DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Symptomatic umbilical hernia.
POSTOPERATIVE DIAGNOSIS:
Symptomatic umbilical hernia.
OPERATION PERFORMED:
Umbilical hernia repair with mesh.
SURGEON: John Doe, MD
ANESTHESIA: General with intubation along with 0.5% plain Marcaine, 1% plain lidocaine.
ANESTHESIOLOGIST: Jane Doe, MD
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old patient who was evaluated as an outpatient and found to have a symptomatic umbilical hernia.
FINDINGS: The patient had a 4 cm subfascial defect, through which protruded a hernia sac. There was no evidence of tissue compromise. No incarceration. There were no other fascial defects in the area.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed supine on the operating room table. After general anesthesia was induced, his abdomen was prepped with Betadine solution and sterilely draped in the usual manner for procedure in this area.
An infraumbilical curvilinear incision was created and extended through subcutaneous tissues to the anterior rectus fascia. The hernia sac was dissected off of the cord structures. It was sharply dissected off of the undersurface of the umbilical skin with the scalpel. A small opening in the hernial sac resulted in omentum protruding. This was placed back within the preperitoneal space and the opening closed with a 3-0 PDS suture. The fascial defects were delineated. The hernia was placed back within the preperitoneal space. The preperitoneal space was developed.
A Bard Ventralex hernia patch, 4.3 x 4.3 cm, was used. It was attached to the anterior rectus fascia with 0 Prolene sutures. Subcutaneous tissues were closed with interrupted sutures of 3-0 PDS. The fascial layer and subcutaneous layer were infiltrated with anesthetic solution. The skin was closed with a subcuticular suture of 4-0 PDS. Half-inch Steri-Strips were applied and a bulky occlusive dressing was applied over this and an abdominal binder placed. The patient tolerated the procedure well and was transferred to the recovery room in stable condition. Estimated blood loss was 10 mL. Sponge, needle, and instrument counts were correct.
