John J Bauer, MD, FACS John J. Bauer, M.D.

Urology Services, Inc.
G-1121 West Hill Rd.
Flint, Michigan 48507
Tel: 810.232.8888
Fax: 810.232.9190

Counseling and Pre-Op Note

Patient Name:



Procedure: Right/left/bilateral inguinal hernia


Patient is a male diagnosed with a symptomatic or asymptomatic inguinal hernia, which is manifest by bulging in the inguinal region and/or the scrotum. It is unlikely to resolve spontaneously and could be complicated by bowel sliding into the hernia sac or communication which could result in a surgical emergency.


Alternative is observation and laparoscopic repair


The risks and complications of the procedure where extensively discussed with the patient. The general risks of this procedure include, but are not limited to bleeding, transfusion, infection, wound infection/dehiscence, pain, scaring of tissues, failure of the procedure, potential injury to other surrounding structures, deep venous thrombosis, pulmonary embolus, myocardial infarction, heart failure, stroke, death or a long-term stay in the Intensive Care Unit (ICU). Additionally, mentioned were the possible serious complications of the anesthesia to include cracked teeth, airway damage, aspiration, pneumonia, spinal head-ache, nerve damage, spinal canal bleeding and malignant hyperthermia. Your anesthesiologist will discuss the risks and complications in more depth separately. Additional procedures may be necessary.

The specific risks of this procedure include, but are not limited to: complete breakdown of the repair, prolonged wound drainage, injury to bowel or intra-abdominal structures, injury to spermatic vessels, testicle and vas deferens which may lead to loss of testicle or future infertility problems. Possible injury to the ilioinguinal nerve is also possible and could lead to anesthetic areas on the scrotal, penile and inguinal skin. The procedure may involve placement of a permanent mesh plug and patch material which has the potential to be chronically infected and may need to be removed. Additionally, you will need to take prophylactic antibiotics for future surgical and dental procedures so the mesh will not be seeded with infection.

You understand the procedure, general and specific risks as discussed and agree to proceed with the procedure. You also understand that not every possible complication can be listed in this counseling note and additional risks are possible, although unlikely.

Physician's Signature: ________________________________ Date: __________________

Patient Signature: __________________________________ Date: __________________

Witness: __________________________________