DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Ventral abdominal hernia.
POSTOPERATIVE DIAGNOSIS: Ventral abdominal hernia.
OPERATION PERFORMED: Laparoscopy and open ventral abdominal herniorrhaphy.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General.
OPERATIVE FINDINGS: There were extensive intraabdominal adhesions making it quite difficult, if is not impossible, to approach this hernia laparoscopically. The defect itself was approximately 5 cm with a very large sac containing omentum and transverse colon.
DESCRIPTION OF OPERATION: With the patient adequately anesthetized under general anesthesia, the abdomen was prepped and draped in the usual fashion and a Foley catheter was placed. With the patient in steep Trendelenburg with the right side rotated down, a left lower quadrant incision was performed. Dissection was performed down to the external oblique fashion, which was incised along its fibers. The internal oblique musculature was spread. The posterior sheath was grasped and elevated, and the peritoneum was entered. A #11 mm trocar was inserted and fixed in place using the balloon. The abdomen was then inflated and the laparoscope was inserted.
This revealed the left lower quadrant encased with dense omental and colonic adhesions. Attempts to perform laparoscopy in all four quadrants failed due to extensive adhesions throughout the abdomen. At that time, it was decided to abort a laparoscopy attempt at this repair. The abdomen was left inflated, and an upper midline incision was performed. Dissection was performed down to the hernia sac, which was quite large. This was sharply and bluntly dissected free from its surrounding attachments down to the level of the fascia. Grasping the sac, the sac was then separated from its deep fascial attachments for approximately 5 to 8 cm surrounding the entire sac. This resulted in several small holes in the hernia sac, which were carefully closed with running #2-0 Vicryl sutures. When the sac was fairly well separated from the deep surface of the fascia, the abdomen was then deflated and the sac was inverted.
A piece of Marlex mesh was cut to size with a good minimum with 3 cm margin surrounding the fascial defect. This was then put in place superficial to the peritoneum and sac and deep to the fascia. A series of 0 Prolene sutures were then used to suture the Marlex mesh to the undersurface of the fascia. Once a ring of occlusive sutures had been applied, the entire system was tested, and there were found to be no defects in the sutured mesh circumference. The fascia was then closed primarily over the mesh with a running #1 PDS suture. Any ongoing blood loss from the subcutaneous tissues was electrocauterized. The wound was then copiously irrigated with saline solution.
Subcutaneous tissue was closed with #3-0 Vicryl sutures in the midline wound. The fascia in the left lower quadrant wound was closed with a running 0-Vicryl suture. All skin wounds were then closed with 4-0 Vicryl subcuticular stitches. Steri-Strips were applied to the wounds, which was dressed, and the patient was returned to the recovery room, awake, and in stable condition. All counts were correct at the end of case x2. There were no complications. Blood loss was minimal.
