Surgical Report Sample:

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RE:   David Jones
DATE 12/01/12
MR:  240804
DOB: 12/01/65

SURGICAL REPORT

PREOPERATIVE DIAGNOSIS:  Left inguinal hernia.

POSTOPERATIVE DIAGNOSIS:  Left indirect inguinal hernia.

PROCEDURE:  Repair of left indirect inguinal hernia with extra large mesh plugs.

FINDINGS:  The patient is a 52-year-old gentleman with multiple medical problems and a symptomatic left inguinal hernia.  He was chronically constipated and this caused that hernia to pop out.  He also had urinary frequency.  In the operating room, he had a left indirect inguinal hernia sac, but also was catheterized before the surgery and 700 cc was removed. 

PROCEDURE: After adequate general endotracheal anesthesia was introduced using a bronchoscopic incubation, a full catheter was placed and an impression device replaced on lower extremity.  The patient was then prepped and draped in the usual sterile manner.  I did a left parallel angle incision.  The fascia was exposed leaving point coagulated a tie with 3-0 Vicryl.  The fascia was lifted through external ring and the cord mobilized with a Penrose drain.  The floor was completely intact and the creamasteric fibers and internal spermatic fascia opened.  It was immediately evident there was indirect sac.  This was dissected down to the internal ring.  It was reduced and the hemostasis was excellent.  The hernia was pushed back and an extra large plug with a central pedal removed was placed and secured with a 2-0 Prolene anteriorally and medially.  The wound was irrigated with antibiotic suture and enclosed with 0 Vicryl on the external, 3-0 Vicryl, 4-0 subcuticular Vicryl, and Steri-Strips on the skin. 

Estimated blood loss through the entire procedure was less than 10 cc and no drainage replaced.  Specimen to pathology was none.  The patient tolerated the procedure well and gauze dressing applied and was taken to recovery room.  He was extubated in stable condition.