Patients sometimes assume that the moment a hernia is found, surgery is immediately scheduled.

That is not how it works.

Before I recommend an operation, I assess several things. Not every hernia needs to be repaired urgently. Some can be watched for a period. Others need to move quickly. A few are emergencies.

The decision is never arbitrary. There is a clear framework behind it. This blog explains what that framework looks like from where I sit.

First: what is the hernia actually doing?

The starting point is always the hernia itself, not what the patient read online, not what a relative advised. The hernia in front of me.

I look at six things:

The six-factor assessment

When I advise surgery sooner

Surgery moves to a higher priority when any of the following are present:

• The hernia is causing symptoms that affect daily life: pain, inability to lift, difficulty with routine activity
• The hernia cannot be pushed back in reliably
• It has grown noticeably over a short period
• The type of hernia carries a higher risk of strangulation: femoral hernias, for example, strangulate at a higher rate than inguinal hernias
• The patient is otherwise fit for surgery: operating on a healthy patient now is safer and yields a better recovery than operating under emergency conditions later
• The hernia has caused an episode of acute pain or difficulty, even if it resolved

In these situations, the benefit of surgery outweighs the risk of waiting. I explain this clearly to the patient, and we plan accordingly.

When watchful waiting is reasonable

For some patients, surgery is not immediately necessary. A period of observation is appropriate when:

• The hernia is small and the patient has no symptoms
• The hernia is easily reducible and has been stable for a significant period
• The patient has medical conditions that make surgery higher risk, and the hernia is not causing significant problems
• The patient is elderly, relatively frail, and the hernia poses a low risk of complication

Watchful waiting is not the same as ignoring the hernia. It means monitoring it at regular intervals, understanding what changes would prompt surgery, and being clear about emergency warning signs.

It is also not indefinite. Most hernias that are being watched will eventually need repair. The question is when, not whether.

The quality of life factor

There is another reason to operate that is sometimes overlooked: the patient simply cannot live comfortably with the hernia.

A hernia that does not meet a strict clinical threshold for urgent surgery can still significantly affect quality of life. A patient who cannot pick up their child, cannot work comfortably, cannot exercise, or cannot sleep without discomfort is not living well.

That matters. The goal of surgery is not only to prevent emergencies. It is to allow patients to live normally.

I take quality-of-life impact seriously as a reason to proceed. A patient who says their hernia is not causing any problem may be downplaying it, may have adjusted their life around it without realising, or may genuinely be fine. Part of my job in the consultation is to understand which is true.

Emergency signs: these cannot wait

Whatever the size or type of hernia, certain symptoms require immediate medical attention. These represent a hernia that has become trapped or whose blood supply is compromised.

Go to hospital immediately if you notice

• Sudden, severe pain at the hernia site that does not settle
• A hernia that was previously reducible but can no longer be pushed back in
• The hernia becomes hard and tender to touch
• Nausea, vomiting, or inability to pass gas alongside hernia pain
• The skin over the hernia becomes red or darkened
• Fever alongside hernia pain

Emergency hernia surgery carries significantly higher risk than planned surgery. This is one of the clearest reasons to have the hernia assessed and repaired while it is still manageable.

What the consultation actually looks like

When a patient comes to see me, the consultation is not a formality before scheduling surgery. It is an assessment.

I examine the hernia. I ask about symptoms, how long it has been there, whether it has changed, what makes it better or worse. I ask about general health, medications, and fitness for surgery. I look at any imaging that has been done.

From that, I give the patient a clear recommendation with a reason behind it. Not just: you need surgery. But: here is what your hernia is doing, here is the risk of leaving it, here is what surgery would involve, and here is what I recommend.

The patient makes the final decision. My job is to make sure they have the information to make it well.

The honest answer to how doctors decide

It is not one question. It is six.

What is the hernia doing? Is it growing? Can it be pushed back? Is it causing symptoms? Is there a risk of it becoming dangerous? And is the patient well enough for surgery now?

When the answers to those questions point toward surgery, I say so. When they do not, I explain why and what to watch for.

What I do not do is recommend surgery for every hernia on the day it is found, or avoid the conversation with patients who are uncomfortable about it. Both of those approaches fail the patient.

One thing worth saying plainly

A hernia does not get better on its own. If one has been found, it will need to be managed. The conversation about surgery is not a question of if. It is a question of when, and what the right conditions are.

Coming in for that conversation early, before the hernia has grown or caused a problem, gives you the most options and the most control over the timing.

That is the position you want to be in.