Hernia repair surgery is one of the most commonly performed operations worldwide, with more than 1 million procedures taking place in the United States each year. This surgical intervention aims to fix a condition where an organ or tissue pushes through a weakened area in the muscle or tissue wall that normally contains it, most often occurring in the abdomen or groin.
Understanding Hernia Repair
A hernia repair, also known as herniorrhaphy, is a surgical procedure designed to treat hernias by returning displaced organs or tissue to their proper position and reinforcing the weakened barrier. During this operation, a surgeon pushes the bulging tissue back into place and strengthens the muscle wall using stitches or surgical mesh. Most hernias form in the abdomen or groin, creating noticeable bulges under the skin where internal tissue presses outward through a tear or gap in the muscle or tissue wall.[1]
The procedure is considered the most common and often the only effective treatment for hernias. While not all hernias require immediate intervention, most eventually need surgical repair since they typically worsen over time. Lifestyle changes such as diet modifications or exercise alone are not enough to repair the condition, and leaving a hernia untreated only allows the problem to progress.[2][4]
Epidemiology
Hernia repair represents a significant portion of surgical procedures performed globally. According to the U.S. Food and Drug Administration, surgeons perform more than 1 million hernia surgeries in the United States annually. Worldwide, approximately 20 million hernia surgeries are performed each year, making it one of the most frequently conducted surgical procedures.[1][11]
The type of hernia significantly influences who is affected. Inguinal hernias, which occur in the groin area, are the most common type and account for approximately 800,000 of the annual hernia repair surgeries in the United States. These hernias are far more prevalent in men than women. Researchers estimate that about 27 percent of men and only 3 percent of women will develop an inguinal hernia at some point in their lives. Men are eight to ten times more likely than women to develop this type of hernia.[11][12]
The risk of developing an inguinal hernia increases with age, with occurrence being most common in people ages 75 to 80. Among men with inguinal hernias, a significant percentage of those initially choosing watchful waiting eventually require surgery—23 percent cross over to surgery after 2 years and 50 percent after 5 years.[11][12]
Femoral hernias, which occur in the upper thigh or outer groin area, are much less common than inguinal hernias but are far more likely to occur in women than in men. They also present a higher risk of complications if not repaired.[11]
Hiatal hernias, where part of the stomach pushes through the diaphragm into the chest cavity, are also common, affecting around 20 percent of people in the United States and 50 percent of those over the age of 50.[15]
Ventral hernias, including umbilical hernias (occurring at the belly button) and incisional hernias (occurring at the site of previous surgery), account for a significant portion of cases. Congenital hernias occur in about 15 percent of newborns, mostly umbilical. Incisional hernias make up about 10 percent of all hernias.[15]
Causes and Types of Hernias
A hernia occurs when part of an internal organ or body part protrudes into an area where it should not be. The underlying cause involves a weakness or opening in the muscle or tissue wall that normally contains the organ. This weakness can develop gradually over time as regular wear and tear on muscles accumulates with aging. Hernias can also result from an injury, surgery, or birth defects.[1][5]
Several specific types of hernias are commonly treated with surgery. A ventral hernia is a bulge of tissues through an opening or defect in the wall of the abdominal muscles. The most common types of ventral hernias are umbilical hernias, which occur at the belly button, and incisional hernias, which occur at the site of a previous surgery that weakened the abdominal wall.[4][6]
An inguinal hernia happens when fatty or intestinal tissues bulge through the inguinal canal in the groin. It is the most common type of hernia among men, affecting 25 percent of them in their lifetimes, compared to 2 percent of women. Men have a small hole in the abdominal wall in the groin where the cord to the testicle passes through. If this hole enlarges abnormally, it can lead to a hernia.[4][5]
A hiatal hernia, also called a para-esophageal hernia, occurs when part of the stomach or other organs from the abdomen protrude into the chest cavity through the opening in the diaphragm where the esophagus passes through.[4]
Risk Factors
Multiple factors increase the risk of developing a hernia that may require surgical repair. Being overweight has direct links to hernia formation due to the increased pressure it can put on the abdominal wall. People with a high body mass index have a greater risk not only for developing hernias but also for complications after undergoing hernia surgery.[20]
Strenuous labor or exercise can contribute to hernia development by putting excessive strain on weakened tissue. This pressure can come from heavy lifting, but also from seemingly harmless activities. Even urinating or coughing can trigger a hernia in susceptible individuals.[15][18]
Smoking is a significant risk factor for hernias. People who smoke develop hernias at higher rates than nonsmokers for several reasons. Long-term smokers often experience chronic coughing, which creates repeated strain on the abdominal wall. Additionally, smoking interferes with collagen formation in the body, and as collagen decreases, so does tissue strength, especially in the abdominal wall. Smokers are four times more likely to have recurring hernias after surgical repair. It is also more common for smokers to develop postoperative infections.[20]
Constipation creates increased pressure within the abdomen during straining, which can contribute to hernia formation or make an existing hernia worse. Previous abdominal surgery also represents a risk factor, as the incision site may weaken over time, potentially leading to an incisional hernia.[15][18]
Symptoms
Hernias can cause various symptoms that affect daily life. A common symptom is a noticeable lump or bulge under the skin, typically in the abdomen or groin area. This bulge may not always be present—for example, it might disappear when lying down. The lump or bulge may increase in size with coughing or straining.[6][11]
Many people experience discomfort, pressure, or pain at the hernia site. For hernias in the groin, pressure and pain often increase not just with strenuous activity but also with every cough or sneeze. The symptoms may worsen when standing, straining, or lifting heavy objects.[2][4]
Some hernias cause mild pain or pressure, while others can appear as a painless lump. Depending on where the hernia is located, it can impact other organs and cause specific complications. For example, if someone has testicles, a hernia can slip past a muscle wall and into the scrotum, causing swelling and pain during sexual activity.[1][5]
Hiatal hernia symptoms differ from other types, as they do not cause a visible bulge. Instead, hiatal hernias may cause symptoms such as heartburn, acid reflux, and regurgitation of food or liquids.[11][22]
When Hernia Surgery Becomes Necessary
Not all hernias require immediate surgical treatment, but most eventually do since they usually worsen over time. Healthcare providers may suggest hernia surgery if the hernia causes pain or bothers the patient during everyday activities. If the hernia is small and not causing any symptoms, surgery may not be needed right away. However, these hernias most often do not go away on their own, tend to get larger, and a significant number eventually need surgical repair.[1][3]
The majority of hernias require some type of surgical approach eventually. Leaving a hernia untreated only makes the condition worse. Most hernias become larger over time and will not permanently resolve on their own. There is a small risk that part of the bowel could get trapped within the hernia, which can lead to a medical emergency.[4][5]
About one-third of groin hernia patients have no symptoms, and for these individuals, watchful waiting may be a safe option. This approach is particularly suitable for adults who are not uncomfortable and whose hernias are reducible—meaning they can be pushed back in. However, most men with an inguinal hernia eventually need surgery due to increased pain with exercise, chronic constipation, or urinary symptoms.[12]
Patients may choose to have surgery if the hernia is causing discomfort or limiting activities, if the hernia is growing larger, or if they and their doctor are worried about the risk of the bowel getting trapped.[5]
Types of Hernia Repair Surgery
There are three main types of hernia repair surgery: open surgery, laparoscopic surgery, and robotic surgery. The choice of surgical approach depends on multiple factors, including the type of hernia, its size, and how complex the surgery will be.[1]
Open hernia repair surgery, also called traditional hernia repair, involves a surgeon making a single incision that allows them to operate directly on the herniated tissue. The surgeon makes a cut near the hernia site, locates the hernia, and separates it from the surrounding tissues. The herniated tissue is either removed or gently pushed back into the abdomen. The surgeon then closes the weakened abdominal muscles with stitches and often reinforces the area with a piece of synthetic or biological mesh sewn into place to strengthen the abdominal wall. At the end of the repair, the cut is closed with stitches, staples, or surgical glue.[1][3]
As a general rule, open surgery is used for hernias that are very small or very large. The size of the incision is determined by the size of the hernia. For example, a small hernia might only require an incision of half an inch, while larger hernias require longer incisions.[4]
Laparoscopic hernia repair surgery, sometimes called “keyhole surgery,” is a minimally invasive approach where the surgeon uses several tiny cuts, usually three or four, to operate. The surgeon inserts a thin tube with a tiny video camera called a laparoscope that projects images of the insides onto a screen. Surgical instruments are inserted into the other incisions to repair the hernia. During the procedure, the abdomen is inflated with carbon dioxide gas to expand the space, giving the surgeon more room to see and work. The hernia hole or defect is covered with mesh and affixed with staples, essentially serving as a patch. Those that fall in between very small and very large hernias can be treated laparoscopically.[1][3][4]
Robotic hernia repair surgery is a type of laparoscopic surgery that uses robotic surgical instruments to operate. The surgeon works at a console driving the technology used to repair the weakened tissue causing the hernia.[1]
Most hernias, regardless of the type of surgery, are repaired with mesh reinforcements made from synthetic or biological materials. Mesh is favored over stitches in many instances, except for very small hernias. For very small hernias, the repair can be made with stitches alone, without mesh.[4]
Anesthesia Options
Hernia repair can be done under different kinds of anesthesia, depending on the type of surgery and patient factors. If a patient receives general anesthesia, they will be unconscious during the procedure. Patients are likely to need general anesthesia for laparoscopic surgery. If given spinal, regional, or local anesthesia, the patient will remain awake, but the pain will be blocked in the area of surgery. For open surgeries, patients may only need local or regional anesthesia and will be awake for surgery but won’t feel pain.[3][5][8]
Preparation for Surgery
Preparing for hernia surgery involves several steps to ensure the procedure goes smoothly and safely. The healthcare provider will determine whether the patient is a candidate for hernia surgery and which type of surgery is best. Preparation includes reviewing the patient’s medical history, including whether they are pregnant, and reviewing all medications, including herbs and supplements they are taking.[1]
Blood tests or imaging may be ordered to ensure the patient is healthy enough for surgery. Healthcare providers will give specific instructions to prepare. For example, patients may be asked to stop taking blood thinners like aspirin or other medications that could increase the risk of bleeding about one week before the repair. Patients will also be asked not to eat or drink anything beginning the night before surgery (except medicines allowed with a sip of water) to reduce the risk of vomiting during surgery.[1][5]
On the day of surgery, patients should wear loose-fitting clothing. They will need to arrange for someone to drive them home after surgery, and this person should stay with them for 24 hours after the procedure if they had general anesthesia.[1][5]
Recovery and Outlook
Recovery from hernia surgery generally takes around four to six weeks, though the timeline varies depending on the type of surgery and individual factors. For most people, a hernia repair does not require overnight hospitalization. However, some patients may need to stay in the hospital for 24 hours for small hernia procedures, and those with complex hernia repairs may need to stay longer. The average length of stay for patients with a complex hernia repair is 1.5 days.[4][6][19]
Laparoscopic procedures generally heal faster than open surgery. If patients have laparoscopic surgery for a ventral hernia, recovery may require an overnight stay in the hospital and pain medications for three to five days. Patients will be restricted from lifting anything more than 20 pounds for two weeks. Depending on their job, they may return to work after a week or two. After about a month, most patients feel fine and are back to normal.[4]
The First Week After Surgery
During the first week after surgery, patients are likely to have pain for a few days. They may also feel tired and have less energy than normal, which is common. Most people feel better after a few days and will probably feel much better within 7 days. For several weeks, patients may feel discomfort or pulling in the hernia repair when they move. Some bruising around the area of the repair or on the genitals is normal.[16][17][21]
An abdominal binder, which is an elastic bandage that wraps around the belly and upper hips, can be helpful during this time. It helps support the belly muscles after surgery and should be worn especially when up and moving. For the first three days, patients should not lift anything more than 5 pounds. After three days and until two weeks, they should not lift anything more than 10 pounds.[21]
Patients should try to walk each day, starting by walking a little more than they did the day before and gradually increasing the amount. Walking boosts blood flow and helps prevent pneumonia, constipation, and blood clots. They should walk short distances three to six times daily, walking slowly and carefully, with a goal of 30 minutes by the end of the first month. However, patients should avoid strenuous activities such as biking, jogging, weight lifting, or aerobic exercise until the doctor says it is okay.[16][17][21]
Weeks 2-4 After Surgery
During weeks two to four after surgery, patients can lift up to 15 pounds. They should continue to use the abdominal binder but can take it off more frequently, gradually decreasing wear time depending on how they are doing. They should continue wearing it during more vigorous activity. Patients should continue staying active with regular daily walking, but not exceed the “talk test”—they should be able to carry on a conversation while walking, though they might be a little out of breath.[21]
Returning to Normal Activities
Most people are able to return to work within 1 to 2 weeks after surgery. However, if the job requires heavy lifting or strenuous activity, patients may need to take 4 to 6 weeks off from work. Patients may drive when they are no longer taking narcotic pain medicine and can quickly move their foot from the gas pedal to the brake. They must also be able to sit comfortably for a long period of time, even if they don’t plan to go far, in case they get caught in traffic.[3][17]
Patients may shower 24 to 48 hours after surgery if their doctor okays it, patting the cut dry. However, they should not take a bath for the first 2 weeks or until the doctor says it is okay. Swimming, taking a bath, or getting in a hot tub should be avoided for at least 2 to 3 weeks, as submerging in water increases the risk of the incision becoming infected.[16][17][23]
Diet and Bowel Management
Patients can eat their normal diet after surgery, but if their stomach is upset, they should try bland, low-fat foods like plain rice, broiled chicken, toast, and yogurt. It is important to drink plenty of fluids unless the doctor advises otherwise—aiming for 6 to 8 cups of fluid a day. Patients should aim to eat 20 to 35 grams of fiber per day to help prevent constipation.[5][17][23]
It is very common to have either constipation or diarrhea after surgery, and it may take some time for bowels to return to normal. Constipation might put pressure on the hernia repair and delay healing. To help prevent constipation, patients should eat plenty of high-fiber foods such as bran, oats, fruit, vegetables, wholemeal breads, and pasta. Patients may want to take a fiber supplement every day or follow discharge instructions to take stool softeners. If constipation persists and they have not had a bowel movement after a couple of days, they should ask their doctor about taking a mild laxative. Patients should avoid straining on the toilet.[16][17][24]
Pain Management
Patients will be given medicine to help with pain relief during and after surgery. It is important to take pain relief medicine on a regular basis for the first few days, as pain can be controlled better when medicine is taken regularly. After a few days, patients can gradually reduce the medicine until they no longer need it. They should switch to over-the-counter pain relievers like acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) as soon as they can tolerate them, as this helps decrease any nausea or constipation from narcotics. Patients should not drink alcohol while taking narcotic pain medication.[17][23][24]
Wound Care
Patients may have some swelling and bruising around the wound site, which is not unusual and is no cause for concern. Surgeons usually use a special skin glue on top of the wound which does not need an additional dressing. Patients should not pick at the glue, as it will gently flake off after 10 to 14 days. If strips of tape are on the cut, patients should leave the tape on for a week or until it falls off. If staples were used to close the cut, patients will need to visit their doctor in 1 to 2 weeks to have them removed.[16][17][24]
The area should be washed daily with warm, soapy water and patted dry. Patients should not use hydrogen peroxide or alcohol, which can slow healing. They may cover the area with a gauze bandage if it weeps or rubs against clothing, changing the bandage every day.[16][17]
Patients may notice tingling, numbness, and itching of the wound, and a hard lumpy feeling as new scar tissues form. This is normal healing. If surgical scars become sensitive, desensitization can be helpful by gently rubbing the area around the incision with light touch using a finger or cotton ball.[21][24]
Risks and Complications
As with any surgery, hernia repair carries some risks. General risks for anesthesia and surgery include reactions to medicines, breathing problems, bleeding, blood clots, infection, nausea, and vomiting.[3]
Specific risks for hernia surgery include damage to other blood vessels or organs, damage to nerves, damage to the testicles if a blood vessel connected to them is harmed, long-term pain in the cut area, and return of the hernia. There can also be injury to the bladder, blood vessels, intestines, or nerves, difficulty passing urine, continued pain, and swelling of the testes or groin area.[3][6][12]
Hernia Recurrence
Sometimes hernias can return after surgical repair, a situation called hernia recurrence. This can result in an incisional hernia, which occurs due to tissue protruding through the incision after surgery. The repair can break down because of problems with infection, improper healing, or issues with the initial repair during the surgery. If the recurrent hernia is left untreated, it can cause problems like an incarcerated hernia (trapping of the intestines), digestive obstruction, or a strangulated hernia caused by a loss of blood supply.[18]
In a study of 221 people who received laparoscopic surgery for a hiatal hernia, only one required a secondary repair reoperation, showing that most people never experience complications or further need for surgery afterward. Once patients have healed from their surgery, they are able to return to their normal life and activities.[22]
Prevention of Hernia Formation and Recurrence
While surgery is necessary to repair an existing hernia, certain lifestyle changes can help prevent hernias from forming or recurring after repair. Watching weight is important, as being overweight increases pressure on the abdominal wall. If patients have extra pounds to lose, starting a weight loss journey may help prevent hernias or improve post-surgical outcomes.[20]
Quitting smoking is crucial. Patients should try not to smoke for 2 weeks after surgery. Smoking has a profound impact on the body’s ability to heal and increases the risk of hernia recurrence and postoperative infections.[20][24]
Choosing the right exercises is important. Physical activity is essential for staying strong and maintaining a healthy weight. However, patients should consult with their doctor about how they should exercise and tailor their program to their hernia and its location. In most cases, exercises that strengthen the abdominal muscles and reduce fat are beneficial. Patients may need to avoid situps and reverse abdominal crunches, lifting heavy weights, exercises with pushing or pulling, and movements that include kicking or punching.[20]
Anything that increases pressure in the abdomen can cause pain and potentially lead to hernia formation or recurrence. This includes strong coughing and sneezing. Taking steps to avoid a chronic cough or sneezing may entail using allergy medications and cough suppressants. Patients should hold a pillow over their incision when they cough or sneeze to protect from possible tearing.[16][21][23]
Pathophysiology
The pathophysiology of a hernia involves changes to the normal structure and function of the muscle or tissue walls that contain organs. When a weakness or defect exists in the muscle wall, increased pressure within the abdomen can cause organs or tissue to push through this opening. This creates a bulge or protrusion where tissue that should be contained within one compartment pushes into another space where it doesn’t belong.[1][15]
The weakness in the tissue can develop for various reasons. Normal aging causes wear and tear on muscles, making them more susceptible to developing weak spots. Previous surgical incisions create areas of weakness where the muscle and tissue were cut and repaired. In some cases, congenital defects present from birth create openings that allow herniation to occur.[15]
When a hernia becomes stuck in the opening and cannot be pushed back in, it is called an incarcerated hernia. If the blood supply to the herniated tissue becomes cut off, the condition is called a strangulated hernia. This leads to tissue death or necrosis and represents a medical emergency requiring immediate surgery.[2][15]
During hernia repair surgery, the surgeon addresses the pathophysiology by returning the displaced tissue to its proper anatomical position and closing or reinforcing the defect in the muscle wall. The use of surgical mesh provides additional structural support to the weakened area, helping to distribute tension more evenly across the repair site and reduce the risk of recurrence.[1]
