernias in male mice without surgery, shows promise in humans, ScienceDaily (2025)
- Gantert, W. et al. Inguinal hernia – Interview, Hirslanden Blog (2019)
