The inferior leaf of the external oblique fascia is grasped with two hemostats, one lateral and the other at the external ring. Using blunt dissection with the peanut on a Kelly, the wispy attachments between the cord and inguinal ligament are swept from lateral to medial, exposing the clean shelving edge of the inguinal ligament and the pubic tubercle. Additional local anesthetic is injected along the ligament and at the pubic tubercle. The superior leaf of the external oblique fascia is grasped by two hemostats. The cord is dissected free, again beginning laterally. The pubic tubercle is cleaned. Further extension of this dissection from above, out along the first centimeter or so of inguinal ligament lateral to the pubic tubercle, ensures an easy mobilization of the cord. The surgeon's finger is placed around the cord and a soft rubber Penrose drain is placed around it for inferior retraction (Figure 1). The cremaster muscle is opened anteriorly and longitudinally for a few centimeters in its proximal region. The sac is identified anterior to the vas deferens and is carefully dissected away from the vas and blood vessels. This dissection is performed using electrocautery at the edge of the sac while gentle traction is applied to the fat and vessels. Historically, this dissection was done bluntly with smooth forceps or with a sweeping motion using a gauze sponge; however, careful dissection with electrocautery along the edge of the sac minimizes bleeding. The sac is freed up well into the internal ring (Figure 2). If the sac is entered, the opening is closed with a 00 absorbable suture. When an extremely large sac associated with an inguinoscrotal hernia is present, it may be prudent to perform a high transection and ligation of the proximal sac. This leaves the distal sac intact and minimizes potential trauma of the cord veins, with consequent testicular complications.
The hernia sac in this example of an indirect hernia is not divided but rather is invaginated back up through the internal ring with an instrument (Figure 3). The internal ring may be sized with the surgeon's finger, which then guides the polypropylene cone or “plug” into the opening. The cone is secured to the con-joint tendon (external oblique muscle) with one or more 00 absorbable sutures. It is important that the cone be positioned behind the muscle and that a sufficient number of sutures be placed such that the sac or preperitoneal fat cannot get out around the perimeter of the cone (Figure 4).
The onlay “patch” of polypropylene mesh is placed with the pointed or shield end overlapping the pubic tubercle. The cord is passed through the lateral slit and the two tails are joined together with 00 absorbable suture (Figure 5). A suture is placed near the cord, thus determining the diameter of the new internal ring. Traditionally, this opening has been sized for easy passage of the cord plus an instrument tip. It is important that the onlay patch be of sufficient size to overlap the inguinal ligament inferiorly, the pubic tubercle medially, and the entire floor centrally, as shown in the cross section (Figure 5A). Additionally, the mesh should reach well lateral to the internal ring. This may require the custom cutting of a sheet of polypropylene mesh for large indirect hernias.
The perimeter of the incision, both deep and superficial, is infiltrated with a long-acting local anesthetic. The external oblique fascia is reapproximated above the level of the cord using an 00 absorbable suture. The closure begins at the external ring with observation of the cord, the ilioinguinal nerve, and the path of each edge of the oblique fascia. Starting the closure here allows the surgeon to size the external ring. The closure is continued laterally as a running suture (Figure 6). Scarpa's fascia is approximated with a few 00 or 000 absorbable sutures and the skin is closed in a subcuticular manner with a fine absorbable suture. Adhesive skin strips and a dry sterile dressing are applied.
Patients operated upon in an ambulatory surgery setting are observed for about an hour until discharge criteria are met. They may take liquids by mouth and are encouraged to void. The homegoing instructions detailing activities and the signs of bleeding or infection are reviewed with the patient and caregiver. Most patients require pain medications for a day or two. Normal activities are resumed as tolerated.