The iliopubic tract. The key to inguinal herniorrhaphy?

The iliopubic tract exists. It is not illusory. It is the small inferior tongue of the transversus abdominis aponeurosis; separated from its parent by the spermatic cord at the internal ring. The tract may be reinforced by a variable number of fibers from the transversalis fascia, however the entire structure is of significant strength in less than 25% of cases. Since the iliopubic tract inserts into the pubic ramus, a significant gap is created between it and the main transversus aponeurosis which inserts some distance above into the rectus sheath. Despite the use of a relaxing incision and irrespective of whether one sutures the transversus aponeurosis to Cooper's ligament, Poupart's ligament, or the iliopubic tract, unacceptable tension occurs. This results from attempting to approximate tissues not normally in apposition. A tension free repair is suggested which should significantly reduce the bête noir of the hernia surgeon-recurrence.