OT notes · Paediatric Surgery

Paediatric inguinal herniotomy

Usual anaesthesia
General anaesthesia, usually with a caudal block, ilioinguinal block or wound infiltration
Position
Supine
Setting
elective

Operative note template for open inguinal herniotomy in an infant or child, with a filled example for an elective right-sided herniotomy in a 2-year-old boy under general anaesthesia with a local nerve block.

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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

  • injury to the vas deferens or testicular vessels
  • testicular atrophy, higher after an incarcerated hernia
  • scrotal haematoma
  • wound infection
  • post-operative hydrocele
  • recurrence, usually within the first year
  • injury to bowel, bladder, ovary or tube in a sliding hernia
  • a hernia may later appear on the other side
  • apnoea after anaesthesia in ex-premature infants

Pre-operative details for this operation

  1. SideRightLeftBilateral
  2. Age, weight and gestation at birthweight in kg; for infants write the corrected (post-conceptional) age if born preterm
  3. PresentationReducibleIncarcerated, reduced manually (time and date)Irreducible, emergency
  4. Testis position on the operated sideIn scrotumUndescendedRetractile
  5. Neonatal historyprematurity, ventilation, apnoea or bradycardia episodes, bronchopulmonary dysplasia, anaemia
  6. Contralateral sideclinically normal / hernia; parents told about contralateral check and their choice
  7. Consentgiven by parent or guardian: name, relation, language
  8. Side markedYes

Anaesthesia and position

  1. AnaesthesiaGeneralSpinalGeneral with caudal block
  2. Regional or local blockCaudalIlioinguinal and iliohypogastric blockWound infiltrationNonedrug, strength and volume (mL/kg)
  3. PositionSupine

Operative findings

  1. SacIndirect, confined to the canalIndirect, reaching the scrotumDirect (rare)
  2. Sac contentsEmptyOmentumBowelOvary / tube (girls)Fluid only
  3. Sliding componentNoYes: bladder / caecum / colon / ovary / tube
  4. Internal ring sizenormal, or wide (more than 1.5 cm)
  5. Vas and testicular vesselsidentified and safe
  6. Associated hydroceleNoneCommunicatingHydrocele of the cord
  7. Testissize, viability after incarceration, position at the end
  8. Contralateral side (if looked at)Not checkedClosedPatent processus vaginalis

Procedure (steps)

  1. Painting and drapingantiseptic used
  2. Skin incisiontransverse, in the lowest inguinal skin crease above the external ring, length in cm
  3. Scarpa's fascia divided, external oblique aponeurosis exposedsuperficial epigastric vein coagulated / ligated
  4. CanalExternal oblique opened 1-2 cm near the deep ringNot opened (sac reached through the external ring)ilioinguinal nerve seen and protected
  5. Cremaster split, sac identified on the anteromedial side of the cord
  6. Vas and vessels separated from the sacnot grasped with forceps; sling used if any
  7. Sac divided and dissected up to the deep ringlevel marked by extraperitoneal fat / inferior epigastric vessels
  8. Contents reduced, sac twisted
  9. High ligationneck transfixed twice, suture material and size (non-absorbable 4/0, or 3/0 in older children)
  10. Distal sacOpened anteriorly and partly excisedLeft openHydrocele drained
  11. Deep ring tightened (Marcy)Not neededDone: sutures used
  12. Testis returned to scrotumconfirmed in scrotum at the end
  13. Local anaesthetic infiltrationdrug, strength, volume, along ilioinguinal and iliohypogastric nerves

Closure, drains and dressing

  1. External obliqueabsorbable suture, size, interrupted or continuous, up to the external ring
  2. Scarpa's fasciaabsorbable, number of stitches
  3. SkinSubcuticular absorbableTissue glue
  4. Dressing

Specimens and implants

  1. Excised sac for HPENot sentSentif sent, the reason
  2. ImplantsNoneno mesh is used in children

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. Observationroutine: home after a short stay; ex-premature infant under 50 weeks post-conceptional age or with lung disease or anaemia: overnight (about 23 h) apnoea and bradycardia monitoring
  2. Feedsbreast or oral feeds from when
  3. Analgesiadrug and weight-based dose (mg/kg), frequency
  4. Woundkeep dry, nappy care, when to open the dressing
  5. Scrotum and testis checkswelling, haematoma, testis position before discharge
  6. Activityno restriction for infants; older children to avoid cycling and rough play until pain settles
  7. Warning signs for parentsfever, wound redness, swelling in the groin or scrotum, poor feeding
  8. Follow-update; check for recurrence and hydrocele

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: Master A.R., 2 years, 12 kg, born at term, right groin swelling on crying for 3 months, reducible. Left side normal.

Case details

Date: 16/06/2026. Elective, day-care list. Start 09:40, end 10:15.

Surgeon: Dr A. (2nd-year resident, Paediatric Surgery). Assistant: Dr B. Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Right indirect inguinal hernia, reducible. No episode of incarceration. Right testis in the scrotum. Weight 12 kg. No neonatal illness.

Hb 11.8 g/dl. Fasting as per anaesthesia instructions.

Consent: procedure-specific consent taken from the mother, Mrs. S.R., in Hindi. Risks explained including vas injury, testicular atrophy, hydrocele and recurrence. Parents did not want the left side explored. Right side marked.

WHO checklist sign in and time out done. Antibiotic prophylaxis: none (clean case, unit policy).

Anaesthesia and position

General anaesthesia. Supine. Parts painted with povidone-iodine and draped.

Procedure

2.5 cm transverse incision in the lowest right inguinal skin crease, above the external ring. Superficial epigastric vein coagulated with bipolar. Scarpa's fascia divided.

External oblique aponeurosis traced to the external ring and opened along its fibres for 1.5 cm near the deep ring. Ilioinguinal nerve seen and kept clear.

Cremaster split. Findings: indirect sac on the anteromedial side of the cord, reaching the upper scrotum, empty. No sliding component. Deep ring not wide. Vas and testicular vessels normal.

Sac lifted with forceps. Vas and vessels teased off the back of the sac without grasping them. Sac divided between clamps.

Proximal sac dissected up to the deep ring, where extraperitoneal fat was seen. Sac twisted, no contents. Neck transfixed twice with polypropylene 4/0 and the excess cut off.

Distal sac opened on its front wall and a part excised. No hydrocele.

Deep ring normal, not tightened. Right testis pulled down and confirmed in the scrotum.

Bupivacaine 0.25%, 3 ml (0.25 ml/kg) infiltrated along the ilioinguinal and iliohypogastric nerves and the wound.

Closure

External oblique closed with continuous polyglactin 910 (Vicryl) 4/0 up to the external ring. Scarpa's fascia with two interrupted Vicryl 4/0. Skin with subcuticular absorbable suture. Dry dressing.

End of procedure

Blood loss negligible. No complications.

Mop, needle and instrument count correct.

Specimen: sac not sent for HPE. Implants: none.

Child awake, crying, shifted to day-care recovery with mother. HR 110/min, SpO2 99% on room air.

Post-op orders

Clear fluids once fully awake, then normal diet.

Oral paracetamol by weight as charted by the anaesthetist.

Check right scrotum for swelling and testis position before discharge.

Discharge home the same day if feeding and passing urine. Keep the dressing dry for 48 hours.

Parents told to return if fever, wound redness, groin or scrotal swelling, or poor feeding.

Review in paediatric surgery OPD after 1 week.

Signature

Dr A., JR-2, Paediatric Surgery. Reg. no. ________. 16/06/2026, 10:30.

Must document for this operation

  • Side operated, and whether the other side was checked. If a hernia appears on the other side later, the note shows whether it was looked for and what the parents chose.
  • Child's weight, and corrected age in ex-premature infants. Weight sets every drug dose, and corrected age decides whether overnight apnoea monitoring is needed.
  • Vas and testicular vessels identified and safe. Vas injury and testicular atrophy are the main medicolegal claims after this operation, and they may only show years later.
  • Level of high ligation and the suture used. A missed sac or a slipped ligature is the usual cause of recurrence, so the next surgeon needs to know what was done.
  • Sac contents and any sliding component. Bowel, bladder or ovary in the sac changes the risk and must be on record if a complication follows.
  • Testis position at the end of the operation. A testis pulled up into the groin during repair can become a trapped undescended testis.
  • Who gave consent and in which language. The child cannot consent, so the parent or guardian's name and relation must be on record.

Common mistakes in these notes

  • Writing 'herniotomy done' with no side.
  • Not recording the weight, then writing drug doses that cannot be checked.
  • Not writing that the vas and vessels were seen and protected.
  • Leaving out the testis position at the end.
  • Not recording whether a caudal or local block was given, with drug and volume.
  • Not noting the parents' decision about the other side.

Indian practice and paperwork

  • Consent must be in a language the parent understands, and taken by the person who will do the procedure. (NABH 5th ed., PRE.4(c) and (e))
  • There is no fixed Indian rule for how long records are kept, but paediatric records are advised to be kept until the child reaches majority. (Thomas J. Indian J Urol 2009;25(3):384-8)
  • The operative note should be written before the child leaves the recovery area. (NABH 5th ed., COP.14(e))

Sources

  • Davenport M, Geiger JD, eds. Operative Pediatric Surgery (Rob & Smith's Operative Surgery). 8th ed. CRC Press; 2021, Ch 24, Inguinal hernia, hydrocele, and other hernias of the abdominal wall (Abdulhai S, Ponsky TA), e-book PDF pp. 585-607.
  • Sriram Bhat M. SRB's Surgical Operations: Text and Atlas. Jaypee; 2014, Ch 30, Surgeries in hernia: Herniotomy in infants, pp. 1129-1132.

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

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