Plate 209

Details of Procedure

The cord is visualized by the approach described in Plate 207. Since the structures of the cord are to be transplanted, it may be easier to separate the cord from the surrounding structures before the hernia sac is identified and opened. The index finger may be inserted beneath the cord from the medial side just above the pubic tubercle in order to assist in the blunt dissection and freeing of the cord from the underlying Poupart's ligament (Figure 20). A curved half-length clamp directed over Poupart's ligament and toward the pubic spine is then passed beneath the cord and guided by the index finger (Figure 21). A tube of soft rubber (Penrose drain) is drawn through beneath the cord for traction (Figure 22). Many times blood vessels that course downward beneath the cord must be clamped and tied to ensure a dry field. The cremaster muscle is divided, and the hernial sac is grasped with toothed forceps preliminary to opening it (Figure 23). Some prefer to completely divide the cremaster muscle near the internal oblique muscle, leaving the vas and its accompanying vessels exposed. The sacrifice of the cremaster muscle at this level permits a more accurate closure of the internal ring. The hernia sac is opened, and traction is maintained by curved or straight hemostats applied to its margin. With the surgeon's index finger in the hernia sac, the vas deferens and accompanying vessels are dissected free by sharp and blunt dissection (Figure 24). With the surgeon's finger in the neck of the hernia sac to ensure that all abdominal contents are completely reduced, a purse-string suture is placed at the inner side proximal to the neck of the sac or several transfixing mattress sutures are used, as preferred (Figure 25). Care must be taken that the adjacent epigastric vessels are not injured.

Closure (Transplantation of Cord, Bassini)

The first step in the closure is to provide adequate retraction of the cord as well as the internal oblique muscle, so that the deep-lying aponeurosis of the transversus abdominis and the transversalis fascia can be identified (Figure 26). It is important to reinforce the weakened area over the ligated hernia sac by approximating the thickened fascia just below the free edge of Poupart's ligament, the so-called iliopubic tract, and the edge of the aponeurosis of the transverse abdominal muscle (Figure 26, suture X). The remaining opening in the cremaster muscle is closed with interrupted sutures unless it has been completely divided adjacent to the internal oblique muscle. The transversalis fascia may appear to be very thinned out adjacent to Poupart's ligament, but an aponeurosis, the strong white membrane forming the inferior margin of the transversus abdominis, is exposed (Figure 26) by retracting the internal oblique sharply upward. The hernial repair is strengthened if an effort is made to approximate the latter structure to the iliopubic tract beyond the margins of Poupart's ligament. The conjoined tendon is retracted upward so that each bite of the needle includes a good portion of the aponeurosis of the transversus muscle (Figure 27) and the thickened fascia adjacent to the margin of Poupart's ligament. Several sutures between the iliopubic tract and the aponeurosis of the transversus muscle are taken lateral to the cord to close the redundancy of the internal ring (Figure 28).

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