1. Marks are made for the procedure. It is important to mark the scrotal skin, prior to its being distorted by the prep and drape.
2. A transverse inguinal incision is used, dissection is carried down to Scarpa’s fascia.
3. Scarpa’s fascia is incised carefully, since rarely a long looping vas will be situated on top of the external oblique aponeurosis.
4. The external oblique aponeurosis is split in the direction of its fibers, and the ilioinguinal nerve is identified and preserved.
5. The hernia sac and cord structures were mobilized from distal to proximal, any traction suture placed through the testicle itself. A reasonable amount of traction must be kept on the testicle to facilitate the next part of the dissection.
6. While preserving downward traction, the hernia sac is skeletonized away from the cord structures. If this proves impossible, or the sac is entered repeatedly, then a sharp iris scissors is used to dissect the sac off of the cord. The sac commonly envelops the cord.
7. Circumferential retroperitoneal mobilization of the vas and vessels is carried out. Lateral attachments may be carefully divided. It is essential to apply upward traction on the hernia sac and perpendicular downward traction on the testicular traction suture. The hernia sac is doubly stick ligated.
8. If necessary, the cord structures can be passed medial to the inferior epigastric vessels. It is not necessary to define these vessels, simply use a right angle clamp to create a space underneath them. This allows for a more “straight shot” for the vessels down to the scrotum.
9. The inguinal canal is dilated over the examining finger, and the previously made scrotal incision sharply incised over the digit.
10. The dartos pouch is created, usually by blunt dissection. Bleeding and small vessels may need to be cauterized.
11. A mosquito clamp is inserted from the scrotum upwards, by pressing the tip of the clamp underneath the fingernail and advancing both as a unit.
12. The traction suture is grasped by the clamp, and the testicle gently pulled downward into the dartos pouch taking care not to twist it.
13. Soft tissue surrounding the inlet of the testicle into the dartos pouch is within either plicated around the testicle to contract it, or alternatively, peritesticular absorbable suture material is used to secure the testicle in the pouch. At testicle under tension will retract regardless of how it is sutured.

14. The dartos pouch skin is closed with a running horizontal mattress chromic suture.
15. The upper incision is closed in layers with absorbable suture.
16. Marcaine is injected into the incision for postoperative analgesia.
17. Two week follow up and six months follow-up are scheduled. Straddle toys and activities which might cause trauma to the area are avoided for at least two weeks.