HerniaSurge Group · 2023

Inguinal Hernia — Operate or Observe? Approach & Timing

Source: International guidelines for groin hernia management, HerniaSurge Group, Hernia 2018; updated per Update of the international HerniaSurge guidelines for groin hernia management, BJS Open 2023 (corrigendum 2024)

Guideline: Strong Guideline: Conditional Guideline: Not recommended ClinicoQ pathway suggestion (not from the cited guideline)

Diagnosis

Diagnostic criteria Groin hernias are diagnosed by physical examination in most men (a palpable bulge or impulse on cough/Valsalva in the inguinal region). Ultrasonography is often needed in women, and is also useful for recurrent hernia, suspected surgical complication, or other causes of groin pain (groin mass, hydrocele). MRI has higher sensitivity/specificity than ultrasound and is used for occult hernias when clinical suspicion remains high despite a negative ultrasound.

⚠ Alarm features (investigate before diagnosing)

Signs of incarceration (irreducible, tender, firm bulge)
Signs of strangulation (severe pain, overlying skin changes, fever, systemic toxicity, signs of bowel obstruction) — surgical emergency
Suspected femoral hernia (higher strangulation risk than inguinal hernia)

Initial workup

Test	When to order
Physical examination	First step in all patients; usually sufficient for diagnosis in men.
Ultrasonography	When exam is inconclusive, in women, or to evaluate a recurrent hernia or other cause of groin pain.
MRI	For suspected occult hernia when clinical suspicion is high despite a negative ultrasound.

Decision Points

❓ Are there signs of incarceration or strangulation?

No — reducible, no systemic signs → Elective repair — technique selection

Yes — irreducible, tender, or systemic signs → Acutely irreducible hernia — reduction vs emergency surgery

❓ For a non-urgent (reducible, no systemic signs) inguinal hernia: is this an asymptomatic/minimally symptomatic male patient?

Yes — asymptomatic/minimally symptomatic male, easily reducible inguinal hernia → Watchful waiting

No — symptomatic, female patient, or femoral hernia → Elective repair — technique selection

❓ Is expertise and resources for a laparo-endoscopic (TEP/TAPP) approach available, and does the patient have a straightforward primary unilateral hernia?

Yes — expertise/resources available, primary unilateral hernia, no relative contraindication → Laparo-endoscopic repair (TEP/TAPP)

No — expertise unavailable, or patient/hernia factors favor an open approach → Open mesh repair (Lichtenstein or preperitoneal)

Mesh declined by an informed patient, or contraindicated (e.g. infected field) → Non-mesh repair (Shouldice)

Treatment

Watchful waiting

1 Watchful waiting with patient education Strong (Guideline recommendation) — safe for asymptomatic/minimally symptomatic men

Dose: -
Duration: Ongoing; reassess if symptoms develop or activities become limited
Evidence level: High
Avoid if: Femoral hernia (higher strangulation risk — should not be managed with watchful waiting), signs of incarceration/strangulation
If no response ClinicoQ pathway: A 2023 systematic review (part of the HerniaSurge update) found about one-third of patients cross over from watchful waiting to surgery within 1.5-3 years, rising to roughly 70% by about 7 years, with similar morbidity, mortality, pain and discomfort between the elective-repair and crossover groups — discuss timing with the patient considering occupation, activity level, and overall health

Elective repair — technique selection

1 Technique selection based on expertise, resources, and patient/hernia factors Guideline recommendation — a mesh-based technique is recommended for the majority of patients (Strong); a non-mesh repair can be suggested after careful patient selection and shared decision-making where expertise is available (Weak)

Dose: -
Duration: Elective scheduling
Evidence level: High
Avoid if: -
If no response: See the technique_selection decision point above for which specific repair to route to

Laparo-endoscopic repair (TEP/TAPP)

1 Totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) mesh repair Strong (Guideline recommendation, upgraded in the 2023 HerniaSurge update) — preferred over open Lichtenstein repair for primary unilateral inguinal hernia in all sexes, given lower postoperative pain and reduced chronic pain incidence, provided a surgeon with specific expertise and sufficient resources is available

Dose: - surgical procedure
Duration: Elective scheduling
Evidence level: High
Avoid if: Relative contraindications: prior prostatic surgery, pelvic radiation, or lower abdominal/pelvic surgery affecting the preperitoneal space; scrotal hernia; when local anesthesia specifically is indicated; regions/settings where TEP/TAPP expertise is unavailable or resources are lacking — an open approach is the better option in these situations
If no response: The learning curve for laparo-endoscopic techniques (especially TEP) is longer than Lichtenstein (roughly 50-100 procedures, with the first 30-50 most critical) and carries rare but severe complications early in the learning curve — must be learned under proper supervision

Open mesh repair (Lichtenstein or preperitoneal)

1 Open Lichtenstein mesh repair, or an open preperitoneal flat mesh technique as an acceptable alternative Guideline recommendation — Lichtenstein remains the standard open technique; an open preperitoneal flat mesh technique is a weak-recommendation acceptable alternative (comparable recurrence, some studies favor it for pain/recovery) where expertise is available

Dose: - surgical procedure
Duration: Elective scheduling
Evidence level: Moderate
Avoid if: Active groin infection at the planned surgical site; patient preference against mesh after informed discussion of alternatives
If no response: -

Non-mesh repair (Shouldice)

1 Shouldice technique (non-mesh, pure tissue repair) Strong (Guideline recommendation, 2023 update) — the best-evaluated and best-standardized non-mesh repair, with lower recurrence than other suture repairs; in selected patients (smaller indirect/direct hernias, younger patients, women after excluding femoral hernia) it can achieve 1-year outcomes comparable to Lichtenstein, TEP and TAPP where expertise is available

Dose: - surgical procedure
Duration: Elective scheduling
Evidence level: Moderate-High
Avoid if: Surgeon lacks specific training in the technique (learning curve is long); larger direct hernias or patients with a weak/thin external oblique fascia where outcomes are less established
If no response: Refer to a surgeon experienced in the Shouldice technique rather than defaulting to mesh if the patient specifically wants a non-mesh option

Acutely irreducible hernia — reduction vs emergency surgery

1 Attempt manual reduction (taxis) — only when there is no clinical suspicion of strangulation or bowel ischemia Guideline recommendation — an acutely irreducible hernia without suspicion of strangulation or bowel ischemia should have manual reduction attempted first; manual reduction is contraindicated if strangulation is suspected

Dose: Gentle manual reduction, with adequate analgesia/sedation; manual reduction is successful in roughly 60% of incarcerated (non-strangulated) inguinal hernias per the surgical literature
Duration: Single attempt; do not persist if reduction is not achieved promptly or the patient's pain worsens
Evidence level: Low-Moderate
Avoid if: Any clinical suspicion of strangulation or bowel ischemia (fever, systemic toxicity, overlying skin changes, severe/worsening pain) — go directly to emergency surgery instead
If no response ClinicoQ pathway: If reduction fails, or strangulation is suspected at any point, proceed immediately to emergency surgery. If reduction succeeds, admit for a period of observation and schedule elective repair rather than discharging without follow-up, since recurrence/re-incarceration can occur before elective repair.

2 Emergency surgical exploration and repair Strong (Guideline recommendation) — mandatory for suspected strangulation/bowel ischemia or failed manual reduction; emergency surgery carries higher morbidity than elective repair, reinforcing earlier elective referral for symptomatic hernias

Dose: - surgical procedure
Duration: Emergency — without delay
Evidence level: Low (emergency setting, limited RCT data)
Avoid if: -
If no response: -

✕ Treatments the guideline advises against

Watchful waiting for femoral hernias: Femoral hernias carry a higher risk of incarceration/strangulation than inguinal hernias and are generally repaired promptly regardless of symptoms.

Non-mesh (pure tissue) repair as the default/first-choice technique for the general patient population: Guideline recommends mesh for the majority of patients given lower recurrence. However, unlike earlier guidance, non-mesh repair (specifically the Shouldice technique) is NOT blanket not-recommended as of the 2023 update — it is a Strong-recommended non-mesh option in carefully selected patients with shared decision-making and available expertise; see the Non-mesh repair (Shouldice) track.

Non-mesh techniques other than Shouldice (e.g. Bassini, Marcy/annulorrhaphy, Moloney darn) for routine practice: Evidence is low-quality or insufficient to support these as alternatives to Shouldice outside of low-resource settings or specific niche indications (e.g. Marcy/annulorrhaphy in young men with small indirect hernias wanting to avoid mesh).

⚠️ Currency note: this page has been revised to reflect the 2023 HerniaSurge update (BJS Open, corrigendum 2024), which updated 10 of the original 2018 guideline's chapters. Notable changes from the original 2018 position: the mesh recommendation was softened from 'all patients' to 'the majority of patients', with the Shouldice non-mesh technique gaining a Strong recommendation as a legitimate alternative; and laparo-endoscopic repair (TEP/TAPP) was upgraded to a Strong recommendation over open Lichtenstein repair when expertise is available. This is an educational summary of current international clinical practice guidelines and does not replace individualized clinical judgment. Final treatment decisions remain the responsibility of the treating physician.