# Closure of inadvertent enterotomy for delayed placement of mesh/Inc hernia repair



## ksb0211 (Nov 15, 2011)

Hoping for some suggestions for this case.  We had a patient who was scheduled for incisional hernia repair.  When the dr went in, there was a change of plans.  Here are the following op notes.  Thanks for any help/suggestions.

11/03/2011

PRE/POSTOPERATIVE DIAGNOSIS
Incarcerated ventral hernia.

OPERATION PERFORMED
Exploratory laparoscopy and laparotomy with closure of inadvertent enterotomy for delayed placement of mesh.

DESCRIPTION OF PROCEDURE
The patient was taken to the OR after induction of adequate general anesthesia.  The patient was prepped with DuraPrep and draped sterilely.  Perioperative antibiotics had been administered.  The initial incision was made with a #15 blade laterally in the mid abdomen.  The Optiview port was passed without difficulty.  I was able to enter the peritoneal cavity and marked adhesions were appreciated, but I was able to get a good purchase and was clearly in a space where there was some adherent omentum to the abdominal wall but I was able to clear things well enough to place a second port inferiorly on the left side.  Once this was done, further clearing was done and placed another port more superiorly.  The adhesions were slowly taken down.  It did tend to bleed from most of the points of dissection but this was readily controlled with electrocautery.  Ultimately reached the point where the hernia was noted in the midline.  At this point, was found that the adhesions were more significant and could not be well addressed laparoscopically.  The midline incision was then opened with a #15 blade and I entered this into the area of pneumoperitoneum.  Then, utilizing careful sharp dissection, the loops of bowel that were tightly adherent to the hernia, hernia sac, margins and the old mesh repair were slowly taken down.  I was able to do this circumferentially and get a good margin.  Copious irrigation was utilized.  As we were examining the bowel prior to performing any mesh closure, a small rent measuring 1 cm was noted without significant spillage.  Decision was that this most likely would not be a problem, but the decision was to close this with running 3-0 Vicryl and then inverting sutures of 3-0 silk.  The rest of the bowel appeared to be healthy without significant abnormality.  Because of the bowel entry, decision was not to place mesh at this time but to close the abdominal cavity after thorough rinsing and to place staples in the skin and plan for return to the OR in 4 days after continued antibiotics.  At that point, appropriate mesh repair can be performed.  This will be addressed with the patient.

11/07/2011

PRE/POSTOPERATIVE DIAGNOSIS
Incisional hernia.

OPERATION PERFORMED
Incisional hernia repair.

DESCRIPTION OF PROCEDURE
The patient was taken to the OR after induction of adequate general anesthesia, the patient was prepped with DuraPrep and draped sterilely.  The staples were removed from the surgery attempt from last week.  The wound was opened, no significant hematoma was noted.  The underlying hernia sac and subcutaneous tissue was opened exposing bowel that was again within the hernia above the fascial level.  This was carefully freed and returned to the peritoneal cavity.  Some relatively loose adhesions were encountered.  This was all thoroughly irrigated with antibiotic solution and then a lap pad was placed to allow further dissection.  The hernia sac was then mobilized.  Superiorly at the top of the fascial defect was the end of a previous mesh repair.  This was polypropylene mesh.  This was cleared of overlying tissue.  The plan was to mobilize the tissue adequately to cover the defect and then placed a new piece of mesh.  The problem was that there were multiple layers and levels within the wound caused by the previous hernia repair and finding the fascia and the previous midline laparotomy incision inferiorly.  The fascia layer was sought laterally.  Once this was done, this was cleared of surrounding tissue and then brought the dissection was brought up to develop a shelf superiorly on top of the mesh.  Once I was able to do this clearly, I trimmed the mesh and then folded the tissues in so that the hernia defect was covered with viable tissue.  The mesh itself blended well with the native fascia.  Once all this was completed, a 6 inch x 6 inch polypropylene mesh was fashioned, trimming of only the corners was needed as it took most of this mesh.  This was then secured in place with running 2-0 Prolene suture.  The peritoneum and hernia sac had been tacked with 0 Vicryl suture to close the defect.  Once this was completed and the mesh was well in place, it was thoroughly irrigated with antibiotic solution.  Good hemostasis was achieved.  The wound was then further closed with interrupted 3-0 Prolene to the edges of the mesh and then 2-0 Vicryl to the deep tissue of the wound.  Clips were applied to the skin.  A 10 mm Jackson-Pratt drain had been placed.  The patient tolerated the procedure.  The estimated blood loss was perhaps 50 mL  He was taken to recovery room in stable condition.


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## Lujanwj (Nov 15, 2011)

I'd suggested 44602-22 998.2 V64.41 for the first one.  44560-58 20680-58 49568 for the second.  With that being said, you're probably going to have an issue with the payer.  As you know the hernia repair would be bundled into the orraphy had it been done on the same date of service.  

Bests,


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