How to know if your hernia needs surgery

It's one of the questions I hear most often in my office: "Doctor, does this hernia really need to be operated on, or can it wait?" The honest answer is: it depends. And it depends on some very specific things, which I'll walk through here based on the most robust evidence we have today — not a generic rule that applies to every hernia.

What a hernia actually is

A hernia happens when an organ or tissue pushes through a weak point in the abdominal wall — in the groin (inguinal), at the belly button (umbilical), above it (epigastric), or through a scar from a previous surgery (incisional). Here's the important detail: the defect doesn't close on its own. Once a hernia exists, only surgery actually fixes it — the question is never "if," it's "when."

When it's fine to wait — "watchful waiting"

For men with a minimally symptomatic inguinal hernia — one that doesn't limit daily activity and reduces easily when pushed — waiting is a genuinely safe option, not something I made up to reassure an anxious patient. A study published in JAMA followed 720 men in this exact situation: half were operated on right away, half were observed. Over two years, the risk of the hernia becoming incarcerated during observation was under 2 per 1,000 patients per year. The international HerniaSurge guidelines, from the European Hernia Society, confirm it: watchful waiting is an acceptable approach when a hernia is minimally symptomatic.

Here's the detail few people mention, though: waiting isn't the same as never needing surgery. In that same study, most of the men who chose to wait ended up having surgery anyway within 7 to 10 years — almost always because the pain gradually increased. A 2021 systematic review of nearly 900 patients found a similar pattern: about a third needed surgery within 3 years, and more than two-thirds within 10. In practice, waiting usually means postponing — not avoiding.

The signs that it's no longer safe to wait

Three signs, in my experience in the office, usually mark that turning point:

• The hernia has started to hurt, even mildly, during everyday activity
• It's visibly growing
• It's become harder — or impossible — to push back in

When any of these show up, the guidelines are unanimous: it's time to schedule surgery. Electively, calmly, without needing to turn into an emergency.

When I don't recommend waiting, full stop

There are important exceptions to the watchful-waiting rule, and I'd rather be direct about them:

• Women. The risk of a femoral hernia — considerably more common in women — is relevant, and femoral hernias strangulate more easily and with less warning. Because of that, for most women with a groin hernia, I already recommend repair as soon as it's diagnosed, even without significant symptoms.
• Femoral hernia, in any patient. Up to 30-40% of them first present as an emergency.
• Umbilical, incisional, and epigastric hernias. Here the scientific evidence is more limited than for inguinal hernia — we don't have the same large randomized studies. Even so, about 65% of adults with an umbilical hernia end up having surgery anyway, and 3-5% require emergency surgery. Obesity significantly raises that risk.

The warning signs — this is an emergency, not an appointment

If you experience sudden, severe pain at the hernia site, it becomes hard and won't push back in, the skin over it changes color, or nausea, vomiting, and an inability to pass gas or have a bowel movement appear — that's the picture of strangulation. It's not time to book a consultation: it's time to go to an emergency room. A strangulated hernia is a surgical emergency, and the numbers leave no doubt why: mortality from emergency hernia surgery can be more than 10 times higher than from an elective operation, especially in older patients or those with other health conditions.

My recommendation, in practice

I don't believe in a one-size-fits-all answer to this question — and I'm usually wary of anyone who offers one. What I do, in the office, is evaluate the type of hernia, the symptoms, your health history, and your routine, so we can decide together whether it's time to operate or whether it's safe to wait — and, if so, what to watch for to know when waiting has stopped being the right choice. If you have a hernia and aren't sure what to do about it, that's exactly the kind of conversation I enjoy having during an evaluation.