Anyone have any suggestions on the follow op report. I have the hernia code but I can'y find anything on the removal oc the left round ligament of the uterus.


PREOPERATIVE DIAGNOSIS: Left inguinal hernia.

POSTOPERATIVE DIAGNOSIS: Left inguinal hernia.

PROCEDURES: 1. Left inguinal herniorrhaphy with mesh.
2. Removal of left round ligament of the uterus.



OPERATIVE FINDINGS: The patient had a small to medium sized indirect hernia sac on the left side. There was no direct hernia.

DESCRIPTION OF PROCEDURE: The patient was placed supine on the operating table. General anesthesia by LMA was begun. The left groin was prepped and draped in the routine sterile fashion. A transverse curvilinear skin incision was made overlying the left inguinal canal and deepened to the level of the external oblique aponeurosis. The external oblique was divided in the course of its fibers to the external ring. The ilioinguinal nerve appeared to be a bifid structure. It was dissected up and away from the underlying canal contents and kept out of harms way the entire procedure. Dissection was begun in the round ligament structures. The sac was dissected out. It was dissected back to a high ligation position. The sac was opened and found to contain no viscera.

The sac was twisted on its self and ligated at its neck with a suture ligature of 2-0 silk. The excess sac was removed and the stump allowed to retract back towards the peritoneal cavity. The round ligament was removed sequentially clamping it proximally and ligating with 3-0 Vicryl and then dividing it distally ligating the distal end with 3-0 Vicryl also. Throughout the procedure, the wound was irrigated intermittently with bacitracin solution. A 6 x 11 cm piece of Ultrapro mesh was then forwarded to the field and soaked in bacitracin solution. The mesh was cut to the appropriate size and was sutured into place with running 2-0 PDS suturing the mesh medially to the fascia, medial to the pubic tubercle, inferiorly to the shelving edge of the inguinal ligament, laterally to the fascia, lateral to the internal ring, and superiorly to the transverse aponeurotic arch. The result was an excellent flat inlay of mesh nicely occupying the floor of the canal. Care was maintained throughout this procedure to avoid any injury to the ilioinguinal nerves. Then 0.5% bupivacaine with epinephrine was infiltrated into the transverse aponeurotic arch, the skin and subcutaneous tissues. The external oblique was closed with running 3-0 Vicryl, the subcutaneous tissue with interrupted 3-0 Vicryl, and the skin was closed with running 4-0 plain subcuticular. Sterile dressings were applied and procedure was completed. Sponge, needle, and instrument counts were reported as correct. The patient tolerated the procedure well. She was awakened, extubated, and taken to the recovery room in satisfactory condition.