Date of Procedure: 04/26/2015

Procedure: Right inguinal hernia repair with mesh

Pre-procedure diagnosis: Right inguinal hernia
Post-procedure diagnosis: Right indirect inguinal hernia
Attending: Dr. Dessi Boneva
Assistants: Dr. Michael Keyes, PGY-2
Anesthestic: GEA
Indications:
21M with a known right inguinal hernia that presents to KRED c/o a 1 day hx of increasing pain in his right groin. Pt
noticed a bulge near his right scrotum that he could not push back in. He stated that the pain got worse prompting
him to come to the ED. Pt currently c/o 9/10 pain in his right scrotum that radiates down his leg. He denies CP,
SOB, N/V/D/F/C or obstructive type symptoms. On exam a reducible right inguinal hernia was found. CT A/P showed
no obvious hernia however a f/u testicular U/S showed RIH w/ bowel contents.
Procedure:
After informed consent was obtained, the patient was taken to the OR and placed in supine position on operating
room table. General endotracheal intubation was performed. The patients right groin was then prepped and draped
in the usual surgical fashion. The landmarks of the anterior superior iliac spine and pubic tubercle were demarcated
with a marking pen and a 5 cm oblique incision was made with a 10 blade scalpel. Electrocautery was used to
dissect the subcutaneous tissue until the fibers of the external oblique aponeurosis were identified. A small incision
was made over the aponeurosis with a 10 blade and the incision line was extended superiorly and inferiorly in the
direction of the fibers using metzenbaum scissors. The inguinal floor was exposed by creating superior and inferior
flaps of the external oblique. The spermatic cord was identified, mobilized at the pubic tubercle and isolated using a
Penrose drain. This was done by dissecting the cremasteric fibers from the cord. The anteromedial aspect of the
cord was examined and an indirect hernia sac was identified. The sac was carefully dissected free of the cord down
to the level of the internal ring. The vas deferens and testicular vessels were identified and protected during the
remainder of the operation. During dissection of the hernia sac, the peritoneum was violated with visualization of
intra-abdominal bowel contents. This was repaired using 0 vicryl suture in an interrupted fashion. Attention was
returned to the hernia sac. The sac was and the contents were reduced into the peritoneal cavity. The sac was
twisted and suture ligated with 3-0 silk suture. The redundant sac tissue was excised using electrocautery. The
stump of the sac was checked for hemostasis and allowed to retract into the abdomen. The floor of the inguinal
canal was assessed digitally and found to be intact. To repair the floor of the canal, a polypropylene mesh was cut
to size in an oval with a longitudinal lateral opening. Starting at the pubic tubercle, the mesh was secured flat with
interrupted 2-0 prolene sutures to the reflected edge of the inguinal ligament inferiorly, the conjoint tendon
superiorly. The ends of the patch were draped around the cord structures at the level of the internal ring then
sutured together. The Penrose drain was removed and the cord itself was returned to its anatomic location above
the mesh. The external oblique aponeurosis and Scarpas fascia was re- approximated using continuous 0-0 vicryl
suture. The dermis was approximated using interrupted 3-0 vicryl. The skin was closed using a 4-0 subcuticular
continuous Monocryl. The operative field was cleaned and dried. Dermabond was applied over the wound. The
testes were gently pulled down into its anatomic position in the scrotum. All instrument and sponge counts were
correct. The patient was extubated and transferred to the PACU in stable condition.