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Overview of treatment for inguinal and femoral hernia in adults


The definitive treatment of all hernias, regardless of their origin or type, is surgical repair [1]. Repair of inguinal or femoral hernia may be the most common operation with over 20 million hernia repairs performed per year worldwide [2], and over 700,000 in the United States [3]. Urgent/emergent repair is indicated for patients who develop complications (eg, bowel obstruction, bowel perforation) related to an inguinal or femoral hernia. For uncomplicated hernias, the optimal timing of repair (watchful waiting versus immediate) and the optimal technique for repair (open versus laparoscopic) remain controversial.

An overview of the treatment of inguinal and femoral hernias is presented here. The epidemiology, pathogenesis, clinical manifestations, and diagnosis of inguinal and femoral hernias in adults, hernias in children, and other hernias are discussed elsewhere. (See "Classification, clinical features and diagnosis of inguinal and femoral hernias in adults" and "Overview of inguinal hernia in children".)


Inguinal or femoral hernia repair has minimal short-term morbidity and patients generally have a rapid return to presurgical health. These excellent surgical outcomes, even among elderly individuals (particularly if local anesthesia can be used), have led to recommendations to offer surgical repair to patients with inguinal or femoral hernia who are symptomatic. Historically, recommendations were that the mere presence of a groin hernia was indication for repair due to the perception that complications were common and increased operative morbidity. Two studies conducted at the turn of the century compared watchful waiting to open mesh repair of inguinal hernia. Both studies showed a negligible rate of hernia accidents (acute incarceration with or without strangulation), but there was a measurable progression of symptoms (pain, discomfort) in the watchful waiting group that led to eventual repair. There was no apparent “penalty” for delaying repair until symptoms developed. (See 'Watchful waiting' below.)

Most large randomized trials have included only men; therefore, caution should be used when extrapolating these data and recommendations to women with groin hernias. Femoral hernias may have a higher rate of incarceration, due to anatomy, but we have no data to support repair over watchful waiting in asymptomatic or minimally symptomatic patients

Strangulated/incarcerated hernia — Urgent/emergent hernia repair should be undertaken for patients with symptoms and signs of strangulated hernia (inguinal or femoral), and in those with acutely incarcerated hernia to reduce the risk of subsequent strangulation. In patients with an acutely incarcerated inguinal hernia who do not have signs of strangulation (skin changes, peritonitis), an attempt at reduction is reasonable as long as the patient is accessible for follow-up over the next day or two. Emergency surgery within four to six hours of onset of symptoms may prevent loss of bowel from a strangulated hernia. The clinical manifestations and diagnosis of incarcerated/strangulated inguinal or femoral hernias are discussed elsewhere. (See "Classification, clinical features and diagnosis of inguinal and femoral hernias in adults".)


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Literature review current through: Mar 2014. | This topic last updated: Oct 31, 2013.
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  1. Rosenberg J, Bisgaard T, Kehlet H, et al. Danish Hernia Database recommendations for the management of inguinal and femoral hernia in adults. Dan Med Bull 2011; 58:C4243.
  2. Bay-Nielsen M, Kehlet H, Strand L, et al. Quality assessment of 26,304 herniorrhaphies in Denmark: a prospective nationwide study. Lancet 2001; 358:1124.
  3. Schumpelick V, Treutner KH, Arlt G. Inguinal hernia repair in adults. Lancet 1994; 344:375.
  4. Gallegos NC, Dawson J, Jarvis M, Hobsley M. Risk of strangulation in groin hernias. Br J Surg 1991; 78:1171.
  5. Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA 2006; 295:285.
  6. O'Dwyer PJ, Norrie J, Alani A, et al. Observation or operation for patients with an asymptomatic inguinal hernia: a randomized clinical trial. Ann Surg 2006; 244:167.
  7. Abi-Haidar Y, Sanchez V, Itani KM. Risk factors and outcomes of acute versus elective groin hernia surgery. J Am Coll Surg 2011; 213:363.
  8. Dahlstrand U, Wollert S, Nordin P, et al. Emergency femoral hernia repair: a study based on a national register. Ann Surg 2009; 249:672.
  9. Ochsenbein-Kölble N, Demartines N, Ochsenbein-Imhof N, Zimmermann R. Cesarean section and simultaneous hernia repair. Arch Surg 2004; 139:893.
  10. Mayer IE, Hussain H. Abdominal pain during pregnancy. Gastroenterol Clin North Am 1998; 27:1.
  11. Buch KE, Tabrizian P, Divino CM. Management of hernias in pregnancy. J Am Coll Surg 2008; 207:539.
  12. Gabriele R, Conte M, Izzo L, Basso L. Cesarean section and hernia repair: simultaneous approach. J Obstet Gynaecol Res 2010; 36:944.
  13. Fitzgibbons RJ Jr, Ramanan B, Arya S, et al. Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg 2013; 258:508.
  14. Hernández-Irizarry R, Zendejas B, Ramirez T, et al. Trends in emergent inguinal hernia surgery in Olmsted County, MN: a population-based study. Hernia 2012; 16:397.
  15. McIntosh A, Hutchinson A, Roberts A, Withers H. Evidence-based management of groin hernia in primary care--a systematic review. Fam Pract 2000; 17:442.
  16. Cheek CM, Williams MH, Farndon JR. Trusses in the management of hernia today. Br J Surg 1995; 82:1611.
  17. Burns E, Whitley A. Trusses. BMJ 1990; 301:1319.
  18. Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2009; 13:343.
  19. Bittner R, Arregui ME, Bisgaard T, et al. Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)]. Surg Endosc 2011; 25:2773.
  20. Carter J, Duh QY. Laparoscopic repair of inguinal hernias. World J Surg 2011; 35:1519.
  21. Rattner DW. Physicians' choice for their own hernia repairs. J Laparoendosc Adv Surg Tech A 2000; 10:75.
  22. Winslow ER, Quasebarth M, Brunt LM. Perioperative outcomes and complications of open vs laparoscopic extraperitoneal inguinal hernia repair in a mature surgical practice. Surg Endosc 2004; 18:221.
  23. Callesen T, Bech K, Kehlet H. Prospective study of chronic pain after groin hernia repair. Br J Surg 1999; 86:1528.
  24. Macrae WA. Chronic pain after surgery. Br J Anaesth 2001; 87:88.
  25. Perkins FM, Kehlet H. Chronic pain as an outcome of surgery. A review of predictive factors. Anesthesiology 2000; 93:1123.
  26. Bay-Nielsen M, Perkins FM, Kehlet H, Danish Hernia Database. Pain and functional impairment 1 year after inguinal herniorrhaphy: a nationwide questionnaire study. Ann Surg 2001; 233:1.
  27. Poobalan AS, Bruce J, Smith WC, et al. A review of chronic pain after inguinal herniorrhaphy. Clin J Pain 2003; 19:48.
  28. Condon RE. Groin pain after hernia repair. Ann Surg 2001; 233:8.
  29. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet 2006; 367:1618.
  30. Kalliomäki ML, Meyerson J, Gunnarsson U, et al. Long-term pain after inguinal hernia repair in a population-based cohort; risk factors and interference with daily activities. Eur J Pain 2008; 12:214.
  31. Poobalan AS, Bruce J, King PM, et al. Chronic pain and quality of life following open inguinal hernia repair. Br J Surg 2001; 88:1122.
  32. Fränneby U, Sandblom G, Nordin P, et al. Risk factors for long-term pain after hernia surgery. Ann Surg 2006; 244:212.
  33. O'Dwyer PJ, Kingsnorth AN, Molloy RG, et al. Randomized clinical trial assessing impact of a lightweight or heavyweight mesh on chronic pain after inguinal hernia repair. Br J Surg 2005; 92:166.
  34. Schopf S, von Ahnen T, von Ahnen M, Schardey H. Chronic pain after laparoscopic transabdominal preperitoneal hernia repair: a randomized comparison of light and extralight titanized polypropylene mesh. World J Surg 2011; 35:302.
  35. Chowbey PK, Garg N, Sharma A, et al. Prospective randomized clinical trial comparing lightweight mesh and heavyweight polypropylene mesh in endoscopic totally extraperitoneal groin hernia repair. Surg Endosc 2010; 24:3073.
  36. Sajid MS, Leaver C, Baig MK, Sains P. Systematic review and meta-analysis of the use of lightweight versus heavyweight mesh in open inguinal hernia repair. Br J Surg 2012; 99:29.
  37. Markar SR, Karthikesalingam A, Alam F, et al. Partially or completely absorbable versus nonabsorbable mesh repair for inguinal hernia: a systematic review and meta-analysis. Surg Laparosc Endosc Percutan Tech 2010; 20:213.
  38. Teng YJ, Pan SM, Liu YL, et al. A meta-analysis of randomized controlled trials of fixation versus nonfixation of mesh in laparoscopic total extraperitoneal inguinal hernia repair. Surg Endosc 2011; 25:2849.
  39. Tam KW, Liang HH, Chai CY. Outcomes of staple fixation of mesh versus nonfixation in laparoscopic total extraperitoneal inguinal repair: a meta-analysis of randomized controlled trials. World J Surg 2010; 34:3065.
  40. Alfieri S, Amid PK, Campanelli G, et al. International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery. Hernia 2011; 15:239.
  41. EU Hernia Trialists Collaboration. Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials. Ann Surg 2002; 235:322.
  42. Nordin P, Zetterström H, Gunnarsson U, Nilsson E. Local, regional, or general anaesthesia in groin hernia repair: multicentre randomised trial. Lancet 2003; 362:853.
  43. Young DV. Comparison of local, spinal, and general anesthesia for inguinal herniorrhaphy. Am J Surg 1987; 153:560.
  44. van Veen RN, Mahabier C, Dawson I, et al. Spinal or local anesthesia in lichtenstein hernia repair: a randomized controlled trial. Ann Surg 2008; 247:428.
  45. Sanabria A, Domínguez LC, Valdivieso E, Gómez G. Prophylactic antibiotics for mesh inguinal hernioplasty: a meta-analysis. Ann Surg 2007; 245:392.
  46. Li JF, Lai DD, Zhang XD, et al. Meta-analysis of the effectiveness of prophylactic antibiotics in the prevention of postoperative complications after tension-free hernioplasty. Can J Surg 2012; 55:27.
  47. Aufenacker TJ, Koelemay MJ, Gouma DJ, Simons MP. Systematic review and meta-analysis of the effectiveness of antibiotic prophylaxis in prevention of wound infection after mesh repair of abdominal wall hernia. Br J Surg 2006; 93:5.
  48. Moon V, Chaudry GA, Choy C, Ferzli GS. Mesh infection in the era of laparoscopy. J Laparoendosc Adv Surg Tech A 2004; 14:349.
  49. Yin Y, Song T, Liao B, et al. Antibiotic prophylaxis in patients undergoing open mesh repair of inguinal hernia: a meta-analysis. Am Surg 2012; 78:359.
  50. Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL. Antibiotic prophylaxis for hernia repair. Cochrane Database Syst Rev 2012; 2:CD003769.
  51. Fry DE. Surgical site infections and the surgical care improvement project (SCIP): evolution of national quality measures. Surg Infect (Larchmt) 2008; 9:579.
  52. Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup, et al. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004; 38:1706.
  53. Sanchez VM, Abi-Haidar YE, Itani KM. Mesh infection in ventral incisional hernia repair: incidence, contributing factors, and treatment. Surg Infect (Larchmt) 2011; 12:205.
  54. . SSAT patient care guidelines. Surgical repair of groin hernias. J Gastrointest Surg 2007; 11:1228.
  55. Scott NW, McCormack K, Graham P, et al. Open mesh versus non-mesh for repair of femoral and inguinal hernia. Cochrane Database Syst Rev 2002; :CD002197.
  56. Zhao G, Gao P, Ma B, et al. Open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials. Ann Surg 2009; 250:35.
  57. Amato B, Moja L, Panico S, et al. Shouldice technique versus other open techniques for inguinal hernia repair. Cochrane Database Syst Rev 2009; :CD001543.
  58. Glassow F. The Shouldice Hospital technique. Int Surg 1986; 71:148.
  59. Rutkow IM, Robbins AW. "Tension-free" inguinal herniorrhaphy: a preliminary report on the "mesh plug" technique. Surgery 1993; 114:3.
  60. Kugel RD. Minimally invasive, nonlaparoscopic, preperitoneal, and sutureless, inguinal herniorrhaphy. Am J Surg 1999; 178:298.
  61. EU Hernia Trialists Collaboration. Mesh compared with non-mesh methods of open groin hernia repair: systematic review of randomized controlled trials. Br J Surg 2000; 87:854.
  62. Eklund AS, Montgomery AK, Rasmussen IC, et al. Low recurrence rate after laparoscopic (TEP) and open (Lichtenstein) inguinal hernia repair: a randomized, multicenter trial with 5-year follow-up. Ann Surg 2009; 249:33.
  63. Matthews RD, Anthony T, Kim LT, et al. Factors associated with postoperative complications and hernia recurrence for patients undergoing inguinal hernia repair: a report from the VA Cooperative Hernia Study Group. Am J Surg 2007; 194:611.
  64. Abrahamson J. Etiology and pathophysiology of primary and recurrent groin hernia formation. Surg Clin North Am 1998; 78:953.
  65. Magnusson N, Nordin P, Hedberg M, et al. The time profile of groin hernia recurrences. Hernia 2010; 14:341.
  66. McKernan JB, Laws HL. Laparoscopic repair of inguinal hernias using a totally extraperitoneal prosthetic approach. Surg Endosc 1993; 7:26.
  67. Ferzli G, Sayad P, Huie F, et al. Endoscopic extraperitoneal herniorrhaphy. A 5-year experience. Surg Endosc 1998; 12:1311.
  68. Wake BL, McCormack K, Fraser C, et al. Transabdominal pre-peritoneal (TAPP) vs totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair. Cochrane Database Syst Rev 2005; :CD004703.
  69. Vader VL, Vogt DM, Zucker KA, et al. Adhesion formation in laparoscopic inguinal hernia repair. Surg Endosc 1997; 11:825.
  70. Brooks DC. Laparoscopic herniorrhaphy: where are we now? Surg Endosc 1999; 13:321.
  71. Wright D, Paterson C, Scott N, et al. Five-year follow-up of patients undergoing laparoscopic or open groin hernia repair: a randomized controlled trial. Ann Surg 2002; 235:333.
  72. Memon MA, Cooper NJ, Memon B, et al. Meta-analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair. Br J Surg 2003; 90:1479.
  73. Karthikesalingam A, Markar SR, Holt PJ, Praseedom RK. Meta-analysis of randomized controlled trials comparing laparoscopic with open mesh repair of recurrent inguinal hernia. Br J Surg 2010; 97:4.
  74. Dedemadi G, Sgourakis G, Radtke A, et al. Laparoscopic versus open mesh repair for recurrent inguinal hernia: a meta-analysis of outcomes. Am J Surg 2010; 200:291.
  75. Bittner R, Sauerland S, Schmedt CG. Comparison of endoscopic techniques vs Shouldice and other open nonmesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials. Surg Endosc 2005; 19:605.
  76. Schmedt CG, Sauerland S, Bittner R. Comparison of endoscopic procedures vs Lichtenstein and other open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials. Surg Endosc 2005; 19:188.
  77. Voyles CR, Hamilton BJ, Johnson WD, Kano N. Meta-analysis of laparoscopic inguinal hernia trials favors open hernia repair with preperitoneal mesh prosthesis. Am J Surg 2002; 184:6.
  78. Grant AM, EU Hernia Trialists Collaboration. Laparoscopic versus open groin hernia repair: meta-analysis of randomised trials based on individual patient data. Hernia 2002; 6:2.
  79. EU Hernia Trialists Collaboration. Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized controlled trials. Br J Surg 2000; 87:860.
  80. McCormack K, Scott NW, Go PM, et al. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev 2003; :CD001785.
  81. Hernandez-Rosa J, Lo CC, Choi JJ, et al. Laparoscopic versus open inguinal hernia repair in octogenarians. Hernia 2011; 15:655.
  82. Sajid MS, Bokhari SA, Mallick AS, et al. Laparoscopic versus open repair of incisional/ventral hernia: a meta-analysis. Am J Surg 2009; 197:64.
  83. Laparoscopic versus open repair of groin hernia: a randomised comparison. The MRC Laparoscopic Groin Hernia Trial Group. Lancet 1999; 354:185.
  84. Wellwood J, Sculpher MJ, Stoker D, et al. Randomised controlled trial of laparoscopic versus open mesh repair for inguinal hernia: outcome and cost. BMJ 1998; 317:103.
  85. Hamza Y, Gabr E, Hammadi H, Khalil R. Four-arm randomized trial comparing laparoscopic and open hernia repairs. Int J Surg 2010; 8:25.
  86. Neumayer L, Giobbie-Hurder A, Jonasson O, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 2004; 350:1819.
  87. Liem MS, van der Graaf Y, van Steensel CJ, et al. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair. N Engl J Med 1997; 336:1541.
  88. Jacobs DO. Mesh repair of inguinal hernias--redux. N Engl J Med 2004; 350:1895.
  89. Wauschkuhn CA, Schwarz J, Bittner R. Laparoscopic transperitoneal inguinal hernia repair (TAPP) after radical prostatectomy: is it safe? Results of prospectively collected data of more than 200 cases. Surg Endosc 2009; 23:973.
  90. Dulucq JL, Wintringer P, Mahajna A. Totally extraperitoneal (TEP) hernia repair after radical prostatectomy or previous lower abdominal surgery: is it safe? A prospective study. Surg Endosc 2006; 20:473.
  91. Deeba S, Purkayastha S, Paraskevas P, et al. Laparoscopic approach to incarcerated and strangulated inguinal hernias. JSLS 2009; 13:327.
  92. Kald A, Anderberg B, Carlsson P, et al. Surgical outcome and cost-minimisation-analyses of laparoscopic and open hernia repair: a randomised prospective trial with one year follow up. Eur J Surg 1997; 163:505.
  93. Sarli L, Iusco DR, Sansebastiano G, Costi R. Simultaneous repair of bilateral inguinal hernias: a prospective, randomized study of open, tension-free versus laparoscopic approach. Surg Laparosc Endosc Percutan Tech 2001; 11:262.
  94. Krähenbühl L, Schäfer M, Schilling M, et al. Simultaneous repair of bilateral groin hernias: open or laparoscopic approach? Surg Laparosc Endosc 1998; 8:313.
  95. Mahon D, Decadt B, Rhodes M. Prospective randomized trial of laparoscopic (transabdominal preperitoneal) vs open (mesh) repair for bilateral and recurrent inguinal hernia. Surg Endosc 2003; 17:1386.
  96. National Institute for Health and Clinical Excellence (NICE). Laparoscopic surgery for inguinal hernia repair. NICE; 2004. Available online at (Accessed on April 22, 2010).
  97. Ohana G, Powsner E, Melki Y, et al. Simultaneous repair of bilateral inguinal hernias: a prospective, randomized study of single versus double mesh laparoscopic totally extraperitoneal repair. Surg Laparosc Endosc Percutan Tech 2006; 16:12.
  98. O'Rourke A, Zell JA, Varkey-Zell TT, et al. Laparoscopic diagnosis and repair of asymptomatic bilateral inguinal hernias. Am J Surg 2002; 183:15.
  99. Amid PK, Shulman AG, Lichtenstein IL. Simultaneous repair of bilateral inguinal hernias under local anesthesia. Ann Surg 1996; 223:249.
  100. Dedemadi G, Sgourakis G, Karaliotas C, et al. Comparison of laparoscopic and open tension-free repair of recurrent inguinal hernias: a prospective randomized study. Surg Endosc 2006; 20:1099.
  101. Eklund A, Rudberg C, Leijonmarck CE, et al. Recurrent inguinal hernia: randomized multicenter trial comparing laparoscopic and Lichtenstein repair. Surg Endosc 2007; 21:634.
  102. Kouhia ST, Huttunen R, Silvasti SO, et al. Lichtenstein hernioplasty versus totally extraperitoneal laparoscopic hernioplasty in treatment of recurrent inguinal hernia--a prospective randomized trial. Ann Surg 2009; 249:384.
  103. Bisgaard T, Bay-Nielsen M, Kehlet H. Re-recurrence after operation for recurrent inguinal hernia. A nationwide 8-year follow-up study on the role of type of repair. Ann Surg 2008; 247:707.
  104. Grant AM, Scott NW, O'Dwyer PJ, MRC Laparoscopic Groin Hernia Trial Group. Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia. Br J Surg 2004; 91:1570.
  105. Heikkinen T, Bringman S, Ohtonen P, et al. Five-year outcome of laparoscopic and Lichtenstein hernioplasties. Surg Endosc 2004; 18:518.
  106. Kumar S, Wilson RG, Nixon SJ, Macintyre IM. Chronic pain after laparoscopic and open mesh repair of groin hernia. Br J Surg 2002; 89:1476.
  107. Myers E, Browne KM, Kavanagh DO, Hurley M. Laparoscopic (TEP) versus Lichtenstein inguinal hernia repair: a comparison of quality-of-life outcomes. World J Surg 2010; 34:3059.
  108. Hindmarsh AC, Cheong E, Lewis MP, Rhodes M. Attendance at a pain clinic with severe chronic pain after open and laparoscopic inguinal hernia repairs. Br J Surg 2003; 90:1152.
  109. Beldi G, Haupt N, Ipaktchi R, et al. Postoperative hypoesthesia and pain: qualitative assessment after open and laparoscopic inguinal hernia repair. Surg Endosc 2008; 22:129.
  110. O'Reilly EA, Burke JP, O'Connell PR. A meta-analysis of surgical morbidity and recurrence after laparoscopic and open repair of primary unilateral inguinal hernia. Ann Surg 2012; 255:846.
  111. Medical Research Council Laparoscopic Groin Hernia Trial Group.. Cost-utility analysis of open versus laparoscopic groin hernia repair: results from a multicentre randomized clinical trial. Br J Surg 2001; 88:653.
  112. Payne JH Jr, Grininger LM, Izawa MT, et al. Laparoscopic or open inguinal herniorrhaphy? A randomized prospective trial. Arch Surg 1994; 129:973.
  113. Hynes DM, Stroupe KT, Luo P, et al. Cost effectiveness of laparoscopic versus open mesh hernia operation: results of a Department of Veterans Affairs randomized clinical trial. J Am Coll Surg 2006; 203:447.
  114. Anadol ZA, Ersoy E, Taneri F, Tekin E. Outcome and cost comparison of laparoscopic transabdominal preperitoneal hernia repair versus Open Lichtenstein technique. J Laparoendosc Adv Surg Tech A 2004; 14:159.
  115. Stylopoulos N, Gazelle GS, Rattner DW. A cost--utility analysis of treatment options for inguinal hernia in 1,513,008 adult patients. Surg Endosc 2003; 17:180.
  116. Koch A, Edwards A, Haapaniemi S, et al. Prospective evaluation of 6895 groin hernia repairs in women. Br J Surg 2005; 92:1553.
  117. Nilsson E, Kald A, Anderberg B, et al. Hernia surgery in a defined population: a prospective three year audit. Eur J Surg 1997; 163:823.
  118. Bay-Nielsen M, Kehlet H. Inguinal herniorrhaphy in women. Hernia 2006; 10:30.
  119. Arenal JJ, Rodríguez-Vielba P, Gallo E, Tinoco C. Hernias of the abdominal wall in patients over the age of 70 years. Eur J Surg 2002; 168:460.
  120. Nilsson H, Stylianidis G, Haapamäki M, et al. Mortality after groin hernia surgery. Ann Surg 2007; 245:656.