OT notes · General Surgery

Incisional hernia repair (open onlay / sublay mesh)

Usual anaesthesia
General with muscle relaxation for most; spinal or epidural for selected small lower abdominal defects
Position
Supine
Setting
elective

Operative note template for open incisional hernia repair with mesh (onlay, retrorectus sublay, preperitoneal or intraperitoneal), with a filled example for a lower midline incisional hernia repaired with a retrorectus polypropylene mesh.

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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

  • seroma and haematoma
  • wound infection and mesh infection, which may need mesh removal
  • injury to bowel stuck to the sac, with possible resection
  • recurrence
  • raised abdominal pressure and breathing difficulty after reducing a large hernia
  • paralytic ileus
  • chronic pain from fixation sutures
  • skin flap necrosis
  • deep vein thrombosis

Pre-operative details for this operation

  1. Previous operationoperation, incision, year, any wound infection or burst abdomen after it
  2. Hernia detailsReduciblePartly reducibleIrreducibleObstructedsite (midline above / below umbilicus, paramedian, subcostal, lateral), size of swelling, skin over it
  3. Defect size and number on USG / CTwidth x length in cm; other defects; loss of domain
  4. Optimisationweight / BMI, diabetes control, smoking stopped, chest physiotherapy, cough and constipation treated
  5. Consent for mesh, possible bowel resection and drainsTaken
  6. Mesh available in OTtype and sizes
  7. Urinary catheterInsertedNot needed

Anaesthesia and position

  1. AnaesthesiaGeneral with relaxationSpinalCombined spinal-epidural
  2. PositionSupine
  3. Skin preparation and drapingantiseptic; incise drape if used

Operative findings

  1. Number and size of defectseach defect width x length in cm; Swiss cheese defects
  2. Sac contentsOmentumSmall bowelLarge bowelPreperitoneal fat only
  3. AdhesionsNoneOmentalBowel to sacDense
  4. Bowel conditionviable / serosal tear repaired / enterotomy / resection
  5. Quality of fascia and rectiHealthyAttenuatedRecti lateralised

Procedure (steps)

  1. IncisionOver old scar with scar excisionTransversePanniculectomy incisionlength in cm
  2. Sac dissected down to the fascial neck
  3. SacPreserved and reducedOpened, adhesiolysis, excess excised
  4. Whole old incision explored for other defectsdefects joined into one if found
  5. Fascial edges clearedhealthy fascia exposed all round; underside freed from bowel
  6. Mesh planeOnlay (over anterior sheath)Retrorectus sublay (Rives-Stoppa)PreperitonealIntraperitoneal (coated / composite mesh only)
  7. Space createdfor retrorectus: posterior sheath incised along medial edge, rectus lifted to linea semilunaris, extent above and below defect in cm
  8. Posterior sheath / peritoneum closedrunning suture; material
  9. Component separationNot neededAnterior (external oblique release)Posterior (transversus abdominis release)side(s)
  10. Mesh placedmaterial, size in cm, overlap beyond defect (at least 5 cm), lies flat
  11. Mesh fixationnumber of stitches, suture material, transfascial U stitches / Reverdin needle / stab incisions
  12. Anterior sheath / linea alba closedsuture material and size, continuous or interrupted, small bites

Closure, drains and dressing

  1. DrainsSuction drain over meshSubcutaneous suction drainRetrorectus drainNonenumber, size (Fr), exit sites
  2. Excess skin excisedYesNo
  3. Subcutaneous layerClosedNot closed (subcutaneous drain in place)
  4. SkinInterruptedStaplesSubcuticular
  5. Dressing and binderabdominal binder applied or not

Specimens and implants

  1. Meshmaterial, size, make, lot / batch no., sticker pasted in file
  2. Sac / scar / omentum for HPESentNot sent
  3. Resected bowel for HPE (if any)SentNot applicable

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. Vitals and abdominal girthwatch for rising abdominal pressure after a large hernia: breathlessness, low urine output
  2. Urine outputhourly if catheterised; catheter removal time
  3. Drainschart daily; keep until output is minimal
  4. Oral intakesips, then liquids; slower if bowel handled
  5. DVT prophylaxisearly ambulation, stockings, heparin as per unit protocol
  6. Chest physiotherapy and spirometry
  7. Abdominal bindersupport during recovery
  8. Avoid straining and liftingtreat constipation and cough
  9. Watch forwound redness, discharge, collection (seroma), ileus
  10. Suture removal and follow-update and clinic

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: Mrs. P.D., 52 years, 76 kg, with a reducible infraumbilical midline incisional hernia 3 years after a lower midline laparotomy for an ovarian cyst. CT shows a single 5 x 4 cm defect with omentum and small bowel as content.

Case details

Date: 18/02/2026. Elective. OT 1.

In OT 09:00. GA induced 09:15. Skin incision 09:45. Closure completed 12:05.

Surgeon: Dr A. (consultant, General Surgery). Assistant: Dr B. (2nd-year resident). Second assistant: Dr C. (1st-year resident).

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: symptomatic reducible incisional hernia in the lower midline scar, increasing in size over 1 year. Swelling 10 x 8 cm, cough impulse present, overlying skin healthy.

CECT abdomen: single infraumbilical midline defect 5 x 4 cm, no loss of domain, no other defect.

Diabetic on metformin, HbA1c 6.9%. Non-smoker. BMI 30.

Consent: general, procedure-specific (mesh, possible bowel resection, drains) and anaesthesia consent taken in Hindi from patient, son as witness.

Foley catheter inserted after induction. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 09:25, 20 min before skin incision.

Anaesthesia and position

General anaesthesia with endotracheal intubation. Supine. Parts painted with chlorhexidine-alcohol and draped.

Procedure

Old infraumbilical midline scar excised as an ellipse, incision 14 cm.

Sac found just under the skin, dissected all round to the fascial neck. Sac opened.

Findings: omentum adherent to the fundus of the sac and one loop of ileum loosely adherent, freed by sharp dissection. Bowel healthy, no serosal tear. Single defect 5 x 4 cm. Whole old scar explored with a finger from inside: no other defect. Fascial edges healthy.

Excess sac excised. Posterior rectus sheath incised along its medial edge on both sides and the rectus muscles lifted off it out to the linea semilunaris. Below the arcuate line the plane continued between rectus and peritoneum, down into the space of Retzius. Retrorectus space created about 6 cm beyond the defect in all directions.

Posterior rectus sheath and peritoneum closed in the midline with a running suture, omentum placed over the bowel first.

Flat polypropylene mesh 15 x 15 cm placed in the retrorectus space, lying flat, with at least 5 cm overlap beyond the defect edge on all sides.

Mesh fixed with 8 transfascial U stitches of polypropylene (Prolene), passed with a Reverdin needle through the rectus and anterior sheath. Stitches placed first at 12, 3, 6 and 9 o'clock, then in between, and tied after all were placed. No bowel caught, checked by palpation.

Anterior rectus sheath / linea alba closed over the mesh with continuous Prolene, small bites.

Closure

One 14 Fr closed suction drain placed over the anterior sheath in the subcutaneous plane, brought out through a separate stab on the right.

Subcutaneous fat not sutured as a drain is in place. Skin closed with interrupted sutures.

Dressing applied. Abdominal binder applied in recovery.

Specimens and implants

Mesh: polypropylene 15 x 15 cm. Make ______, lot no. ______. Sticker pasted in the case file.

Specimen: excised scar and sac in formalin, sent for HPE.

End of procedure

Estimated blood loss 150 ml. No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications. No bowel injury.

Extubated on table. Shifted to post-operative ward in stable condition. Pulse 88/min, BP 130/80 mmHg, SpO2 98% on room air.

Post-op orders

Pulse, BP, SpO2, respiratory rate half-hourly for 4 hours, then 4-hourly. Hourly urine output.

Nil by mouth for 6 hours, then sips; liquids on POD 1 if abdomen soft.

Blood sugar 6-hourly; diabetic regimen as per physician.

Analgesia as per ward protocol.

Early ambulation from POD 1. Stockings. Heparin prophylaxis as per unit protocol.

Incentive spirometry. Abdominal binder when out of bed.

Drain output charted daily; remove when minimal. Catheter out on POD 1.

Review of wound on POD 3. Suture removal on POD 12.

Signature

Dr B., JR-2, General Surgery, for Dr A. Reg. no. ________. 18/02/2026, 12:20.

Must document for this operation

  • Number, size and site of every defect found, and that the whole old scar was explored. A missed defect appears later as a 'recurrence' and is an audit and medicolegal point.
  • The plane of the mesh (onlay, retrorectus, preperitoneal, intraperitoneal). The next surgeon opening this abdomen must know where the mesh lies and whether it touches bowel.
  • Mesh material, size, overlap, make and lot number, with sticker. Needed for implant recall, for mesh infection and for any redo repair.
  • Bowel handled, any serosal tear or enterotomy, and how it was repaired. If there is a leak or ileus after surgery, the team needs to know the bowel was handled; contamination also changes the choice of mesh.
  • Whether component separation was done, and which side. A later lateral bulge or a redo operation depends on which muscle layer was divided.
  • Drains: number, site, and what plane they lie in. Nurses chart each drain separately and the removal plan depends on it.

Common mistakes in these notes

  • Writing 'meshplasty done' with no plane, size or overlap.
  • Not recording the defect size in both dimensions.
  • Leaving out that bowel was adherent and was freed.
  • Not pasting the mesh sticker or writing the lot number.
  • Writing 'onlay' when the mesh was actually placed retrorectus, or the reverse.

Sources

  • Bhat SR. SRB's Surgical Operations: Text and Atlas. Jaypee; 2014, Ch 30, Surgeries in Hernia: Incisional hernia (pre-op preparation, Cattell and Keel repairs, prosthetic repair, Rives-Stoppa, intraperitoneal, component separation, post-op care), pp. 1163-1172.
  • Scott-Conner CEH, Dawson DL, eds. Scott-Conner & Dawson: Essential Operative Techniques and Anatomy. 4th ed. Wolters Kluwer; 2015, Ch 47, Open Repair of Ventral Hernias (Arshava EV), pp. 250-261.
  • Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press, Ch 6, Surgical access to the abdomen and abdominal wall: Incisional hernias, mesh selection and placement, Rives-Stoppa-Wantz repair, components separation, pp. 86-89.
  • Bratzler DW, et al. ASHP/IDSA/SIS/SHEA Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm 2013;70:195-283. Table 1 (cefazolin 2 g adult, 3 g if 120 kg or more, redose at 4 h), Table 2 and text (hernia repair: single dose cefazolin within 60 min before incision). www.ashp.org/-/media/assets/policy-guidelines/docs/therapeutic-guidelines/therapeutic-guidelines-antimicrobial-prophylaxis-surgery.pdf

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

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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