Skin Incision: 6-8 cm Oblique Incision Parallel and Just Superior to the Inguinal Ligament

Dissection

• Carry Incision Down Through the Subcutaneous Tissue and Scarpa’s Fascia
• Expose and Longitudinally Incise the External Oblique Aponeurosis to Enter the Inguinal Canal
  • Preserve the Ilioinguinal Nerve
• Mobilize and Isolate the Spermatic Cord and Encircle it with a Penrose Drain
• Dissect the Hernia Sac from the Spermatic Cord and Reduce It
• Consider High Ligation and Resection of the Sac vs Reduction Alone

Repair

• Tailor a Flat Mesh to Fit the Inguinal Floor
  • Classically Use a Polypropylene Mesh
• Fix the Medial Edge of the Mesh to the Pubic Tubercle
  • Should Overlap 2 cm to Reduce Medial Recurrence
• Secure the Inferior Edge of the Mesh to the Inferior Shelving Edge of the Inguinal Ligament
  • Can Be Interrupted or Running
  • Generally Begins Medially and Proceeds Laterally
• Cut the Lateral End of the Mesh to Create Superior and Inferior Tails
  • Extend the Mesh Slit from the Lateral Edge to the Level of the Spermatic Cord
  • Tails are Generally Cut with 1/3 the Width Below and 2/3 the Width Above
• Pass the Superior Tail Deep to the Spermatic Cord to Create a Keyhole Around the Cord and Overlap the Two Mesh Tails
• Loosely Approximate the Mesh Tails with a Single Suture to Recreate the Internal Ring without Constriction
• Loosely Fix the Mesh Superiorly to the Internal Oblique Muscle or Conjoined Tendon
• Ensure the Mesh Lies Flat and Without Folding or Tension

Generally Uses Nonabsorbable Polypropylene (Prolene) Suture

Closure

• Return the Spermatic Cord to the Inguinal Canal
• Close the External Oblique Aponeurosis Over the Spermatic Cord
  • Preserve the Ilioinguinal Nerve
• Close Scarpa’s Fascia and Skin