Shouldice Repair for Left Direct Inguinal Hernia

1. Introduction

2. Surgical Approach

1. Inject Local Anesthetic

3. Incision

4. Exposure of External Oblique

1. Inject More Local Anesthetic

5. Mobilization of External Oblique

6. Inguinal Dissection and Identification and Preservation of Nerves

7. Skeletonize Cord Structure and Look for the Indirect Hernia Sac / Peritoneum

8. Skeletonize Hernia Sac and Examine Internal Inguinal Ring and Peritoneum

9. Division of Cremaster Muscle Fibers with Genital Branch of Genitofemoral Nerve

1. Inject More Local Anesthetic
2. Inject More Local Anesthetic

10. Divide Floor of Inguinal Canal

1. Divide the Floor, Comprised of Aponeurosis to Transversus Abdominis and Transversalis Fascia (Often Fused)
2. Excise Redundant Transversalis Fascia (if Present)
3. Check for Femoral Hernia

11. Four-Layer Shouldice Repair

1. Layer One: Rectus Abdominis to Transversalis Fascia with Anchor to Inguinal Ligament
2. Incorporate Internal Oblique, Cremaster Bundle, and External Oblique to Recreate Internal Ring
3. Confirm the Internal Ring is Appropriate
4. Layer Two: Internal Oblique Muscle and Rectus to External Oblique Fascia
5. Layer Three: Close Reinforcement of Internal Oblique and Rectus to External Oblique
6. Layer Four: Wide Reinforcement of Rectus to External Oblique

12. Closure

1. Reposition Spermatic Cord Back in Place
2. Close External Oblique
3. Close Scarpa's Fascia
4. Close Skin

13. Post-op Remarks