Plate 216

### Details of Procedure

The incision and exposure is the same as that utilized for the indirect hernia (Plate 215). The external oblique fascia is opened and the superior and inferior edges are grasped with pairs of hemostats. The shelving edge of the inguinal ligament is cleared first with blunt dissection using a peanut on a Kelly. However, as the surgeon begins the superior exposure, the direct floor is not apparent as a structure separate from the cord. It appears as though the cord and hernial process covered both areas (Figure 1). As the cremaster is opened anteriorly, the cord is identified as separate from the direct herniation. The cord is dissected free and isolated for retraction with a soft rubber Penrose drain. The direct hernial sac, which is often quite large compared to its defect in the floor, is cleaned carefully back to its junction with the floor or transversalis fascia and muscle. A suitable zone approximately 1 cm above the junction of the direct sac with the floor is chosen for incision with the electrocautery. As the sac is cut, the preperitoneal fat literally pops into view (Figure 2). This circumscription is carried for 360 degrees about the entire neck of the sac. This allows the tethered sac and its content of preperitoneal fat to be easily returned into the preperitoneal space. The actual size of the direct defect is often smaller than anticipated. On palpation of the defect, there is usually a clearcut rim of transversalis fascia and muscle that persists, although these layers are often quite thin. The polypropylene cone or “plug” is placed into the direct opening such that its rim is directly flush with the transversalis floor. Multiple interrupted 00 absorbable sutures are used to secure the perimeter of cone to the transversalis tissues (Figure 3). Usually eight or more sutures are placed such that none of the preperitoneal fat can protrude between the edge of the cone and the rim of the transversalis. The cremaster is opened anteriorly (Figure 4) and a search is made for any indirect hernia, which may require a second cone for repair. The cord structures including the vas are identified and the cremasteric opening is not closed. The onlay “patch” of polypropylene mesh is placed over the entire direct floor in the same manner as described in the preceding plate for indirect ...

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