DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES: Incarcerated left inguinal hernia with small bowel obstruction in addition to postoperative state from right upper lobectomy, postoperative pneumonia and atrial fibrillation.
POSTOPERATIVE DIAGNOSES: Incarcerated left inguinal hernia with small bowel obstruction in addition to postoperative state from right upper lobectomy, postoperative pneumonia and atrial fibrillation.
OPERATION PERFORMED: Repair of left inguinal hernia.
SURGEON: John Doe, MD
ANESTHESIA: Spinal.
SPECIMENS: Cord lipoma and hernia sac.
DRAINS: None.
MATERIALS USED: Large Bard PerFix mesh plug.
BLOOD PRODUCTS: None.
ESTIMATED BLOOD LOSS: Minimal.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old male with multiple problems. He is recovering from a right upper lobectomy. He has developed pneumonia, has had severe cough, and his pre-existing hernias had become incarcerated and now has a bowel obstruction, resulting in worsening pulmonary problems. He has been in atrial fibrillation intermittently and in the CCU.
OPERATIVE FINDINGS: An incarcerated hernia, which is partially a sliding hernia as well involving a large portion of the sigmoid colon. Bowel was viable, but somewhat edematous.
DESCRIPTION OF OPERATION: After verbal and visual identification, the patient was placed in the supine position on the operating room table. Monitoring devices were applied, including pneumatic compressive stockings. He was subsequently set up, and a spinal anesthetic was administered by the anesthesiologist. He was then repositioned supine with his left side down to accentuate the left-sided spinal block.
The left inguinal region, lower abdomen, hemiscrotum and external genitalia were then prepped with Betadine and draped in sterile fashion. We then made a 7 cm incision over the left inguinal canal. Electrocautery was used to carry this down through the subcutaneous tissue. We encountered a huge hernia sac filled with bowel extending well into the hemiscrotum. We continued to dissect laterally to find the external abdominal oblique aponeurosis and the external ring. This external ring aperture was pushed extremely laterally given the large size of the hernia. We then opened the inguinal canal extending laterally. We were able to dissect the hernia sac out of the hemiscrotum. We dissected the cord structures away from the hernia sac. We could not reduce the contents of the hernia sac; although, there was no dead bowel appearance within this.
We then opened the hernia sac and began reducing the contents back through the internal ring into the abdominal cavity. The distal portion of the sigmoid colon was part of the hernia sac forming a sliding-type hiatal hernia. We had to dissect these peritoneal attachments from the distal portion of the sigmoid colon to the point that it allowed us to reduce this into the abdominal cavity. We then had to close the peritoneal defect using a running 2-0 Prolene suture. We excised some of the excess hernia sac as well. This was all closed as one layer of the suture.
We then inverted the hernia sac through the internal ring and a large Bard PerFix mesh plug was placed through the defect, and we secured this circumferentially to the fascial edges with interrupted 2-0 Vicryl sutures. The onlay patch was then placed in the inguinal canal. The tails were reapproximated lateral to the cord structures with 2-0 Vicryl suture. We secured this to the floor of the inguinal canal with interrupted 2-0 Vicryl sutures at the level of the pubic tubercle, transverse arch, and shelving edge of Poupart ligament. The tails were placed well beneath the external abdominal oblique aponeurosis laterally. The cord structures returned to the inguinal canal and the external oblique was closed over the inguinal canal with a running 2-0 Vicryl suture. Care was taken not to entrap structures or to over tighten the external ring.
Scarpa fascia was approximated with inverted interrupted 3-0 Vicryl sutures as was the deep dermis. The skin edge was approximated with running subcuticular 4-0 Vicryl suture. Steri-Strips and sterile surgical dressings were then applied. The patient was then transported to the recovery room. He tolerated this under spinal anesthesia very well. He was stable throughout the procedure and very comfortable.
