The floor of the inguinal canal is formed by the transversalis fascia and the inguinal ligament, reinforced medially by the lacunar (Gimbernat's) ligament and posteriorly by the reflected inguinal ligament and conjoint tendon. This aponeurotic floor is the primary barrier to direct inguinal hernia formation.
Weakness of the inguinal canal floor aponeurosis in the medial triangle of Hesselbach allows direct inguinal hernia protrusion medial to the inferior epigastric vessels. Shouldice and Bassini repairs reconstruct this floor using the transversalis fascia and conjoint tendon. Laparoscopic mesh repair reinforces the floor from the preperitoneal space. The floor integrity is assessed during open hernia surgery by its resistance to digital pressure.
Protrusion through a weakness in the inguinal canal floor aponeurosis medial to the inferior epigastric vessels, producing a reducible medial groin bulge that does not extend into the scrotum, repaired by floor reconstruction or mesh reinforcement.
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