The firm ridge of the falx could be easily palpated through the lax floor and the surgeon elected to repair the floor without opening the transversalis fascia. The first bite medially included the two layers of the conjoined tendon and the edge of Henle's ligament above, and the iliopubic tract laterally. Number 0 braided non absorbable suture was used.
The suture placement is shown schematically. The lateral bites of iliopubic tract near the deep ring must be taken carefully to avoid injury to the underlying iliac and inferior epigastric vessels. If the iliopubic tract is thinned out by the stretching of a large direct hernia or is inherently insubstantial, a McVay repair or a tension free (Lichtenstein) mesh repair could be used. The inguinal ligament, although incorporated in a Shouldice repair, is not substantial enough to use alone for the lateral bites. If there is a high-arching falx and tension bringing it down to the iliopubic tract, a tension free repair is the best alternative. Preliminary imbrication of the transversalis over a large direct bulge can simplify the placement of the mesh.
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