# Mesh infection/small bowel fistula to mesh



## ginasn (Jan 27, 2012)

Could someone please help me with this op note? I have coded it as 44120 and 11008, with dx 996.70 and e878.9, I don't think this is correct and would love to have someone with more experience with surgery to look this over. 
Thanks so very much....
PREOPERATIVE DIAGNOSES:
1. Mesh infection (placed by ) with failure to resolve with long-term intravenous antibiotics.
2. Suspected small-bowel fistula to mesh.
3. Multiple prior ventral hernia repairs including use of mesh by members of the Surgical group.

POSTOPERATIVE DIAGNOSES:
1. Mesh infection (placed by Dr. ) with failure to resolve with long-term intravenous antibiotics.
2. Suspected small-bowel fistula to mesh.
3. Multiple prior ventral hernia repairs including use of mesh by members of the Gerig Surgical group.
4. Infected mesh fistulized to segment of small bowel.
5. Extensive adhesions.

PROCEDURES:
1. Extensive adhesiolysis.
2. Removal of infected mesh (foreign body) en bloc with segment of small bowel fistulized to the mesh.
3. Side-to-side stapled anastomosis.

SURGEON:

ANESTHESIA:
General.

ESTIMATED BLOOD LOSS:
Less than or equal to 250 mL.

SPECIMENS:
Small bowel fistula/segment of small bowel en bloc with mesh.

FINDINGS:
A composite mesh had been used, as described in operative note by Dr.

INDICATIONS FOR PROCEDURE:
The patient had an abdominal wall abscess at site of prior mesh repair. The area was explored several weeks ago and unincorporated superior aspect of the composite mesh was removed, leaving the incorporated portions of mesh as well as the deeper component of mesh, which appeared to be incorporated circumferentially.  The patient had use of a Wound V.A.C, long-term antibiotics and subsequently E. faecalis was cultured from the wound, sensitive only to vancomycin and penicillin. With the patient's PENICILLIN allergy, she was placed on IV vancomycin for 3 weeks.  Followup CT scan showed continued fluid collection adjacent to the mesh with abutted thickened small bowel.  The patient continued to have purulent drainage and open wound.  Of note, is there was improvement in the cellulitis surrounding the open wound.

PROCEDURE IN DETAIL:
The patient was counseled to undergo removal of mesh and likely segmental small-bowel resection.  The patient wished to proceed with plan as outlined.  Informed consent was obtained prior to procedure.  The patient received vancomycin 1.5 g as well as mefoxin 2 g IV piggyback.  She was brought to the operating suite where she was placed on operative table in supine position.  General anesthesia was induced.  SCD stockings were placed, Foley catheter placed and NG tube placed.  Abdomen was positioned, prepped and draped in the usual fashion.

The abnormal skin and soft tissue overlying wound was excised with elliptical incision, extended superiorly and inferiorly, and fascia was opened superior to the mesh. Fascia was then skeletonized off of the mesh circumferentially.  Of note is that the inferior aspect of the mesh was scarred and/or in continuity with a large sheet of intraperitoneal mesh, and this larger piece of mesh was related to a prior lower abdominal hernia repair, and it appeared to consist of polypropylene mesh which, to some degree, had epithelialized. Upon entry into the peritoneal cavity superior to the mesh, extensive adhesiolysis was performed.  The mesh was gradually free from surrounding tissues.  A segment of small bowel was bunched up to the mesh, and 1 loop could be freed with minimal injury to the serosa. Now a single matted loop was obviously stuck to the mesh in with the segment of bowel which had formed a fistula. The previously described polypropylene mesh, also inferior to fascia caudad, was extensively scarred to the composite mesh, and portion of the mesh was freed from fascia. A portion of this mesh was removed with a composite mesh.

The patient's remaining fascia, albeit thin, appeared satisfactory for primary tissue closure.

A segment of small bowel was then removed in the usual fashion using #55 staplers x2, takedown of the mesentery with a LigaSure, control of small bleeding points with 2-0 Vicryl and 3-0 Vicryl figure-of-8 sutures in the mesentery, and then reanastomosis using a reload of the 55 mm stapler followed by use of the TA 60 stapler.  Of note is that the staple lines were inspected prior to use of TA 60 stapler, and there was no bleeding.

The staple line was then oversewn with running 3-0 Vicryl in locking fashion; this was also to control bleeding and additional 3-0 Vicryl was placed at the apex for reinforcement. A running 3-0 Vicryl were used to close the mesenteric defect.

The small bowel was run to the extent possible from ligament of Treitz beyond the anastomosis into the pelvis where additional adhesions were noted. The transverse colon, right and left colons were palpated as much as could be done to ensure no pathology. The patient had atretic uterus and adnexa palpated. 

The liver was palpated and was normal as were the gallbladder, spleen and stomach.  NG tube was repositioned within the stomach in a more satisfactory position.

Multiple liters of saline irrigation were then used; all quadrants were suctioned free of irrigation.  Omentum was placed over the small bowel, and the fascia was closed with multiple interrupted 0 Prolene sutures in figure-of-8 fashion. The wound was thoroughly irrigated and a JP drain was placed to drain subcutaneous space. Skin was closed with skin clips.

JP was secured with 3-0 nylon.  Xeroform and appropriate dressings were applied.

First and final sponge, needle and instrument counts were correct.

Abdominal binder was applied.

The patient was awoken from general anesthesia and taken to recovery room in satisfactory condition.  There were no complications.  The patient's male friend in the surgical lounge was updated in regards to the patient's status.


----------

