The open preperitoneal approach with mesh is an old surgical procedure but little implemented in daily practice. Surgeons who have used it regularly have reported excellent results for all types of inguinal hernias. There is significant conceptual confusion regarding its use and indications, which account for the reduced implementation and diffusion in the surgical arena. The open preperitoneal approach with mesh here described can be used in any type of inguinal hernia, in men and women, in the context of elective and urgent operations, allows a critical view of the myopectineal orifice, uses a large mesh, is easy to teach, and provides a physiological repair placing the mesh at the level of the transversalis fascia and taking advantage of the intraabdominal pressure for maintaining the mesh in situ (Pascal’s principle). Moreover, the procedure is associated with a low number of complications and can be performed on an ambulatory surgery basis.