Last reviewed 01/2018
The initial incision for inguinal hernia repair begins at the level of the deep inguinal ring and runs medially 1cm above the inguinal ligament to the pubic tubercle where it twists a short distance caudally. The skin and subcutaneous fat are then divided down to the external oblique aponeurosis using diathermy to seal vessels. The deep thigh fascia is then incised to check the femoral region for a concomitant femoral hernia.
Following the line of the inguinal canal, the external oblique aponeurosis is then incised to the deep inguinal canal and up to its juncture with the lateral rectus sheath. The cord is thus exposed. The cremaster muscle is then dissected carefully off the contents of the cord, divided and ligated. At this point, a hernia within the cord should be visible. The subsequent management of the hernial sac depends on whether it is direct or indirect - see the following sections. The transversalis fascia is freed from the cord and underlying fat at the deep inguinal ring and transected down to the pubic tubercle. Repair is then started at the medial end of the canal, the transversalis fascia being carefully sutured together to reconstitute the posterior wall of the canal in the first of two layers. Once the deep ring has been reinforced, the direction of suturing is reversed and the free margin of the upper medial flap and lower lateral flap of the transversalis fascia are brought together. The technique of doubling-back is called double-breasting.
Moving medially, the conjoint tendon is then sutured to the upturned edge of the inguinal ligament from the medial margin of the deep inguinal ring. At the pubic tubercle, the direction is again reversed until the conjoint tendon is flush with the emerging spermatic cord. With the cord back within the canal, the external oblique aponeurosis is closed above it to create an anterior wall and external