Open Inguinal Hernia Repair — Key Steps and Mesh Fixation

Right inguinal hernia discussed; landmarks include the anterior superior iliac spine (ASIS) at the hip and the pubic bone.
Incision planned between the landmark points; local anesthetic given in the area.

Incision through subcutaneous tissues to access the external oblique and its fascia.
External oblique opened sharply to enter the inguinal canal.
Ilioinguinal nerve preserved unless absolutely necessary to cut it.
Cord structures contain vas deferens, testicular vessels, cremasteric muscles, and associated vessels.
Penrose drain placed around the cord to maintain control and retraction.

Fat attached to the cord dissected away to reveal the hernia sac.
Vas deferens and surrounding venous structures identified; genital branch of the genital femoral nerve runs through and is preserved.
Floor of the inguinal canal inspected; no direct defect observed.
Goal: free hernia sac into the preperitoneal space above the internal ring and reduce contents back to proper position.

Hernia sac clamped and ligated, then divided.
Sac opened; contents (intestines/abdominal fat) can be felt as the sac is reduced.
Sac closed and reduced back under the muscle.
Any cord lipoma removed with electrocautery.

Mesh used: Barred Soft Mesh (thin and flexible).
Mesh fixed to the pubic bone with absorbable sutures to secure anchoring.
A slit is made in the mesh to allow cord structures to pass through; slit is then closed.
Mesh is laid along and around the inguinal canal, with the lateral (top) portion tucked between internal and external oblique muscles to provide coverage.
Mesh fixed to the inguinal ligament at several points to secure it.
The cord is passed through the mesh slit and the slit is closed again.
If the mesh opening around the cord is a bit loose, an additional suture is placed to tighten it.
Mesh wraps around the cord to create a barrier while not constricting the cord structures.

Ilioinguinal nerve repositioned under the mesh to avoid compression.
Mesh and nerve placement ensure the nerve lies in its normal course beneath the mesh.
External oblique fascia closed over nerve and mesh.

Local anesthetic provided for postoperative pain control.
Penrose drain removed before closure.
Scarpa's fascia closed in a couple of locations to approximate deep tissues.
Subcutaneous tissues closed, followed by a running subcuticular skin closure.
Dermabond (medical superglue) applied as the primary dressing.
Final checks ensure tissue layers are closed and clean before leaving the operating room.