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Background Cost-effectiveness of tension-free inguinal hernia repair at a private 20-bed rural hospital in Esmeraldas Province, Ecuador, was calculated relative to no treatment. Methods Lichtenstein repair using mosquito net or polypropylene commercial mesh was provided to patients with inguinal hernia by surgeons from Europe and North America. Prospective data were collected from provider, patient, and societal perspectives, with component costs collected on site and from local supply companies or published literature. Patient outcomes were forecasted using disability adjusted life years (DALYs) averted. Uncertainty in patient-level data was evaluated with Monte–Carlo simulation. Results: Surgery was provided to 102 patients with inguinal hernias of various sizes. Local anesthesia was used for 80% of operations during the first mission, and spinal anesthesia was used for 89% in the second mission. Few …