Tbilisi State Medical University

Department of surgery
DR. liana saginashvili
6th year student Raghad Shakib Younus

Medical Case
Isamilova tamam
69 year old
Married, retired/house wife
Admission date: 13/11/2018 9:10a.m.

Clinical diagnosis:
 Main diagnosis – massive ventral hernia
 Complication – none
 Concurrent diseases –

Main Complications:

 abdominal mass at the anterior abdominal wall

 weakness
 difficulty walking
Before admission hernia was incarcerated, but then it resolved by itself

Anamnesis morbi:

Abdominal mass for 10 years, it was small then increased gradually, now doesn’t resolve
completely, she was admitted for the plan operation.

Anamnesis Viti:
She is married, she has healthy children, she has arterial hypertension

Status presence:

 Patient general condition is good

 Skin and mucus – normal
 She is 2nd degree obese
 Bone and joint – normal
 Temperature – 36.9c
 Cardiac –
o HR – 85
o BP – 140/70
o Dull heart sounds
  Respiratory –
o RR – 17
o Clear sounds on percussion
o Vascular breathing on auscultation
 GTI –
o Tongue is wet, free swallowing, no pain
o Abdomen is distended
o Under the umbilicus there is a big mass 15cm. which by pressing doesn’t
reduce
o Painless abdominal wall
o No irritation of peritoneum
 Perirectal investigation –
o Rectal ampulla is free, painless without pathology
o Defection is normal
 UT –
o Normal urination
o Kidneys are normal
o pasternatsky sign is negative
 nervous system –
o conscious
o alert

Primary diagnosis:

Massive ventral hernia

Investigations:

 Lab tests
 Imaging tests – US and chest X-ray

Consultation of cardiologist, therapist and anesthesiologist before surgery were done

Operation consultation:

 Confirming diagnosis – Abdominal mass for 10 years, it was small then increased
gradually, now doesn’t resolve completely, she was admitted for the plan operation.
 Indication for surgery – massive ventral hernia
 Operation plan – hernioplasty by using mesh (non-tension)
 Type of anesthesia – endotracheal
Signature: R
Informed consent
During operation can be:
 Iatrogenic damage
 Anatomical abnormality
 Bleeding
Post operation complications:
 Suppuration of wound
 Bleeding
 Thromboembolism
 Peritonitis
 Recurrence of hernia
Patient signature: I.T.
Operation date: 13/11/2018
Started at 1:00 p.m.
Finished at 2:05 p.m.

Intra operative diagnosis:

Operation name: ventral hernioplasty by using only mesh

Courses morbi:

 General condition – good

 Wound condition – good
 Urination and defection – normal
 Medications –
o Antibiotics – rasiosef, fracsipalrin 0.4g p/d
o Pain killers – analgin 50% 2g. , dimedrol 1g.

Differential diagnosis:
 Ventral hernia
 Hiatal hernia
 Lipoma
 Tumor

Epicrisis:

Ismailovsa tamam was admitted to the hospital complaining of abdominal mass at the
anterior abdominal wall which was diagnosed after making the necessary tests and massive
ventral hernia, consultations were done and operation was planned as hernioplasty with
mesh.

After operation condition of the patient was good with no complications

Patient was discharged 5 days after operation.