DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right inguinal hernia.
POSTOPERATIVE DIAGNOSES:
1. Right inguinal hernia.
2. Indirect hernia found.
3. Lipoma of the cord.
PROCEDURE PERFORMED: Laparoscopic preperitoneal right inguinal hernia repair with placement of mesh.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
OPERATIVE FINDINGS: A moderate to large sized direct inguinal hernia, also a moderate sized lipoma of the cord. No indirect hernia sac was noted.
DESCRIPTION OF PROCEDURE: The patient was placed on the operating table in the supine position. After suitable general anesthesia was obtained, a Foley catheter was placed, and the abdomen was prepped and draped in the usual sterile manner. A transverse infraumbilical incision was made and carried down through the skin and subcutaneous tissue with a scalpel. Bleeding points were controlled with electrocautery device.
The right anterior rectus fascia sheath was transversely incised. The rectus muscle was dissected laterally. The dissected lumen was placed down to the pubic tubercle area and noted to be in good position laparoscopically. This was then inflated to 40 puffs of air, creating a preperitoneal space. The dissecting balloon was removed and a structured balloon was placed in the same plane, inflated and locked in place. A pneumopreperitoneum was established. The patient was placed in a Trendelenburg position. Next, 5 mm ports were placed in the lower midline under direct visualization, after skin incisions were made. Blunt and sharp dissection revealed the above findings.
The majority of the direct hernia was reduced bluntly by the insufflating balloon, and the remaining few attachments were taken down under direct visualization with full reduction of the direct hernia. Laterally, the cord structures were isolated. A moderate sized lipoma of the cord was reduced from the canal. No indirect sac was noted on skeletonization of the cord structures. A piece of Ultrapro mesh was then cut in proper size with a slit placed laterally. This was placed into preperitoneal space. The slit was placed around the spermatic cord, forming a new internal ring with the inferior flap overlapping the superior flap laterally. A 5 mm tack was then used, the tacks to stay as superior as possible, tacking the overlying flaps of mesh and then medially along the anterior abdominal wall, and then along the pubic area and the ileopubic tract area to keep it in place over the direct defect. The mesh was noted to lay quite nice and flat along the abdominal wall.
The pre-peritoneum was desufflated under direct visualization. All ports were then removed. The anterior rectus fascia was closed with a running heavy Vicryl suture. The abdomen was closed with 3-0 Vicryl subcutaneous and 4-0 Vicryl subcuticular skin closure. Steri-Strips and Band-Aids were applied. The Foley catheter was removed, and the right testicle was noted to be in the appropriate hemiscrotum. The patient tolerated the procedure well and was taken back to the recovery room with stable vital signs.
