Skin Incision: 6-8 cm Oblique Incision Parallel and Just Superior to the Inguinal Ligament

Dissection

• Carry Incision Down Through the Subcutaneous Tissue and Scarpa’s Fascia
• Expose and Longitudinally Incise the External Oblique Aponeurosis to Enter the Inguinal Canal
  • Preserve the Ilioinguinal Nerve
• Mobilize and Isolate the Spermatic Cord and Encircle it with a Penrose Drain
• Dissect the Hernia Sac from the Spermatic Cord and Reduce It
• Consider High Ligation and Resection of the Sac vs Reduction Alone
• Incise the Posterior Wall (Transversalis Fascia) from the Internal Ring to the Pubic Tubercle to Expose the Preperitoneal Space and Facilitate Reduction of the Hernia Sac
  • Develop the Preperitoneal Plane to Expose Cooper’s Ligament Along the Superior Pubic Ramus

Repair

• Approximate the Conjoined Tendon (Internal Oblique and Transversus Abdominis Aponeurosis) to Cooper’s Ligament
  • Classically Uses Interrupted Nonabsorbable Sutures
  • Begins Medially at the Pubic Tubercle
  • Continue Laterally Along Cooper’s Ligament Until It Can No Longer Be Safely Reached
• Place a “Transition Stitch” Incorporating the Conjoined Tendon, Cooper’s Ligament, AND the Shelving Edge of the Inguinal Ligament
• Continue the Lateral Repair by Approximating the Conjoined Tendon to the Shelving Edge of the Inguinal Ligament
  • Continue Until the Internal Ring is Recreated Around the Spermatic Cord without Constriction

Caution: Avoid Injury to the Femoral Vein During Lateral Dissection Along Cooper’s Ligament as it Terminates Near the Vein – One of the Classic Reasons for the Transition Stitch

May Create a “Relaxing Incision” of the Anterior Rectus Sheath if Under Perceived Tension

Closure

• Return the Spermatic Cord to the Inguinal Canal
• Close the External Oblique Aponeurosis Over the Spermatic Cord
  • Preserve the Ilioinguinal Nerve
• Close Scarpa’s Fascia and Skin