What are the step‑by‑step instructions for performing an open inguinal hernia repair using the McVay (Cooper‑ligament) technique?

McVay (Cooper's Ligament) Repair: Step-by-Step Technique

The McVay repair is a tissue-based open inguinal hernia technique that addresses posterior wall defects by suturing the transversus abdominis aponeurosis and transversalis fascia to Cooper's ligament, but it has been largely superseded by mesh-based repairs due to superior recurrence rates with synthetic mesh (0% vs 19% with tissue repair). 1

Historical Context and Current Role

The McVay technique, first published in 1949, was designed to repair both inguinal and femoral hernias through a single inguinal approach by utilizing Cooper's ligament instead of the inguinal ligament. 2 While this method addresses the posterior wall of the inguinal canal—a key advantage over other tissue repairs—it creates significant tension on approximated tissues, leading to postoperative pain and prolonged recovery. 3

Modern guidelines strongly recommend mesh repair as the standard approach for all non-complicated inguinal hernias due to markedly lower recurrence rates without increased infection risk. 1

Surgical Steps of the Modified McVay Technique

1. Incision and Exposure

• Make a standard inguinal incision 1 cm above the medial half of the inguinal ligament to access the inguinal canal. 4
• Open the external oblique aponeurosis along the direction of its fibers to expose the inguinal canal contents. 5

2. Sac Management

• Identify and isolate the hernia sac from the spermatic cord structures. 5
• Perform high ligation of the indirect hernia sac at the level of the internal ring. 5
• For direct hernias, reduce the sac and identify the defect in the transversalis fascia. 2

3. Posterior Wall Reconstruction (Core of McVay Technique)

• Identify Cooper's ligament (pectineal ligament) along the superior pubic ramus—this is the critical anatomical landmark that distinguishes McVay from Bassini repair. 2, 3
• Suture the transversus abdominis aponeurosis and transversalis fascia to Cooper's ligament using interrupted non-absorbable sutures, starting medially at the pubic tubercle and extending laterally. 2
• This closure addresses both the inguinal and femoral spaces simultaneously, preventing femoral hernia formation. 3

4. Transition Suture and Relaxing Incision

• Place a "transition suture" where Cooper's ligament ends laterally, attaching the transversus to the inguinal ligament to avoid a gap. 3
• Perform a relaxing incision in the anterior rectus sheath 1-2 cm medial to the rectus muscle edge to reduce tension on the repair—this step is mandatory to prevent excessive tension. 5

5. Spermatic Cord Repositioning

• Reposition the spermatic cord outlet cranially (superiorly) to reduce tension on the repair. 5
• Place the cord between the layers of the external oblique aponeurosis. 5

6. Closure

• Close the external oblique aponeurosis over the cord to reconstruct the external ring. 5
• Close skin and subcutaneous layers in standard fashion. 5

Critical Technical Points

• Accurate anatomical identification is mandatory: The transversalis fascia and Cooper's ligament must be clearly visualized before suturing. 2
• The relaxing incision is not optional—without it, the repair creates unacceptable tension leading to pain and recurrence. 5, 3
• The technique is particularly useful for femoral hernias because it directly closes the femoral canal by suturing to Cooper's ligament. 6, 3

Major Limitations and Modern Alternatives

The McVay repair has been abandoned in most modern practice because:

• Tension on the repair causes significant postoperative pain and delayed return to activities. 3
• Recurrence rates with tissue repairs reach 19%, compared to 0% with synthetic mesh in clean fields. 1
• The relaxing incision creates an additional potential site for hernia formation. 3

For femoral hernias specifically, tension-free mesh techniques applying McVay principles (covering the myopectineal orifice with mesh anchored to Cooper's ligament) achieve zero recurrence with shorter operative times and faster recovery. 6

When McVay Might Still Be Considered

• Contaminated fields (CDC Class III-IV) with small defects (<3 cm): Primary tissue repair with non-absorbable sutures is recommended when mesh cannot be safely used. 1
• Strangulated hernias with bowel necrosis and gross contamination where biological mesh is unavailable. 1

However, even in clean-contaminated fields with intestinal strangulation and bowel resection without gross spillage, synthetic mesh remains appropriate and yields significantly lower recurrence (OR 0.34, p=0.02). 1

Common Pitfalls

• Failing to identify Cooper's ligament accurately leads to inadequate posterior wall repair. 2
• Omitting the relaxing incision creates excessive tension, increasing pain and recurrence risk. 5
• Attempting McVay repair without thorough anatomical knowledge of the myopectineal orifice structures risks injury to femoral vessels. 2
• Using tissue repair when mesh is appropriate exposes patients to preventable recurrence. 1