Do Inguinal Hernias Need to Be Repaired?
Not all inguinal hernias require immediate surgical repair—watchful waiting is a reasonable option for asymptomatic or minimally symptomatic hernias in carefully selected patients, while symptomatic hernias and all incarcerated/strangulated hernias mandate surgical intervention. 1, 2, 3
Decision Algorithm for Repair vs. Observation
Immediate Emergency Repair Required
Any hernia with signs of strangulation or incarceration requires emergency surgical intervention within 6 hours to prevent bowel necrosis and mortality. 1, 4, 5
Emergency indicators include:
- Irreducible hernia with systemic symptoms (fever, tachycardia, leukocytosis) 4
- Abdominal wall rigidity or peritoneal signs 4
- Skin changes over the hernia (erythema, warmth, discoloration) 1, 4
- Elevated biomarkers suggesting bowel strangulation (lactate, CPK, D-dimer) 1, 4
- SIRS criteria or contrast-enhanced CT findings indicating bowel ischemia 1, 2
Delayed diagnosis beyond 24 hours dramatically increases mortality, and every hour counts—early intervention (<6 hours from symptom onset) reduces bowel resection risk by 90% (OR 0.1). 1, 4, 5
Elective Repair Recommended
All symptomatic inguinal hernias should undergo elective surgical repair with mesh, as this significantly reduces recurrence rates (0% vs 19% with tissue repair) without increasing infection risk. 4
Symptomatic hernias present with:
- Pain interfering with daily activities 3
- Discomfort during physical activity 1
- Progressive enlargement causing concern 1
Watchful Waiting Acceptable
Watchful waiting is a reasonable option for asymptomatic or minimally symptomatic inguinal hernias, as acute incarceration rates are low and delaying repair until symptoms appear is safe. 3
However, consider earlier repair in high-risk populations:
- Femoral hernias carry an 8-fold higher risk of requiring bowel resection and should be repaired promptly 1, 4
- Women with inguinal hernias should undergo laparoscopic repair to avoid missing femoral hernias and reduce chronic pain risk 4
- Patients with ASA score 3-4 are at significantly higher risk for bowel resection if incarceration occurs 6
- Patients with cirrhosis and uncontrolled ascites should have ascites controlled before elective repair, as uncontrolled ascites increases recurrence and complication rates 2
Conversion Rates from Observation to Surgery
The conversion rate from watchful waiting to elective surgery ranges from 35-58%, indicating that most patients initially observed will eventually require repair. 3
Special Considerations for Older Adults
In older persons (≥65 years), the decision requires careful assessment of surgical risk versus hernia-related complications, as surgery carries increased mortality risk in this population. 7
Factors favoring repair:
- Symptomatic hernias causing functional impairment 7
- Femoral hernias (high strangulation risk) 1, 4
- Good functional status and low frailty 7
Factors favoring observation:
Common Pitfalls to Avoid
- Missing femoral hernias in women—always consider laparoscopic approach for comprehensive evaluation 4
- Overlooking contralateral hernias (present in 11.2-50% of cases)—laparoscopic approach allows bilateral assessment 1, 4
- Attempting manual reduction when contraindicated (peritoneal signs, skin changes, firm irreducible mass)—these require immediate surgery 2, 4
- Delaying surgery in strangulated hernias—time from symptom onset to surgery is the single most important prognostic factor, with symptomatic periods exceeding 8 hours significantly increasing morbidity 4
- Using tissue repair instead of mesh in appropriate candidates—results in unacceptably high recurrence rates (19% vs 0%) 4