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A D V E R T I S E M E N T
A D V E R T I S E M E N T
If the sac is large, the peritoneal incision is continued carefully around the neck of the sac in order to leave the sac in place, a so called ring excision.
A D V E R T I S E M E N T
The preperitoneal fat and fascia layer is incised down to the deep side of the transversus abdominus muscle which is covered with transversalis fascia. The upper flap of peritoneum is dissected at the level of transversalis fascia, leaving the fatty layer on the peritoneum. Care in dissection is necessary medial to the deep ring to avoid injuring the inferior epigastric vessels. A wide dissection of flaps beyond the margins of the inguinal floor is critical to allow comfortable placement of an adequate size mesh to prevent recurrence.
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A D V E R T I S E M E N T
Completion of the upper flap includes medial mobilization of the bladder in the prevesicle plane to expose the deep side of the rectus abdominis muscle and pubic bone. The medial side of the lower flap is dissected off the iliopubic tract, lacunar ligament and pectineal ligament, again leaving the preperitoneal fat with the flap. If a direct hernia is present, it is often necessary to peel the redundant preperitoneal fat and peritoneum out of the defect in a hand over hand fashion. The exception to the deep level of dissection of the peritoneal flaps is over the vas, iliac vessels and spermatic vessels. The peritoneum is more closely adherent to these structures and the plane of dissection should be kept close to the deep surface of the peritoneum, leaving fat on the vascular side, to avoid injury.
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This page was last modified on 3/1/1998.
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