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Backgrounds: The optimal surgical strategy for the treatment of chronic pain after inguinal hernia repair is controversial and based on relatively weak evidence. The purpose of this study was to analyze pain-related functional impairment using a simplified clinical treatment algorithm for a standardized surgical treatment. The algorithm was predefined, and the indication to operate was based on strict criteria.Methods: This was a prospective, non-controlled, explorative study. The pain operation was either open triple neurectomy with total mesh removal or laparoscopic retroperitoneal triple neurectomy. A clinically relevant postoperative change was defined as ⩾25% change from the baseline level. Primary outcome was pain-related impairment of physical function using the Activity Assessment Scale. Secondary outcomes included Individual Patient-Reported Outcome Measures, Hospital Anxiety and Depression Scale, and PainDETECT Questionnaire.Results: A total of 240 patients were referred (2016–2019). Sixty-six patients were included for the analysis. A total of 25% of referred patients were offered a pain operation. Follow-up was a median 3 months (range: 3–13). Activity Assessment Scale scores were clinically relevant improved in 43 patients (68%), not clinically relevant different in 19 (30%), and clinically relevant worsened in one (2%). Secondary outcome scores were all significantly improved (P< 0.05) except for the risk of postoperative depression (P= 0.092). Fifty-one patients (77%) reported that chronic groin pain was reduced after the operation.Conclusions: Pain-related functional impairment was improved with clinical relevance in roughly 70% of patients through a simplified clinical algorithm for surgical treatment of severe chronic pain after an inguinal hernia repair.