If the direct space/Hesselbach’s triangle is intact, a choice of repair must be made. If the internal ring is dilated less than 2cm, a high ligation and “ring pexy”/Marcy repair may be sufficient in a young patient. Significant dilation of the internal ring impinging on the direct space (Nyhus type III hernia) requires a formal tissue or mesh repair. The following sequence shows an iliopubic tract/Shouldice type tissue repair. This is an “anatomic” repair using the patient’s own tissues. It requires that the tissues around the hernia are strong and not attenuated and weakened by the hernia. The first step is carefully opening the transversalis fascia of the deep ring over the inferior epigastric vessels.
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