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Left direct inguinal hernia generate OT notes

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I now have comprehensive material to generate a complete, well-structured OT (Operation Theatre) note for a left direct inguinal hernia repair (Lichtenstein technique). Let me compose it.

OT NOTES - LEFT DIRECT INGUINAL HERNIA REPAIR

(Lichtenstein Tension-Free Mesh Hernioplasty)

Date: 25/07/2026 OT No.: ___ Surgeon: ___ Assistant: ___ Anaesthetist: ___ Scrub Nurse: ___

PATIENT DETAILS

Name:___
Age/Sex:___ / Male
IP No.:___
Ward:___
Diagnosis:Left Direct Inguinal Hernia
Procedure:Left Lichtenstein Tension-Free Mesh Hernioplasty

PRE-OPERATIVE DETAILS

  • ASA Grade: ___
  • Informed consent: Obtained
  • Pre-op investigations: WBC, Hb, BT/CT, RBS, RFT, ECG, CXR - within normal limits
  • Prophylactic antibiotics: Inj. Cefazolin 1 g IV given 30 min before incision
  • Allergies: NIL known
  • Pre-operative mark: Left groin - confirmed

ANAESTHESIA

  • Type: Spinal anaesthesia (preferred for open inguinal hernia repair) / General anaesthesia
  • Agent (spinal): 0.5% hyperbaric bupivacaine 2.5-3 ml intrathecally at L3-L4 interspace
  • Position for block: Sitting / Left lateral decubitus
  • Sensory level achieved: T10
  • IV access: 18G IV cannula, right forearm
  • Monitoring: SpO2, NIBP, ECG - throughout procedure

POSITION

  • Supine
  • Arms by sides / left arm tucked
  • Slight Trendelenburg (5-10°) may be used to aid bowel retraction

PREPARATION & DRAPING

  • Skin preparation: Povidone-iodine / Chlorhexidine 0.5% in alcohol from umbilicus to mid-thigh, including left groin and upper scrotum
  • Sterile draping to expose left inguinal region
  • Foley catheter: Not routinely required

OPERATIVE DETAILS - STEP BY STEP

Step 1 - Incision: An oblique skin incision ~8-10 cm was made in the left groin, starting 1-2 cm above the pubic tubercle and extending laterally, parallel to and 1 cm above the inguinal ligament. The incision was carried through skin and subcutaneous tissue (Camper's and Scarpa's fascia).
Step 2 - External Oblique Aponeurosis: The external oblique aponeurosis was identified and cleared of overlying fat. It was incised sharply along its fibers, ~5 cm from its reflection into the inguinal ligament, extending medially to the external inguinal ring and laterally several centimeters past the internal ring. The two leaves of external oblique were reflected and held with artery clips.
Step 3 - Nerve Identification:
  • Ilioinguinal nerve - identified coursing anteromedial to the spermatic cord and preserved
  • Iliohypogastric nerve - identified in the upper leaf of external oblique, preserved
  • Genital branch of genitofemoral nerve - noted with the cord structures
(Proper nerve identification is the cornerstone of reduced chronic post-operative groin pain.)
Step 4 - Spermatic Cord Mobilization: The spermatic cord was mobilized at the pubic tubercle by blunt and sharp dissection. A Penrose drain / soft rubber sling was passed around the cord for retraction. The cremaster muscle fibers were split along their length, exposing the floor of the inguinal canal.
Step 5 - Hernia Sac Identification: Inspection of the inguinal floor revealed a direct hernia: a broad-based bulge through a weakness in the transversalis fascia medial to the inferior epigastric vessels, within Hesselbach's triangle. No indirect sac was identified at the internal ring. The hernia contents (pre-peritoneal fat / omentum) were reduced into the peritoneal cavity.
Step 6 - Management of the Hernia: The transversalis fascia was opened and the direct sac was dissected free. Contents were reduced. The sac was not ligated but inverted and the transversalis fascia was imbricated with interrupted 2-0 Vicryl sutures to reduce dead space and minimize seroma/hematoma formation.
Step 7 - Mesh Preparation (Lichtenstein Repair): A piece of polypropylene flat mesh (15 × 8 cm, "flat iron" shaped) was fashioned. A keyhole slit was cut at the distal lateral corner of the mesh to accommodate the spermatic cord, creating two tails (upper: 2/3 width; lower: 1/3 width).
Step 8 - Mesh Fixation: The periosteum overlying the pubic tubercle was exposed and cleared medially toward the midline by ~2 cm.
  • The medial edge of the mesh was sutured to the anterior rectus sheath, overlapping the pubic tubercle by at least 1.5-2 cm (to prevent medial recurrence) - using a continuous 0 Prolene (non-absorbable monofilament suture)
  • This suture was run inferolaterally along the shelving edge of the inguinal ligament from the pubic tubercle to a point just lateral to the internal inguinal ring and tied
  • Note: sutures were NOT placed directly into the periosteum of the pubic tubercle (to minimize risk of osteitis and chronic pain)
  • The superior border of the mesh was fixed to the conjoint tendon / internal oblique aponeurosis with interrupted 2-0 Vicryl sutures, taking care to avoid the ilioinguinal and iliohypogastric nerves
  • The two tails were wrapped around the spermatic cord and sutured together with a 0 Prolene interrupted stitch to the inguinal ligament, reconstituting the internal inguinal ring (snug, not tight - admitting one fingertip)
  • Mesh extended at least 2-3 cm superior to Hesselbach's triangle
Step 9 - Haemostasis: Meticulous haemostasis achieved with electrocautery throughout. No active bleeding points.
Step 10 - Wound Closure:
  • Spermatic cord returned to its anatomical position within the inguinal canal
  • External oblique aponeurosis closed over the cord with continuous 2-0 Vicryl sutures, reconstituting the external ring (loose enough to admit one fingertip)
  • Scarpa's fascia approximated with interrupted 2-0 Vicryl
  • Skin closed with 3-0 Monocryl subcuticular suture / staples
  • Wound dressed with sterile dressing

INTRA-OPERATIVE FINDINGS

FindingDetails
Hernia typeLeft direct inguinal hernia (Type II / Nyhus classification)
Hernia defect sizeApprox. 3 × 3 cm, medial to inferior epigastric vessels
Hernia contentsPre-peritoneal fat / reduced without difficulty
Indirect sacNot present
Cord structuresNormal - vas deferens and testicular vessels intact
Femoral canalNormal
Mesh usedPolypropylene flat mesh 15 × 8 cm
BleedingMinimal, well controlled
ComplicationsNil intra-operative

SPECIAL NOTES

  • Direct hernia confirmed medial to inferior epigastric vessels (within Hesselbach's triangle)
  • Mesh overlaps pubic tubercle medially and internal ring laterally - adequate coverage
  • All three inguinal nerves identified and preserved
  • Cord structures intact; testicular viability maintained

POST-OPERATIVE ORDERS

  1. NPO until fully awake / 4 hours post-op, then liquid diet → soft diet
  2. IV fluids: RL 500 ml at 100 ml/hr; taper as tolerated
  3. Analgesia:
    • Inj. Paracetamol 1 g IV 8-hourly × 24 hours
    • Tab. Ibuprofen 400 mg BD with food (avoid NSAIDs if contraindicated)
  4. Antibiotics: Tab. Amoxiclav 625 mg BD × 5 days
  5. Monitor: Vitals 4-hourly; watch for wound haematoma, urinary retention
  6. Scrotal support / ice pack to scrotum if scrotal oedema
  7. Avoid heavy lifting / straining for 6 weeks
  8. Suture removal on Day 7-10 (if non-absorbable skin suture used)
  9. Follow-up in surgical OPD: Day 7 and Week 6

SPECIMEN SENT

  • Pre-peritoneal fat / sac fragment (if excised) for histopathology: Yes / No

SURGEON'S SIGNATURE

Procedure duration: _____ minutes Blood loss: < 50 mL (estimated) Surgeon: _________________________ Date: 25/07/2026
References: Sabiston Textbook of Surgery 21e - Tension-Free Anterior Inguinal Hernia Repair; Schwartz's Principles of Surgery 11e - Lichtenstein Tension-Free Repair; Fischer's Mastery of Surgery 8e - Inguinal Hernia.

Paragraph format and make it concise

OT NOTES - LEFT DIRECT INGUINAL HERNIA REPAIR

Date: 25/07/2026 | Surgeon: ___ | Anaesthetist: ___ | Scrub Nurse: ___ Patient: ___ | Age/Sex: ___/M | IP No.: ___ | Diagnosis: Left Direct Inguinal Hernia Procedure: Left Lichtenstein Tension-Free Mesh Hernioplasty
Anaesthesia & Preparation: The patient was taken to the OT, identity and site confirmed, and placed supine on the OT table. Spinal anaesthesia was administered at L3-L4 with 0.5% hyperbaric bupivacaine, achieving a T10 sensory level. Inj. Cefazolin 1 g IV was given 30 minutes prior to incision. The left groin was prepared with povidone-iodine and draped sterilely, exposing the inguinal region.
Incision & Exposure: An oblique incision of approximately 8-10 cm was made 1 cm above and parallel to the inguinal ligament, extending from 1 cm above the pubic tubercle to just lateral to the internal ring. Skin, Camper's and Scarpa's fascia were divided. The external oblique aponeurosis was identified, incised along its fibers from the external ring laterally, and its two leaves were reflected, exposing the inguinal canal.
Nerve Identification & Cord Mobilization: The ilioinguinal nerve, iliohypogastric nerve, and genital branch of the genitofemoral nerve were carefully identified and preserved. The spermatic cord was mobilized at the pubic tubercle and slung with a soft rubber sling. Cremaster fibers were split to expose the floor of the inguinal canal.
Hernia Findings & Sac Management: Intraoperative findings confirmed a left direct inguinal hernia - a broad-based defect (~3 × 3 cm) in the transversalis fascia medial to the inferior epigastric vessels, within Hesselbach's triangle. No indirect component was identified at the internal ring. The herniated pre-peritoneal fat was reduced. The direct sac was dissected, contents reduced, and the transversalis fascia imbricated with interrupted 2-0 Vicryl to obliterate dead space.
Mesh Repair (Lichtenstein): A polypropylene flat mesh (15 × 8 cm) was fashioned with a keyhole slit at its lateral corner to accommodate the spermatic cord. The medial edge was sutured to the anterior rectus sheath, overlapping the pubic tubercle by 2 cm, using continuous 0-Prolene. This suture was continued along the shelving edge of the inguinal ligament to a point just lateral to the internal ring. Sutures were deliberately avoided from the periosteum of the pubic tubercle to minimize chronic pain. The superior border of the mesh was fixed to the conjoint tendon with interrupted 2-0 Vicryl, with care to avoid nerve entrapment. The two lateral tails were wrapped snugly around the cord and sutured together to the inguinal ligament with 0-Prolene, reconstituting the internal ring. Adequate mesh overlap was confirmed over Hesselbach's triangle.
Haemostasis & Wound Closure: Meticulous haemostasis was achieved with electrocautery. The spermatic cord was returned to its anatomical position. The external oblique aponeurosis was closed with continuous 2-0 Vicryl, reconstituting the external ring. Scarpa's fascia was approximated with interrupted 2-0 Vicryl. Skin was closed with 3-0 Monocryl subcuticular suture. Sterile dressing was applied.
Operative Summary: Procedure duration: ___ min | EBL: < 50 mL | Intraoperative complications: Nil | Mesh used: Polypropylene 15 × 8 cm | Specimen for HPE: Yes / No
Post-op Orders: Monitor vitals 4-hourly. IV Paracetamol 1 g 8-hourly × 24 hrs, then oral analgesics. IV fluids until tolerating orals. Tab. Amoxiclav 625 mg BD × 5 days. Scrotal support. Avoid heavy lifting for 6 weeks. OPD review on Day 7 and Week 6.
Surgeon's Signature: _________________________
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