A hernia is the protrusion of an organ or tissue through a defect in the wall of the cavity that normally contains it. The commonest are abdominal wall hernias: inguinal (groin — by far the most common, approximately 75% of all abdominal wall hernias); femoral (below the inguinal ligament — more common in women and with the highest strangulation risk); umbilical and paraumbilical; epigastric; incisional (through a previous surgical wound); and spigelian. Hiatus hernia (stomach through the diaphragm) is a distinct entity managed quite differently. Symptoms: a lump that appears on standing, coughing or straining and reduces on lying down; dragging or aching discomfort; and — in complicated hernias — severe pain, irreducibility, vomiting and obstruction.

When is a hernia an emergency?

A hernia becomes an emergency when it strangulates — when the blood supply to the herniated contents is cut off. Warning signs requiring immediate hospital assessment: the lump becomes hard, tender and cannot be pushed back in; the overlying skin becomes red or discoloured; severe and worsening pain; vomiting, abdominal distension, absolute constipation (bowel obstruction); fever or feeling systemically unwell. Strangulated bowel progresses to infarction and perforation within hours, so delay is directly harmful. Do not attempt forceful reduction of a tender irreducible hernia. Femoral hernias have the highest risk (approximately 15-20% strangulate within 3 months of presentation) and should always be repaired promptly rather than observed.

Does every hernia need surgery?

No. Watchful waiting is a validated option for men with asymptomatic or minimally symptomatic INGUINAL hernias — two randomised trials showed the acute strangulation rate is very low (approximately 0.2% per year). However, roughly 70% eventually opt for surgery within 10 years as symptoms progress, and delayed emergency repair carries higher morbidity than elective repair. Surgery IS recommended for: any symptomatic hernia; all femoral hernias (high strangulation risk); hernias in women (a higher proportion are femoral, and occult femoral hernias are often found at operation); any hernia with a history of incarceration; and enlarging hernias. Paediatric umbilical hernias, by contrast, usually close spontaneously by age 4-5 and should be left alone.

For inguinal hernia repair, yes — the evidence base is extensive and mesh is the international standard, reducing recurrence from approximately 10-15% with suture repair to approximately 1-3%. Much of the public anxiety about "mesh" derives from transvaginal mesh used for pelvic organ prolapse and stress incontinence, and from certain composite intraperitoneal ventral meshes — these are different products in different anatomical situations, and their problems should not be generalised to inguinal hernia mesh. That said, honest counselling matters: chronic groin pain occurs in approximately 10-12% of patients after inguinal repair (activity-limiting in 1-3%), and this is more often related to nerve injury or entrapment than to the mesh itself. Mesh infection and erosion are rare. Patients who prefer to avoid mesh can be offered a tissue repair (Shouldice), accepting a higher recurrence rate.

What is a hiatus hernia and is it dangerous?

A hiatus hernia is the protrusion of part of the stomach up through the oesophageal opening in the diaphragm. Type I (sliding) accounts for over 95%: the gastro-oesophageal junction slides above the diaphragm. It is common, often asymptomatic, and its main significance is as a contributor to gastro-oesophageal reflux — treatment targets the reflux (weight loss, PPI), not the hernia itself; surgery is reserved for refractory reflux, when fundoplication is performed alongside hernia repair. Types II-IV (paraoesophageal) are much less common but more dangerous: the fundus (or colon, spleen, pancreas) herniates alongside a normally positioned gastro-oesophageal junction, risking gastric volvulus, incarceration, strangulation, and Cameron lesions (linear gastric erosions causing iron deficiency anaemia). Symptomatic paraoesophageal hernias should be repaired; asymptomatic ones in frail elderly patients are generally observed.

How does GMJ News cover hernias?

GMJ News covers strangulation recognition and emergency management, inguinal anatomy (direct vs indirect, Hesselbach's triangle), tension-free mesh repair and the mesh controversy in accurate context, open vs laparoscopic approaches (HerniaSurge guidance), watchful waiting evidence (Fitzgibbons JAMA 2006), femoral hernia strangulation risk, chronic post-herniorrhaphy inguinal pain, hiatus hernia types I-IV, incisional hernia prevention (STITCH small-bites technique), paediatric vs adult umbilical hernia, and sportsman's groin. Directly relevant to PHIG's surgical safety and essential surgery programme.

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Hernia

GMJ News knowledge hub · last reviewed September 2026 · Georgian Medical Journal

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Hernias — the protrusion of an organ or tissue through a defect in the wall of the cavity that normally contains it — represent one of the largest surgical burdens globally, with inguinal hernia repair among the most commonly performed operations worldwide (over 20 million procedures annually) and a lifetime risk of approximately 27% in men and 3% in women (WHO). The clinical priority is recognising the emergency: an irreducible, tender hernia with overlying erythema, systemic upset or signs of bowel obstruction indicates strangulation — ischaemia of the herniated contents — requiring immediate surgical exploration, since delay leads to bowel infarction, perforation and a mortality that rises steeply with each hour of ischaemia; while asymptomatic or minimally symptomatic inguinal hernias in men may be safely managed with watchful waiting, as multiple randomised trials have shown low rates of acute complication.

Key messages

Strangulation is the emergency — irreducible, tender, systemically unwell

The critical recognition: a hernia that is irreducible AND tender, with overlying erythema, systemic upset, or features of bowel obstruction (vomiting, distension, absolute constipation), indicates STRANGULATION — ischaemia of the herniated contents. This requires immediate surgical exploration. Mortality rises steeply with each hour of delay as ischaemic bowel progresses to infarction and perforation. Do not attempt forceful reduction of a tender, irreducible hernia — reduction en masse can return ischaemic bowel to the abdomen and mask the emergency. Femoral hernias have the highest strangulation risk (approximately 15-20% at 3 months) and should always be repaired promptly.

Inguinal hernia repair — among the most common operations globally

Over 20 million inguinal hernia repairs are performed worldwide each year. Lifetime risk of inguinal hernia: approximately 27% in men, 3% in women. Anatomy determines type: indirect (through the deep inguinal ring, lateral to the inferior epigastric vessels — the commonest, congenital patent processus vaginalis origin, may descend into the scrotum); direct (through Hesselbach's triangle, medial to the inferior epigastric vessels — acquired posterior wall weakness, rarely descends into the scrotum). The distinction matters less clinically than it once did, since modern repair reinforces the whole inguinal floor regardless of type.

Mesh repair is the standard — and the mesh controversy needs context

Tension-free mesh repair (Lichtenstein open, or laparoscopic TEP/TAPP) is the international standard for adult inguinal hernia, reducing recurrence from approximately 10-15% (suture repair) to approximately 1-3%. The mesh controversy in public discourse largely derives from vaginal mesh for pelvic organ prolapse and from certain composite ventral meshes — NOT from standard inguinal hernia mesh, which has an extensive evidence base and low complication rates. Patients should be counselled accurately: chronic postoperative inguinal pain occurs in approximately 10-12% (mild in most, disabling in 1-3%), and is more often related to nerve handling than to mesh itself.

Watchful waiting is legitimate for minimally symptomatic inguinal hernia in men

Two randomised trials (Fitzgibbons, JAMA 2006; O'Dwyer, Ann Surg 2006) showed that watchful waiting for asymptomatic or minimally symptomatic inguinal hernia in men is safe: the rate of acute strangulation is very low (approximately 0.2% per year). However, most patients eventually cross over to surgery due to progressive symptoms (approximately 70% by 10 years). Watchful waiting is therefore a reasonable option for men with minimal symptoms, particularly with significant comorbidity — but NOT for: femoral hernias (high strangulation risk — always repair); symptomatic hernias; women (higher proportion are femoral); or any hernia with a history of incarceration.

Hiatus hernia — a different entity entirely

Hiatus hernia: protrusion of the stomach through the oesophageal hiatus of the diaphragm. Type I (sliding, >95%): gastro-oesophageal junction migrates above the diaphragm — associated with GORD; treat the reflux, not the hernia; repair only for refractory symptoms alongside fundoplication. Types II-IV (paraoesophageal): the GOJ stays in place while the fundus (or other organs) herniate alongside the oesophagus — risk of gastric volvulus, incarceration, strangulation and Cameron lesions (linear gastric erosions causing iron deficiency anaemia). Symptomatic paraoesophageal hernias should be repaired; asymptomatic ones in elderly patients are now generally observed, as elective repair carries meaningful morbidity.

Incisional hernia — a major and under-recognised surgical complication

Incisional hernia occurs after approximately 10-20% of midline laparotomies (higher with wound infection, obesity, emergency surgery, malnutrition, smoking, steroids, connective tissue disorders). Prevention: the "small bites" technique for midline closure (5mm bites, 5mm intervals, suture:wound length ratio ≥4:1, continuous slowly absorbable monofilament) — the STITCH trial (Lancet 2015) reduced incisional hernia from 21% to 13%. Repair is technically demanding, with high recurrence in large or recurrent defects; component separation and complex abdominal wall reconstruction may be required. Optimise before elective repair: smoking cessation, weight loss, glycaemic control.

Key statistics

>20 million

inguinal hernia repairs performed worldwide annually

WHO/HerniaSurge

27% vs 3%

lifetime risk of inguinal hernia in men vs women

HerniaSurge/EHS

1-3%

recurrence after tension-free mesh repair vs 10-15% after suture repair

HerniaSurge

15-20%

strangulation risk for femoral hernia at 3 months — always repair promptly

EHS/HerniaSurge

STITCH 2015

small-bites midline closure cut incisional hernia from 21% to 13% (Lancet)

Lancet 2015

~0.2%/year

acute strangulation rate for minimally symptomatic inguinal hernia under watchful waiting

JAMA 2006

Hernia types — relative strangulation risk and repair urgency

Source: HerniaSurge/EHS. Femoral hernias carry the highest strangulation risk; sliding hiatus hernia rarely needs repair.

Glossary of key terms

Hernia terminology
SurgeryReducible: contents can be returned to the abdominal cavity. Irreducible (incarcerated): contents cannot be reduced, but remain viable — no ischaemia. Obstructed: herniated bowel lumen is occluded, causing bowel obstruction, but blood supply is intact. Strangulated: blood supply to the herniated contents is compromised — ischaemia progressing to infarction, perforation, peritonitis and sepsis. A SURGICAL EMERGENCY. Richter's hernia: only part of the circumference of the bowel wall is herniated and strangulated — dangerous because it can strangulate and perforate WITHOUT causing bowel obstruction, so the classic obstructive signs are absent. Littre's hernia: contains a Meckel's diverticulum. Amyand's hernia: contains the appendix. Sliding hernia: a retroperitoneal organ (colon, bladder) forms part of the sac wall — caution during sac dissection.

Inguinal anatomy — the operative landmarks
Anatomy/SurgeryInguinal canal: extends from the deep (internal) ring to the superficial (external) ring; transmits the spermatic cord (men) or round ligament (women). Deep ring: an opening in the transversalis fascia, LATERAL to the inferior epigastric vessels — indirect hernias emerge here. Hesselbach's triangle: bounded by the inferior epigastric vessels laterally, the rectus sheath medially and the inguinal ligament inferiorly — direct hernias push through the weakened transversalis fascia here, MEDIAL to the inferior epigastric vessels. Femoral canal: below the inguinal ligament, medial to the femoral vein — femoral hernias emerge here (narrow, rigid ring → high strangulation risk). The "triangle of doom" (external iliac vessels) and "triangle of pain" (lateral femoral cutaneous and genitofemoral nerves) are laparoscopic no-tack zones.

Open vs laparoscopic repair
HerniaSurge/EHSLichtenstein open mesh repair: the reference standard — reliable, teachable, performable under local anaesthesia (valuable for high-risk patients and in resource-limited settings), low cost. Laparoscopic (TEP — totally extraperitoneal; TAPP — transabdominal preperitoneal): less acute postoperative pain, faster return to normal activity, lower chronic pain rates, and clearly superior for BILATERAL and RECURRENT (after previous open repair) hernias — because it uses a virgin plane. Requires general anaesthesia and has a longer learning curve. HerniaSurge guidance: laparoscopic repair preferred for bilateral and recurrent-after-open hernias; either approach acceptable for primary unilateral, depending on surgeon expertise and patient factors.

Chronic post-herniorrhaphy inguinal pain (CPIP)
Surgery/PainChronic pain persisting >3 months after inguinal hernia repair occurs in approximately 10-12% of patients, and is moderate-to-severe or activity-limiting in approximately 1-3%. It is now recognised as the most important outcome measure after hernia surgery — more so than recurrence. Mechanisms: neuropathic (injury, entrapment or fibrosis involving the ilioinguinal, iliohypogastric or genital branch of the genitofemoral nerve); nociceptive (mesh-related inflammation, meshoma, periostitis from pubic tubercle sutures); or referred. Prevention: identify and protect (or, in some protocols, deliberately excise) the three inguinal nerves; avoid tacks in the triangle of pain laparoscopically; avoid heavyweight mesh. Management: neuropathic agents (gabapentinoids, TCAs); nerve blocks; and, in selected refractory cases, triple neurectomy with or without mesh removal.

Umbilical and epigastric hernia
SurgeryPaediatric umbilical hernia: extremely common; the great majority close spontaneously by age 4-5; repair is indicated only for very large defects, persistence beyond age 4-5, or complications (incarceration is rare). Do NOT strap or tape. Adult umbilical hernia: does NOT close spontaneously; associated with obesity, ascites, pregnancy and raised intra-abdominal pressure; carries a genuine incarceration risk (the neck is often narrow) and should generally be repaired. Special caution in cirrhosis with ascites: umbilical hernia rupture is a life-threatening complication, but repair in decompensated cirrhosis carries high morbidity — control the ascites (TIPS, medical therapy) and repair electively rather than waiting for emergency presentation. Epigastric hernia: defect in the linea alba above the umbilicus, often containing only preperitoneal fat but frequently painful out of proportion to size.

Sportsman's groin (inguinal disruption)
Sports medicine/SurgeryA common source of diagnostic confusion: chronic activity-related groin pain in athletes, WITHOUT a demonstrable hernia. Terminology has been standardised (Doha agreement) to describe five entities: adductor-related; iliopsoas-related; inguinal-related; pubic-related; and hip-related groin pain. "Inguinal disruption" (sports hernia, Gilmore's groin, athletic pubalgia) involves posterior inguinal wall weakness, conjoint tendon or aponeurotic injury without a true hernia sac. Diagnosis: clinical, supported by MRI (to exclude adductor and pubic bone pathology). Management: structured physiotherapy and load management first-line, with surgery reserved for those failing 3-6 months of appropriate rehabilitation. Operating on athletes without excluding adductor and hip pathology is a recognised cause of persistent symptoms.

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