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If an indirect hernia is present, the edge may be seen lying on the cord structures. If the sac extends down into the scrotum, the portion over the cord is isolated and dissected distally to the pubic tubercle. The scrotal portion is best left in place, as peeling it off the cord may damage the pampiniform plexus and lead to ischemic orchitis. The cord is divided at the pubic tubercle in that case and the distal end left open.
The relationships of the indirect sac are shown. If there is no obvious sac, the cord is dissected to the internal ring where the peritoneal reflection (10:00 position on the left side, 2:00 position on the right) is identified to confirm that no indirect sac is present.
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