# Lap chole w/hernia repair



## nabernhardt (Aug 20, 2012)

I am needing help please on this op note.  I am thinking 47562 (lap chole) and 49653 (hernia repair) or is this open since he did laparotomy?
PROCEDURE: the abdominal was entered through an epigastric incision with
local anesthetic being injected in the skin and then a 5 mm incision and port placement with direct intra laparoscopic port guidance. After safely entering the abdomen, a pneumoperitoneum was established. A 5 mm port was placed on the right side of the abdomen under direct visualization. Incarcerated hernia was noted above the umbilicus in this epigastric area where the hernia was noted. This was reduced with laparoscopic assistance and palpation externally. Some omental
bleeding was seen and was controlled with the electrocautery device initially. After completely reducing the hernia, the incision in the fascia was made through the hernia site with a 10-12 mm port. After assuring adequate positioning, the gallbladder was identified and with the patient in the head-elevated position rotated towards the right side up, the gallbladder was controlled. The cystic duct was subsequently identified and dissected free from surrounding tissue as was the artery. After confirming the critical view, the cystic duct was doubly clipped proximally, then distally and divided as was the cystic artery. The gallbladder was freed from the liver bed with the cauterized spatula dissecting device using heparinized lactated ringers solution as necessary. Prior to release of the final attachments, the liver bed was assured to be hemostatic as was the cystic duct and
artery stumps with good clip placement. The gallbladder was freed and brought out through the epigastric incision without enlargement. At this point, attention was turned towards the omentum, which had been reduced from the hernia and after initial fascial closure of the hernia with laparoscopic guidance, it was felt that I could not completely be certain of adequate hemostasis in this omentum. Repeated attempts to visualize this laparoscopically failed and even attempt to pull the omentum back through the epigastric incision also failed. The incision was then enlarged in stages and subsequently was enlarged large enough to allow for a more thorough laparotomy evaluation of the omentum. The omentum appeared to be oozing from several sites but no distinct
site, although several sutures were placed in the omentum itself in an attempt to maintain
hemostasis. Due to generalized oozing, the harmonic scalpel was used and a large portion of the omentum was removed with cautious harmonic scalpel use for good hemostasis. After assuring hemostasis at this point and removal of a section of the omentum without injury to the underlying bowel, the abdominal cavity was further irrigated and inspected and after assuring adequate hemostasis, the fascia was closed with running #1 Prolene suture starting at both apices of the incision and running back towards the middle, thus completing a hernia repair with permanent sutures. The subsequent incision was approximately 10 cm in size at the completion of the procedure and it was felt that this was required to aid in adequate exposure.


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## nabernhardt (Aug 24, 2012)

Now I am thinking a lap chole with an Open hernia repair incarcerated?


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## syllingk (Aug 24, 2012)

I am thinking 49255, 47562.


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## nabernhardt (Aug 24, 2012)

i never thought about that
would you still code a hernia repair as open or lap?


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## syllingk (Aug 24, 2012)

You can't code the hernia repair. Doctor put his trocar through it. It is included in the Lap Chole.


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## nabernhardt (Aug 24, 2012)

ok thank you.  really appreciate your help with this.


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