Inguinal hernia !

An inguinal hernia is a bulge in the groin where fat or bowel pushes through a weak spot in the lower abdominal wall, above the inguinal ligament.

Updated 2026-10-29

Structures involved

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In embryology

In the clinical exam

What it is

Protrusion of abdominal contents, such as fat or bowel, through the inguinal canal or its posterior wall above the inguinal ligament, felt as a groin bulge.

Who gets it

The most common abdominal wall hernia. It occurs in both sexes but is much more common in men; indirect hernias are the commonest type in men, women and children. Groin hernia repair is among the most frequent general surgery operations worldwide.

Causes

Indirect: a patent processus vaginalis lets contents pass through the deep inguinal ring, along the canal
Direct: acquired weakness of the transversalis fascia in the posterior wall (Hesselbach triangle)
Raised intra-abdominal pressure acting on a weak area

Risk factors

Male sex and older age
Family history
Prematurity and low birth weight (indirect hernia in infants)
Chronic cough, constipation, straining to pass urine (prostatic enlargement)
Heavy lifting, previous hernia on the other side
Connective tissue disorders, smoking, previous lower abdominal surgery

Pathophysiology

An indirect hernia enters the deep ring, a gap in the transversalis fascia lateral to the inferior epigastric vessels, and follows the spermatic cord (or round ligament), sometimes into the scrotum or labium. A direct hernia bulges through the Hesselbach triangle, medial to the vessels. A narrow neck can trap contents (incarceration) and cut off their blood supply (strangulation).

Classification

Indirect (lateral to the inferior epigastric vessels, through the deep ring)
Direct (medial to the vessels, through Hesselbach triangle)
Pantaloon (combined direct and indirect)
Reducible, incarcerated (irreducible) or strangulated
Femoral hernia is a separate groin hernia, below the inguinal ligament
Formal systems exist (e.g., European Hernia Society, Nyhus)

Symptoms and signs

Groin bulge that grows when standing, coughing or straining and goes back when lying down
Dragging discomfort or aching in the groin, worse at the end of the day
Swelling extending into the scrotum (indirect hernia in men)
May be painless and found on examination

Diagnosis

Clinical: Examination standing and lying, with a cough impulse; position relative to the pubic tubercle (inguinal: above and medial; femoral: below and lateral). Distinguishing direct from indirect by examination is unreliable and is usually confirmed at surgery.
Tests: Not needed for an uncomplicated hernia. In suspected strangulation: blood count, lactate, electrolytes and kidney function.
Imaging: Usually none. Ultrasound for an unclear or occult hernia; MRI or CT if still in doubt. CT in suspected obstruction or strangulation.

Differential diagnosis

Femoral hernia
Hydrocele, spermatocele or varicocele
Inguinal lymphadenopathy
Lipoma of the cord or groin
Undescended or retractile testis
Femoral artery aneurysm, saphena varix or psoas abscess

Goal of treatment

Relieve symptoms and prevent incarceration and strangulation with a durable, low-recurrence repair, while limiting chronic postoperative pain.

Treatment

Follow-up: Watchful waiting is a reasonable option for men with minimal or no symptoms, with advice about warning signs; many later need surgery.
Surgical: Open mesh repair (e.g., Lichtenstein tension-free technique) reinforces the posterior wall; it can be done under local, regional or general anaesthesia.
Surgical: Laparoscopic preperitoneal mesh repair (TAPP or TEP), useful for bilateral or recurrent hernias and in women, because it also covers the femoral canal.
Acute: An incarcerated, painful hernia needs emergency assessment; gentle reduction may be tried only when strangulation is not suspected, followed by early repair.
Surgical: Emergency surgery for strangulation, with bowel resection if non-viable. In children, herniotomy (ligation of the sac) without mesh.

Complications

Incarceration and strangulation with bowel obstruction or necrosis
Chronic postoperative groin pain from the ilioinguinal, iliohypogastric or genital branch of the genitofemoral nerve
Recurrence
Seroma, haematoma, wound or mesh infection
Ischaemic orchitis or testicular atrophy, vas deferens injury
Urinary retention after surgery

Prognosis

Elective repair has good results and a low recurrence rate. Emergency repair of a strangulated hernia carries clearly higher morbidity and mortality, especially in older patients.

Prevention

Treating chronic cough, constipation and urinary obstruction
Timely repair of symptomatic hernias and of femoral hernias

Test yourself

Think of the answer, then tap the question to see it.

Which landmark separates an indirect from a direct inguinal hernia?

The inferior epigastric vessels: indirect hernias are lateral (through the deep ring), direct hernias are medial (through Hesselbach triangle).

What are the boundaries of the Hesselbach triangle?

Inferior epigastric vessels laterally, the lateral border of the rectus abdominis medially and the inguinal ligament inferiorly.

Which is the most common type of groin hernia in women?

The indirect inguinal hernia; femoral hernias are more common in women than in men but are still less frequent than inguinal hernias.

Why is a femoral hernia repaired promptly?

Its narrow, rigid neck gives it a high risk of incarceration and strangulation.

Which nerves are at risk of injury causing chronic pain after inguinal hernia repair?

The ilioinguinal, iliohypogastric and the genital branch of the genitofemoral nerve.

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Educational information, not medical advice. For any symptom, see a health professional.

Sources: Open Inguinal Hernia Repair (StatPearls (NCBI Bookshelf), 2026).

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Representative model, for educational purposes only.

Inguinal canal highlighted on the Durgical 3D model