# Incisional hernia repairs with retrorectus mesh placement



## Codehound1 (Mar 10, 2015)

I'm thinking these are the correct codes, but I could use some input...

49561-22      Dx 552.21 (incarcerated incis hern), 568.0 (adhes), V64.41 (lap to open), V45.89 (s/p open chole)
49560-59,51  Dx 553.21 (incis hern), V45.89 (s/p open chole)
+49568         Dx 553.21, V45.89

PROCEDURE PERFORMED:  
1.Laparoscopic converted to open incisional hernia repair.
2.Incisional hernia repair with retrorectus placement of mesh.
3.Lysis of adhesions (45 minutes).

OPERATIVE FINDINGS:  Large fascial defect of incisional hernia at the umbilicus with 2 separate lower midline incisional hernias, one extending to the left of the previous incision and the other extending to the right of the previous incision.

DESCRIPTION OF PROCEDURE:  After informed consent was obtained, the patient was brought back to the operating room and placed in supine position.  General endotracheal anesthesia was initiated.  The patient's abdomen was prepped and draped in usual sterile fashion.  Appropriate preoperative antibiotics and time-out was accomplished per protocol.  A periumbilical incision was made on the right side of the abdomen using a scalpel.  A 5 mm port was placed under direct visualization.  The abdominal cavity was then insufflated with CO2 gas.  An additional 5-mm port was placed in the left lower quadrant under direct visualization.  The abdominal cavity was then explored and the patient was noted to have a relatively large fascial defect at the level of the umbilicus in his previous incision.  The patient was also noticed laparoscopically was that he had another hernia kind of in the right lower quadrant or inferolateral to the midline incision on the right side along with 1 on the left side as well.  There was significant abdominal adhesions to the anterior abdominal wall a few cm above the umbilicus and extended all the way up and these were pretty dense adhesions and with this, it was felt best to proceed an open repair versus a laparoscopic repair.  At this point, an elliptical incision was made around the umbilicus in the old midline scar using a scalpel.  The incision was carried down through the subcutaneous tissues using Bovie electrocautery.  The hernia sac was entered and the abdominal cavity was deflated with CO2 gas.  The hernia sac was completely opened and all the hernia sac was completely excised and this left about a 3-inch fascial defect.  This was extended down inferiorly to incorporate the incisional hernias on the left and right side of the previous midline incision.  The patient did have some incarcerated omentum in this, which was completely freed up using Bovie electrocautery.  With this, lysis of adhesions was then performed inferiorly separating the omentum from the anterior abdominal wall.  All of this was performed right at the umbilicus and down inferiorly into the pelvis.  This was all free of adhesions.  There was a significant amount of adhesions in both lateral aspects of the abdomen and upper abdomen and this was left alone.  At this point, it had a relatively large fascial defect after incorporating the 2 additional incisional hernias in addition to the 1 at the umbilicus.  With this, the posterior fascia was opened and mobilized from the rectus muscle anteriorly.  This was performed lateral all the way to the inferior epigastric vessels and this was performed equally on both sides.  This was also performed inferiorly as well as superiorly.  The retrorectus fascia was then closed using a #1 PDS suture starting cranially and descended down caudally a far as we could with minimal tension.  Another #1 PDS suture was then used to close the rest of the retrorectus fascia and this was performed laterally from one lateral side to the other lateral side in a facilitating complete closure of the retrorectus fascia.  With this, a piece of Prolene mesh measuring 6 x 6 inches in size was placed in the retrorectus fashion and this was sutured in placed using #1 Prolene sutures in a horizontal mattress fashion going through the anterior abdominal wall circumferentially.  With this, this retrorectus space was then copiously irrigated with sterile normal saline.  Excellent hemostasis was obtained.  A drain was then brought through the anterior abdominal wall and placed in the retrorectus space.  All the Prolene sutures were then tied in place.  The anterior fascia was then reapproximated in the midline using a #1 PDS suture in a running fashion.  Two 15-French round JP drains were then brought through separate stab incisions and placed between the abdominal wall and the skin in this space and all of the drains were sutured in place using a nylon suture.  With this, the subcutaneous tissues were then reapproximated using a 2-0 Vicryl suture in a running fashion.  The skin was then reapproximated using staples...


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## cynthiabrown (Mar 10, 2015)

It sounds like there was only one incision,right?   do 49561-22+49568. drop to paper and mail it in


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