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Inguinal Hernia



Inguinal (groin) hernias are one of the commonest forms of hernia.  The lifetime risk for men is 27% and for women 3%.  They are also commonly referred to as groin hernias or ruptures.  They may also be confused with another type of groin hernia which occurs below the crease line in the groin: a femoral hernia.  Inguinal hernias may be associated with groin pain with or without a swelling. When inguinal hernias enlarge, they can advance into the scrotum in males and labia in females.

It is estimated that world wide that over 20 million repairs of inguinal hernia are carried out annually, 100,000  in the  UK and on a pro rata basis, 13,500 repairs per year would be expected in Hong Kong.

Do I have a hernia: the diagnosis?

Your doctor will take a history of the condition which usually implies the length of time the swelling and / or pain have been present.  Clinical examination will confirm the suspected diagnosis of an inguinal hernia. For most patients the diagnosis will be very evident without the need for further investigations.


Are there different types of inguinal hernia?

Yes.  These are often referred to a indirect where the hernial sac starts lateral (towards the outside) of the epigastric blood vessels at the level of the deep inguinal ring or direct where the hernial sac comes through a weak posterior wall, medial (towards the midline) of the epigastric blood vessels.  The essence of the repair is the same for both.


Suspected (occult) hernias

Where there is some doubt about the presence or absence of a hernia due to the presence of a cough impulse on examination or pain in the groin without a swelling, the following options are available: surgical exploration of the groin; ultrasound scanning; CT or MRI scanning; herniogram and 3mm diagnostic laparoscopy.


It is no longer justifiable to proceed to straight to exploration of the groin since the negative exploration rate will be 75%.  The listed radiological investigations are experience dependent and give rise to both false positive and negative results.


The HKHC advocates the use of a diagnostic 3mm laparoscopy to determine the presence or absence of a hernia.  The results are unequivocal with direct viewing of the potential sites for inguinal and femoral hernias to occur.   Occult hernias will be detected in 25% of patients.


Why should an inguinal hernia be repaired?

The natural history of these hernias is to continue to enlarge with extension of the hernia into the scrotum in the man and labia in a woman if left untreated.  There is also the ever pending risk of incarceration and strangulation.


Are there any medical treatments for inguinal hernia?

Yes.  A truss (or support) can be prescribed to keep your hernia or hernias in.  This is unsatisfactory in the medium and long term as they can cause local skin problems, become foul smelling or fail to control the hernia particularly as it enlarges.  Trusses should be reserved only for patients who have severe concomitant medical problems where the risks of fixing the hernia even under local anaesthesia outweigh the benefits of having a definitive repair.

How can my hernia be repaired?

There are dozens of techniques which have been used over the last century to repair inguinal hernias.  There is now a clear choice between open and laparoscopic surgery.


Open Surgery for Inguinal Hernias

Sutured repair: 

Studies have shown that using stitches alone to repair a hernia, results in unacceptable recurrence (failure) rates of 10-20%1,2.  Recurrence occurs because the inguinal canal is repaired under tension, thereby predisposing the patient’s sutures to give way with time.  The exception to this high recurrence rate is a triple layered repair advocated by the Shouldice clinic in North America3.  However, for the majority of other surgeons globally, few can match the <1% reported recurrence rate from the Shouldice clinic, because of the inherent difficulties in learning the correct technique4.  Comparing the Shouldice technique to the laparoscopic approach, keyhole surgery results in fewer complications and an earlier return to work and normal life style5.

Tension free mesh repair:

Meshes are a lattice work of nylon type materials which are permanent and not absorbed by the body.  They are used to repair and strengthen the inguinal canal and are fixed in place with stitches or staples.  The principal method used to perform open hernia repair through a groin incision is the Lichtenstein technique advocated by Lichtenstein clinic1.  This operation takes approximately 40-50 minutes for one groin (depending on the size of the hernia and the experience of the surgeon).  This has been adopted widely by many surgeons as it is relatively easy to learn as it can be performed under local anaesthesia, and as it has a low recurrence rate of <2%1,6.  It has been shown to be a good operation in the hands of a generalist6.  However, the main disadvantages are the high frequency of minor complications6-9 the post operative discomfort and the problem of chronic wound and nerve ailments in up to 30% of patients, one year after surgery6,10-12. 


Laparoscopic (keyhole) Surgery for Inguinal Hernias

This minimally invasive technique provides the same advantages of a tension free mesh repair but reduces many of the problems associated with open mesh repair.  The operation is performed through 3 small incisions (port sites).  Using a video-camera attached to a telescope in one port, your surgeon uses the other two ports to perform the operation and place the large mesh accurately to repair the defect. 

As there is no muscle cutting or mesh fixation as in the open technique, pain and discomfort are substantially reduced. Little debate exists regarding the superiority of the laparoscopic technique for repairing bilateral and recurrent hernias8,13.  More recently, two very large systematic reviews of randomised controlled trials of open versus laparoscopic inguinal hernia repairs also confirm the overall benefits of the laparoscopic approach9,14.

It is important to appreciate that there are two widely used methods for using the keyhole approach.  One involves going into the abdominal cavity (intra-abdominal) and the other remains outside the peritoneal cavity (extra-peritoneal).  The extra-peritoneal approach is more difficult to learn and is more technically demanding, but accidental damage to intra-abdominal organs and adhesions by the intestines to the mesh is minimised by comparison to the intra-abdominal approach.  At the HKHC, the extra-peritoneal approach is used when laparoscopic surgery is utilised for this very reason, by experienced surgeons performing this technique to minimise risk and maximise patient safety.


Why might I need both groins repaired?

One third of inguinal hernias are bilateral (both sides).  Meshes are placed laparoscopically on both sides through the same set of incisions without much additional discomfort.  If patients who are having a hernia repair performed, also have the opposite side explored, an unsuspected hernia will be found in 12% patients.  Furthermore, during the first five years after your operation there is at least a 10% chance of developing a hernia on the opposite side, and during your life–time, this risk increases to 25%.  Following the lead of many European centres for hernia surgery, the HKHC advocates preventive mesh placement on the opposite side if you have only one hernia present because it can be accomplished safely, with little extra discomfort, operating time and cost.  This option can be fully discussed with you. 


How long does a laparoscopic inguinal hernia surgery take?

The average time for one side would be 40 minutes; where there is a hernia on one side and a preventive mesh is placed on the other side: 50 minutes; and where there is a hernia on both sides: 60minutes.  Repairs may take more or less time depending on size of the hernia, the experience of the surgeon and other factors such as whether the hernia is recurrent or not.


What approach should be used for recurrent inguinal hernias?

A recurrent hernia is one in which a previous repair has been carried out.  Where open surgery has been performed in the past and the hernia has recurred, then the laparoscopic approach with mesh repair is ideal since unviolated tissue planes are used.  Also the risk to the very important spermatic cord structures is minimised and therefore the overall risk of damaging the testicular blood supply is reduced.


Is the mesh fixed in place?

No.  It has been shown that there is no need to stitch, staple or tack the mesh in place as it is held in place by the pressure of abdominal contents pressing against the muscle wall.    The body then reacts to the mesh by stimulating an inflammatory response which in turn stimulates the formation of fibrous tissue which grows through the pores in the mesh and holds it in place.  The result is that of your groin tissues being stronger by this combination of artificial material and natural tissue.


The other major benefit of not fixing the mesh in place is that it reduces the discomfort associated with the operation because staples or tacks are not fired into muscle, tendon, bone or nerves.


Can the mesh be rejected?

Meshes are made of an inert nylon material.  While there is an initial reaction to the mesh, this settles rapidly and you will not be aware of its presence.  Meshes have been safely used since 1958 and with developments in biotechnology over the past 50 years the ideal characteristics for a mesh have gradually been improved.  A larger piece of mesh is used than is necessary (usually 9 x 15cm),  as it may shrink by up to 20%. 

Can I combine my laparoscopic hernia operation with male sterilisation?

Yes.  Vasectomy is a common method of family planning and is usually performed by clipping and dividing the vas in the left and right scrotum.  The common problems after vasectomy are scrotal infection, bruising, swelling and discomfort.  These complications can be avoided by performing the vasectomy laparoscopically at the time of hernia repair if you have hernias in both groins or if you opt to have preventive mesh placed in the opposite groin.  The only disadvantage is that if you wanted a reversal of vasectomy later, the chances of success would be much less.


Why does the Hong Kong Hernia Center advocate the laparoscopic approach?

Studies 4-9, 11-14 have shown:

  1. There is less pain and discomfort

  2. Earlier return to work

  3. Earlier return to normal activities

  4. A low recurrence rate (<2%)

  5. Fewer minor complications after surgery

  6. Less chronic wound problems and groin discomfort in the long term

  7. The further advantages of treating bilateral and recurrent hernias

  8. Prevention of the development of femoral hernias as the mesh covers this potential defect

  9. Additional options of preventive mesh placement and vasectomy


When does the HKHC not use the laparoscopic technique?

More than 90% of inguinal hernias can be safely operated on using the laparoscopic technique. However, in certain cases it is not the preferred approach such as:

  1. If the patient has significant cardiopulmonary disease (heart/lung)

  2. If the hernia is not fully reducible

  3. If the hernia is extremely large

  4. If the hernia presents as an emergency with symptoms suggestive of strangulation or intestinal obstruction

  5. If the patient is extremely over-weight

  6. If the operation cannot be completed for technical reasons laparoscopically


How soon after the operation can I get back to normal activities and work?

In general, you would be advised you to take 1-2 weeks off work.  Your ability to return to work is governed by the level of discomfort you feel, and that varies with each individual.  However, many office workers return to full duties in less than one week.  You would be given three days medication when you leave the hospital and often the pain killers are not required for longer.  Early mobilisation and walking is encouraged.  You may return to driving once you feel confident that you are able to perform an emergency stop without reservation (on average 5 to 7 days).  For the first two weeks after your operation, you need to allow time for the body to react to the mesh and fix it in place by the growth of fibrous tissue through for the mesh which holds the mesh in place.  Therefore you must avoid strenuous activity which includes sport, heavy lifting and sexual intercourse.  Your dressings will be waterproof and therefore you can shower and bath normally.  Prolonged soaking is not recommended however.  The adherent dressing will usually remain in place until you are seen at the follow-up consultation 10 days after surgery and should not require changing.


Are there any possible complications?

Surgery is usually for most patients uneventful but complications, if they occur, are usually minor and are related to the surgeon’s experience.  Ask your surgeon about their experience and complications.  There may be some bruising at the wound site; mild bruising in the scrotum and root of penis; tissue swelling at the site of hernia in response to the mesh; infection of the mesh or the wound is rare and can be minimised by a single dose of antibiotics prior to operation; damage to the testicular blood supply (particularly at risk in open hernia surgery for recurrence); damage to the skin nerves (particularly with open surgery); and recurrence of the hernia (<2%).

Contact Us

If you need any advice or help with hernia-related conditions, feel free to contact us.



  1. Lichtenstein IL, Shulman AG, Parviz KA, Montllor MM.  The tension-free hernioplasty.  American Journal of Surgery 1989; 157: 188-193

  2. Conceptualization and measurement of physiological health for adults.  Santa Monica, CA: Rand, 1983: 3-120

  3. Welsh DRJ, Alexander MAJ.  The Shouldice repair.  Surgical Clinics of North America 1993; 73:451-469

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  5. Fleming WR, Elliott TB, Jones R McL, Hardy KJ.  Randomized clinical trial comparing totally extraperitoneal inguinal hernia repair with the Shouldice technique.  British Journal of Surgery 2001; 88: 1183-1188.

  6. The MRC Laparoscopic Groin Hernia Trial Group.  Laparoscopic versus open repair of groin hernia: a randomized comparison.  Lancet 1999; 354: 185-190.

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  15. Arroyo A, Garcia P, Perez F, et al.  Randomized clinical trial comparing suture and mesh repair of umbilical hernia in adults. British Journal of Surgery 2001; 88: 1321-1323.

  16. Macleod DAD, Gibbon WW.  The sportsman’s groin. . British Journal of Surgery 1999; 86: 849-850

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