Inguinal hernia repair is the most common procedure performed by general surgeons, estimated at more than 20 million hernias’ interventions every year around the world (1). Inguinal hernias comprises for up to 97% of groin hernias with the distinct dominance in occurrence in males (90.2% males vs. 9.8% females) (2). Except the male gender, other patient-related risk factors for developing an inguinal hernia include older age, positive family history, systemic connective tissue disorders and coexistence of hiatal hernia (3, 4). Smoking is also a potential risk factor for herniation, although its influence is uncertain. Some studies show that tobacco use changes the collagen metabolism causing the serologic turnover of type IV collagen, which increases the risk for inguinal hernia (5). However, recent research shows the negative link between smoking and development of inguinal hernia, which still remains unexplained (6). The cumulative work exposure causing the increased intraabdominal pressure is involved in lateral hernia formation. Studies show that prolonged standing or walking, frequent heavy lifting and total load of daily lifting activities are external risk factors for lateral hernia creation (7, 8). By definition, the inguinal hernia is a condition when part of an intestine or fat protrudes through the area of weakness in the groin region. The inguinal hernias have three components: the neck (opening in the abdominal wall), the sac, which is formed by the protrusion of the peritoneum, and the contents that include any tissue or organ that shifts through the neck to the hernia sac. The position of hernia sac towards the inferior epigastric vessels determines the division of inguinal hernia into direct (appears medially to the vessels) and indirect (localizes laterally to the epigastric vessels) (9). In some cases, hernial sacs are present on both sides of the inferior epigastric vessels. This condition is known as a pantaloon hernia and is defined as ipsilateral, concurrent direct and indirect hernias. The clinical manifestation of inguinal hernia includes the wide range of sympomts. Most frequently, patients complain of hernia, groin or lower abdomen pain, increased peristalsis, pain during sexual activity and lower urinary tract symptoms. Up to 7% of patients may remain asymptomatic (10-12).

Proper physical examination is essential in the diagnosis process of inguinal hernia. Firstly, the visual inspection of inguinal area should be performed to detect any bulge or asymmetry in groin region. Secondly, the inguinal area should be palpated in standing and supine position in order to reveal the presence of hernia. The examination should be performed in relaxed position and in the situation of increased intraabdominal pressure, thus the patient should be asked to cough or perform the Valsalva maneuver. The radiological investigation is needed when the clinical evaluation has not reveal any findings. Ultrasonography is usually the first choice test as it is widely available, inexpensive and has minimal complications. It has the overall sensitivity of 96.6% and specificity of 84.8% (13). If needed, magnetic resonance imaging or computer tomography may be used to verify the proper diagnosis. The only treatment of inguinal hernia is a surgical treatment that is based on the repair of the posterior wall of inguinal canal. The “watchful waiting” may be applied only to male patients with primary, minimally symptomatic or asymptomatic inguinal hernia (14). The open approaches are based on either pure tissues approximation or tension free mesh repair. The primary methods for tissue repairs include the Bassini, Shouldice, Halstead and McVay procedure. The Lichtenstein method is the most frequently performed open mesh-based technique. Totally extraperitoneal (TEP) repair and transabdominal preperitoneal (TAPP) repair are methods of laparoscopic surgery. In TEP method the mesh is inserted directly into the preperitoneal space, whereas, in the TAPP technique the preperitoneal space is reached through the peritoneal cavity. Recent study shows that sutured repairs are associated with a higher risk of reoperation for recurrence of hernia over 5 years compared with the open mesh and laparoscopic mesh repair. The overall recurrence rate in the non-mesh group was evaluated at 18.3%, in the open mesh group was 13.2% and in the laparoscopic mesh group was 11.2%. Other possible complications after surgical treatment of inguinal hernia include: bowel obstruction, bleeding, infection, late intraabdominal abscess, enterocutaneous fistula, seroma, hematoma, nonhealing wounds and chronic pain (15).

The aim of the study was to present the natural history of inguinal hernia including patients’ age and profession, most frequently reported complaints, comorbidities and surgical approaches for inguinal hernia repair.

We analyzed the medical records of 365 patients who underwent inguinal hernia repair between 2013 and 2017 at the I^st Department of General and Endocrinological Surgery, University Hospital in Bialystok and at the Surgery Department at the Independent Public Health Care Center in Lapy. The procedure has been performed by the same operating team – operator and two assistants. Factors such as, age, profession, coexisting diseases, clinical symptoms and type of inguinal hernia have been analyzed. Different surgical approaches have also been investigated including changes in the methods used within studied period.

The study group included 365 patients age 21-72, average age 59.5. Males accounted for 87% (n = 317) with average age of 56 years, while the percentage of female patients was 13% (n = 48) with the average age of 63 years. According to age by decade, almost half of women was at their 6^th decade of life. In case of men, no peak of incidence has been observed, but almost 77% of male patients were between 31 and 60 years old (fig. 1).