Lichtenstein tension-free mesh repair of inguinal hernia

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

• recurrence of the hernia
• chronic groin pain (inguinodynia) or numbness from nerve injury
• haematoma or seroma in the groin or scrotum
• wound infection and mesh infection needing mesh removal
• injury to the vas deferens or testicular vessels
• testicular swelling, ischaemic orchitis or atrophy
• injury to bowel or bladder in the sac

Pre-operative details for this operation

1. Side and type (clinical)RightLeftBilateralindirect / direct / not sure; reducible, irreducible; complete (scrotal) or incomplete
2. Site markedYes, arrow on the correct groin
3. Primary or recurrentif recurrent: previous operation, date, mesh used
4. Both testes examined before surgerysize, position, hydrocele
5. Precipitating factors checkedcough, constipation, prostatism (urinary symptoms)
6. Antiplatelets or anticoagulantsdrug and date stopped
7. Mesh availabletype and size in OT before incision

Anaesthesia and position

1. AnaesthesiaSpinalLocal infiltration with sedationGeneralif local: drugs, strengths, total volume
2. PositionSupine
3. BladderVoided before OTCatheterised

Operative findings

1. Type of herniaIndirectDirectPantaloon (both)SlidingFemoral also present
2. Sacsize, extent (funicular / scrotal), thin or thick
3. ContentsEmptyOmentumSmall bowelLarge bowelBladder wallviability
4. Deep ring and posterior wallsize of deep ring, strength of posterior wall, size of direct defect in cm
5. Nerves identifiedilioinguinal, iliohypogastric, genital branch of genitofemoral: preserved or divided
6. Cord structuresvas and vessels seen and safe; lipoma of the cord

Procedure (steps)

1. Skin incisionSkin crease (transverse)Oblique, parallel to inguinal ligamentlength and position relative to the inguinal ligament and pubic tubercle
2. Superficial veins ligated, external oblique aponeurosis opened through the superficial ring
3. Ilioinguinal and iliohypogastric nerves identifiedPreservedDivided (reason)
4. Cord mobilised at the pubic tubercle and slungsling used (Penrose drain, gauze, hernia ring)
5. CremasterOpened and preservedPartly excised
6. Indirect sacDissected to the neck, opened, contents reduced, transfixed and excisedInverted without openingTransected, distal part left openNo indirect sac foundsuture used to transfix
7. Direct sacInverted, transversalis fascia plicatedInverted onlyNot presentsuture used for plication
8. Meshmaterial, weight, size (e.g. 15 x 8 cm), trimmed or not; lot and batch number, sticker
9. Mesh placed mediallyoverlap beyond the pubic tubercle in cm; first stitch to tissue over the tubercle, not periosteum
10. Lower edge fixed to inguinal ligamentContinuousInterruptedsuture material and size; stopped lateral to the deep ring
11. Mesh slit, tails around the cordtails crossed and sutured to each other and to inguinal ligament; new deep ring size
12. Upper edge fixed to internal oblique / conjoint tendonloose interrupted sutures, material; iliohypogastric nerve seen and avoided
13. Lateral tails tucked under external obliquedistance beyond deep ring

Closure, drains and dressing

1. Haemostasis of cord and canal checked
2. External oblique aponeurosissuture and technique; new superficial ring not tight
3. Subcutaneous tissueinterrupted absorbable sutures
4. SkinSubcuticular absorbableInterrupted monofilament
5. Testis pulled back into scrotum at endYes
6. DrainNoneClosed suction drain (reason)

Specimens and implants

1. Mesh sticker pasted in case sheetmaker, type, size, lot/batch, expiry
2. Sac or cord 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
2. Dietnormal diet once recovered from anaesthesia
3. Analgesiadrug, dose, frequency
4. Mobilisationwalk the same day; avoid straining
5. Wounddressing change and wound check at 5 to 7 days; non-absorbable sutures out at 7 days
6. Dischargeday care or next day unless elderly or with cardiac or chest disease

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