This is a modified McVay hernia repair technique. My career experience with over 6,000 cases is a recurrence rate of 2.7%. Significant persistent chronic pain only occurred in 2 patients. Using general anesthesia combined with local and regional block and perioperative gabapentin resulted in excellent control of postoperative pain control with 50% of patients never taking a pain pill. You may email me if you would like more details of this anesthesia technique.
Open the inguinal canal in the standard fashion.
Ligate and resect cord lipoma and hernia sac.
Preserve cremasteric muscle and identifiable nerves.
Do not open posterior wall of inguinal canal.
Identify transversalis fascia just inferior to visible muscle by grabbing and distracting with Allis clamp then grabbing a bigger bite with a second clamp.
Use a permanent braided suture like 2-0 Ethibond for the repair. Do not use Prolene suture.
Starting medially place two stitches in Coopers ligament taking care not to impinge the femoral vein.
Transition to the shelving edge of the inguinal ligament and proceed lateral to the internal ring.
Snug the internal ring with two stitches lateral to the ring.
Preform a relaxing incision in the rectus sheath if required. You can easily identify tension by palpation.
Close the external oblique fascia as far medial as possible with absorbable suture.
Comments - The internal ring is a common site for recurrences, snugging the ring with two lateral repair sutures prevents this. Resecting the cremasteric muscle may result in ptosis of the testicle. Resecting nerves may result in distressing dysesthesia. Prolene sutures in the groin causes chronic inflammation which may result in chronic pain. Preserving the shutter function of the roof of the inguinal canal decreases recurrences.