Once the continuity of the direct floor is restored, the repair continues in the same manner as that for an indirect inguinal herniorrhaphy for a Lichtenstein indirect inguinal herniorrhaphy. The cremaster muscle is opened anteriorly. The vital cord structures are identified and the indirect sac is freed from the cord using electrocautery and gentle traction. The key landmark is the vas, which is directly posterior to the sac. After the sac is opened and examined, a transfixing nonabsorbable suture is placed through its neck and ligated (Figure 8). The excess sac is then excised, as is any significant lateral lipoma of the cord. Alternatively some surgeons do not open the hernia sac and merely return it to the preoperational space.
A rectangular piece of polypropylene mesh approximately 2½ to 3 cm by 8 to 10 cm in size is cut with a lateral slit for the cord and a medial blunt oval for the pubis (Figure 9). The mesh is positioned on the floor of the canal with the tails overlapping lateral to the internal ring and cord. A nonabsorbable 00 suture anchors the mesh to the pubic tubercle. This continuous suture secures the inferior edge of the mesh to the inguinal ligament while interrupted absorbable sutures anchor the superior edge to the internal oblique muscle (Figure 10). Care is taken in the placement of the superior suture so as to avoid any nerve branches. Additional care is needed in the placement of sutures laterally so as to avoid the ilioinguinal nerve, which lies upon the internal oblique muscle just lateral to the cord. The two tails of the mesh are overlapped and then sewn together. It is important that the mesh not be stretched tightly. The superior suture placements are chosen such that the mesh is not stretched but rather is loose and almost wrinkles longitudinally. The importance of this maneuver becomes apparent when the patient is asked to cough or strain (an advantage possible with the use of local anesthesia). The wrinkles disappear as the abdominal wall tightens. If the mesh had been placed without slack, the suture lines would now be under tension. A few interrupted sutures are placed to further close the lateral slit and create an appropriate size for the internal ring opening. Currently, only a few (4 or 5) loops of each continuous suture are placed on the inferior and superior edges of the mesh by Lichtenstein surgeons.
An alternate pattern for the mesh may be used where the slit is placed inferior to the cord (Figure 11). The mesh is sewn in place with the same continuous nonabsorbable suture, which begins at the pubic tubercle. Additional interrupted sutures are used to anchor the superior edge of the mesh to the internal oblique muscle and to close the inferior slit about the cord (Figure 12). A modification described in the classic Lichtenstein repair is shown for males in this illustration where the spermatic cord has been thinned and partitioned. The superior bundle of cremasteric muscle has been transected and ligated at the internal ring. The cord is then partitioned into a major portion containing ilioinguinal nerve, vas, and major vessels and a minor portion containing the intact inferior cremaster muscle bundle with the external spermatic vessels and the genital branch of the genitofemoral nerve. The major cord exits through the internal ring and is shown encircled with a soft rubber Penrose drain. The minor portion is left undisturbed, with minimal dissection or disruption in the floor of the canal near the internal ring. This minor portion now exits through a separate opening left between the inferior edge of the mesh and the inguinal ligament. It is important to use a double loop or locking stitch on either side of this opening such that the minor portion of the cord will not be compressed.
The external oblique fascia is reapproximated with a running suture, which may begin at either end of the incision and which creates a snug defined external ring (Figure 13). Scarpa's fascia is approximated with interrupted absorbable sutures and the skin is approximated with subcutaneous absorbable sutures reinforced with skin tapes. A small dressing is applied to cover the incision.
The patient may return home several hours after the operation with written instructions concerning activities, signs of bleeding or infection, or any other unusual reaction. Oral narcotic is supplied, and an ice pack may be applied locally for several hours. The patient should rest in bed except for voiding in the bathroom on the day of surgery. A suspensory for men is optional. Physical activity is restricted for an additional few days. Many experience improvement after 3 days, and some may drive or return to light duty work after 5 to 7 days. Vigorous exertion, as in sports, is limited for a few weeks, and extreme exertion should be avoided.