Purpose <p>Persistent postoperative pain is a major challenge in inguinal hernia surgery. However, the impact of intraoperative nerve management on postoperative pain is poorly understood. The aim was to evaluate how management of the three inguinal nerves during anterior mesh repair of inguinal hernia affects the risk for persistent postoperative pain.</p> Methods <p> Cohort study based on data from the Swedish Hernia Register (SHR) concerning management of the three inguinal nerves. Adult patients with an open anterior mesh repair between 2012 and 2017 and who had responded to a patient-reported outcome measure (PROM) questionnaire one year after surgery were included in the study.</p> Results <p> Out of eligible patients, 34,115 (69%) responded to the PROM questionnaire. Of these, 25.9% reported pain that could not be ignored and 15.7% reported pain interfering with daily activities one year after surgery. Identifying and/or preserving any of the three groin nerves was not seen to have a significant impact on the risk for persistent groin pain in multivariable ordinal regression analysis adjusted for type of anaesthesia, gender, age and emergency surgery.</p> Conclusion <p> In a setting where the nerves are handled according to the surgeon’s intraoperative judgement focusing on identifying and/or preserving the nerves, there was no association between intraoperative management of the three inguinal nerves and the risk for persistent postoperative pain one year after surgery. While careful tissue handling is crucial to the avoidance of postoperative pain, pragmatic nerve resection did not increase the risk for persistent pain one year after surgery.</p>