PREOPERATIVE DIAGNOSIS: Right abdominal wall spigelian hernia.
POSTOPERATIVE DIAGNOSIS: Right abdominal wall spigelian hernia.
PROCEDURE PERFORMED: Repair of right abdominal wall spigelian hernia using polypropylene mesh.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 25 mL.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: This patient presents with history of a slowly enlarging bulge along her right lower quadrant abdominal wall just lateral to her rectus abdominus musculature. Physical examination and CT scan of the abdomen and pelvis were consistent with a right spigelian hernia containing small bowel loops without obstruction. The patient will now undergo planned repair of this large right spigelian hernia using polypropylene mesh.
DESCRIPTION OF PROCEDURE: The patient was transported to the operating room and placed supine on the operating table. Following induction of satisfactory general endotracheal anesthesia, the abdomen was prepped and draped in the customary fashion using iodine solution, Ioban drape and sterile towels and sheets.
A right lower quadrant oblique incision was made overlying the palpable hernia and the dissection carried into the subcutaneous tissue. All bleeding points were controlled with the Bovie electrocautery. The dissection was carried down to the level of the external oblique musculature, which was opened along the course of its fibers. The hernia sac was identified and was carefully mobilized from the surrounding muscle of the abdominal wall. The sac was opened and was found to contain small bowel loops which were easily reduced back into the abdominal cavity. No other fascial defects were identified along the right lower quadrant abdominal wall or the lower midline. The omentum was returned to its normal position overlying the small bowel and the excess hernia sac excised. The peritoneum was closed with running 2-0 Vicryl suture, and a retromuscular extraperitoneal plane developed beneath the internal oblique musculature. This extended at least 3 to 4 cm beyond the margins of the defect and all bleeding points were controlled with the Bovie electrocautery. Next, an appropriate size piece of Prolene mesh was positioned in this retromuscular space extending at least 3 to 4 cm beyond the edges of the defect. The mesh was secured in place with horizontal mattress sutures of 0 Prolene placed in the internal oblique musculature.
The external oblique musculature was then closed with running 0 Prolene suture, and at the completion of the repair, the defect appeared to be well covered with both muscle as well as mesh. The area of dissection was thoroughly irrigated with Kantrex solution and checked for hemostasis. The subcutaneous tissue was then closed with interrupted 3-0 Vicryl sutures and 0.5% Marcaine instilled into the incision. The skin was closed with a running 4-0 Vicryl subcuticular suture, and benzoin and Steri-Strips as well as a Tegaderm dressing placed across the incision. The patient was awakened and transported back to the recovery room in satisfactory condition with sponge and needle counts reported as correct at the end of the procedure.
