Once the transversalis fascia has been approximated and double-breasted posterior to the cord, the conjoint tendon is used to reinforce further the posterior wall. Commencing laterally at the medial border of the deep ring, a continuous suture is run from the deep edge of the inguinal ligament - superficial to transversalis fascia - to the conjoint tendon. The deep surface of the conjoint tendon is taken up by the stitch before passing inferomedially again to the inguinal ligament.
As with the transversalis fascia, the sutures are sited at an alternating distance from the wound edge so as to reduce the likelihood of the stitch tearing. Also, as with the deeper repair, the continuous stitch passes from the deep ring to the pubis and back again before being tied at the medial border of the ring.
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