DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left inguinal hernia.
POSTOPERATIVE DIAGNOSIS: Left inguinal hernia, direct.
OPERATION PERFORMED: Laparoscopic preperitoneal left inguinal hernia repair.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia combined with endotracheal tube intubation.
SPECIMEN: None.
COMPLICATIONS: None.
DRAINS: None.
ESTIMATED BLOOD LOSS: Negligible.
INTRAOPERATIVE FINDINGS: Upon looking with the laparoscope, a large direct hernia was identified. There was no cord lipoma identified. There was no indirect inguinal hernia or femoral hernia identified. No other abdominal pathology was noted. There were no rents made within the peritoneum during the course of our dissection.
INDICATIONS FOR OPERATION: This (XX)-year-old Hispanic male has developed a symptomatic left inguinal hernia. Repair has been indicated, and because of the patient’s preference, a laparoscopic repair has been elected. Operative consent was signed and placed upon the chart.
DESCRIPTION OF OPERATION: The patient was taken to the operating room, and the site of surgery was verified. The patient was then placed in the supine position with arms tucked at the sides. Bilateral lower extremity athrombics were placed. After obtaining adequate anesthesia, the patient’s abdomen was then prepped and draped in the standard sterile fashion. The patient was then slightly placed in Trendelenburg position. Local anesthetic was then infiltrated in an infraumbilical location near the midline.
Incision was then made and deepened through the subcutaneous tissues. Just a little bit to the left of the midline, an incision was then made with an 11 blade through the anterior rectus sheath, and the rectus muscle was then moved laterally, and the posterior sheath was identified. Upon doing this, a 10 mm trocar in the inflation balloon was then placed down within the space and then adequately insufflated. Once this was completed, this trocar was then changed out for a 10 mm balloon and trocar that was then insufflated. Once this occurred, the abdomen was then insufflated with carbon dioxide to a pneumoperitoneum of 250 mmHg. Placement of the laparoscope revealed a left inguinal hernia with a direct defect.
At this time, we then went ahead and placed two more 5 mm trocars within the midline location under direct vision. The left inguinal region was then inspected along with the median umbilical ligament, medial umbilical ligament, and the lateral umbilical fold was then identified. The peritoneum in the lateral aspect, approximately 2 cm above the superior edge of the direct hernia defect, extending from the anterior to superior iliac spine, was then mobilized with blunt along with sharp dissection. The inferior epigastric vessels were exposed, and the pubic symphysis was identified. Cooper ligament was also dissected to this junction with the femoral vein. Dissection was carried inferiorly to the iliopubic tract with care taken to avoid any injury to the femoral branch of the genitofemoral nerve and the lateral femoral cutaneous nerve. The cord structures were then slightly skeletonized.
The direct hernia sac was identified with gentle traction. There was no indirect sac noted even though there was easy mobilization of the cord structures to make sure that there was no cord lipoma, which was not present. Once our dissection had been completed, a large piece of 3D Max mesh was then rolled longitudinally into a compact cylinder and passed through a trocar. The cylinder was placed along the inferior aspect of the working space and then unrolled into place to completely cover the direct defect along with the femoral spaces. The mesh was then stapled into place, first along the superior border of the prosthesis from near the pubic symphysis toward the anterior superior iliac spine. The inferior border of the mesh was then stapled to the Cooper ligament medially, the pubic tubercle to the level of the femoral vein. Care was taken not to disrupt any vascular structures. The lateral portion of the mesh was then easily placed down within the dissection plane and was shown to lie comfortably. There were no tacking sutures in this area.
After assuring adequate hemostasis using electrocautery, the trocars were then removed, and the pneumoperitoneum was slowly evacuated while making sure our mesh stayed in proper position. The trocar incisions were then closed with simple interrupted sutures of 4-0 Monocryl. A sterile dressing was applied. The patient tolerated the procedure well and was then taken to the postanesthesia care unit in stable condition. All sponge, instrument, and needle counts were correct at the end of the case.
