Umbilical / paraumbilical hernia repair

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

• wound infection and mesh infection, which may need mesh removal
• seroma or haematoma
• recurrence of the hernia
• injury to bowel or omentum stuck in the sac
• loss of the umbilicus or change in its shape (umbilectomy)
• skin necrosis over the umbilicus
• chronic pain
• conversion to a bigger incision if contents are not reducible

Pre-operative details for this operation

1. Type of herniaTrue umbilicalParaumbilical (supraumbilical)Paraumbilical (infraumbilical)Recurrent
2. Clinical size and reducibilityReduciblePartly reducibleIrreducibleObstructed / strangulatedsize of swelling, cough impulse, skin over it (healthy / thin / ulcerated)
3. Defect size on examination or USG / CTcm; note divarication of recti or other midline defects
4. Risk factorsBMI, diabetes (HbA1c), smoking, cough, ascites / cirrhosis, constipation, prostatism
5. Consent for mesh and for possible umbilectomyTakenNot applicable
6. Mesh available in OTtype and size kept ready

Anaesthesia and position

1. AnaesthesiaSpinalGeneralLocal with sedationif GA, reason (large defect, obese, needs relaxation)
2. PositionSupine
3. Skin preparationumbilicus cleaned of debris before painting; antiseptic used

Operative findings

1. SacTrue peritoneal sacPreperitoneal fat only, no sacMultiloculated
2. ContentsOmentumSmall bowelTransverse colonEmptyadherent or free; viability if obstructed
3. Defect size and positionmeasured diameter in cm, above / below umbilicus
4. Other defects or divarication of rectiNone foundPresent (describe)
5. Fascial edge qualityHealthyAttenuated

Procedure (steps)

1. IncisionInfraumbilical curvilinearSupraumbilical curvilinearTransverse elliptical excising umbilicusVerticallength in cm; why umbilectomy if done
2. Umbilical skin dissected off the sac
3. Sac dissected circumferentially down to the fascial neck
4. Sac handlingReduced intactOpened, contents reduced, excess sac excisedSac excised, peritoneum closedsuture used to close peritoneum if done
5. Contents handledadhesiolysis, omentum excised (ligated with what), bowel viability
6. Defect enlargedNot neededEnlarged transverselyEnlarged vertically
7. Type of repairSuture repairMayo (vest over pants)Preperitoneal / sublay meshIntraperitoneal composite mesh / patch device
8. Preperitoneal / retrorectus space createdextent beyond defect edge in cm
9. Mesh placed and fixedmaterial, size (cm), overlap beyond defect, fixation stitches and suture
10. Fascial defect closeddirection (transverse / vertical), suture material and size, interrupted / continuous
11. Umbilicoplastyunderside of umbilical skin tacked to fascia with which suture

Closure, drains and dressing

1. Haemostasiscautery; note any engorged veins (portal hypertension)
2. DrainNoneSuction drain subcutaneousSuction drain over meshsize (Fr), exit site
3. Subcutaneous tissueclosed with which suture, to reduce dead space
4. SkinInterruptedSubcuticularStaplessuture material and size
5. DressingPressure dressing with pad in umbilicusSimple dressing

Specimens and implants

1. Meshmaterial, size, make, lot / batch no., sticker pasted in file
2. Sac / excised omentum sent for HPEYesNo
3. Sac fluid for cultureSentNot 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. Vitalspulse, BP, respiratory rate as per ward routine
2. Oral intakeliquids when awake after spinal / GA; earlier if no bowel handled
3. Drainchart output daily; remove when output is low
4. Abdominal binder / supportif advised by operating surgeon
5. Mobilisationearly; avoid straining and heavy lifting
6. Watch forabdominal distension, vomiting, wound redness or discharge, collection under umbilicus
7. Stool softenerif constipated; avoid straining
8. Suture removal and follow-update of review, 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