# Inguinal exploration, no hernia



## MEZIESKY (May 26, 2015)

I am just not sure on this on. No hernia was found. He just did exploration. Thanks for any input

PREOPERATIVE DIAGNOSIS:  Recurrent right inguinal hernia (ICD-9 code 550.9).

POSTOPERATIVE DIAGNOSES:
1.  No evidence of recurrent hernia.
2.  Hydrocele.

PROCEDURE PERFORMED:  Right inguinal exploration.


ANESTHESIA:  General/local (10 mL of 0.5% Marcaine equally mixture of 1%
Xylocaine plain) injected locally in right inguinal region, as well as a
dedicated right ilioinguinal nerve block.

INDICATIONS:  This pleasant 88-year-old gentleman was referred to my office by
 with a bulge in his right groin with some dull, gnawing pain. 
Examination revealed a bulge in the right inguinal region, which suggested a
recurrent hernia.  He has had previous mesh repair in the past.  Based on these
symptom complexes, I recommended exploration.  Of note, he also had a scrotal
mass which I felt was a hydrocele.

DESCRIPTION OF PROCEDURE:  The patient was marked in holding and brought to the
OR and placed under general anesthesia and the right inguinal region was prepped
and draped in the usual sterile fashion.  The planned procedure was confirmed
with the operating team.  I started by infiltrating the proposed incision with
local anesthetic and an additional 5 mL was used for ilioinguinal nerve block. 
An incision was made 2 fingerbreadths above the inguinal crease and dissection
was carried down through rather thin Scarpa's fascia to reveal an external
oblique aponeurosis.  The external oblique was scarred and was opened using
electrocautery.  Once we got into the inguinal floor, mesh came into view and it
was carefully dissected from the cord.  The cord itself was rather attenuated
and the internal ring wrapped around it nicely.  The mesh itself had some
eventration.  It pushed down a little bit, but the repair itself was intact all
the way from pubic tubercle to internal ring.  I did not see evidence to suggest
either a recurrent direct or indirect hernia.  Felt that the repair was intact. 
As such, the wound was irrigated.  The cord replaced.  It was closed with 3-0
PDS in interrupted fashion and 4-0 Monocryl for the skin.

The patient tolerated the procedure well, was returned to the recovery room in
stable condition.


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## mitchellde (May 26, 2015)

You use an exporatory surgical code like a 49010.  Your dx will be the V71.89 do not use the 550.9 code since it does not exist.  The hydrocele was not addressed in this operative procedure, it was something he felt on the exam.


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## MEZIESKY (May 27, 2015)

Thank you


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