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Overview of treatment for inguinal and femoral hernia in

adults
Author: David C Brooks, MD
Section Editor: Michael Rosen, MD
Deputy Editor: Wenliang Chen, MD, PhD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Mar 2019. | This topic last updated: Jan 28, 2019.

INTRODUCTION

The definitive treatment of all hernias, regardless of origin or type, is surgical repair [1]. Groin
hernia repair is one of the most commonly performed operations. Over 20 million inguinal or
femoral hernias are repaired every year worldwide [2], including over 700,000 in the United States
[3].

An inguinal or femoral hernia repair is performed urgently in patients who develop complications
such as acute incarceration or strangulation. For patients without a complication, the optimal
timing of repair (watchful waiting versus early repair) and the optimal surgical technique (open
versus laparoscopic) are controversial and are the focus of this topic.

The clinical features and diagnosis of an inguinal or femoral hernia, the technical details of
performing an inguinal or femoral hernia repair, the complications of hernia repair, and the
treatment of recurrent hernias are discussed separately in other topics. (See "Classification,
clinical features, and diagnosis of inguinal and femoral hernias in adults" and "Open surgical repair
of inguinal and femoral hernia in adults" and "Laparoscopic inguinal and femoral hernia repair in
adults" and "Overview of complications of inguinal and femoral hernia repair" and "Recurrent
inguinal and femoral hernia".)

INDICATIONS FOR SURGICAL REPAIR

There was a time when the mere presence of a groin hernia was a sufficient indication for surgical
repair. Contemporary practice, however, triages patients to surgery versus watchful waiting
according to the severity of symptoms and the type of hernia (inguinal versus femoral).

Complicated hernia — Patients who develop strangulation or bowel obstruction should undergo
urgent surgical repair. Surgery performed within four to six hours from the onset of symptoms may
prevent bowel loss due to one of these complications.

Patients with an acutely incarcerated inguinal hernia but without signs of strangulation (eg, skin
changes, peritonitis) should be offered urgent surgical repair. However, hernia reduction can be
attempted in patients who wish to delay surgery. If hernia reduction is successful, the patient
should follow up with his/her surgeon within one to two days to exclude recurrent incarceration and
arrange for elective repair. Those who fail hernia reduction should proceed urgently to surgery.

The clinical manifestations and diagnosis of incarcerated/strangulated inguinal or femoral hernias

can be found elsewhere. (See "Classification, clinical features, and diagnosis of inguinal and
femoral hernias in adults".)

Uncomplicated hernias — In patients with uncomplicated inguinal or femoral hernias, surgical

repair is intended to relieve symptoms and to prevent future complications. The indications for
surgical repair of uncomplicated hernias are less rigid than complicated hernias and depend upon
the type of hernias (inguinal versus femoral) involved, the severity of symptoms, and patient
preference. In select patients, watchful waiting is an alternative to surgery. (See 'Asymptomatic
hernia' below.)

Femoral hernia — For all patients with a newly diagnosed femoral hernia, we suggest elective
surgical repair, rather than watchful waiting, regardless of the patient's sex and symptoms.
Femoral hernias are associated with a high risk of complications, and therefore early elective
surgical repair is indicated.

Femoral hernias are associated with a higher risk of developing complications than inguinal
hernias. In one study, the rates of strangulation were 22 and 45 percent at 3 and 21 months,
respectively, for femoral hernias, compared with 2.8 and 4.5 percent for inguinal hernias [4].

Thus, early elective repair is advised for patients with a newly diagnosed femoral hernia to avoid
complications that may necessitate urgent surgery. Urgent surgery for complicated hernias is more
likely to involve bowel resection, which is associated with a higher mortality rate. In one study, for
example, bowel resection was required in 23 percent of urgent compared with 0.6 percent of
elective femoral hernia repairs, and urgent femoral hernia repairs were associated with a 10-fold
increase in mortality [5].

For patients who have a long-standing (>3 months) femoral hernia that is asymptomatic, surgery is
preferred, but observation is a reasonable option.

Inguinal hernia — For patients with moderate-to-severe symptoms from an inguinal hernia,
surgical repair is indicated. Patients with minimal or no symptoms from an inguinal hernia may be
managed with elective surgery or watchful waiting.

The only nonsurgical therapy for groin hernia in men is a truss. A truss is a strap similar to an
athletic supporter with a metal or hard plastic plug positioned to lie over the hernia defect. When
applied appropriately, the hard disc or plug exerts pressure to keep the hernia contents in the
abdomen. Although the use of a truss may be helpful in certain situations, we generally discourage
their use because there is insufficient evidence to prove their efficacy [6,7]. In addition,
inappropriate use of a truss may harm abdominal contents in a hernia sac or complicate
subsequent surgical repair [8].

Symptomatic hernia — Patients with significant symptoms attributable to an inguinal hernia

should undergo elective surgical repair [1]. Such symptoms typically include:

● Groin pain with exertion (eg, lifting)

● Inability to perform daily activities due to pain or discomfort from the hernia
● Inability to manually reduce the hernia (ie, chronic incarceration)

Asymptomatic hernia — For patients with minimal or no symptoms from an inguinal hernia,
we suggest elective hernia repair, or watchful waiting for those who wish to avoid surgery. The
latter patients must lack hernia-related pain or discomfort limiting usual activities or recent difficulty
in reducing the hernia [9]. Patients with a minimally symptomatic chronically incarcerated inguinal
hernia can undergo watchful waiting as they were not excluded from the trials to be discussed
below.

Historically, inguinal hernias were repaired once detected, under the assumption that
complications from unrepaired hernias were common and could increase operative morbidity.
However, three randomized trials to date have compared watchful waiting with surgical repair of
inguinal hernias [10-12] and demonstrated that delaying surgical repair in asymptomatic patients
was safe, as acute complications rarely occurred (1.8 emergency operations/1000 patient-years).
However, for 38 percent of patients at three years [12], and about 70 percent of patients at 7 to 10
years [13,14], surgical repair was required eventually because symptoms (usually pain) gradually
increased over time. This information is particularly important when counselling young patients.
Surgical outcomes of delayed repairs were not compromised compared with immediate surgery.

Patients with inguinal hernias managed with watchful waiting should be counseled about
modifiable risk factors, including smoking cessation, medical optimization (eg, diabetes), and
weight loss. They should be told that there is no evidence that physical activity will result in a
hernia incarceration or clinical worsening of an existing hernia [9]. Thus, there is no compelling
reason for such patients to curtail beneficial physical activities (eg, cardiovascular or aerobic
exercises) out of concern for exacerbating the hernia. Patients who opt for watchful waiting should
seek prompt surgical evaluation if they experience new-onset pain or discomfort with certain
physical activities, or if their hernia becomes acutely incarcerated (for those whose hernias were
reducible).

CONTRAINDICATIONS TO SURGICAL REPAIR

Inguinal or femoral hernia repair can be performed with minimal morbidity and mortality in almost
all patients, including those who are older and/or have medical comorbidities (eg, advanced liver
disease [15,16]); most patients enjoy a rapid recovery to presurgical health shortly after surgery.
Thus, there is no contraindication to urgent repair of complicated hernias. However, pregnant
women should not have elective repair of an inguinal or femoral hernia until at least four weeks
after delivery.

For patients who cannot tolerate general anesthesia, inguinal or femoral hernias can be repaired
under local anesthesia using one of the open techniques. For patients with an active groin
infection or systemic sepsis, mesh placement is contraindicated, but groin hernias can be repaired
using nonmesh techniques when necessary. (See "Wound infection following repair of abdominal
wall hernia".)

Pregnancy — The prevalence of inguinal hernias during pregnancy is low and estimated to be
1:2000 [17]. Elective repair of a groin hernia during pregnancy is generally contraindicated.
Expectant management during the peripartum period has been associated with few serious
hernia-related complications. In one study, seven women with groin hernias were managed
nonoperatively, and each had their hernias repaired after delivery [18]. Although combined
cesarean delivery and hernia repair have been reported [17,19], elective hernia repair should
generally be deferred for at least four weeks postpartum to allow the lax abdominal wall to return
to its baseline.
Urgent hernia repair during pregnancy may be required if the patient develops severe discomfort
or one of the complications, such as acute incarceration, strangulation, or bowel obstruction. In
one study, such complications were rare and only accounted for <5 percent of intestinal
obstructions observed during pregnancy [20].

CHOOSING A SURGICAL APPROACH

While all surgeons perform open groin hernia repairs, some also perform laparoscopic repairs. In
general, surgeons should choose the approach with which they are most comfortable and most
experienced. For surgeons who are equally facile with both repairs, the choice of a surgical
approach depends upon hernia and patient characteristics. The process described below and
outlined in the accompanying algorithm reflects the author's preference and should not be
regarded as the only approach (algorithm 1).

Patients precluded from laparoscopic repair — While open repair of an inguinal or femoral
hernia is feasible in almost all patients, laparoscopic repair cannot be safely performed in certain
patients due to patient or technical reasons.

Patients with prior surgery involving the preperitoneal space — Laparoscopic repair,
especially with the totally extraperitoneal (TEP) technique, requires the development and
maintenance of the preperitoneal space. Adhesions formed after previous surgery, incision, or
mesh placement could render that space inaccessible.

Thus, we perform an open hernia repair for patients who have had one or more previous surgeries
involving the preperitoneal space (eg, prostatectomy, hysterectomy, cesarean section, or
laparotomy via lower midline incision). Although laparoscopic surgery is feasible in such patients
(especially with the transabdominal preperitoneal patch [TAPP] technique), it is technically
challenging, requires a longer operative time, and is associated with more complications than
open surgery in such patients [21,22].

Patients with complicated hernia — We repair all incarcerated or strangulated groin hernias
with an open approach to minimize the risk of bowel injury. A laparoscopic approach is
theoretically possible but difficult to perform [23-25].

Furthermore, in cases where bowel perforation has occurred due to bowel ischemia or necrosis,
the placement of mesh is contraindicated, thereby precluding a laparoscopic repair. Open repair
can be performed with or without mesh and therefore is the preferred treatment for complicated
hernias in which the risk of active infection or contamination (from perforation) is high. (See 'Open
techniques' below and "Wound infection following repair of abdominal wall hernia".)

We also prefer to repair large scrotal hernias (>3 cm) with an open approach because of the
technical difficulty associated with managing and reducing a large hernia sac laparoscopically [26].

Patients with ascites — In patients with ascites, we prefer an open approach to laparoscopic
approaches. In particular, the laparoscopic TAPP approach (which is transperitoneal) should be
avoided. Prior to surgery, ascites should be minimized as much as possible with medical
treatment. At the time of surgery, the hernia sac should be left intact to avoid complications such
as persistent leakage of ascitic fluid. (See "Open surgical repair of inguinal and femoral hernia in
adults" and "Laparoscopic inguinal and femoral hernia repair in adults".)

Patients who cannot tolerate general anesthesia — Laparoscopic groin hernia repair is
typically performed under general anesthesia. Thus, patients who cannot tolerate general
anesthesia for medical reasons should undergo open repair under local or regional anesthesia.
(See 'Choice of anesthesia' below.)

Patients eligible for both open and laparoscopic repair — Patients who do not have a history
of prior preperitoneal surgery, ascites, or a complicated hernia are eligible for both open and
laparoscopic repairs of a groin hernia. The choice of the surgical procedure then depends upon
whether the hernia is primary or recurrent, unilateral or bilateral, and femoral or inguinal.

Primary hernia — A primary, unilateral inguinal hernia can be repaired open or

laparoscopically based upon surgeon and patient preference. A primary, unilateral femoral hernia,
and all bilateral hernias (both inguinal and femoral), should be repaired laparoscopically.

Unilateral hernia

Inguinal hernia — There is no consensus as to whether the optimal approach to inguinal

hernia repair is open or laparoscopic [27-29]. Some surgeons prefer to repair a primary, unilateral
inguinal hernia with an open technique, while others prefer a laparoscopic approach. Although
there is growing support for laparoscopic repair for unilateral primary inguinal hernias, the total
difference in outcomes remains relatively small despite statistical significance given the large
sample sizes afforded with national registry studies [30]. Therefore, a primary, unilateral inguinal
hernia can still be repaired open or laparoscopically based upon surgeon and patient preferences.

Open and laparoscopic approaches have been directly compared, most often in inguinal hernia
repairs. In general, laparoscopic repair has been associated with less postoperative pain and
quicker recovery but longer operative time and higher recurrence rates [24,31-43]. Laparoscopic
repair could also result in serious complications (eg, massive pelvic bleeding) that would rarely
occur during open repairs.

● The largest trial randomly assigned 1983 men with inguinal hernias to receive open or
laparoscopic mesh repair at 1 of 14 United States Veterans Affairs Medical Centers [44].
Patients treated laparoscopically had less pain on the day of surgery and at two weeks and
returned to work one day earlier. However, they suffered more postoperative complications
(39 versus 33.4 percent), life-threatening complications (1.1 versus 0.1 percent), and hernia
recurrences (10.1 versus 4.9 percent at two years). In subgroup analysis, the difference in
recurrence rate was significant for primary (10.1 versus 4 percent), but not recurrent, hernias
(10 versus 14 percent). This trial has been criticized for higher than average rates of
recurrences in both groups due to surgeon inexperience, as well as for a patient population
that is older (average age 58) and less healthy (only 34 percent were American Society of
Anesthesiologists class I) than the average patient who needs inguinal hernia repair.

● A subsequent trial randomly assigned 389 patients with a primary unilateral inguinal hernia to
receive either open Lichtenstein repair under local anesthesia or laparoscopic total
extraperitoneal (TEP) repair under general anesthesia [45]. Fewer patients in the laparoscopic
group reported having persistent groin pain at one year (21 versus 33 percent). However, this
difference may not be clinically relevant, as most patients reported mild pain (described as
"can be easily ignored" on the questionnaire); only a few patients in each group (2 percent in
the laparoscopic versus 3 percent in open group) reported severe pain. In addition, fewer
patients in the laparoscopic group reported having groin pain that limited their ability to
perform physical exercise (3 versus 8 percent). The recurrence rates at one year were
similarly low in both groups (1 percent laparoscopic versus 2 percent open).

● A Swedish prospective cohort study of over 20,000 patients undergoing elective unilateral
groin hernia repair between 2012 and 2015 showed that groin pain interfering with daily
activities persisted at one year after surgery in 15.2 percent of patients, higher than previously
estimated. The risk of chronic pain was lower with TEP than with open anterior mesh
(Lichtenstein) repair (adjusted odds ratio 0.84, 95% CI 0.74-0.96), but at the price of a higher
risk of recurrence requiring reoperation (adjusted odds ratio 2.14, 95% CI 1.52-2.98) at 2.5
years [46].

● A 50,000 patient European registry (Herniamed) study compared three methods of unilateral
inguinal hernia repair using propensity-score matching [30]. Compared with both TEP and
laparoscopic transabdominal patch plasty (TAPP), open Lichtenstein repair was associated
with more postoperative complications (3.4 versus 1.7 percent TEP; 3.8 versus 3.3 percent
 TAPP), reoperations (1.1 versus 0.8 percent TEP; 1.2 versus 0.9 percent TAPP), and chronic
pain at rest (5.2 versus 4.3 percent TEP; 5 versus 4.5 percent TAPP) and on exertion (10.6
versus 7.7 percent TEP; 10.2 versus 7.8 percent TAPP), but not recurrence. TEP was
associated with more intraoperative complications than open Lichtenstein repair (0.9 versus
1.2 percent TEP), and TAPP was associated with more postoperative complications than TEP
(3 versus 1.7 percent). Otherwise, TEP and TAPP were comparable in all other reported
outcomes. However, the follow-up period was only one year, which may be too short to
capture all recurrences.

Femoral hernia — We prefer to repair a femoral hernia laparoscopically because of its

ease of access. Anterior femoral hernia repairs require a breach of the inguinal canal to gain
access to the femoral hernia posteriorly; posterior repairs have direct access to the femoral hernia
without going through the inguinal canal. In one study, posterior repair of femoral hernias was
associated with a lower recurrence rate than anterior repair [5]. Posterior repairs are mostly done
laparoscopically as the only open posterior repair (Kugel) is rarely performed.

In addition, laparoscopic femoral hernia repair is also better at identifying occult hernias [47]. In
one study of 250 men undergoing laparoscopic repair of presumed inguinal hernias, femoral
hernias were detected in addition to (29) or in lieu of (4) inguinal hernias in 33 patients (13.2
percent) [48]. Of the 33 patients with a femoral hernia, 61 percent had undergone a previous open
inguinal hernia repair, reflecting either the failure to recognize a concomitant femoral hernia during
their initial open surgery or the interval development of a femoral hernia.

Bilateral hernias — We prefer to repair bilateral groin hernias laparoscopically because:

● Both hernias can be repaired through the same incisions, which improves cosmesis.

● A single large piece of mesh can be used with a laparoscopic TEP repair, reducing costs and
potentially the risk of direct hernia recurrence medially [49].

● A laparoscopic approach permits exploration of the contralateral groin in patients with

symptoms suggestive but not diagnostic of a contralateral hernia [50].

Three randomized trials have independently concluded that laparoscopic compared with open
repair of bilateral inguinal hernias caused less postoperative pain, faster recovery, and similar
rates of recurrence [51-53]. The National Institute for Health and Clinical Excellence (NICE) in the
United Kingdom advocates laparoscopic repair for patients with bilateral hernias [54].

When laparoscopic repair is not available, the alternative for patients with bilateral hernias is
bilateral open tension-free mesh repair, which can be performed as a single operation, rather than
two separate procedures [55].

Recurrent hernia — We prefer to repair a recurrent groin hernia with a laparoscopic approach
if the initial repair was open, but with an open approach if the initial repair was laparoscopic. The
rationale is that recurrent hernia repair is optimal if performed in a previously undissected tissue
plane.

Patients with prior open repair — Many surgeons feel that recurrent hernias, particularly
those that recur after an anterior mesh repair, are best addressed via a laparoscopic technique
[33,37]. As with primary repairs, a laparoscopic repair of recurrent hernias was also associated
with faster recovery, less postoperative pain, and fewer complications [37,53,56-58]. The NICE in
the United Kingdom also advocates laparoscopic repair for recurrent hernias [54].

Patients with prior laparoscopic repair — An open repair is required for patients with a
recurrent hernia if they have had a previous laparoscopic hernia repair (usually with mesh
placement) or other surgeries involving the preperitoneal space (eg, prostatectomy, hysterectomy,
cesarean section, or laparotomy via lower midline incision). In such patients, the preperitoneal
space may be difficult to access. (See 'Patients with prior surgery involving the preperitoneal
space' above.)

Special considerations

Cost effectiveness — Studies have generally found an overall cost benefit for open, as
opposed to laparoscopic, hernia repair [59-63]. Factors considered in such studies included the
cost of operating room time and equipment (especially single-use items), length of hospital stay,
and the cost of treating potential complications. Variations in one or more of these factors (eg, by
using reusable equipment) could make laparoscopic surgery more cost-effective [59].

Female patients — Groin hernias are uncommon in females; less than 8 percent of hernia
repairs are performed in women [5,64-66]. Compared with men, women are more likely to have
femoral hernias, complicated hernias (incarceration or strangulation), or recurrent hernias [64].
(See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults",
section on 'Epidemiology' and "Classification, clinical features, and diagnosis of inguinal and
femoral hernias in adults", section on 'Femoral hernia'.)

For women who have had a prior surgery involving the preperitoneal space (eg, cesarean section
or hysterectomy), an open anterior mesh repair is the best option. In others, a laparoscopic
approach is preferred because it allows identification and repair of occult hernias (especially
femoral hernias).
SURGICAL TECHNIQUES

Specific techniques of inguinal or femoral hernia repair are briefly discussed below. Detailed
information can be found in other topics. (See "Open surgical repair of inguinal and femoral hernia
in adults" and "Laparoscopic inguinal and femoral hernia repair in adults".)

Open techniques — Open techniques approach the hernia defect anteriorly and include tension-
free mesh repairs as well as primary tissue approximation nonmesh repairs. For patients in whom
mesh placement is not contraindicated, we recommend using a mesh repair technique to achieve
a tension-free repair rather than a nonmesh repair technique. Nonmesh repair techniques may be
required for patients with active groin infection or contamination (eg, as a result of bowel
perforation from a strangulated hernia).

Open tension-free mesh repairs — Successful hernia repair depends upon a tension-free
closure, which is typically achieved with placement of a mesh. Multiple studies have demonstrated
that tension-free mesh repair of inguinal hernias reduces postoperative groin pain, expedites
recovery, and reduces recurrence rate [1,2,26,67-70]. Thus, the tension-free mesh techniques are
most widely used and endorsed by various hernia societies [1,27,28]. Tension-free repairs that use
mesh include Lichtenstein, plug and patch, and Kugel (preperitoneal repair). (See "Open surgical
repair of inguinal and femoral hernia in adults", section on 'Mesh versus non-mesh repair' and
"Open surgical repair of inguinal and femoral hernia in adults", section on 'Hernia repair
techniques'.)

Open primary tissue approximation nonmesh repairs — Shouldice, Bassini, and McVay
repairs are open techniques that achieve primary tissue approximation without the use of mesh
[69,71-75]. Although the Shouldice repair does not incorporate mesh, some regard it as a tension-
free technique. Nonmesh repair techniques are primarily used when mesh placement is
contraindicated, such as when there is active infection or contamination of the groin, or when the
use of a mesh is cost prohibitive (eg, in resource-limited settings). (See "Open surgical repair of
inguinal and femoral hernia in adults", section on 'Hernia repair techniques'.)

Laparoscopic techniques — Laparoscopic repairs approach the hernia defect posteriorly. The
two main techniques are totally extraperitoneal (TEP) repair and transabdominal preperitoneal
patch (TAPP) repair, both of which require the use of mesh and are considered tension-free
repairs [76]. The mesh employed for these repairs must be of sufficient size to cover the entire
preperitoneal groin space in order to prevent recurrences. (See "Laparoscopic inguinal and
femoral hernia repair in adults", section on 'Laparoscopic repair approaches'.)
PREOPERATIVE PREPARATION

Inguinal and femoral hernias can usually be repaired with minimal morbidity and mortality. We use
the following preoperative routine to optimize patient outcomes and experience.

Confirm presence and location of hernia — The diagnosis of an inguinal or femoral hernia is
clinical for most patients. Immediately prior to surgery, the patient should be reexamined to confirm
the presence of a hernia and mark its laterality. (See "Classification, clinical features, and
diagnosis of inguinal and femoral hernias in adults".)

Obtain informed consent — The risks and benefits of hernia repair versus watchful waiting,
including potential complications of each approach, should be reviewed with the patient. In
particular, the surgeon should inform the patient of a potential risk of chronic groin pain or
discomfort after groin hernia repair. If surgical repair is elected, the risks and benefits of an open
versus laparoscopic approach should also be discussed with the patient. (See 'Choosing a
surgical approach' above.)

Medical risk assessment — Much of the preoperative medical evaluation is directed toward
ensuring that the patient can tolerate anesthesia, especially if general anesthesia is planned. (See
"Preoperative medical evaluation of the healthy adult patient" and "Evaluation of cardiac risk prior
to noncardiac surgery" and "Evaluation of preoperative pulmonary risk" and "Perioperative
management of blood glucose in adults with diabetes mellitus".)

Treat hernia complications if present — Patients with complicated hernias should receive
complication-specific treatment prior to hernia repair. As examples, patients with bowel obstruction
require fluid resuscitation and nasogastric decompression; patients with bowel ischemia or
perforation require antimicrobial coverage. (See "Management of small bowel obstruction in
adults" and "Overview of gastrointestinal tract perforation", section on 'Initial management'.)

Preoperative prophylaxis — Most inguinal and femoral hernia repairs are elective procedures
performed in an outpatient setting. Thromboprophylaxis and/or prophylactic antibiotics may be
required in selected patients to prevent complications such as venous thromboembolism (VTE) or
surgical site infection (SSI).

Thromboprophylaxis — Thromboprophylaxis is administered according to the patient's risks

of developing VTE perioperatively (table 1). Patients who are young (<40 years of age), otherwise
healthy, and have no other risk factors for VTE do not require pharmacologic thromboprophylaxis.
Mechanical thromboprophylaxis may be applied to patients undergoing general anesthesia, or at
the surgeon's discretion. (See "Prevention of venous thromboembolic disease in adult
nonorthopedic surgical patients".)

Antibiotics — For patients undergoing uncomplicated inguinal or femoral hernia repair with
planned mesh placement, we recommend administering prophylactic antibiotics rather than no
antibiotics. Patients with complicated hernias require broader antimicrobial coverage than
prophylactic antibiotics. For patients undergoing uncomplicated inguinal or femoral hernia repair
without planned mesh placement, prophylactic antibiotics may be omitted based upon surgeon
preference.

The role of prophylactic antibiotics given prior to inguinal or femoral hernia repair remains
controversial [77-82]. Uncomplicated hernia surgery is considered clean surgery, for which
prophylactic antibiotics are not indicated. Some surgeons, however, prefer to administer antibiotics
to patients undergoing hernioplasty (ie, hernia repair with mesh) to prevent potential mesh
infection [82,83]. Others omit routine prophylactic antibiotics because the risk of SSI after groin
hernia surgery is low, and most SSIs that occur are superficial and can be easily treated with oral
antibiotics. (See "Overview of complications of inguinal and femoral hernia repair", section on
'Superficial incisional surgical site infection'.)

A 2012 Cochrane review of 17 randomized trials demonstrated a lower rate of SSI in patients who
received, compared with those who did not receive, prophylactic antibiotics (3.1 versus 4.5
percent, odds ratio 0.64, 95% CI 0.50-0.82) [83]. In subgroup analyses, however, the difference
was smaller in patients without mesh placement (3.5 versus 4.9 percent, odds ratio 0.71, 95% CI
0.51-1.00) than in those with mesh placement (2.4 versus 4.2 percent, odds ratio 0.56, 95% CI
0.38-0.81).

Prophylactic antibiotics should cover the usual skin flora, including aerobic gram-positive
organisms, aerobic streptococci, staphylococci, and enterococci (table 2) [84]. To be effective,
prophylactic antibiotics must be administered within one hour before the time of incision [85,86].
(See "Antimicrobial prophylaxis for prevention of surgical site infection in adults" and "Antimicrobial
prophylaxis for prevention of surgical site infection following gastrointestinal procedures in adults".)

Patients undergoing urgent inguinal or femoral hernia repairs should receive antibiotics according
to the complication (eg, bowel perforation, bowel ischemia, or obstruction). For those patients,
antibiotics are considered therapeutic rather than prophylactic, and the initial coverage should be
broad (table 2). Once an intraoperative culture has been obtained, further antibiotic therapy should
be guided by microbiology data. (See "Overview of gastrointestinal tract perforation".)
Choice of anesthesia — Inguinal or femoral hernia repair can be performed using general,
neuraxial (spinal or epidural), or regional anesthesia (peripheral nerve block, local) [87,88]. The
choice of anesthesia depends upon the type and size of the hernia, surgical approach, and
patient/surgeon preferences. (See "Overview of anesthesia".)

Anesthesia for open repair — We prefer to perform open groin hernia repair with local
anesthesia, especially in patients with comorbidities (eg, advanced liver disease).

In a randomized trial of 616 patients undergoing open inguinal hernia repairs, the use of local
anesthesia resulted in less postoperative pain and nausea, a shorter recovery room stay (3.1
versus 6.2 and 6.2 hours), and fewer unplanned overnight admissions (3 versus 14 and 22
percent), compared with the use of regional and general anesthesia, respectively [87]. Another
randomized trial of open inguinal hernia repairs also found that local anesthesia resulted in less
postoperative pain, a shorter operating time, and fewer overnight stays than spinal anesthesia
[89].

Local anesthesia can be administered as a nerve block of the ilioinguinal and iliohypogastric
nerves, or as direct infiltration into the incision site(s). Nerve block may be more difficult to
administer but causes less soft tissue edema than direct infiltration. Some surgeons use a
combination of both nerve blocks and local infiltration. Local anesthesia for open groin hernia
repair is typically given in the context of "monitored anesthesia care," which also provides
intravenous sedatives for patient relaxation and additional intravenous analgesics. (See "Nerve
blocks of the scalp, neck, and trunk: Techniques", section on 'Ilioinguinal and iliohypogastric nerve
block'.)

The main disadvantage of local anesthesia is that it may not provide adequate anesthesia during
the repair of large hernias, particularly in patients who have a loss of abdominal domain. In such
patients, general anesthesia is preferred. General anesthesia can also be used in open hernia
repair by patient or surgeon preference.

Anesthesia for laparoscopic repair — Anesthesia requirements for laparoscopic inguinal or

femoral hernia repairs vary depending upon the technique used:

● Transabdominal preperitoneal patch (TAPP) repair requires general anesthesia.

● Intraperitoneal onlay mesh (IPOM) repair requires general anesthesia.

● Totally extraperitoneal (TEP) repairs are most often performed under general anesthesia but
can also be performed under spinal or epidural anesthesia.
MORBIDITY AND MORTALITY

Mortality — The 30-day mortality rate for inguinal or femoral hernia repair is 0.1 percent after
elective surgery and 2.8 to 3.1 percent after urgent surgery [64,90,91]. The mortality rate is higher
when bowel resection is performed with hernia repair [92]. Other risk factors associated with a
higher mortality rate include:

● Older age – Older patients have higher mortality rates after emergency hernia repair. In one
study, the mortality rates were 1, 5, and 16 percent, respectively, for patients who were in their
seventies, eighties, and nineties [91].

● Femoral hernia – Femoral hernia repairs are associated with higher mortality than inguinal
hernia repairs [5]. In one study, the 30-day standardized mortality ratios were higher for
femoral than inguinal hernia repairs in both men (6.81 and 1.29) and women (7.16 versus
2.82) [92].

● Women – Women have higher mortality after groin hernia repair than men [5]. However, it is
not clear if female sex is an independent risk factor, as women who require groin hernia
surgeries tend to be older, have more femoral hernias, and are more likely to require
emergency operations.

● Urgent/emergency surgery.

Morbidity — Minor complications of inguinal or femoral hernia repair, including superficial wound
infection and seroma/hematoma formation, are common and easily managed.

Serious complications include hernia recurrence and post-herniorrhaphy neuralgia. Recurrence

after either a laparoscopic or open inguinal hernia repair is rare, with a rate generally under 4
percent. Chronic groin pain or discomfort occurs more frequently, around 5 to 10 percent, and can
be debilitating on occasion. Complications of groin hernia repairs are discussed separately in other
topics. (See "Post-herniorrhaphy groin pain" and "Overview of complications of inguinal and
femoral hernia repair".)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Groin hernia in adults".)
INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics."
The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading
level, and they answer the four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who prefer short, easy-to-
read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and
more detailed. These articles are written at the 10th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Inguinal and femoral (groin) hernias (The Basics)")

SUMMARY AND RECOMMENDATIONS

● The definitive treatment of all hernias, regardless of origin or type, is surgical repair.
Inguinal/femoral hernia repair is one of the most commonly performed operations in the world.
(See 'Introduction' above.)

● Patients who develop strangulation or bowel obstruction from an inguinal or femoral hernia
should undergo urgent surgical repair. Patients with an acutely incarcerated inguinal hernia
but without signs of strangulation or obstruction also require surgery, typically urgently.
However, for those who wish to delay surgery, nonsurgical hernia reduction can be attempted,
and, if successful, elective hernia repair can be performed at a later time. (See 'Complicated
hernia' above.)

● Patients with an uncomplicated inguinal or femoral hernia may undergo surgical repair or be
managed with watchful waiting depending upon the hernia type, severity of symptoms, and
the preference of the patient, as follows:

• For patients with newly diagnosed femoral hernia, we recommend elective repair, rather
than watchful waiting, regardless of symptoms (Grade 1B). In patients with long-standing
femoral hernias (>3 months), surgery is preferred, but observation is a reasonable option.
(See 'Femoral hernia' above.)
 • For patients with moderate or severe symptoms attributable to an inguinal hernia, we
recommend elective repair rather than watchful waiting (Grade 1B). (See 'Symptomatic
hernia' above.)

• Patients who have an inguinal hernia but minimal or no symptoms, who wish to avoid
surgery, can be managed with watchful waiting provided that they are appropriately
counseled to seek prompt medical attention should the hernia become acutely
incarcerated or more symptomatic. Although acute complications rarely occurred (1.8
emergency operations/1000 patient-years), about 70 percent of patients eventually
required hernia repair at 7 to 10 years due to increasing symptoms (usually pain).
Trusses are associated with negative consequences and should not be used to manage
symptoms related to inguinal hernias. (See 'Asymptomatic hernia' above.)

● The surgical approach to groin hernia repair should be the one that the surgeon is most
comfortable with and most experienced in performing. For surgeons who are equally facile
with both open and laparoscopic repairs, the choice of a surgical approach depends upon
hernia and patient characteristics as follows (algorithm 1):

• We prefer an open approach for patients with prior surgery involving the preperitoneal
space (including laparoscopic groin hernia repair, prostatectomy, hysterectomy, cesarean
section, and laparotomy via lower midline incision), complicated inguinal hernias
(infected, incarcerated, strangulated, large scrotal), ascites, or intolerance of general
anesthesia. Laparoscopic repair is relatively contraindicated in these patients. (See
'Patients precluded from laparoscopic repair' above.)

• A primary, unilateral inguinal hernia can be repaired open or laparoscopically based upon
surgeon and patient preferences. (See 'Inguinal hernia' above.)

• We prefer to repair a femoral hernia laparoscopically. (See 'Femoral hernia' above.)

• We prefer to repair bilateral inguinal or femoral hernias laparoscopically. (See 'Bilateral

hernias' above.)

• We prefer to repair a recurrent groin hernia with a laparoscopic approach if the initial
repair was open, but with an open approach if the initial repair was laparoscopic. (See
'Recurrent hernia' above.)

● For patients with uncomplicated inguinal and femoral hernias, we recommend performing a
tension-free repair, which typically requires the use of mesh, rather than a repair that
produces tension (ie, most nonmesh primary tissue approximation repairs except Shouldice)
 (Grade 1B). Nonmesh repair techniques may be required for patients with active groin
infection or contamination (eg, as a result of bowel perforation from a strangulated hernia), or
when the use of a mesh is cost prohibitive. (See 'Surgical techniques' above.)

● For patients undergoing elective inguinal or femoral hernia repair requiring mesh placement,
we suggest using preoperative prophylactic antibiotics (Grade 2B). (See 'Antibiotics' above.)

● We prefer to perform open groin hernia repair under local anesthesia, especially in patients
with comorbidities (eg, advanced liver disease). Most laparoscopic repairs require general
anesthesia. (See 'Choice of anesthesia' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

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Topic 3687 Version 26.0

GRAPHICS

Choosing a surgical approach (open versus laparoscopic) for groin hernia repair

* Hernias with active infection or contamination require an open repair without the use of mesh; a tension-free mesh repair is
recommended for all other hernias.

Graphic 107556 Version 2.0

Modified Caprini risk assessment model for VTE in general surgical patients

Risk score

1 point 2 points 3 points 5 points

Age 41 to 60 years Age 61 to 74 years Age ≥75 years Stroke (<1 month)

Minor surgery Arthroscopic surgery History of VTE Elective arthroplasty

BMI >25 kg/m 2 Major open surgery (>45 Family history of VTE Hip, pelvis, or leg fracture
minutes)

Swollen legs Laparoscopic surgery (>45 Factor V Leiden Acute spinal cord injury
minutes) (<1 month)

Varicose veins Malignancy Prothrombin 20210A

Pregnancy or postpartum Confined to bed (>72 Lupus anticoagulant

hours)

History of unexplained or Immobilizing plaster cast Anticardiolipin antibodies

recurrent spontaneous
abortion

Oral contraceptives or Central venous access Elevated serum

hormone replacement homocysteine

Sepsis (<1 month) Heparin-induced

thrombocytopenia

Serious lung disease, Other congenital or

including pneumonia (<1 acquired thrombophilia
month)

Abnormal pulmonary
function

Acute myocardial infarction

Congestive heart failure

(<1 month)

History of inflammatory
bowel disease

Medical patient at bed rest

Interpretation

Estimated VTE risk in

the absence of
Surgical risk category* Score pharmacologic or
mechanical prophylaxis
(percent)

Very low (see text for 0 <0.5

definition)

Low 1 to 2 1.5

Moderate 3 to 4 3.0

High ≥5 6.0

VTE: venous thromboembolism; BMI: body mass index.

* This table is applicable only to general, abdominal-pelvic, bariatric, vascular, and plastic and reconstructive surgery. See
text for other types of surgery (eg, cancer surgery).
From: Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy
and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practical guidelines.
Chest 2012; 141:e227S. Copyright © 2012. Reproduced with permission from the American College of Chest Physicians.

Graphic 83739 Version 14.0

Antimicrobial prophylaxis for gastrointestinal surgery in adults

Nature of Common Recommended Usual adult Redose

operation pathogens antimicrobials dose* interval ¶

Gastroduodenal surgery

Procedures Enteric gram- Cefazolin Δ <120 kg: 2 g IV Four hours

involving entry negative bacilli, ≥120 kg: 3 g IV
into lumen of gram-positive cocci
gastrointestinal
tract

Procedures not Enteric gram- High risk ◊ only: <120 kg: 2 g IV Four hours
involving entry negative bacilli, cefazolin Δ ≥120 kg: 3 g IV
into lumen of gram-positive cocci
gastrointestinal
tract (selective
vagotomy,
antireflux)

Biliary tract surgery (including pancreatic procedures)

Open procedure Enteric gram- Cefazolin Δ ¥ <120 kg: 2 g IV Four hours

or laparoscopic negative bacilli, ≥120 kg: 3 g IV
procedure (high enterococci,
risk) § clostridia OR cefotetan 2 g IV Six hours

OR cefoxitin 2 g IV Two hours

OR ampicillin- 3 g IV Two hours

sulbactam

Laparoscopic N/A None None None

procedure (low
risk)

Appendectomy ‡

Enteric gram- Cefoxitin Δ 2 g IV Two hours

negative bacilli,
OR cefotetan Δ 2 g IV Six hours
anaerobes,
enterococci OR cefazolin Δ <120 kg: 2 g IV Four hours
≥120 kg: 3 g IV

PLUS metronidazole 500 mg IV N/A

Small intestine surgery

Nonobstructed Enteric gram- Cefazolin Δ <120 kg: 2 g IV Four hours

negative bacilli, ≥120 kg: 3 g IV
gram-positive cocci

Obstructed Enteric gram- Cefoxitin Δ 2 g IV Two hours

negative bacilli,
OR cefotetan Δ 2 g IV Six hours
anaerobes,
enterococci OR cefazolin Δ <120 kg: 2 g IV Four hours
≥120 kg: 3 g IV

PLUS metronidazole 500 mg IV N/A

Hernia repair

Aerobic gram- Cefazolin Δ <120 kg: 2 g IV Four hours

positive organisms ≥120 kg: 3 g IV

Colorectal surgery †
 Enteric gram- Parenteral:
negative bacilli,
Cefoxitin Δ 2 g IV Two hours
anaerobes,
enterococci OR cefotetan Δ 2 g IV Six hours

OR cefazolin Δ <120 kg: 2 g IV Four hours

≥120 kg: 3 g IV

PLUS 500 mg IV N/A

metronidazole

OR ampicillin- 3 g IV (based on Two hours

sulbactam Δ,** combination)

Oral (used in conjunction with mechanical bowel preparation):

Neomycin PLUS ¶¶ ¶¶
erythromycin
base or
metronidazole

IV: intravenous.
* Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes before the procedure. If
vancomycin or a fluoroquinolone is used, the infusion should be started within 60 to 120 minutes before the initial incision
to have adequate tissue levels at the time of incision and to minimize the possibility of an infusion reaction close to the
time of induction of anesthesia.
¶ For prolonged procedures (>3 hours) or those with major blood loss or in patients with extensive burns, additional
intraoperative doses should be given at intervals one to two times the half-life of the drug.
Δ For patients allergic to penicillins and cephalosporins, clindamycin (900 mg) or vancomycin (15 mg/kg IV; not to exceed
2 g) with either gentamicin (5 mg/kg IV), ciprofloxacin (400 mg IV), levofloxacin (500 mg IV), or aztreonam (2 g IV) is a
reasonable alternative. Metronidazole (500 mg IV) plus an aminoglycoside or fluoroquinolone are also acceptable
alternative regimens, although metronidazole plus aztreonam should not be used, since this regimen does not have
aerobic gram-positive activity.
◊ Morbid obesity, gastrointestinal (GI) obstruction, decreased gastric acidity or GI motility, gastric bleeding, malignancy
or perforation, or immunosuppression.
§ Factors that indicate high risk may include age >70 years, pregnancy, acute cholecystitis, nonfunctioning gall bladder,
obstructive jaundice, common bile duct stones, immunosuppression.
¥ Cefotetan, cefoxitin, and ampicillin-sulbactam are reasonable alternatives.
‡ For a ruptured viscus, therapy is often continued for approximately five days.
† Use of ertapenem or other carbapenems not recommended due to concerns of resistance.
** Due to increasing resistance of Escherichia coli to fluoroquinolones and ampicillin-sulbactam, local sensitivity profiles
should be reviewed prior to use.
¶¶ In addition to mechanical bowel preparation, the following oral antibiotic regimen is administered: neomycin (1 g) plus
erythromycin base (1 g) OR neomycin (1 g) plus metronidazole (1 g). The oral regimen should be given as three doses
over approximately 10 hours the afternoon and evening before the operation. Issues related to mechanical bowel
preparation are discussed further separately; refer to the UpToDate topic on overview of colon resection.

Data from:
1. Antimicrobial prophylaxis for surgery. Med Lett Drugs Ther 2016; 58:63.
2. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg
Infec (Larchmt) 2013; 14:73.

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Contributor Disclosures
David C Brooks, MD Nothing to disclose Michael Rosen, MD Grant/Research/Clinical Trial Support:
Intuitive Surgical [Inguinal hernia (Surgical robot)]; Miromatrix [Mesh (Mesh)]; Pacira [Ventral hernia repair
(Bupivacaine)]. Consultant/Advisory Boards: Artiste Medical [Mesh (Mesh)]. Employment: Medical Director of
AHSQC (Americas Hernia Society Quality Collaborative). Wenliang Chen, MD, PhD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
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