Excise the old scar and deepen the incision cautiously until you encounter the hernia sac. Often, the sac lies quite close to the skin surface. It may be adherent to the old scar. It will look somewhat like a large lipoma and, as with a lipoma, is easily “shelled out” of the surrounding tissues. Dissect laterally around the sac and then deep to expose good fascia well past the edge of the defect. Define the defect on all sides, raising
flaps of subcutaneous tissue and skin as the dissection progresses. In most cases, the entire length of the old incision should be exposed because multiple defects are quite common and may otherwise be overlooked. Lateral defects, which frequently occur at points where retention sutures have cut through the fascia or at old drain sites, must be sought as well. Expose good fascia on all sides of the old incision. If possible, dissect the sac away from the fascia and reduce it. You will then be able to perform the repair in a totally extraperitoneal fashion. It is critical to clean the underside of the fascia carefully so that gut is not caught in a stitch during the repair.

Generally, multiple adjacent defects should be made into one defect by excising intervening bridges of attenuated fascia. Débride all attenuated fascia, hernia sac, or scar tissue.

If the defect is small, close it with interrupted nonabsorbable sutures. Be careful to avoid excess tension. If tension is required to appose the fascial edges, the repair will fail. Remember that it is difficult to assess the tension on the repair under the conditions of muscle relaxation associated with general or spinal anesthesia. Therefore, if there is any tension, consider performing separation of parts or using prosthetic material to bridge the gap (see subsequent sections and references at the end).