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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.
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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 ...