Shouldice Repair of Inguinal Hernia - general and visceral surgery

Duplicating the transversalis fascia and attaching the transversus abdominis and internal oblique to the inguinal ligament.

Make the skin incision, measuring about 4 cm, in the line of the inguinal canal 2 fingers medial to it (solid line), or make a transverse incision 2 fingers superior to the pubic bone. Then divide the subcutaneous tissue down to the external oblique aponeurosis.

Now longitudinally divide the fibers of the external oblique, including the superficial inguinal ring. After clamping the aponeurotic flaps and retracting them upward, free the aponeurosis from the internal oblique and cremaster by blunt dissection.
Caution: The iliohypogastric nerve courses immediately below the aponeurosis!

Pass a tape around the spermatic cord, gently lift it and free the cord by blunt dissection from the transversalis fascia below.
After dividing the cremaster muscle longitudinally, excise its fibers leaving generous stumps, thereby freeing the cord. In this step of the procedure the ilioinguinal nerve and the genital branch of the genitofemoral nerve must be spared.
Important: Postoperative neuralgia can be prevented by proceeding as follows: If you cannot spare the ilioinguinal and/or hypogastric nerves and/or the genital branch of the genitofemoral nerve, you must excise them and infiltrate their stumps with local anesthetic.

Sparing the cord, free the hernia sac down to the hernia defect in the transversalis fascia. Ligate and excise any preperitoneal lipoma.

Direct hernia

In direct hernia the hernia sac usually does not have to opened. In case of a large sac, it should be reduced and the base closed with a purse string suture.
Present special case: After opening the sac a sliding hernia is seen with the appendix as its contents. After partial adhesiolysis of the mesoappendix from the hernia sac and reduction of the appendix, the peritoneum is closed with a continuous suture.

Indirect hernia

In order to safely spare the testicular vessels, free the deep inguinal ring completely and follow the cord to the level of the ring. Splay open the hernia sac and reduce its contents. Close the base of the hernia sac with an outer purse string suture and remove the excess.
Tip: Once you have excvised the excess hernia sac, rule out any bleeding along the stump resection line of the sac by slackening the stay sutures first before cutting them off. In case of any bleeding you can easily pull up the stump with the stay sutures and institute the necessary hemostatic measures. If the stump does not retract out of sight spontaneously, reduce and submerge it by suture.