Inguinal hernias are extra-abdominal hernias that occur in the inguinal region and include hiatal, ventral, femoral and, more rarely, perivascular femoral hernias. Inguinal hernia is also the most common type of various extra-abdominal hernias, with a prevalence of 1% to 5% in people over 60 years of age. Theoretically, there are more than 3 million adult inguinal hernia cases in China each year, and a conservative estimate is that no less than 1 million patients need to be treated. However, the actual number of patients seen is far less than this number. I. Current situation of inguinal hernia in China As we know, the situation in which human tissues or organs enter the adjacent parts from their normal anatomical parts through some weak areas such as normal or abnormal orifices or defects formed congenitally or acquired is collectively called hernia. In the case of inguinal hernias, the presence of an abdominal wall defect in the inguinal region and a hernia sac structure protruding to the body surface makes it obvious that non-surgical treatment will almost always fail to cure the condition. Although inguinal hernias often significantly affect work and life and reduce the quality of life, most of them do not cause serious symptoms and life threatening conditions until they become incarcerated, so a large number of patients do not opt for surgical treatment in the early stages and use some non-surgical treatment instead. So, let’s learn about the types of non-surgical and surgical treatments for inguinal hernia and the applicable population. 1. Non-surgical treatment for inguinal hernia includes strapping method, hernia belt, Chinese medicine treatment, and local injection treatment. The strapping method is only suitable for infants under 1 week of age. The hernia may disappear on its own as the inguinal tissues of the infant grow stronger. Therefore, inguinal hernias in infants can be treated with local pressure bandages on the hernia for observation. Hernia belts are indicated for those who are old and frail, have a short life expectancy or are otherwise contraindicated for surgery. However, long-term use of the hernia belt may cause gradual hypertrophy of the hernia sac neck, which may promote adhesion of the hernia contents to the hernia sac and increase the incidence of hernia intussusception, and increase the difficulty and risk of subsequent surgery, so it is not recommended for routine use. Although TCM treatment of inguinal hernia has its own TCM theory, it cannot change the pathological defect of inguinal hernia, much less the associated complications and risks. Local injection therapy involves local injection of substances such as sclerosing agents, chemical gels, and biogels into the groin with the expectation that they will adhere to close the abdominal wall defect. However, this is not the case. Blood lessons from home and abroad have proved that injection therapy not only cannot cure hernias, but can cause serious consequences such as abdominal adhesions, intestinal obstruction, spermatic cord vascular occlusion, vas deferens damage, and even loss of fertility, and local inflammation and scarring after injection increase the surgical difficulty and risk for future surgery. Therefore, this method is no longer used in regular hospitals and should be discarded. 2. The surgical treatment of inguinal hernia can be divided into two categories: conventional surgery and lumpectomy. Conventional surgery can be further divided into tissue-to-tissue tension suture repair (also called classical surgery), such as Bassini and Shouldice, and tension-free hernia repair surgery using hernia repair materials. Tension-free hernia repairs include those that strengthen the posterior inguinal wall: e.g., simple flat patch repair (Lichtenstein, Trabucco, etc.) and mesh-flat patch repair (e.g., Rutkow, Millikan, etc.), as well as tension-free hernia repairs that target the anterior peritoneal space of the “musculo-pubic foramen”: e.g. Kugel, Gilbert, Stoppa, etc. Laparoscopic inguinal hernia repairs are all tension-free hernia repairs using hernia repair materials and are divided into the following three categories according to the surgical approach and rationale: a. Transperitoneal extraperitoneal (TEP) repairs, which have the advantage of being less disruptive to intra-abdominal organs because they do not enter the peritoneal cavity. b. Transperitoneal pre-peritoneal repair (TAPP), which is easier to detect bilateral, compound and occult hernias because it enters the peritoneal cavity. It also facilitates the observation and management of cases of incarcerated hernia and hernia contents that are not easily retractable. c. Intraperitoneal patch repair (IPOM) is used when there are difficulties in the implementation of the above two methods and is not recommended as the preferred method for lumpectomy for the time being. When repairing by this method, the repair material must be anti-adhesion material. Each of these surgical approaches has its own advantages and disadvantages, and there is no single optimal surgical approach that can solve all inguinal hernia problems. However, in general, tension-free hernia repair surgery using hernia repair materials has become a mainstream surgical procedure because of its low recurrence rate, mild postoperative pain, and minimally invasive surgery. Throughout the history of inguinal hernia treatment in China, it can be said to be the epitome of the history of surgery. Inguinal hernia surgery is also a classic surgical procedure and one of the introductory surgical courses for surgical residents. However, with the in-depth research on abdominal wall hernia in recent years, inguinal hernia is not a “simple minor problem”, and inguinal hernia repair surgery is not a “simple minor surgery”. Since the establishment of the Chinese Medical Association Hernia and Abdominal Wall Surgery Group, the surgical treatment of inguinal hernia in China has developed considerably, but there are still some problems. 1. The problem of surgical standardization. Surgery is a highly practical discipline. The current educational approach has led a significant proportion of surgeons to start performing inguinal hernia surgery alone without good basic and specialized training, based only on self-learning surgical atlas and watching surgical videos. The lack of standardized surgery has caused a large variation in the recurrence rate and complication rate of inguinal hernia in China. after the invention of Bassini surgery in 1887, many surgeons did not understand its essence, but instead dozens of so-called modified surgical procedures emerged, and historical practice proved that the efficacy of these procedures was rather inferior to the traditional Bassini procedure, which shows the importance of standardization. The publication of the Chinese Medical Association guidelines for the treatment of adult inguinal hernia can help improve this situation, and the guidelines also clearly point out the issue of qualification and training of inguinal hernia surgeons, who must pass the specialist training to be competent. 2. The problem of specialization. Surgical treatment of inguinal hernia has been a basic operation in general surgery in the past. Data show that inguinal hernia is currently performed mainly in secondary hospitals in China. A considerable number of inguinal hernia surgeries are performed by junior surgeons who lack surgical experience. Once senior general surgeons have gained experience, their interest immediately shifts to those “high, large, and difficult” surgeries. According to statistics, the postoperative recurrence rate of inguinal hernia in general surgery is about 7%, while that of hernia specialists is 0-1%, so the difference is obvious. Therefore, the specialization of inguinal hernia can ensure the efficacy of patients and is conducive to the development of hernia surgery. At present, there are still very few hernia specialists in China, and they need to be trained urgently. 3. The problem of personalized treatment. With the promotion of tension-free hernia repair, many doctors gave up the traditional hernia repair; with the emergence of laparoscopic hernia repair, many people hurriedly joined the team of laparoscopic surgery. The result was a wave of high recurrence and complications after hernia repair. Modern research has found that inguinal hernia is a disease caused by multiple factors or a combination of factors. Each individual is unique and there is no one golden procedure, so it is particularly important to individualize treatment according to the patient’s specific situation. For example, inguinal hernias in children are mostly curable with only high ligation of the hernia sac; young patients with well-developed abdominal wall muscles can also be repaired with autologous tissues; hernia repair in male patients of childbearing age tries to avoid causing dysfunction of the urogenital fatty fascial compartment; femoral hernias are common in female patients, and repair of the entire musculo-pubic foramen is performed as much as possible; and so on. A complete medical history, family history, and detailed physical examination are all part of inguinal hernia treatment. Only by ensuring adequate consultation time and providing an individualized treatment plan can exact efficacy be guaranteed. 4. The problem of overtreatment. The diagnosis of inguinal hernia can be made mostly by the physician’s questioning and physical examination, and the sensitivity and specificity of ultrasound for inguinal hernia diagnosis can reach 90%. Only a very small number of patients such as recurrent hernias require further imaging. In developed countries in Europe and the United States, open hernia repair is still the mainstream, accounting for more than 80% of cases, most of which are performed by same-day surgery using local anesthesia, and there is still a place for traditional hernia repair. In China, however, inpatient surgery with semi- or general anesthesia is still the mainstay, with major examinations, placement of all patches and lumpectomy at every turn, which is driven by the doctor’s specialist concept and level of diagnosis and treatment, and not denying the economic interests. 5, the problem of laparoscopic surgery. Laparoscopic surgery is a rapidly growing surgical modality in the past one or two decades, and is the biggest development in modern surgery. Most laparoscopic surgery has the advantages of minimally invasive, beautiful incision and fast postoperative recovery, so it is loved and recognized by the majority of patients, and even some doctors call it a “no-incision” treatment method. In the field of inguinal hernia treatment laparoscopic surgery is also developing rapidly and the surgical procedures are becoming increasingly standardized. Laparoscopic inguinal hernia repair has three small incisions (usually one 10 mm and two 5 mm), is less painful, and can be performed bilaterally, but it is expensive, requires general anesthesia, has high operative demands, and has a long learning curve. Some scholars have suggested that laparoscopic surgery is not minimally invasive surgery and therefore remains controversial. The latest international pooled analysis shows that laparoscopic hernia repair is not superior to open tension-free repair, but has better outcomes in recurrent hernias. Personally, I believe that laparoscopic inguinal hernia repair is a new approach that is still under development and needs more experience. At this stage, patients with bilateral inguinal hernia or patients with recurrent open surgery should be more appropriately selected and treated in a hernia surgery specialty with laparoscopic experience. 6. The problem of disease staging. Staging of inguinal hernia is a more detailed division of the hernia condition based on the classification of the hernia. The typing is helpful for the selection of surgical modality and postoperative follow-up, as well as for academic exchange and statistical analysis. At present, there are more than ten types of inguinal hernia staging at home and abroad, and the existing staging system is still imperfect and somewhat subjective. Therefore, it is necessary to develop a unified standard that is widely accepted in China. Until then, the description of hernias should be recorded in detail for the hernia portal, hernia ring, hernia sac, and hernia contents to facilitate summary review. 7. The problem of efficacy assessment. In most hernia surgery specialties, the recurrence rate of inguinal hernia is below 1%, while chronic postoperative pain, abdominal wall discomfort, postoperative infection, and abnormal sexual function are becoming the biggest confusion for patients after surgery. The survey shows that although some patients do not have hernia recurrence after surgery, their quality of life is instead inferior to that before surgery, which is a matter of concern. Inguinal hernia repair should not only focus on recurrence rate, but also on postoperative pain and comfort of life. Therefore how to assess the efficacy completely and accurately also becomes a new issue. In general, only through careful understanding and use of norms, thorough eating of each surgical modality and individualized specialist treatment can we achieve a low recurrence rate while reducing surgical complications and truly ensuring efficacy. By understanding the above-mentioned current situation of inguinal hernia treatment and the problems of surgery in China, we understand that inguinal hernia is never a simple minor problem, nor a simple surgery to cure it casually. Based on a full understanding of the patient’s condition and examination, the optimal treatment plan must be given according to the individual situation, and the surgical method must be standardized to ensure the efficacy of inguinal hernia. With the popularity of tension-free repair, the maturation of minimally invasive surgical techniques and advances in anesthesia and analgesia, day surgery for inguinal hernia has matured and inguinal hernia treatment has become more convenient than ever. The inguinal hernia can be cured in one day, relieving the patient of years or even decades of pain, and avoiding the risk of life-threatening acute ingrowth of the hernia. Patients who were apprehensive about surgery will then revert to surgical treatment. I anticipate that the number of patients undergoing surgery in hernia specialties will increase and the demands on physicians will become higher and higher. As a hernia specialist, we must insist on scientific care, excellence and innovation so that we can meet the needs of the majority of patients.