The right groin is shown, with the patient's head to the left. The inguinal canal is located using bony landmarks (see inguinal anatomy). The inguinal ligament runs between anterior superior spine of ilium and pubic tubercle. The latter is at the base of the scrotum. The superficial inguinal ring is just lateral to the pubic tubercle and the deep ring is midway between the two bony points. An incision 3cm above and parallel to the inguinal canal affords good exposure. A skin wheal was raised slightly longer than the intended incision using a combination short (1% lidocaine) and long acting (1/4% bupivicaine) anesthesia without epinephrine (surgeon's choice). Bicarbonate is added to reduce the acidity and sting of the mixture. The swelling of the dermal skin wheal gives immediate anesthesia, even before the drug takes effect.
The subcutaneous tissue was infiltrated in a fan pattern starting in three positions (ends and middle) in the skin wheal. A total of 30-40 cc in skin and sub-Q is usually sufficient. Direct local infiltration, as practiced at the Shouldice Clinic, was used in this case. Blocking the ilioinguinal nerve medial to the anterior superior spine plus a field block is an alternate approach.
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