DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Symptomatic left inguinal hernia.
2. Morbid obesity.
3. Obstructive sleep apnea.
POSTOPERATIVE DIAGNOSES:
1. Symptomatic left inguinal hernia.
2. Morbid obesity.
3. Obstructive sleep apnea.
4. Indirect and direct left inguinal hernia.
OPERATION PERFORMED: Open left inguinal herniorrhaphy with mesh, Gore-Tex bioabsorbable plug for indirect portion, Bard extra large plug for direct portion.
SURGEON: John Doe, MD
SEDATION: General with endotracheal intubation
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old gentleman who presents with a symptomatic left inguinal hernia. The patient presents at this time for a left inguinal herniorrhaphy. The different options were discussed with the patient, both open and laparoscopic. The patient opted to have open left inguinal herniorrhaphy. The procedure including risks and potential complications such as bleeding, infection, nerve injury, post inguinal hernia pain syndrome and recurrence were discussed with the patient. The possibility of infection of the mesh requiring further surgery was discussed. The patient understood and agreed to proceed as planned.
OPERATIVE FINDINGS: The patient had a large indirect left inguinal hernia. The patient also had a large direct inguinal hernia. There was large amount of fat in the inguinal canal associated with the cord structures.
DESCRIPTION OF OPERATION: The patient was brought into the operating room and placed in the supine position. Once appropriate monitors were applied, the patient was intubated and general anesthesia was achieved. The patient’s abdomen was widely prepped and draped in a sterile fashion. An incision was made in the left inguinal hernia and taken down to the external oblique aponeurosis. The external oblique aponeurosis was attenuated with some fatty tissue bulging through the wall of the external oblique aponeurosis. The external oblique aponeurosis was incised and the cord structures encircled. There was a large amount of fatty tissue in this area. The cord structures were carefully encircled at the pubic tubercle. The fatty tissues were teased away from the cord structures. There was a large indirect inguinal hernia which had a large amount of preperitoneal fat associated with the hernia sac. This was freed up and reduced into the preperitoneal space. This hernia defect was repaired using a Gore-Tex bioabsorbable plug. It was placed into this area after rehydrating it and then it was tacked with the inner leaf to the adjacent structures to secure the repair.
Satisfied with this repair, attention was turned towards the inguinal canal floor. There was evidence for 2 moderate-size hernias right next to each other with a small bridge of normal tissue. The bridge of normal tissue was incised to make one hernia defect. The transversalis fascia was incised circumferentially. This allowed for the fatty tissue to be reduced into preperitoneal space. Because the entire floor had to be reconstructed, it was done with a permanent mesh. A Bard extra large plug accommodated the defect well. The inner leafs were tacked circumferentially to the conjoined tendon and shelving edge circumferentially using 2-0 Prolene sutures.
Satisfied with this repair, an onlay patch was then placed over the inguinal canal for tacking at the pubic tubercle using a U stitch of 2-0 Prolene. Care was taken to incise the opening to accommodate the large cord structures in order not to impinge on the cord structures. The onlay patch was tacked to the conjoined tendon using 2-0 Vicryl sutures. Satisfied with the way the onlay patch laid, it was then closed in the external oblique aponeurosis using a continuous 2-0 Vicryl suture. Care was taken not to impinge on the cord structures at the newly constructed internal ring and newly constructed external ring.
The wound was vigorously irrigated. Hemostasis was achieved. There was no active bleeding noted. At this point, Scarpa fascia was approximated using a single 3-0 Vicryl suture. Skin was then closed using 4-0 Vicryl in subcuticular fashion. Steri-Strips were applied and sterile dressing. The patient tolerated the procedure well without any complications. Estimated blood loss was approximately 10 mL. All instrument and sponge counts were reported correct x2. The patient was extubated and taken to the recovery room in stable condition.
