After division of the skin, subcutaneous fat is encountered. This is divided along the length of the incision down to the external oblique aponeurosis. At this stage, haemostasis is carefully obtained either with bipolar coagulation or ligatures for larger vessels. The external oblique aponeurosis is identified by the inferomedial orientation of its fibres. At this level, a self-retaining retractor is placed into the wound to ensure better access.
Then, the surgeon follows the external oblique aponeurosis inferiorly to its continuation with the deep fascia of the thigh. The latter is divided along the same line as the initial incision to visualise the femoral canal. The purpose of this step is to exclude a small, simultaneous femoral hernia or a very large femoral hernia that is mimicking an inguinal hernia.
Next, the external oblique aponeurosis is divided along the length of its fibres laterally from the level of the external ring. This creates upper and lower flaps which are bluntly dissected off the underlying cord.
With the cord exposed, the cremaster muscle is most superficial. This is divided along the length of the cord from pubic tubercle to conjoint tendon. For the Shouldice repair, it is dissected off the cord, ligated and divided at each end.
The cord is inspected. Usually, the hernial sac is evident at this stage. A lipoma may be visible; it should be carefully dissected away.
The management of different types of hernial sac is considered in the submenu.
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