Procedure in detail:
The patient was correctly identified, brought to the operating room and transferred to the operating table. General anesthesia was administered. He was positioned supine and both groins were prepped and draped in sterile fashion.
I began with a transverse incision parallel and superior to the inguinal ligament on the . I then used electrocaudery to dissect down through Scarpa's fasia to expose the external oblique fascia. The external oblique was then opened in the direction of its fibers using metzenbaum scissors. The external ring was opened. The scissors were used to bluntly elevate the fascia and protect the ileoinguinal nerve. I then exposed the inguinal floor by clearing flaps along the external oblique fascia.
The cord contents to include hernia sac were then identified and isolated at the level of the pubic tubercle with a penrose. The anteriomedial aspect of the cord was inspected for indirect hernia. The posteriomedial aspect of the cord was inspected for direct hernia. The hernia sac was dissected free from the cord down to the level of the internal ring. The Vas Deferens and testicular vessels were protected during this dissection.
A preperitoneal plane was bluntly dissected out through the internal ring. Hemostasis was obtained. I then placed a Prolene Hernia System mesh into this preperitoneal space to lie flat. The medial (external) portion of the mesh was then tacked to the pubic tubercle with 0 Ethibond. The superior aspect of the mesh was tacked to the conjoint tendon. The inferior aspect of the mesh was tacked to the shelving edge of the inguinal ligament. I then made a slit in the mesh to accommodate the cord structures. The internal ring was then re-created by closing the slit around the cord structures with enough space to prevent strangulation.
The external oblique was then closed with a running 2-0 vicryl. Scarpa's fascia was closed with interrupted 3-0 vicryl. Skin was closed with running 4-0 monocryl. Irrigation was used at each of these layers. Dermabond was applied as dressing.
Testicles were pulled down into normal anatomic position at completion of the case.