Tension free mesh repair, step by step

1. Skin incision about 1.5 cm above and parallel to Poupart's ligament.
2. Ligation of the superficial epigastrivc vein (do not coagulate)
3. Opening Scarpa's fascia
4. Opening external aponeurosis following fibre direction. Avoid damage to the ilioinguinal nerve.
5. Isolate spermatic cord
6. Identify genitofemoral nerve (genital branche), this runs dorsal and parallel to the spermatic cord, underneath the cremaster muscle fibers
7. Isolate hernia sac and/or preperitoneal lipoma
8. Repositioning hernia (do not ligate!)
9. Lipoma can be ligated
10. In case of a large lateral hernia (scrotal) the hernia sac can be transected and proximally ligated. The distal part can remain in situ however needs to be left open widely.
11. Suture mesh with Prolene. First suture through the lateral rectus border just cranially to the pubic tubercle. Proceed along Poupart's ligament with large steps and small bites.
12. Tie a knot when the internal ring has been reached (preferably an Aberbeen knot)
13. Create a new internal ring by attaching the lower edge of the upper part of the mesh to Poupart's ligament.
14. Secure upper part with single sutures. Beware of the iliohypogastric nerve.
15. Close the external aponeurosis and create new external ring
16. Close Scarpa's fascia
17. Skin closure (intracutaneous resorbable)
18. Infiltrate wound with local anaesthesia