OT notes · General Surgery

Laparoscopic inguinal hernia repair (TEP / TAPP)

Usual anaesthesia
General anaesthesia
Position
Supine (head-down tilt helps), arms tucked; surgeon on the side opposite the hernia
Setting
elective

Operative note template for laparoscopic inguinal hernia repair by TEP or TAPP, with a filled example for an elective right direct inguinal hernia repaired by TEP.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • conversion to open repair
  • injury to bladder, bowel or iliac vessels
  • bleeding from inferior epigastric vessels
  • injury to vas deferens or testicular vessels
  • seroma or haematoma in the groin or scrotum
  • nerve injury with thigh numbness or pain (lateral femoral cutaneous, genitofemoral)
  • recurrence of the hernia
  • mesh infection, displacement or erosion

Pre-operative details for this operation

  1. Side and type (clinical)RightLeftBilateralprimary or recurrent; previous repair and approach
  2. Site markedYes, both sides examined, marked side(s) confirmed
  3. Previous lower abdominal or pelvic surgerymidline scar, caesarean, prostatectomy, pelvic radiation (these make TEP difficult)
  4. BladderVoided just before OTCatheterised
  5. Antiplatelets or anticoagulantsdrug and date stopped
  6. Consent for conversion to open (Lichtenstein) repairTaken
  7. Mesh and fixation device availabletype, size; tacker or glue if planned

Anaesthesia and position

  1. AnaesthesiaGeneral with endotracheal intubation
  2. ApproachTEPTAPPeTEP
  3. Position and teamsupine, head-down; surgeon opposite the hernia side; monitor at the foot end
  4. AccessTEP: sub-umbilical incision, anterior rectus sheath opened, rectus retracted; balloon or telescope dissection. TAPP: open or Veress umbilical entry
  5. Portssizes and sites
  6. CO2 pressuremmHg
  7. Telescope0 degree30 degree

Operative findings

  1. Hernia type on each sideIndirect (lateral to inferior epigastric vessels)Direct (medial)FemoralPantaloonNo herniarecord for both sides if both were seen
  2. Size of defectdiameter in cm or finger breadths
  3. Sacreduced fully or transected; contents
  4. Cord lipomaNonePresent, reducedPresent, excised
  5. Landmarks identifiedpubic symphysis, Cooper ligament, inferior epigastric vessels, iliopubic tract, vas, testicular vessels, iliac vein
  6. Contralateral side (TAPP or on dissection)normal / occult hernia

Procedure (steps)

  1. Entry into the preperitoneal space (TEP) or peritoneal cavity (TAPP)
  2. TAPP: peritoneal incisionfrom the medial umbilical ligament to the ASIS, about 2 cm above the defect; flaps raised
  3. Medial dissectionpubic tubercle across the midline, Cooper ligament, space of Retzius 2 to 3 cm below the pubis
  4. Direct sac reducedpseudosac (transversalis fascia) separated; fixed up or not
  5. Femoral orifice checkeddissection between Cooper ligament and iliac vein
  6. Indirect sacFully reducedTransected, proximal end looped or ligated, distal left openNo indirect sacvas and testicular vessels seen and separated
  7. Parietalisation of the cord and cord lipoma reduced
  8. Lateral dissectionbeyond the ASIS along the psoas
  9. Critical view of the myopectineal orificeAchievedNot achieved (reason)
  10. Haemostasis checked before mesh
  11. Meshmaterial, size (at least 15 x 10 cm), slit or no slit; lot and batch number, sticker
  12. Mesh fixationNoneTacks to Cooper ligament / pubic boneTacks along upper edgeGlueSuturesnumber of tacks; none placed below the iliopubic tract lateral to the vas
  13. Peritoneal tear (TEP)NonePresent, closedPresent, Veress placed to vent
  14. TAPP: peritoneal flap closedsuture, tacks or clips; no gaps
  15. Desufflation under visionmesh stays flat, lower edge does not roll up

Closure, drains and dressing

  1. Ports removed under vision
  2. Fascia of 10 mm port sitessuture material and size
  3. SkinSubcuticular absorbableInterruptedSkin glue
  4. DrainNoneClosed suction drain in preperitoneal space
  5. Local anaesthetic to port sitesdrug, strength, volume, if given

Specimens and implants

  1. Mesh sticker pasted in case sheetmaker, type, size, lot/batch, expiry
  2. Tacker or gluetype, number of tacks, lot number
  3. Sac or lipoma sent for HPESentNot sent

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Vitalspulse, BP; watch for groin or scrotal swelling and abdominal distension
  2. Urinerecord first void; catheter out when awake if placed
  3. Dietliquids when awake, then normal
  4. Analgesiadrug, dose, frequency
  5. Mobilisationwalk the same day
  6. Seroma advicegroin swelling in the first weeks may be a seroma; review at follow-up
  7. Discharge and follow-upport-site check; review for recurrence and chronic pain

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. V.S., 48 years, right groin swelling for 1 year, globular, reducible, not entering the scrotum. Left groin normal on examination. No previous abdominal surgery.

Case details

Date: 03/03/2027. Elective right laparoscopic TEP mesh repair. OT 3.

In OT 09:00. GA induced 09:10. Incision 09:22. Ports out 10:30. Closure completed 10:38.

Surgeon: Dr A. (3rd-year resident, General Surgery). Camera: Dr B. Consultant: Dr C., scrubbed for the dissection.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: symptomatic right reducible inguinal hernia, clinically direct.

Right groin marked with an arrow in the ward and checked at time out. Voided urine just before shifting.

Consent: general, procedure-specific (including conversion to open repair, bladder and vessel injury, seroma, chronic pain, recurrence) and anaesthesia consent taken in Telugu from patient, brother as witness.

WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 09:12, before incision. Polypropylene mesh 15 x 15 cm and tacker in OT.

Anaesthesia and position

General anaesthesia with endotracheal intubation. Supine, both arms tucked, slight head-down tilt.

Surgeon on the patient's left, camera assistant beside the surgeon, monitor at the foot end on the right.

Abdomen and groins painted with povidone-iodine and draped.

Findings

Right direct inguinal hernia, defect about 3 cm, medial to the inferior epigastric vessels, with a white pseudosac. No indirect sac. Small cord lipoma lateral to the cord.

No femoral hernia. Left side not dissected.

Pubic symphysis, Cooper ligament, inferior epigastric vessels, iliopubic tract, vas and testicular vessels, and iliac vein identified.

Procedure

10 mm sub-umbilical transverse incision. Right anterior rectus sheath opened, rectus retracted laterally, preperitoneal space entered behind the rectus.

Space developed with the 0 degree telescope towards the pubis. CO2 insufflation at 12 mmHg. Two 5 mm midline ports placed under vision below the camera port. Changed to 30 degree telescope.

Medial dissection: pubic tubercle cleared across the midline, Cooper ligament cleared, space of Retzius opened about 2 to 3 cm below the pubis.

Direct sac reduced by traction and counter-traction, pseudosac separated. Femoral orifice checked between Cooper ligament and iliac vein: no hernia.

Cord lipoma reduced. Peritoneum swept off the vas and testicular vessels (parietalisation) until the cord lay flat.

Lateral dissection along the psoas to beyond the ASIS. Critical view of the myopectineal orifice achieved. Haemostasis checked.

No peritoneal tear.

Polypropylene mesh 15 x 15 cm (lot no. ____) rolled, passed through the 10 mm port, unrolled flat over the direct, indirect and femoral spaces without folds.

Mesh fixed with two tacks, one to the pubic bone and one to Cooper ligament. No tacks lateral to the vas below the iliopubic tract.

CO2 let out under vision. Lower edge of mesh stayed flat and did not roll.

Closure

Ports removed under vision. Anterior rectus sheath at the 10 mm site closed with polyglactin 910 (Vicryl).

Skin closed with subcuticular absorbable suture. No drain. Dressings applied.

Specimens and implants

Implants: polypropylene mesh 15 x 15 cm, maker, lot and expiry recorded; tacker lot recorded; two tacks used. Stickers pasted on the OT register and case sheet.

Specimens: none.

End of procedure

Estimated blood loss about 10 ml. No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications. No conversion.

Extubated and shifted to post-operative ward in stable condition. Pulse 80/min, BP 126/80 mmHg.

Post-op orders

Pulse and BP 1-hourly for 4 hours. Watch for groin or scrotal swelling.

Record first void.

Liquids when fully awake, then normal diet.

No further antibiotic doses.

Analgesia as charted by the anaesthetist.

Walk this evening. Avoid heavy lifting.

Explain that a soft groin swelling in the first weeks may be a seroma and should be shown at follow-up. Port-site check at follow-up.

Signature

Dr A., JR-3, General Surgery. Reg. no. ________. 03/03/2027, 10:50.

Must document for this operation

  • Approach (TEP or TAPP) and side, with the marked side confirmed. The next surgeon choosing an approach for a recurrence needs to know which planes have already been used.
  • Type and size of each defect found, and that the femoral orifice was checked. The critical view of the myopectineal orifice includes checking the femoral orifice, and the note shows it was done.
  • Mesh maker, material, size, lot number, and the fixation used (number and site of tacks). Implant recalls, chronic pain work-up and later surgery all need the exact product and tack sites.
  • That no tacks were placed in the triangles of doom and pain (below the iliopubic tract lateral to the vas). Nerve and vessel injury from tacks is the main medicolegal issue after this operation.
  • Any peritoneal tear, bladder or vessel injury, and how it was managed. These explain later bowel adhesion to mesh, haematoma or urinary symptoms.
  • Conversion to open, if done, with the reason. Conversion is an audited outcome and must be justified in the record.

Common mistakes in these notes

  • Writing 'TEP done, mesh placed' with no mesh size, lot number or fixation details.
  • Not recording the type of hernia and whether the femoral canal was checked.
  • Leaving out a peritoneal tear or how it was closed.
  • Not stating how the indirect sac was handled (reduced or transected).
  • Forgetting the contralateral side findings in a TAPP, where both sides are seen.
  • Omitting the reason for conversion when the repair was converted to open.

Indian practice and paperwork

  • The ICMR national antimicrobial guideline lists cefazolin or cefuroxime as prophylaxis for placement of prostheses or implants, given within one hour before incision and not continued beyond 24 hours. (ICMR. Treatment Guidelines for Antimicrobial Use in Common Syndromes, 2nd ed. 2019. Ch 10, sections 10.3.8, 10.3.10 and Table 10.2 (pp. 99-100). https://www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/Treatment_Guidelines_2019_Final.pdf)
  • SRB, an Indian operative text, lists previous midline scar, previous caesarean, pelvic surgery or pelvic radiation as contraindications to TEP. Record these in the pre-op section when choosing TEP or TAPP. (SRB's Surgical Operations 2014, Ch 30, printed p. 1154 (PDF 1161))
  • Under AB PM-JAY (HBP 2022) this operation is booked as SG050B (Groin Hernia Repair, Inguinal - Lap, polypropylene mesh mapped as implant). NHA guidelines say package stratification depends on items such as type of anaesthesia and surgical technique, so the note must state the anaesthesia and approach that match the booked code; OT notes are also asked for in audits of on-table deaths and LAMA/DAMA cases. State rates vary. (AB PM-JAY HBP 2022 package master (Gujarat SHA SACHIS, https://www.sachis.in/assets/HBP-2022.pdf) and NHA HBP 2.2 User Guidelines (https://hem.nha.gov.in/HBP.pdf))
  • NABH requires the batch and serial number of any implant (here the mesh, and tacks if used) to be recorded in the patient's medical record, the master logbook and the discharge summary. Paste the mesh sticker in the note. (NABH Hospital Accreditation Standards 5th ed. (2020), MOM.10(d))

Sources

  • Scott-Conner CEH, Dawson DL, eds. Essential Operative Techniques and Anatomy. 4th ed. Wolters Kluwer; 2015, Ch 116, Laparoscopic inguinal hernia repair, pp. 620-630.
  • Bhat SM. SRB's Surgical Operations: Text and Atlas. Jaypee; 2014, Ch 30, Surgeries in hernia: TAPP and TEP repair; Ch 18 (insufflation pressure), pp. 1151-1159; 549.
  • Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press, Ch 16, Surgery of the groin: laparoscopic TEP and TAPP, pp. 336; 341-342.
  • Baig SJ, et al., eds. Newer Concepts and Procedures in Hernia Surgery: An Atlas. Springer; 2022, Ch 1, Understanding the critical view of the myopectineal orifice (Felix, Lourie, Daes), pp. 3-10.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1 (cefazolin 2 g, within 60 min before incision) and Table 2 (hernia repair: cefazolin). academic.oup.com/ajhp/article/70/3/195/5112717
  • ICMR. Treatment Guidelines for Antimicrobial Use in Common Syndromes. 2nd ed. 2019. Ch 10. www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/Treatment_Guidelines_2019_Final.pdf
  • Royal College of Surgeons of England. Good Surgical Practice 2025, section 3.5 item 7: operative notes must identify any prosthesis used, including serial numbers. www.rcseng.ac.uk/-/media/Files/RCS/Standards-and-research/GSP/Good-Surgical-Practice-Guide-2025.pdf

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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