The incision is carried down through Scarpa's fascia to the external oblique aponeurosis. Additional local is infiltrated beneath this fascia, especially laterally (Figure 4). The external oblique is opened in a direction parallel to its fibers down through the external ring. Care is taken to lift this fascia away from the cord and ilioinguinal nerve during the opening so as to lessen the chance of transection of the nerve.
The free edges of the external oblique fascia are grasped with a pair of hemostats medially and laterally. Using blunt dissection, the fascia is separated from the internal oblique muscle superiorly and the cord inferiorly. The cord is encircled with a soft rubber Penrose drain. Additional local anesthesia is injected along the inguinal ligament and about the pubic tubercle. The direct hernial sac is carefully separated from the cord, which is cleaned back to the level of its exit at the internal ring. It is verified that this is a direct herniation rather than a medial protrusion of an indirect herniation. The cremaster muscle about the cord is opened anteriorly. The cord structures are identified and the region of the internal ring inspected for evidence of an indirect hernia and sac. A direct hernia only is shown (Figure 5). The direct hernial sac is cleaned with blunt and sharp dissection around to its neck. This protrudes through a defect in the transversalis fascia of the canal floor. These defects may be discrete, with a finger-sized punched out hole, or may involve the entire floor as a diffuse blowout from the inguinal ligament below to the conjoint tendon above. Some surgeons prefer to open the direct sac, reduce the properitoneal fat, and excise the residual sac, as is done with indirect hernias. Almost always, however, the sac and fat are easily reduced (Figure 5) and then kept reduced with an instrument as the floor is reconstructed.
A continuous nonabsorbable 00 suture is placed for reconstruction of the canal floor. This begins at the pubic tubercle and approximates the residual transversalis fascia just above the inguinal ligament to the transversalis fascia or muscle just below the conjoint tendon so as to imbricate the herniation (Figure 6). This suture continues laterally to the level of the internal ring. Care is taken to avoid the inferior epigastric vessels. After this suture is tied, the internal ring should be snug about the cord (Figure 7). The floor of the canal is now solid and the conjoint tendon lies in its normal position. The conjoint tendon is not artificially pulled down under tension to the inguinal ligament as in the classic Bassini repair.