Inguinal hernia

Types

• Indirect inguinal hernia: passes through the deep inguinal ring and may extend into the scrotum or labia. It is often related to a persistent processus vaginalis and is the usual type in children.
• Direct inguinal hernia: pushes through a weakness in the posterior wall of the inguinal canal, medial to the inferior epigastric vessels. It is usually acquired in adults.
• A femoral hernia is a separate groin hernia below the inguinal ligament. It is more frequent in women and carries a relatively high risk of incarceration.

Symptoms and signs

• Reducible groin swelling or discomfort
• Dragging sensation or pain on exertion
• Lump enlarges on cough or Valsalva maneuver
• In men, extension into the scrotum can occur
• Some patients have no symptoms and notice only a bulge

When it is an emergency

• A painful, firm lump that cannot be pushed back
• Increasing or constant severe pain
• Vomiting, abdominal distension, inability to pass stool or gas
• Red, purple, or very tender skin over the lump
• Fever or systemic unwellness

Diagnosis

Treatment

• Symptomatic hernias: elective surgical repair is generally recommended.
• Incarcerated or strangulated hernia: urgent reduction or emergency operation.
• Minimally symptomatic inguinal hernia in some men: watchful waiting can be reasonable after surgical assessment, provided there are clear safety-net instructions.
• Repair is usually with mesh in adults, using an open or laparoscopic/posterior minimally invasive approach. Laparoscopic repair is particularly useful for bilateral hernias or recurrence after a previous open repair, when appropriate expertise is available.

Children

Latest inguinal hernia management guidelines

1. Current international reference for adults

• Diagnosis: Clinical examination is usually sufficient for an obvious groin hernia. Ultrasound, dynamic MRI, or CT is for uncertain or occult cases.
• Elective repair: A mesh repair is recommended for most adults because it lowers recurrence without increasing chronic pain.
• Primary unilateral male inguinal hernia: If expertise and resources are available, laparo-endoscopic repair with TEP or TAPP is preferred because recovery is faster and chronic pain is less frequent than with open anterior repair.
• Open anterior mesh repair remains appropriate where local anesthesia is preferred, minimally invasive expertise/resources are unavailable, or after circumstances such as prior prostate surgery, pelvic radiation, or certain major pelvic operations.
• Non-mesh repair: If mesh is declined or unsuitable, Shouldice repair is the best evaluated tissue repair, but should be performed by an experienced surgeon.
• Recurrence: Use the opposite anatomical plane from the original repair. For example, a recurrence after an open anterior repair is generally approached with posterior laparo-endoscopic repair, while recurrence after a posterior repair is generally approached anteriorly.
• Women: Timely repair and a laparo-endoscopic approach are favored when feasible, because a femoral hernia may coexist or be missed with an anterior approach.
• Asymptomatic or minimally symptomatic men: Watchful waiting is acceptable after shared decision-making and clear advice about warning symptoms. Many eventually choose surgery due to worsening symptoms.
• Acute painful irreducible groin hernia: Prompt emergency surgical assessment is required. Clinical findings plus biochemical tests guide concern for bowel ischemia, but blood tests alone cannot exclude it.

2. Most recent national guideline publication

3. Important population-specific guidance

• Children: The European Pediatric Surgeons' Association guideline remains the key evidence-based pediatric source: Morini et al., 2022 [Systematic Review and Practice Guideline, PMID: 33567466]. A diagnosed pediatric inguinal hernia is generally repaired because of the risk of incarceration.
• Scrotal inguinal hernia: The European Hernia Society lists a 2023 guideline specific to scrotal inguinal hernias, which should be used for large or complex scrotal presentations.
• Future update: A 2026 EAES-SAGES-EHS multi-society groin hernia guideline appears to be in development, based on a published protocol, but it should not yet replace the 2023 HerniaSurge recommendations.