# Perineal Incisional Hernia Repair???



## RainyDaze (Dec 21, 2012)

I need some help with this.  Doc did a perineal incisional hernia repair 1 year after patient underwent a abdominoperineal resection.  Here is the op note.  The hospital coder coded it as 49560/49568, but I'm not sure about that since it wasn't an abdominal hernia????  Any thoughts would be appreciated, I'm stumped!



PREOPERATIVE DIAGNOSIS: Perineal incisional hernia.

POSTOPERATIVE DIAGNOSIS: Perineal incisional hernia.

OPERATIVE PROCEDURE: Repair of perineal incisional hernia with Strattice mesh (10 x 10 cm firm).

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, placed supine on his cart. After general endotracheal anesthesia, he was transferred to a prone jackknife position on the operating table, securely padded. His endotracheal tube was intact. I then shaved the perineal skin around his prior scar. He was then prepped with Betadine and draped in the usual sterile fashion. I infiltrated the skin with 0.25% Marcaine, excised an ellipse of redundant skin and discarded this. I then carried the incision into the subq tissue and immediately encountered the hernia sac. I opened the hernia sac.  It was somewhat thick-walled and extended fairly deep, about 5 cm, where I could see some small bowel in the perineal cavity with a little bit of serous fluid. I opened the sac its entire length. I then palpated laterally and all I could feel was scar tissue, so I raised the subq tissue off the hernia sac laterally until I could feel thicker tissue. I never did see the levator muscles, though I felt that laterally there would be enough tissue to anchor what was likely the levator muscle remnants laterally. I then measured the defect from the coccyx to the perineum. It measured 5 cm and its width was about 5 cm.  I could palpate the inside of the obturator fascia, and I felt I could anchor some Strattice mesh below the levator muscles near the obturator fascia and then closed the subq tissue/levator muscle layer over the mesh.  So I took a 10 x 10 cm Strattice firm mesh, soaked it, and then I drew lines across both axes. I then anchored it to the fascia next to the coccyx with #1 Vicryl suture posteriorly, anchored it to the perineum where I could feel thickened tissue, likely close to the exiguous muscle, and then I placed sutures on this side to close the defect so that no bowel could slip through, so basically the mesh was touching the small bowel. I then folded the flaps of mesh over, placed a drain in this layer next to the mesh, and then closed the hernia sac/subq tissue layer over the drain and mesh.  A JP drain was brought out through the left perineum and sutured to the skin with 3-0 nylon suture. The wound was then irrigated, and I placed Marcaine in the subq layers in addition to the skin using a total of 26 mL. The skin was then closed with running 4-0 Vicryl subcuticular suture and Dermabond. The drain was covered with biopatch and OpSite. He was then transferred back to the cart in a supine position, extubated, brought to recovery in stable condition tolerating the procedure well. Sponge, instrument, and needle counts were correct. Time of this operation was 1 hour. No specimens.


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## ktiz27 (Dec 21, 2012)

It should be coded as 49999


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## RainyDaze (Dec 21, 2012)

Thank you for the help!


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