Safer Hernia Care for All: How We Can Prevent, Repair and Learn

Hernia is rarely the first condition that comes to mind when we talk about long-term, non-communicable disease, yet it fits the description almost perfectly. It is chronic, it is progressive, it is not going to resolve on its own, and it is common in the developed and developing world.

Around 220 million people worldwide are estimated to be living with an inguinal hernia. Roughly 20 million repairs are carried out each year — less than a tenth of the prevalent burden — and more than a quarter of men will undergo a groin hernia repair at some point in their lives. Behind the numbers are people who cannot or struggle to lift, sleep comfortably, return to physical work, and who quietly adjust their lives around a condition that is treatable without need for access to highly specialist care and arguably with simple equipment.

Untreated hernia is not benign: it accounts for tens of thousands of deaths and several million disability-adjusted life years (DALY) lost every year. For a condition that a well-trained surgeon can fix in under an hour, that is a remarkable amount of avoidable harm.

Patient safety in hernia begins before any hernia exists. Incisional hernia is the one abdominal wall hernia that surgeons create ourselves, and it complicates 10–20% of midline laparotomies in the short term, rising towards 30% or more with longer follow-up and imaging-based surveillance.

We now have good evidence about how to reduce that. Reproducible and simple techniques such as the small bites closure can halve the odds of incisional hernia at one year at the cost of a few extra minutes of operating time. That is one of the better returns on investment available to a general surgeon. It sits alongside the fundamentals: handling tissue gently, avoiding tension and ischaemia, optimising nutrition, glycaemic control and stopping smoking before elective surgery, and taking the closure as seriously as the indication for the surgery rather than delegating it as an end-of-list afterthought.

Where randomised evidence supports it, prophylactic mesh belongs in the same conversation. The European Hernia Society’s 2023 rapid guideline, developed with ESCP and EAES and with patient representatives on the panel, suggests a synthetic non-absorbable mesh when constructing an end colostomy in patients with a reasonable life expectancy, and recommends it for those at high risk of parastomal herniation. The evidence is not uniform, and the long-term data remain contested, which is precisely why the recommendation is graded, discussed with the patient and documented.

New evidence is published every year on various aspects of hernia prevention, and it should be discussed and be given attention more than it currently receives. Prevention should be deliberate and evidence-led, not reflexive in either direction.

Which brings us to the record. Mesh is one of the most frequently implanted devices in surgery, and until very recently it was among the least tracked. Baroness Cumberlege’s First Do No Harm review called for national registries capable of monitoring implantable devices across a patient’s lifetime; hernia mesh should be no different from a hip or a breast implant in that respect. The British Hernia Society Registry, launched at the end of 2024 and now reporting its first annual data, captures operative technique, mesh details and — importantly — patient-reported outcomes. It is voluntary but we can do better. If we want to be able to answer a patient who asks questions about the materials implanted into them, then participation needs to become routine and mandatory rather than exceptional.

The final piece is access. Hernia surgery lacks the drama of cancer or transplant work, and it is often the first thing to be displaced when elective capacity is squeezed — with the predictable consequence that more patients present as emergencies, where mortality is substantially higher. Globally the disparity is starker still: in much of sub-Saharan Africa the hernia repair rate is a fraction of the estimated need, in populations that are young and economically active, so that an untreated hernia removes a wage-earner from a household for years. Scaling up repair in these settings, including through supervised task-sharing, has been shown to be highly cost-effective — in Ghana, around US$120–130 per DALY averted. Few interventions in surgery do so much good so cheaply.

So, the call to action is unfashionably simple. Closure time in abdominal surgery is not “coffee time”. Use sound technique and prophylactic mesh where the evidence supports it. Record every implant. And treat the hernia waiting list not as low-priority work but as one of the most efficient routes we have, to getting people back to work, back to their families and back to health.