Discharge Summary-Page 1

ADM ISSION DIAGNOSIS: Incisional ventra l hern ia.

DISCHARGE DIAGNOSIS: Incisional ventra l herni a, status post laparoscopicincisional hernia repair.

SURGICAL PROCEDURES: Laparoscopic incisional herni a repa ir.

HISTORY OF PRESENT ILLNESS: This is a 73-year-old gentleman who haspreviously undergone a vertical banded gastroplasty followed by aRoux-en-Y gastric bypass. He tolerated these procedures well without anypostoperative complications; however, he has recently noticed a mass inhis upper abdomen. This extends off to the le ft side of his abdomen andis associated with pain bilaterally. This pain worsens with any increasein intraabdorn inal pressure; however, he has had no obstructive symptomsand continues to have regular bowel movements. He has undergone athorough evaluation of this mass per his primary care provider and wasreferred to Dr._for an incisional hernia repair.

HOSPITAL COU RSE: The patient presented to thewhere he underwent the above-mentioned laparoscopic

incisional hernia repair. He tolerated the procedure well without anypostoperative complications. Please refer to the operative note dictatingthe electronic medical record for any further details of this procedure.The patient recovered briefly in the Postanesthesia Care Unit and wastransferred subsequently to the surgical fl oor. His diet was slowlyadvanced beginning with clear liquids to a regular diet, which hetolerated well without any compla ints of nausea or vomiting. Onpostoperative day #1, the patient did compla in of increased pain that wasmoderately controlled with his ora l Lortab. He was started on extrastrength ibuprofen, which he received one dose and had excellent painrelief. The patient was ambulatory in his room and in the halls withoutdifficulty. His incisions were dry without stigmata of infection. The

Discharge Summary-Page 2

pati ent was felt stable for discharge hom e.

DISCHARGE INSTRUCTIONS: The pati ent was given exquisite dischargeinstructions per Dr._standard routine. He was told that he couldshower the second morning after the surgery and to remove the dressing onthird morning. He was told to observe his wound for any signs or symptomsof infection including redn ess, swelling, increased pain , drainage, orfever and given the number and told to ca ll should heexperience any of these symptoms or concerns. Furthermore, he was toldnot to lift anything greater than to pounds for the next 6 weeks, but toresume his other norm al daily activities such as walking. He wasdischarged home with a prescription for Lortab , senna, and ibuprofen . Hewas told that he could resume his other horne medications as previouslyprescribed.

DISCHARGE ME DICATIONS:I . Lortab 7.5/500 mg, take one to two tablets every 4 to 6 hours as neededfor pain, 40 tablets dispensed.

2. Senna-S 2 tabl ets ora ll y twice daily, 20 tabl ets were dispensed.3 . Ibuprofen 800 mg ora lly every 8 hours p.r.n. for pain, dispensed 30tabl ets.

Hff I

CHIEF COMPlAINT: Abdominal wall mass.

~ISTORY OF PRFSENT ILLNESS: The patient is a 73-year-old gentleman who has undernone a previous vertica l bandedgastroplasty in _ in addition to conversion of this to a Roux-en-Y gastric bypass in _ . He did not have any difficultiesafter either of these procedures. He has recently noticed a mass in the upper portion of his abdomen. This extends off to theleft side of his abdomen. It is associated with pain in his lower abdomen that is bilateral. This worsens with any sort of increasein intraabdominal pressure. He denies any obstructive symptoms. He has had no change in his bowel movements. He has hadno change in his urinary habits. He underwent evaluation of this mass via his primary care provider. An ultrasound wasperformed which showed evidence of an incisional hernia to be present and he now presents to my clinic for repair.

PAST MEDICAL HISTORY: Hypertension .

( .ST SURGICAL HISTORY: As above. In addition, exploratory laparotomy in _ for a questionable gastric abnormality Ihatwas found to be normal. He has also had knee surgery x2 and back surgery.

ALLERGIES: No known medication allergies.

CURRENT MEDICATIONS: Lisinoprillhydrochiorothiazide, aspirin.

FAMILY HISTORY: Noncontributory.

, OCIAL HISTORY: The patient does not smoke or drink. He is currently retired but used to work as a truck driver.

REViEW OF SYSTEMS: The patient denies any cardiopulmonary symptoms and is able to participate in his activities of dailyliving without difficulty. He has no specific GI symptoms with regards to reflux. nausea, vomiting, or change in bowel habits. Hehas no urinary symptoms. He den ies any HEENT-type symptoms.

PHYSICAL EXAMINATION: Vilal Signs: Temperature 98.4, heart rate 86, blood pressure 133177, resp iratory rate 16, height 6feet 0 inches, weight 294 pounds (BMI 40). HEENT: The scierae are anicteric and the oropharynx is clear. Neck: No jugularvenous distention or lymphadenopathy. Chest: Clear to auscultation bilaterally. Cardiac: Regular rate and rhythm. Abdomen:Soft. There is a significant eventration with diastasis in his midabdomen. There is a palpable hernia that is present in the centerof this. This hernia is reducible. I do not palpate any hepatosplenomegaly or any other abdominal abnormalities though theexam is limited by his body habitus. Back: No eVA tenderness or spinal abnormalities. Extremities: No clubbing, cyanosis, oredema. .

ASSESSMENT: Symptomatic incisional hernia.

PLAN: The patient is a candidate for laparoscopic repair of this hernia. He has not had a previous hernia repair and I feel it isreasonable to try an initial attempt with a laparoscope and mesh implantation. This will not fix his diastasis but should hopefullytake care of his hernia. I have reviewed the risks and benefits of the operation with the patient inclUding the risk of bleeding,infection, bleeding or infection requiring reoperation, inability to complete the procedure laparoscopically, and damage tointraabdaminal structures requiring more extensive surgery. I have answered all questions about the procedure. A consentform was signed in clinic. The patient will undergo a preoperative CSC, SMP, and ECG. Anv abnormalities identified on thesestudies will be addressed priorto his procedure. His procedure has been scheduled for Because of the extentof his procedure and also his age, a 23-hour stay will be initiated for after his procedure.

Operative Report-Page 1

PREOP ERATIVE DIAGNOSIS: Incisional hernia .

POSTOPERAn VE DIAGNOSIS: Incisional hernia.

PROCED URE: Laparoscopic incisional herniorrhaphy with mesh.

ANESTHESIA: General endotracheal.

INDI CAn ONS: The patient is a 73-year-old gentleman who has previouslyundergone a vert ica l-banded gastroplasty and this was converted to aRoux-en-Y gastric bypass. He has had a single midline incision and now hasdeveloped a painful mass in his epigastrium. Clinical evaluation and CTscanning has confirmed the diagnosis of a symptomatic incisional herniaand he will now undergo repair.

FINDINGS: lncisional hernia, not incarcerated.

PROCEDURE IN DETAIL: The patient was brought to the operating room andplaced supine on the operating table. Genera l endotracheal anesthesia wasinduced and his abdomen was prepped and draped sterilely. Then 0.25%Marcaine infiltrated into his surgical sites for postoperative analgesia.A small nick was made in the left upper quadrant. A Veress needle wasinserted into the abdomen through this nick. After confirmingintraabdominal position of the needle, pneumoperitoneum to 15 mmHg wasgenerated. A 5-mm port was placed in the left side of the abdomen using anOptiview technique. Under direct vision, a second right-sided port and a

Operative Report-Page 2

left- sided port were placed . Utilizing these three 5 mm ports adhesions tothe anterior abdominal wa ll were taken down with combination of sharpdissection and electrocautery. This exposed a Swiss cheese type herniadefect in the upper portion of his abdomen. All fat and these herniadefects were reduced. Adhesions were taken down up underneath thediaphragm to allow for placement of the mesh into this position . Once th iswas completed, an 8 inch x 10 inch piece of Physiomesh was brought to theoperating field . A suture was placed in the superior and inferi or aspectsof the mesh . The superior suture was placed approx imate ly I inch from themesh edge to allow it to be placed in the subxiphoid position and have themesh flip up underneath the diaphragm to be tacked under the diaphragm .The mesh was then inserted into the abdomen and unfolded. The epigastricsuture was brought through counter incisions on the anterior abdomina lwa ll. The intraabdominal pressure was then turned down to 8. The mesh wasthen stretched inferiorl y and a mark was made on the anterior abdominalwall inferiorly where all defects would be covered and the mesh would betensioned appropriate ly. A counter incision was made in this location andthe preplaced 0 PDS suture was brought through the anterior abdominalwall. These 2 sutures were held on tension. With the intraabdominalpressure still at 8, two rows of tacks were placed circumferentiallythrough the anterior abdominal wa ll. To facilitate this, two further 5 mmports needed to be placed in the lateral aspects of the abdomen. Once thetacking of the mesh was completed two more transfascial sutures wereplaced in the lateral aspects of the mesh. This was done by passing an 0PDS suture transfasc ially lateral to the mesh through one of the 5-mm portsite incisions. The endo close was then passed through the mesh and thesuture grasped and brought back out through the anterior abdominal wall.Thi s was done on both the right and left sides of the abdomen. With the 4transfascial sutures now in place, the mesh was inspected and found to beappropriately positioned. All of these sutures were tied. The ports wereremoved and the pneum operitoneum released. To faci litate placement of themesh, one of the 5 mm ports was changed out for an II mm port and thisport site fascia l defect was encircled with an 0 Vicryl suture to occ ludeits fascial defect. The pneumoperitoneum was released by removing theremainder of the ports. The skin incisions were closed with 4-0 Monocrylsubcuticular suture and Steri-Strips. The patient tolerated the procedurewell, there were no complications, and estimated blood loss was minimal.He was then extubated in the operating room and transported to therecovery in stable condition.