repair of transversalis fascia

Last reviewed 01/2018

Once a superior and inferior flap of transversalis fascia have been dissected out along the length of the inguinal canal, they are approximated and reinforced using a double-breasting technique.

The free edge of the lower flap is sutured to the undersurface of the superior flap at a distance of 0.2-0.4cm from the latter's edge. The repair is commenced at the medial edge of the canal in the lower flap where it is inserted into the periosteum of the pubic tubercle. The suture is continuous. It must be ensured that the stump of the excised sac and the peritoneum are reduced behind the transversalis fascia as it is approximated in a superolateral direction. Eventually, the transversalis fascia comes to lie around the medial border cord as part of the reconstituted deep ring; the repair should not be too tight at this point.

The suture is not secured but instead the direction of suturing is reversed back towards the pubic bone. During this second pass, the remaining free edge of the superior flap is sutured to the reflected deep edge of the inguinal ligament as it forms the floor of the canal deep to the cord. Again, a continuous technique is used. This second layer produces a double-breasting effect. This has the effect of reinforcing the main area of weakness - the medial part of the posterior wall.

The tranversalis fascia is relatively weak, so to reduce the risk of stitches tearing the layer in one plane, on both passes bites are taken of alternating distance from the wound edge. This aims to redistribute tension at two levels within each edge of fascia.