Resident Notes

These templates are to increase documentation efficiency and guide clinical reasoning. When creating new templates, do not include any PHI. Do not include any personal contact information. Attending specific ordersets and instructions should be included in the Survival Guides within their Organization.

TICU admission assessment and plan Author: Garrett Skinner Service: TICU

Surgery D transplant floor assessment and plan Author: Garrett Skinner Service: Transplant (EC-D)

Surgical floor - assessment and plan Author: Garrett Skinner Service: none

Quick exam Author: Garrett Skinner Service: none

Review of systems Author: Garrett Skinner Service: none

Blank exam Author: Garrett Skinner Service: none

ICU exam Author: Garrett Skinner Service: none

Surgical consult assessment Author: Garrett Skinner Service: none

Example - Trauma assessment and plan Author: Garrett Skinner Service: Trauma

TICU transplant DDKT admission Author: Garrett Skinner Service: TICU

# Resident To-do:

[ ] Make sure that all post op admits have the post op labs drawn and CXR as ordered in the Kidney post op order set
[ ] Ensure that the post op renal US is preformed and update the surgeon on the results.
[ ] Review the summary of the patients past medical history can be found in the Transplant medicine preoperative clearance note.
[ ] Ensure that all comorbid conditions are listed under the appropriate system
[ ] Complete a medicine reconciliation with the help of transplant surgery.
[ ] Monitor UOP and update trauma surgery if there is a sudden decrease in UOP.
[ ] Monitor SBP closely and update trauma surgery and/or medicine if you are considering starting a drip.
[ ] Monitor BMP closely, some patients may need treatment for electrolyte derangements or dialysis. Make sure to discuss with transplant medicine.

This is a *** year old *** with a past medical history of *** who presents to the TICU s/p DDKT on ***.

# Neuro
Sedation: None
Pain: Tylenol 650 PRN, Oxycodone 5/10 PRN, Dilaudid PRN

# Cardiovascular
MAP: ***
HR: ***
HDS
Hydralazine 20 mg IV q4h PRN SBP >170. Nofity resident if more than 3 doses given.
Labaetolol 10 mg q15m PRN SBP >180. Nofity resident if more than 3 doses given.

# GI
Diet: ***
Zofran PRN
Bowel regimen: Cater oil 60 mL PO x1, bisacodyl EC 10 mg PO BID, Bisacodyl Supp 10 mg PR daily PRN, Senna/Doc BID.

# Renal
S/p DDKT on ***
Foley catheter
BMP on arrival: ***
Post op renal US: ***
D51/2NS @ 50
Replace UOP with 1:1 fluids
Transplant medicine following
CMP q6h x4

#Hematology
Preop Hgb: ***
Intraop blood loss: *** 
Hgb on arrival: ***
Platelets: ***
PT/INR: *** 
aPTT: *** 
CBC q4h x6

# Infectious
WBC: ***
Transplant medicine following 
Ppx abx: Valcyte, Bactrim
Immunosuppressents: Thymoglobulin in AM, Solumredrol in AM, Cellcept BID, Prednisone 5 mg daily on POD2, Tacrolimus BID

# Endocrine
BG on arrival: ***
Insulin: ***
POC BG schedule: ***

# MSK
No skin breakdown
Bendryle PRN for itching

# Prophylaxis
SCDs
SQH
Pepcid

# Access
Arterial line: ***
PIVs

# Disposition
TICU

Thoracic discharge diet Author: Garrett Skinner Service: Thoracic

Pediatric exam Author: Garrett Skinner Service: Ped-surg

NICU exam Author: Garrett Skinner Service: Ped-surg

Vascular exam Author: Garrett Skinner Service: Vasc (red/EC-D)

Surgical primary assessment Author: Garrett Skinner Service: none

Trauma assessment and plan Author: Garrett Skinner Service: Trauma

Thoracic GI discharge diet Author: Garrett Skinner Service: Thoracic

Thoracic discharge activity Author: Garrett Skinner Service: Thoracic

Thoracic discharge hygiene Author: Garrett Skinner Service: Thoracic

11R lymph node Author: Garrett Skinner Service: Thoracic

Preoperative Author: Garrett Skinner Service: none

9 node Author: Garrett Skinner Service: Thoracic

Lateral decubitus with bean bag Author: Garrett Skinner Service: Thoracic

Intubation with double lumen Author: Garrett Skinner Service: Thoracic

Safety check Author: Garrett Skinner Service: none

Thoracic MDC template Author: Garrett Skinner Service: Thoracic

Thoracic ROS Author: Garrett Skinner Service: Thoracic

Thoracic GI general plan Author: Garrett Skinner Service: Thoracic

Thoracic general plan Author: Garrett Skinner Service: Thoracic

Thoracic home atrium shower instructions Author: Garrett Skinner Service: Thoracic

7 lymph node station Author: Garrett Skinner Service: Thoracic

Thoracic exam Author: Garrett Skinner Service: Thoracic

Thoracic discharge instructions Author: Garrett Skinner Service: Thoracic

TICU progress note assessment and plan Author: Garrett Skinner Service: TICU

10R lymph node station biopsy Author: Garrett Skinner Service: Thoracic

4R and 2R lymph node station biopsy Author: Garrett Skinner Service: Thoracic

VATS Wedge resection with CT marker Author: Garrett Skinner Service: Thoracic

The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed.  All questions answered.  The patient was transported to the operating room and placed on the table in supine position.  A safety check was performed before induction of anesthetic and  all were in agreement of patient and procedure and side.  General anesthesia was induced the patient was intubated with a double-lumen ET tube.  Bronchoscopy confirmed appropriate position of the tube and did not show any evidence of disease in the [] bronchi. The patient was placed in the [right/left] lateral decubitus secured with straps, [beanbag/anterior and posterior pads] and all bony prominences padded.  Bronchoscopy was again performed confirming appropriate location of the double lumen ET tube.

The [left/right] chest was prepped including the marker placed by the interventional radiologists, allowed appropriate time to dry and draped in normal sterile fashion.  Timeout was done confirming patient, procedure, equipment, imaging, allergies and all were in agreement.  The anesthesia team began single lung ventilation.  The first incision was made along the mid axillary line approximately [number] rib space.  This was carried down through the muscle layer and the pleural cavity was entered bluntly.  A second port was placed along the anteriorly at the level of the [rib number] rib space under direct visulaization.  Upon entering the pleural cavity it was noted that [findings].  CT guided marker string was visible in the [lobe].

The [lobe] at the location of the CT-guided marker was grasped and retracted and compression clamp was placed.  Next the wedge resection was performed using sequential endogia staple loads.  The specimen was divided from the remaining lung and the staple line and was noted to be hemostatic.  The specimen was removed in a bag.  The [nodule/marker/both nodule and marker] were palpated.

Attention was turned to the inferior pulmonary ligament. This was released with electrocautery to the level of the inferior pulmonary vein. Level 9 lymph nodes were sampled and sent for permanent pathology.

[other nodal station dictation]

Posterior rib blocks were performed with Ropivacaine.

Attention was turned to the port sites.  Hemostasis was achieved with electrocautery.  A [size] French chest tube was placed through the mid axillary line port and positioned superior to the lung to the apex of the thorax.  The lung was inflated completely under direct visualization.  The anesthesiologist did not note any air leak.  The chest tube was connected to the atrium and to suction. A 2-0 Vicryl u-stitch was placed around the chest tube at the muscle layer.  The chest tube was secured to the skin with 0 Ethibond.

The anterior port was closed at the muscular layer with 2-0 Vicryl figure-of-eight stitch and at the deep dermal layer with buried interrupted 2-0 Vicryl.  The skin was closed with running 4-0 Monocryl and Dermabond.  Chest tube dressing was applied.  All counts were noted to be correct.  The patient was liberated from anesthesia uneventfully and transported the PACU in stable condition.  Postoperative PACU chest x-ray with was ordered.

Sacral decubitus ulcer debridement - lateral decubitus position - (OR) Author: Garrett Skinner Service: GS (white)

Sacral Ulcer Debridement

Risks, benefits, alternatives discussed with the patient's HCP and informed consent was obtained.  The patient was placed on the OR bed in supine position.  General anesthesia was induced, and the patient was intubated without issue.  The patient was positioned in the right lateral decubitus position.  This was secured with a beanbag and all bony prominences padded.  Straps were placed to secure the patient.  Superficial wound cultures were taken.  The wound was prepped with iodine and draped in a sterile fashion.

Necrotic tissue was sharply debrided to the areas of healthy tissue around the wound using electrocautery.  The deep tissue was debrided and there was no exposed bone.  Debrided tissue was sent for culture and pathology.  Hemostasis was achieved with topical lidocaine with epinephrine 10 cc and electrocautery.

Wound measured []

ACell was placed throughout the entire wound bed covered with Xeroform and then sprayed with an additional local anesthetic and allowed to dry.  Next bacitracin was placed and saturated with Xeroform.  Dry Kerlix placed over this.  ABD over this and secured with tape and finally Ioban was placed on top.

The patient was replaced in the supine position liberated from anesthesia uneventfully and transferred to the PACU in stable condition.

Sacral decubitus ulcer debridement - bedside Author: Garrett Skinner Service: GS (white)

Sacral decubitus ulcer debridement eqiupment Author: Garrett Skinner Service: GS (white)

Laparoscopic cholecystectomy - MM Author: Garrett Skinner Service: GS (white)

The abdomen was accessed via optical trocar in the left upper quadrant and insufflated. The area was inspected and there was no bleeding or visceral injury. 11 mm supra umbilical, 5 mm right lateral, 5 mm right upper quadrant trocars were placed under direct visualization.

The gallbladder was visualized and noted to be [appearance]. The gallbladder was retreated towards the patient’s right shoulder. Adheared stomach and fat were bluntly pushed away from the gallbladder. The hepatocystic triangle was dissected with blunt technique and hook cautery. The cystic duct and after were identified and skelatonized. The lower 1/3 of the gallbladder was dissected from the liver bed and the CVOS was achieved.

The cystic duct and arteries were clipped in triplicate and transected with scissors. The gallbladder was separated from the cystic plate with hook cautery. It was placed in a bag. The clips were noted to be in place. The liver bed was noted to be hemostatic.

The gallbladder was removed through the umbilical incision. The umbilical fascia was closed with 2-0 Vicryl and the Carter-Thomason device. An additional interrupted 2-0 Vircyl  simple stitch was used.

The abdomen was desufflated. The skin incisions were closed with 4-0 Monocryl and dressed with derma bond. The patient was liberated from anesthesia, extubated and transported to the PACU in stable condition.

The attending surgeon was present throughout the entire procedure.

Laparoscopic appendectomy - MM Author: Garrett Skinner Service: GS (white)

The abdomen was accessed via optical trocar in the left upper quadrant and insufflated. The area was inspected and there was no bleeding or visceral injury. A 12 mm infraumbilical trocar was placed and a 5 mm left lower quadrant trocar under direct visualization. The patient was placed in Trendenlenurg.

The appendix was visualized in [area] and noted to be [perforated?]. The cecum was noted to be [appearance]. The appendix was grasped and retracted upwards. The mesoappendix was transected to the base using the Harmonic scalpel. The appendix was separated at its base using an EndoGia [color] staple load. The staple line was noted to be intact and hemostatic.

The appendix was placed in a bag. The area was gently irrigated. The appendix was removed through the umbilical incision. The abdomen was desufflated and the umbilical fascia closed with 2-0 Vircyl using the Carter-Thomason device. The skin of all three incisions were closed with 4-0 Monocryl and dressed with Dermabond.

The patient was liberated from anesthesia, extubated and transported to the PACU in stable condition.

The attending surgeon was present throughout the entire procedure.

Laparoscopic appendectomy - CS Author: Garrett Skinner Service: GS (white)

Informed consent was obtained. Preoperative antibiotics were provided. The patient was brought into the operating room and positioned supine upon the operating table. General anesthesia was induced, and the patient was intubated without complications. The left arm was tucked. The patient's abdomen was prepped with chlorhexidine and draped in standard sterile fashion. A timeout was performed, correctly identifying patient, procedure, site and side of surgery. All were in agreement.

Access to the peritoneal cavity was gained safely through an incision in the left upper quadrant using the Optiview technique. The abdomen was examined which demonstrated no injury to the bowel.  Pneumoperitoneum was achieved.  A 12 cm port was placed in the left lower quadrant under direct visualization.  A 5 mm suprapubic port was also placed.  We then placed the patient in Trendelenburg with right side up.

The appendix was located in [ ] and noted to be [ ]. A window was created with blunt dissection between the appendix and mesoappendix. The base of the appendix was transected with an Ethicon 45mm blue load Echelon Flex powered laparoscopic stapler. The mesoappendix was dissected using a Harmonic scalpel. The abdomen was examined thoroughly was deemed hemostatic. The 12mm port was extended to accommodate the large appendix. The appendix was removed in an EndoCatch bag. The abdomen was desufflated. A fascial closure was performed at the LLQ port site using an 0-Vicryl running stitch. Skin for all three incisions was approximated using 4-0 Monocryl and dressed with Dermabond.

Instrument and sponge counts were correct at the end of the procedure. The patient was extubated in the OR and transferred to the PACU in stable condition. The attending surgeon was present and scrubbed during the entire procedure.

Timeout Author: Garrett Skinner Service: none

PEG tube - YP Author: Garrett Skinner Service: Surg-onc (blue)

Preop ICU Author: Garrett Skinner Service: none

Open tracheostomy - YP Author: Garrett Skinner Service: Surg-onc (blue)

The patient was met in the surgical ICU, patient, consent, site and procedure to be performed confirmed. The patient was transported to the operating room and placed on the table in supine position. General anesthesia was induced and was already intubated. The patient was secured to the table with straps and all boney areas padded. A shoulder roll was placed. A timeout was done and all were in agreement.

The neck was prepped with Betadine and draped in normal sterile fashion. A curvilinear incision over the expected location of the 1st and 2nd tracheal ring was made. The incision was carried down through the platysma. The strap muscles were identified and retracted laterally and preserved.  The thyroid isthmus was retracted superiorly and preserved.  The trachea was identified. A tracheal hook was used to lift the trachea and expose the 2-3rd tracheal ring. The anesthesia team deflated the balloon, reduced the Fi02. An tracheotomy was created with 15 blade and dilated with tracheal dilator. 2-0 Prolene stay sutures were placed in the superior and inferior aspect of the tracheotomy.  The ET tube was retracted just above the level of the tracheotomy.  A lubricated 7.5 cuffed Portex tracheostomy tube was placed.  It was connected to the anesthesia circuit and there was return of end-tidal CO2.  The tracheostomy wings were secured to the skin with 2-0 nylon.  The stay sutures were secured to the chest and neck with Steri-Strips.  All counts were correct.

IPOM laparoscopic umbilical/ventral hernia repair - JB Author: Garrett Skinner Service: none

The abdomen was entered in the right upper quadrant with Optiview trocar.  The abdomen insufflated.  There is noted to be no injury upon entry.  Additional 5 mm ports were placed in the left upper quadrant right lower quadrant and left lower quadrant under direct vision.

There was noted to be _.

This was reduced with the help of the LigaSure. The defect was noted to be _ cm. A _ cm circular IPOM Parietene mesh was used.  Four 0 PDS sutures were placed near the edge of the mesh in the cardinal directions.  The mesh was introduced into the abdomen.  The sutures were retrieved outside the abdomen percutaneously via 4 stab incisions around the umbilicus.  The mesh was retracted up against the abdominal wall and these sutures were tied.  The mesh was then secured with many SureStrap staples.  The area was noted to be hemostatic.  The abdomen desufflated and all ports were removed.  All skin incisions were closed with 4-0 Monocryl and dressed with Dermabond.

The patient was liberated from anesthesia and transferred to PACU in stable condition.

General post op instructions Author: Garrett Skinner Service: none

General Surgery Postoperative Instructions

The following instructions will guide you through your post-operative care. If you have any questions, please do not hesitate to call the office or reach the covering physician via the answering service

Wound Care:
Your incisions are closed with absorbable suture. Glue is applied over the incision that will fall off on its own.

Hygeine:
Avoid scrubbing your surgical sites or immersing them (baths/pools etc) for the next few weeks.  Simply let soapy water run over the area, rinse well and pat dry. Okay to shower starting tomorrow.

Activity:
You will gradually build up your endurance with normal day-to day activities around the home. However, avoid excessive straining (lifting >10 lbs), cadio exercise or deep stretching activities like yoga.  You are safe to drive when you no longer need narcotic pain meds

Medications and Pain Control:
You may be sent home with pain medication to help alleviate pain after surgery.   These medications should only be taken if needed and as prescribed.   Pain is usually the most severe for the first 24-48 hours after surgery and should improve over the next 1-2 weeks.  Most of your surgical site pain will be controlled with over-the-counter Tylenol or Ibuprofen (Advil, Motrin). Alternate Tylenol and Ibuprofen every 3 hours for the first 1-2 days. Narcotic medications should be reserved for severe breakthrough pain and should always be taken with a stool softener to avoid constipation.  Prescriptions are already be sent to your pharmacy.  Only restart blood-thinning medications as discussed with your doctors.

Diet:
After anesthesia and some surgeries it may take several days for your appetite to fully return and before you can finish a regular portion size, but you may resume a normal healthy diet as tolerated with any restrictions discussed with your doctor.  Avoid carbonated beverages which cause bloating pain and hydrate with plenty of water as your body recovers.  If you had your gallbladder removed, you may better tolerate a low fat diet for 1-2 weeks and can expect some loose stools which typically resolve after a week.  If you were treated for diverticulitis, you will be advised to continue a low fiber diet.

Follow Up Instructions:
Call the office as soon as possible to schedule a follow-up appointment in 2-3 weeks.  You will be provided with work notes/disability forms

If at any point in time you are unable to speak quickly with a physician and experience severe pain not alleviated with medication, high fevers (>102.5F), excessive bleeding, chest pain, difficulty breathing, or dizziness, call 9-1-1 or go to the emergency room for further evaluation

We hope you had a good experience! Once again, do not hesitate to call the office if you have any questions or concerns and we will be more than happy to help out as you recover from surgery.

open inguinal herniorrhaphy - KC Author: Garrett Skinner Service: GS (white)

The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed.  All questions answered.  The patient was transported to the operating room and placed on the table in supine position. General anesthesia was induced and patient was intubated without issue. The patient was secured to the table with straps and all boney areas padded.  The left inguinal area was prepped and draped in normal sterile fashion with Ioban.  A timeout was done and all were in agreement.  Incision was made over the medial aspect just above the inguinal ligament ligament.  Incision was carried down through Scarpa's fascia external bleak was identified.  This was opened along its fibers sharply with Metzenbaum along the length of the inguinal canal.  The ilioinguinal nerve was identified and protected the cord was gently dissected away from the external oblique fascia and it was encircled with a Penrose drain.  No direct hernia was noted.  The cord was opened at the level of the cremasterics along their direction.  The vas deferens and pampiniform plexus were identified and protected.  A large indirect hernia was noted without any contents in the sac.  This was gently and meticulously freed from the cord.  It was simply reduced into the internal ring and the internal ring was closed slightly with interrupted 2-0 Vicryl in order to prevent the sac from coming back out.  Polypropylene mesh was fashioned and was secured to the periosteum of the pubic tubercle with a single interrupted 0 PDS stitch.  It was then secured to the conjoined tendon and internal oblique on the superior aspect of the floor and then to the shelving edge of the inguinal ligament on the inferior aspect all with interrupted 0 PDS.  The internal ring was recreated with the tails of the mesh secured with 0 PDS on either side of the ring.  It was not too tight.  Hemostasis was achieved with electrocautery.  External oblique was closed with running 2-0 Vicryl.  Local field block was done with 1% lidocaine without epi.  Scarpa's fascia was closed with interrupted Vicryl.  Deep dermal was closed with interrupted Vicryl.  It was closed with 4-0 Vicryl.  The wound was dressed with Dermabond.  The patient was awakened from anesthesia next day without issue and transported to PACU in stable condition.

Umbilical hernia repair with mesh - TF Author: Garrett Skinner Service: none

The patient was brought to the operating room and placed in the supine position.  General anesthesia was initiated without incident.  Preoperative antibiotics were administered. The umbilicus was prepped and draped in standard sterile fashion. A timeout was performed by which the patient was identified using 2 patient identifiers, and the site and proposed procedure were confirmed.  All team members agreed.

A 6cm curvilinear supraumbilical incision was made using a #15 blade and carried down into the subcutaneous tissues using electrocautery and assuring hemostasis along the way. Defect in the fascia was noted deep to our incision. A hernia sac was identified more caudal to the initial fascial defect with a second defect in the fascia seen. We dissected circumferentially around the hernia sac away from the fascia using a mix of electrocautery and blunt finger dissection. The sac was ligated and handed off for specimen. 
 
The defect was estimated at _ cm in length. A _ mesh was placed at the _ level.

The fascia was closed with _. The umbilicus was reapproximated to the underlying fascia using a 3-0 Vicryl sutures.

The surgical site was instilled with 15ml of a 1:1 mixture of 0.5% Marcaine and 1% lidocaine with epinephrine. The remainder of the incision was closed in 
layers using 3-0 Vicryl interrupted sutures in the deep dermal layer. We then place a 4-0 Monocryl running subcuticular suture. The incision was covered with Dermabond. A sterile dressing with a cotton ball in the umbilicus was placed after the Dermabond had dried.

The patient was liberated from anesthesia and brought to the PACU in stable condition.  The sponge, instrument and needle counts at the end procedure were all correct. The attending was present and active for the entirety of the procedure.

Left open inguinal hernia repair - MS Author: Garrett Skinner Service: none

The patient was brought to the operating room and placed in the supine position. General anesthesia was induced and airway was secured with GET. The left groin was prepped and draped in standard sterile fashion. Preoperative antibiotics were administered. A timeout was performed by which the patient was identified using 2 patient identifiers, and the site and proposed procedure were confirmed. All team members were in agreement.

A 5cm oblique incision was made 1 finger's breadth above the inguinal ligament between the ASIS and pubic tubercle using the 10 blade. Using electrocautery this was carried down to the external oblique aponeurosis as hemostasis was assured along the way. The external oblique aponeurosis was identified, cleared of overlying tissues, and incised.  The incision was carried medially to the external ring and laterally to reveal the underlying cord. The ilioinguinal nerve was identified and transected with Metzenbaums scissors. The spermatic cord structures were bluntly dissected off of the posterior aspect of the external oblique aponeurosis using finger dissection.

The spermatic cord and hernia sac were then finger dissected off of the floor of the inguinal canal at the level of the pubic tubercle. The hernia sac was then separated from the spermatic cord. Cord lipoma was identified and reduced into the peritoneal cavity. The internal ring was approximated with a figure of eight stitch using a 2-0 vicryl

We then turned our attention to our hernia repair. The Prolene keyhole mesh was secured to the pubic tubercle with prolene.  The inferior border was sutured to the shelving edge of inguinal ligament with running prolene. The superior border was sutured to the transversalis fascia with interrupted prolene sutures. Care was taken not to entrap any nerves. The hernia defect was completely covered by the mesh overlapping onto normal healthy tissue and we were satisfied with the extent of our repair.

The internal ring was re-created by suturing the tails of the mesh together, with care taken to avoid impinging on the cord structures. A small finger was easily able to pass in the reconstructed ring.  The surgical incision was then irrigated and hemostasis was assured. The cord was verified to be intact and in a neutral position. The mesh repair was tension free and flat.

The external oblique fascia was closed in a running fashion with 3-0 Vicryl. The remainder of the incision was closed in layers using 3-0 Vicryl running sutures in Scarpa's fascia and interrupted deep dermal layer. 10 cc local anesthetic was injected. Skin was then closed with a 4-0 Monocryl running subcuticular suture. The incision was covered with Dermabond. The testicles were palpated and were mobile and normal to inspection.

At the completion of the procedure, the patient was transferred to the cart and brought to the PACU in stable condition.  The sponge, instrument and needle counts at the end procedure were correct x2. The attending was present and active for the entirety of the procedure.

VA Operative report template Author: Garrett Skinner Service: none

Right open inguinal hernia - TF Author: Garrett Skinner Service: none

The patient was brought to the operating room and placed in the supine position. General anesthesia was initiated without incident. The right groin was prepped and draped in standard sterile fashion. Preoperative antibiotics were administered. A timeout was performed by which the patient was identified using 2 patient identifiers, and the site and proposed procedure were confirmed. All team members were in agreement.

An 6cm oblique incision was made 1 finger's breadth above the inguinal ligament between the ASIS and pubic tubercle. Using electrocautery this was carried down to the external oblique aponeurosis as hemostasis was assured along the way. The external oblique aponeurosis was identified, cleared of overlying tissues, and incised with Metzenbaum scissors.  The incision was carried medially to the external ring and laterally to reveal the underlying cord. The spermatic cord structures were bluntly dissected off of the posterior aspect of the external oblique aponeurosis using finger dissection.

The spermatic cord was then finger dissected off of the floor of the inguinal canal at the level of the pubic tubercle and encircled with a Penrose drain.

There was noted to be ***.

The Prolene 6.1 x 13.7cm keyhole mesh was secured to the pubic tubercle with 0 Prolene.

The inferior border was sutured to the shelving edge of inguinal ligament with a running 0 Vicryl suture. With care taken to ensure that the mesh sat flat on the floor of the inguinal canal, the superior border was sutured to the transversalis fascia with interrupted 0 Vicryl sutures.  Care was taken not to entrap any nerves. The hernia defect was completely covered by the mesh overlapping onto normal healthy tissue and we were satisfied with the extent of our repair.

The external oblique fascia was closed in a running fashion with 2-0 Vicryl. The remainder of the incision was closed in layers using 3-0 Vicryl running sutures in Scarpa's fascia and interrupted deep dermal layer. 10 cc local anesthetic was injected. Skin was then closed with a 4-0 Monocryl running subcuticular suture. The incision was covered with Dermabond. The testicles were palpated and were mobile and normal to inspection.

The patient was liberated from anesthesia and brought to the PACU in stable condition.  The sponge, instrument and needle counts at the end procedure were correct x2. The attending present and active for the entirety of the procedure.

open inguinal hernia post op instructions Author: Garrett Skinner Service: none

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