Here's a summary of my OR report. Hope you understand it and hope it helps you
SIGNIFICANT FINDINGS: Patient did have evidence of tears in a mild fashion near the rectus insertion site. However, at both adductors there are significant rents with the tendinous portion and in doing the epimysiotomies some extra fluid expelled. This was relative convincing from the standpoint of understanding her problem.
DETAILS OF PROCEDURE: ….. In this operation, i.e. pelvic floor repair, the anterior pelvis floor i.e. the pubis and its ligamentous attachment was stabilized; rather than the posterior inguinal floor itself like a hernia. A three dimensional plan was designed so that the anterior abdominal attachments to the pubis and adjacent ligaments were reattached and/or reinforced. This was accomplished by creating a broad band distal end of the rectus abdominus muscular fascia and attaching it directly to the pubis and portion of the inguinal ligament, staying as anteriorly as possible in order to provide pure anterior pelvic support. The focus was not on closing the internal ring where a hernia would develop or would cause a weakness in the inguinal floor. The sutures were placed in a rear vertical line so that the rectus was attached as medially as possible, as close a possible to the pubis. The internal ring itself was left loose. As part of the procedure he posterior layer of sutures was placed as posteriorly as possible onto the rectus fascia so that the real line of support, i.e. second row of sutures, could achieve maximal anterior pelvic stability. A search occurred for a real inquinal hernia because an indirect hernia or a small direct hernia would not be repaired by this technique. In the course of the technique the original insertion site of the rectus muscle was checked after the sutures had been secured to see if there waa any apparent residual weakness to compare to the new insertion of the rectus. Therefore, a third row of sutures was necessary. The reaction that had been created by the repeated micro-trauma, which is the cause of the injury, was not dissected in its entirety for fear of disrupting whatever attachments were left and natural.
Branches of the iloinguinal nerve were dived bilaterally because these would hae gotten in the way of the repair. The round ligament was surrounded and divided between 2-0 silk sutures. The lateral edge of the rectus muscle was brought down to the pubis and inquinal ligament with reinforcement sutures to achieve a satisfactory vertical attachment. The procedure was performed in two layers principally with interrupted 2-0 silk suture for the posterior layer and interrupted figure –of-eight 0 tycron suture for the anterior layer. Reinforcement 0 tycron sutures were used to further stabilize the anterior pelvis more superficially and interiorly. These were carefully placed from the rectus sheath onto the pubis and inguinal ligaments. Then the external oblique aponeurosis was re-approximated with running 2-0 chromic suture, interrupted 3-0 dexon and the fatty tissue with 4-0 subcuticular dexon.
For the adductor component procedure, the following considerations were necessary. First of all, the weakness of the abdominal musculature has created a compartment syndrome caused by the unopposed action of the adductor muscles in a relative sense. Second, considerable inflammatory reaction had occurred at both the insertion site of the adductor onto the pubis as well as along the posterior aspect of the adductor compartment where the teeth-like prominences of the superior edge of the inferior pubic ramus was located. In addition, the third consideration was that the abdominal musculator be additionally stabilized from below by suturing the cut end of the proximal adductor epimysium to the pubis and reattached rectus muscle above. It was necessary to ensure that the ilioinguinal nerve was not entrapped at this stage in this portion of the repair. Chromic sutures are used to perform this portion of the attachment stabilization. The components of the repair include this stabilition from below; a complete cut of the entire anterior and lateral epimysium i.e. the covering of the muscle of the adductor. It was important to keep well as muscle itself intact as well as free up the adductor muscles from each other and from the underlying tissue to complete the correction of the compartment syndrome. During this process edema was released related to the entrapment. The junction of the adductor into the pubis is dissected throughout its medial and lateral course. A small vein overlying the repair was mobilized and dissected away from the site of subsequent incisions. Then debridement of calcium and fibrosis was performed. …………….
A tunnel was made on the right and left side down to the adductor longus muscle and tendon. A muscle and tendon was dissected to its junction with the pubis and with identification of adjacent structures. Multiple longitudinal incisions were made into the pubis and junction tendons to achieve a satisfactory possibility for a neovasularity. Approximately 20 cuts were made on each side. Complete anterior and lateral epmysial releases were performed 3 centimeters distal with the muscle still attached. ……….