The sac is opened within 2 to 3 cm of its neck, and exploration is carried out with the index finger to rule out the presence of a “pantaloon” or secondary direct or femoral hernia (Figure 10). To ensure obliteration of the sac, a purse-string suture is placed at the inner side of the neck (Figure 11), or several transfixing sutures may be used if preferred. The lumen of the neck of the sac must be visualized as sutures are placed or tied to avoid possible injury to omentum or intestine. This suture should include the transversalis fascia with the peritoneum. The neck of the sac can sometimes be identified as a slightly thickened white ring. The sac should be ligated proximal to this ring. After the purse-string suture is tied, the excess sac is amputated with scissors (Figure 12).
If desired, the ligated sac may be anchored to the overlying muscle. In this instance the long ends of the suture used to close the neck of the sac are rethreaded. The needle is inserted beneath the transversalis fascia and brought up in the edge of the internal oblique muscle, the two ends being brought through separately and tied (Figure 13). Care should be taken to avoid injuring the inferior deep epigastric vessels.
Although the classic inguinal hernia operations utilize high ligation with division of the hernia sac, two alternate methods have gained popularity with mesh repair. In small to medium-sized indirect hernias, the sac is left intact as it is dissected from the posterior cord structures. Electrocautery is used along the edge of the sac while gentle traction is applied. This minimizes bleeding and ecchymosis after surgery. Any entry into the sac is used for finger exploration and guidance of further dissection well up into the internal ring. Any opening in the sac is closed using 00 absorbable suture, and the entire sac, along with any lipoma of the cord, is returned to the preperitoneal space behind the abdominal muscular wall.