# Open and Laparoscopic repair of hernia



## ch81059 (Feb 17, 2014)

Hi,
My surgeons have been doing hernia repairs lately with an open approach and then finishing the repair laparoscopically.  Has anyone else come across this?  I know we can't bill as open and laparascopic and usually it wouldn't be an issue.  If it's a lap converted to open it's one thing but this is completely different.  I'm not sure if I should just use the open code or if I should be using some type of unlisted code.  Any input would be appreciated.  Thanks

PREOPERATIVE DIAGNOSIS
Left flank hernia.

POSTOPERATIVE DIAGNOSIS
Left flank hernia.

*PROCEDURE PERFORMED
Open and laparoscopic repair of left flank hernia.*

BRIEF HISTORY OF PRESENT ILLNESS

This is a 55-year-old female who, over the last several months to years,
has developed a left flank hernia from a previous surgical incision
site. She presented to clinic for elective hernioplasty and
thus the patient was scheduled for an elective repair of the left flank
hernia on January 27, 2014.

PROCEDURE IN DETAIL
After an informed consent was obtained, the patient was taken back to
the operating room and laid in the right lateral decubitus position. A
beanbag was used for placement. Prior to placing the patient on the
beanbag, the patient was given general endotracheal anesthesia. *The left
flank was then widely prepped and draped in the usual sterile fashion.
Incision was carried over the previous surgical incision site.
Dissection was carried down to the hernia sac through all muscle layers.
An incision was then carried down into the peritoneal cavity.* All
omental adhesions were released circumferentially. Skin flaps were
raised superior to the muscles caudally, cephalad, medially and
laterally in preparation for the soft mesh placement later on in the
case. Once all adhesions were broken up intraperitoneally, a 20 x 25 cm
DualMesh was then used with previously placed 0 Gore-Tex PTFE sutures
proximally. Six sutures were pre-placed on the surgical table and a
Reverdin's needle was used to place transfascial sutures circumferentially. These were then brought up and tied in place. Lateral most stitch was secured into the left psoas muscle. Sutures were then tied down. As we were tying the transfascial sutures, care was taken to exclude all fat or intra-abdominal contents from becoming incarcerated between the mesh and the abdominal wall. *The incision was then closed with 0 Prolene in a running fashion and subcuticular stitches using 3-0 Vicryl in running fashion were used. A trocar was then inserted into the abdomen, anteromedially to the incision site. Pneumoperitoneum was then achieved. An additional trocar was placed superior to this and the fascia was tacked into place using SecureStrap and SorbaFix Tacker in a dual crown technique. Of note, prior to wound closure the Bard ultra
light mesh placed and secured in place using SecureStrap. A drain was
carried out through the skin and was tied in place using a drain stitch.
The incision was then closed with skin stapler.* The patient tolerated
this procedure well.


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## juneh (Apr 30, 2014)

*Help also needed!*

Well there is alot of discussion and no real direction on how to code these new hybrid procedures. Any help would be greatly appreciated!


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## JSYLVAIN (Jun 17, 2014)

Most of the work is completed open, and the tacking is done lap, so we use the open code.


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