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Inguinal hernia

Last updated: May 26, 2021

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An inguinal hernia (IH) is an abnormal protrusion of intraabdominal contents through the inguinal canal. IH is one of two different types of groin hernias (in addition to the less common femoral hernia), and can be further subdivided based on anatomic location: an indirect inguinal hernia protrudes lateral to the inferior epigastric vessels through the deep inguinal ring, whereas a direct inguinal hernia protrudes medial to the inferior epigastric vessels through a defect in the posterior wall of the inguinal canal. An uncomplicated inguinal hernia typically manifests as a mass in the groin with or without pain (inguinodynia). Incarceration, obstruction, and strangulation of hernial contents are collectively referred to as complicated inguinal hernia. IH is a clinical diagnosis. Imaging, preferably with ultrasound, is indicated if the clinical diagnosis is uncertain. Surgery is the only definitive management of IH and can be performed as an open surgery or laparoscopically. A strangulated inguinal hernia is a surgical emergency. In patients with an incarcerated hernia with/without bowel obstruction, manual reduction of the hernia may be considered as a temporizing measure before surgery. Conservative management may be considered in a select group of patients with small, uncomplicated inguinal hernia.

Overview of hernias
Inguinal hernia Femoral hernia
Indirect Direct


  • Less common hernia (∼ 5% of all cases)
  • More common in women
  • More common in older men
Clinical features
  • Surgical repair

See “Femoral hernia” for further information.

Epidemiological data refers to the US, unless otherwise specified.

Inguinal canal

Hesselbach triangle borders


Direct inguinal hernia

Indirect inguinal hernia

"The DIRECT path leads through the MiDdle, the INDIRECT path goes beLow." (DIRECT hernias lie MeDial and INDIRECT hernias lie Lateral to the inferior epigastric vessels)


Uncomplicated inguinal hernia [5][6][7]

  • Typically manifests as an ill-defined mass in the inguinal region with the following features:
    • Increases in size when coughing or straining
    • Decreases in size on lying supine
    • Inguinal pain; (inguinodynia) or vague inguinal discomfort that increases with physical activity; can also be painless
  • Inguinodynia with no palpable groin mass is typically the only manifestation of an occult inguinal hernia. [8]
  • Physical examination

Complicated inguinal hernia [6][7][9]

Manual reduction of inguinal hernia should not be attempted if there are any signs of strangulation!

Inguinal hernia is typically a clinical diagnosis. Imaging is useful if the clinical diagnosis is in doubt. All patients should be evaluated for risk factors for an acquired inguinal hernia.

Imaging [5][10]

Emergency surgery should not be delayed for imaging in unstable patients with signs of strangulation or bowel obstruction. [5]

Laboratory studies [15]

The following tests should be obtained in patients with strangulated inguinal hernia or incarcerated inguinal hernia with bowel obstruction for supportive diagnostic evidence and to assess for complications. [18]

Groin or scrotal mass [6][7]

A groin bulge with an expansile cough impulse above the inguinal ligament is diagnostic of an inguinal hernia. A femoral hernia typically manifests as a groin bulge below the inguinal ligament and lateral to the pubic tubercle. [7]

Inguinodynia [6]

The differential diagnoses listed here are not exhaustive.

Surgical repair of the hernial defect is the only definitive treatment of inguinal hernia. The management of direct inguinal hernia and indirect inguinal hernia does not differ.

Approach [5][6]

Complicated inguinal hernia [7][15]

Acute management

Strangulated inguinal hernia and incarcerated inguinal hernia with mechanical bowel obstruction are surgical emergencies.

Manual reduction of inguinal hernia [19][21]

  • Indication: Consider as a temporizing measure before surgery in patients with incarcerated hernia with/without bowel obstruction.
  • Contraindication: strangulated inguinal hernia
  • Successful hernia reduction: Observe the patient for 12–24 hours.
    • Symptoms improve: Schedule an elective hernia repair as early as possible.
    • Symptoms worsen: Immediate surgical consult to evaluate for reduction en masse. [22]
  • Unsuccessful hernia reduction: urgent surgery (see “Surgical procedures” below)

Manual reduction of hernial contents is contraindicated if there are signs of a strangulated hernia, as necrotic bowel or omentum can be pushed into the abdominal cavity, potentially leading to serious complications including peritonitis. [21]

Incarcerated inguinal hernia causing bowel obstruction (without evidence of strangulation) is not a contraindication for manual reduction of hernial contents. [19]

Uncomplicated inguinal hernia

Elective surgery [5][23][24]

  • Indications
  • Procedures: See “Surgical procedures” below.

Conservative management (watchful waiting) [5][15]

  • Indications [23]
  • Contraindications [5]
  • General recommendations [5]
    • Consider the use of a truss.
    • Advice against lifting heavy weights.
    • Advice to return to hospital if symptoms worsen. [5]
    • Evaluate and treat potential risk factors of hernia.

Surgeries for inguinal hernia

Once the hernial contents are reduced (i.e., returned to the abdominal cavity), the goal of hernia surgery is to reinforce the posterior wall of the inguinal canal with a synthetic mesh or through primary tissue approximation. Emergency surgery is associated with an increased risk of complications; elective surgery is preferred when it is an option.

Hernioplasty (mesh repair)

Herniorrhaphy (non-mesh repair)

  • Definition: open surgical repair of a hernial defect using autologous tissue
  • Indication: Consider in patients at high risk of surgical site infection. [7][20]
  • Options: Shouldice repair
    • A pure tissue repair that involves a multilayer imbricated repair of the posterior wall of the inguinal canal with a continuous running suture technique. [7]
    • Preferred procedure when hernioplasty is not feasible
    • Has a lower recurrence rate than other non-mesh repairs
  • Important consideration: Herniorrhaphy is associated with a greater risk of recurrence than hernioplasty. [25]

Complicated inguinal hernia

Uncomplicated inguinal hernia

Preoperative complications [5]

Postoperative complications [5]

We list the most important complications. The selection is not exhaustive.

Inguinal hernia in infants

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