Plate 210
###### Figure 37

A second layer of 00 nonabsorbable sutures includes unequal portions of the shelving edge of Poupart's ligament and a bite of the conjoined tendon. This suture line extends from the pubic tubercle outward over the deep epigastric vessels until the cord appears to be angulated laterally. Before these sutures are placed, the mobility and composition of the tendon should be determined. In many instances the conjoined tendon cannot be brought down to Poupart's ligament except under a great deal of tension. A preliminary trial should be carried out by attempting to approximate the conjoined tendon to Poupart's ligament at the proposed suture line to determine the amount of tension that will be present (Figure 29). The medial leaf of the external oblique fascia is retracted medially, and by blunt dissection the underlying sheath of the rectus is exposed (Figure 30). If the tension appears to be excessive, relaxation of the fascia with retained support of the underlying rectus muscle is achieved by multiple incisions in the rectus sheath (Figure 31). The relaxing incisions can be made about 1 cm apart and 1 cm in length. Eight or ten or even more may be required to produce the desired relaxation (Figures 31 and 32). The number required can be judged by the spread of the tissues as the incisions are made and as traction on the fascia is maintained. The conjoined tendon is sutured to the lower edge of Poupart's ligament adjacent to the suture line that has approximated the aponeurosis of the transverse abdominal muscle to the iliopubic tract. The initial suture should include the periosteum of the pubic spine and the medial portion of the conjoined tendon. Several sutures are taken to approximate the muscle to Poupart's ligament above the point of exit of the cord, but these must not constrict the cord, especially if its size has been decreased markedly by the excision of some of the dilated veins and the cremaster muscle (Figure ...

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