Inguinal/Umbilical Hernia Repair Operative Note

Patient: [Full name, MRN, DOB/age]

Date of Surgery: [Date]

Surgeon: [Primary surgeon name and credentials]

Assistant(s): [Assistants and credentials, or "None"]

Anesthesia: [General / Regional / Local / MAC] — [Anesthesiologist and/or CRNA]

Urgency: [Elective / Urgent / Emergent]

(Laterality must be explicitly stated in Diagnoses, Procedures, Findings, and Procedure Description—do not infer from other sections. For sex-specific cord/adnexal documentation, prompt for details if not provided; do not leave blank.)

Preoperative Diagnosis

• [Diagnosis with laterality and qualifier if applicable, e.g., "Right inguinal hernia, incarcerated" or "Bilateral inguinal hernias"]
• [Additional diagnosis with laterality] (Include only if applicable)
• [Umbilical hernia] (Include only if applicable)

Postoperative Diagnosis

• [Diagnosis with laterality, updated per intraoperative findings]
• [Additional diagnosis with laterality] (Include only if applicable)
• [Umbilical hernia with intraoperative characterization] (Include only if applicable)

Procedure(s) Performed

• [Open / Laparoscopic] [right / left / bilateral] inguinal hernia repair [with high ligation / other technique]
• Open umbilical hernia repair with [primary fascial closure / mesh reinforcement] (Include only if applicable)
• [Orchiopexy / Hydrocelectomy / Contralateral exploration / Other] — [side] (Include only if applicable)

Indication

[Brief rationale for surgery in 1–3 sentences including key symptoms, examination findings, and failure of nonoperative management if relevant]

Intraoperative Details

Wound Class: [I / II / III / IV]

Antibiotic Prophylaxis: [Agent and timing relative to incision / None]

Position: [Supine / Lithotomy / Other]

EBL: [Volume in mL / Minimal]

Drains: [Type, size, and location / None]

Specimens: [Description with site/side and destination / None]

Implants: [Mesh type, size, manufacturer, lot/UDI, anatomic plane, fixation method] (Include only if mesh placed; omit line entirely if no implants)

Findings

• [Right / Left] inguinal region: (Include for each side addressed)
  • Hernia type: [Indirect / Direct / Femoral]
  • Sac contents: [None / Bowel / Omentum / Fluid / Ovary and fallopian tube]
  • Reducibility: [Reducible / Incarcerated / Strangulated]
  • [Associated hydrocele / Other pertinent findings] (Include only if applicable)
• Umbilical region: (Include only if applicable)
  • Defect size: [Greatest dimension in cm]
  • Sac contents: [None / Omentum / Bowel / Fluid]
  • Reducibility: [Reducible / Incarcerated / Strangulated]
• Cord structures (male): Vas deferens and testicular vessels [identified and preserved / injury noted—see Complications]. Testis position at case completion: [within scrotum / other]. (Required for male patients undergoing inguinal repair)
• Adnexal structures (female): [Ovary/tube not encountered / Ovary and fallopian tube encountered, reduced by (technique), confirmed viable by (assessment), returned to peritoneal cavity]. (Required for female patients if adnexa encountered)
• Contralateral internal ring (laparoscopic): [Inspected—patent processus vaginalis present/absent; repair performed/not indicated / Not inspected]. (Include only for laparoscopic approach)

Procedure Description

Preparation

[Anesthesia induction]. [Patient positioning and surgical time-out]. [Skin prep and drape]. [Incision site(s) marked]. [Local anesthetic infiltration, if used].

Inguinal Hernia Repair — [Right / Left]

(Repeat this subsection for each side. Include only the approach used.)

Open approach: [Incision placement and length]. [Dissection to external oblique]. [Opening of inguinal canal and identification of cord structures or round ligament]. [Explicit identification and preservation of vas deferens and testicular vessels, or round ligament in females]. [Hernia sac handling: opened vs intact, contents assessment, reduction technique]. [High ligation with suture type/size and method]. [Distal sac management]. [For incarcerated hernia: reduction method and viability assessment of contents].

Laparoscopic approach: [Port placement sites, sizes, and entry method]. [Insufflation pressure]. [Bilateral internal ring inspection]. [Closure technique for internal ring/PPV with suture type/size and knot technique]. [Confirmation that closure did not entrap cord structures]. [Desufflation and port closure].

Umbilical Hernia Repair

(Include only if performed.) [Incision and dissection to fascia]. [Sac management: reduction and/or excision]. [Defect measurement]. [Fascial closure with suture type/size and technique]. [Umbilicoplasty, if performed].

Closure

[Hemostasis confirmed]. [Fascial closure with suture type/size]. [Subcutaneous closure, if performed]. [Skin closure method]. [Dressing applied]. [Local anesthetic at closure, if used].

Counts

Sponge, needle, and instrument counts [correct / discrepancy encountered—describe reconciliation and resolution].

Complications

[None / Description of complication, immediate consequences, corrective measures taken, and anticipated clinical impact] (Always document explicitly; distinguish expected surgical steps from true complications)

Disposition and Postoperative Plan

Condition: [Extubated / Remained intubated], [stable / unstable] at case completion.

Destination: [PACU / Ward / Home].

Postoperative Instructions:

• Pain management: [Medication plan]
• Diet: [Advance as tolerated / Clear liquids then advance / Other]
• Wound care: [Dressing management and bathing instructions]
• Activity: [Restrictions and duration]
• Follow-up: [Timing and provider]
• Return precautions: [Fever, increasing pain, swelling, wound drainage/erythema, vomiting, scrotal changes]