Even in the face of an obvious direct hernia, no inguinal hernia operation is complete until the spermatic cord is examined for the presence of an indirect (see inguinal hernia anatomy and repair). After mobilizing this large direct hernia sac, only careful inspection of the cord revealed a small indirect sac.
The inguinal floor was imbricated with running 2-0 monofilament suture to control the large floppy sac prior to placing a mesh patch for repair. Some surgeons place a mesh plug in the inverted direct sac in addition to the patch.
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