Inguinal hernias are caused by a metabolic disorder, which leads to a progressive destruction of the fibroconnective tissue of the groin, making the tissue unsuitable for being used in hernia repair
Traditional tissue repairs are associated with undue tension at the suture line, which leads to more post-op pain, longer recovery time and higher recurrence rate
Technique
A 5 cm to 6 cm transverse incision is made within a Langer’s line, beginning from the pubic tubercle 2 fingerbreadth above inguinal ligament
External oblique aponeurosis opened in the line of its fibres
Spermatic cord with its cremasteric covering, external spermatic vessels, and the genital nerve are freed from the inguinal floor and lifted
Spermatic cord is also dissected free from the pubic bone area for approx 2 cm medial to the pubic tubercle to make room for extending the mesh beyond the pubic tubercle
External oblique aponeurosis is dissected from the underlying internal oblique muscle and aponeurosis high enough to make room for 6-7cm mesh
Sac is then dissected from the cord beyond its neck
Inverted into the preperitoneal space (may require ligation /excision)
If the sac is very large, the sac is divided at the midpoint of the inguinal canal.
The proximal end is closed, dissected away from the cord structures, and inverted into the preperitoneal space
Direct hernia bulge is large, it is inverted utilizing a purse-string on the transversalis fascia
This is only to make the floor of the inguinal canal flat in order to facilitate placement of the mesh
First anchoring suture of the mesh fixes the mesh to the anterior rectus sheath where it inserts into the pubic bone
Lower edge of the mesh is sutured to the inguinal ligament in a continuous fashion - ends at the lateral border of the deep ring
Upper tail is then crossed over the lower one and are sutured together and down onto inguinal ligament , tucked under the external oblique aponeurosis
Upper edge of the mesh is fixed in place, care is taken to keep the mesh slightly relaxed