When Is Hernia Surgery Necessary?

Why hernias do not go away on their own

A hernia is a hole or weakness in the muscle or connective tissue of your abdominal wall. Unlike a cut in the skin, which can heal and close, this type of defect cannot repair itself. Without surgery, the hole stays — and in most cases it slowly gets bigger over the years as the tissue around it is gradually stretched by the pressure of ordinary daily life.

This means that a hernia diagnosed today will, for most people, eventually need surgery. The real question is not whether it needs repair, but when — and that depends on the type of hernia you have, how big it is, the symptoms it is causing you, and how the risks of surgery compare to the risks of leaving it alone.

How surgeons think through the decision

When you see a surgeon about a hernia, the consultation follows a logical series of questions to work out the right recommendation for you:

Which hernias always need surgery?

Femoral hernias

Femoral hernias — which appear as lumps in the upper inner thigh, just below the crease of the groin — are far more common in women than men. The reason they are treated urgently is the anatomy: the femoral canal, the narrow passage the hernia squeezes through, is rigid and tight, which means tissue can get trapped and cut off from its blood supply with very little warning. For this reason, surgeons recommend prompt repair in all patients who are fit for an operation — even if the hernia is small and not causing any symptoms yet.

Hernias that are stuck or strangulated

Any hernia that cannot be gently pushed back in needs urgent surgical assessment. If the blood supply to the trapped tissue has been cut off — strangulation — this is a genuine surgical emergency that needs an operation within hours. If you have a hernia that has suddenly become painful, hard, and will not reduce, go to the emergency department immediately.

Any hernia that is causing symptoms

If your hernia is causing significant pain, discomfort, dragging, or limiting what you can do in your daily life, it should be repaired when you are medically fit for surgery. There is no benefit to watching and waiting once a hernia is affecting your quality of life — and delay gives the hernia time to grow, making the eventual operation more complex.

Inguinal hernias — a more nuanced situation

Inguinal hernias — groin hernias — are the most common type, and they have been studied in randomised trials comparing watchful waiting with early surgery. For inguinal hernias in men that have no or minimal symptoms, the evidence shows watchful waiting is safe in the short to medium term — the annual risk of strangulation is quite low, at around 0.3% per year. That said, most men who start off watching and waiting do eventually develop symptoms and choose surgery within a few years anyway.

What this means practically: if you are an older man with a truly asymptomatic small inguinal hernia, and your anaesthetic risk is significant, watching and waiting with regular review is a reasonable choice. If you are younger and fit, most surgeons will recommend planned repair sooner, because waiting gives the hernia time to grow and makes the surgery more involved.

Inguinal hernias in women are handled differently. Women have a higher rate of femoral hernias, which can be mistaken for inguinal hernias on examination — and femoral hernias carry much higher risk. For this reason, the threshold for surgery in women is lower, and a keyhole approach is usually recommended so the surgeon can inspect and repair both spaces at the same time.

Umbilical and ventral hernias

Umbilical hernias in adults do not heal on their own. The general approach is:

• Small umbilical hernias (less than 1 cm) that are causing no symptoms in elderly or medically unfit patients — watching and waiting is a reasonable option to discuss with your surgeon
• Umbilical hernias causing symptoms — repair is recommended when you are fit for surgery
• Umbilical hernias larger than 1–2 cm — repair is generally recommended, because as the hernia grows, bowel is more likely to get through the gap and become trapped
• Epigastric hernias (in the upper middle abdomen) — usually repaired when they are causing pain, since they very rarely shrink or go away on their own

Incisional hernias

An incisional hernia — one that develops at the site of a previous surgical scar — is generally recommended for repair in anyone who is reasonably fit for surgery. There are three reasons for acting earlier rather than later: incisional hernias tend to grow progressively over time; larger incisional hernias are much more complex and risky to repair; and a small hernia repaired now is a far simpler, safer operation than a large one repaired years down the track. Before elective repair, your surgeon may ask you to lose weight, stop smoking, and make sure your blood sugar is well controlled — all of which meaningfully reduce your risk.

When watchful waiting is appropriate

Watching and waiting may be the right approach for you if:

• Your hernia is small, not causing symptoms, and easily pushed back in
• You have significant heart, lung, or other health conditions that substantially increase the risk of a general anaesthetic
• You are elderly and the risks of surgery genuinely outweigh the risks of the hernia itself
• You are preparing for surgery — for example, you are working on losing weight or quitting smoking before your planned repair

Watchful waiting is not the same as ignoring your hernia. It requires regular check-ups with your surgeon. If you notice any new symptoms — more pain than usual, difficulty pushing the hernia back in, or nausea and vomiting — you need to be assessed urgently.

Getting ready for planned hernia surgery

If you are not quite ready for surgery — perhaps because of your weight, smoking, or a medical condition that needs to be brought under better control — the weeks or months before your operation can be used really well:

• Losing weight makes the operation itself simpler and significantly reduces the risk of complications and the hernia coming back. Even a 10% reduction in body weight makes a real difference for larger or incisional hernias.
• Quitting smoking helps your wound heal more reliably and reduces the risk of complications with the anaesthetic. Ideally, aim to stop at least six weeks before your planned operation.
• Getting your blood sugar under control — poorly managed diabetes substantially raises the risk of wound complications after surgery.
• Treating a persistent cough — a chronic cough from asthma, reflux, or a chest condition increases the pressure inside your abdomen with every cough, which puts extra strain on the repair and increases the chance of the hernia returning.

What happens if you delay repair for too long?

It is tempting to hope that if a hernia is not causing much trouble, it will stay that way indefinitely. Unfortunately, the evidence does not support that hope. Over time:

• Hernias tend to grow — both the gap in the abdominal wall and the amount of tissue that has pushed through it tend to get larger
• Larger hernias are harder to repair and carry a higher chance of complications and of the hernia coming back after surgery
• In severe cases, "loss of domain" can develop — where so much bowel has permanently moved into the hernia that it no longer fits back in the abdominal cavity comfortably. This makes repair dramatically more difficult and risky.
• Emergency repair after strangulation carries a much higher risk of serious complications and death compared to a planned operation

For most people, a planned repair done at the right time — on your terms, when you are prepared — is substantially safer than an emergency operation performed in the middle of a crisis.

Frequently asked questions