# Repair of sliding iguinal hernia , Incarcerated?



## Trendale (Jun 20, 2011)

Hello,

Can someone help with the following surgery? I am trying to figure out if this should be code 49525 or 49507. There is further instructions  in CPT under 49525 to see other codes for Incarcerated.  The patient is over 5 years old. Also Should I append a modifier 22 as well due to the time spent? (90 minutes) Thanks in advance!

A skin incision was made in the left groin.  Scarpa
fascia was divided.  Hemostasis was strict and achieved with
electrocoagulation.  Dissection was carried down to the external
oblique aponeurosis.  An incision was made in the external oblique
aponeurosis lateral to the incarcerated hernia.  The external oblique
aponeurosis was opened and dissected free from the surrounding
tissues.  The large incarcerated left inguinal hernia was dissected
out of the scrotum.  The hernia sac was opened and this contained a
fairly large amount of bloody fluid along with an incarcerated portion
of sigmoid colon and also some extraperitoneal adipose tissue as this
represented a sliding inguinal hernia.  The defect involved most of
the inguinal floor.  The defect was gently dilated and the colon was
reduced without a great deal of difficulty.  Some of the
extraperitoneal adipose tissue was also reduced.  The excess hernia
sac was transected and discarded.  The peritoneum was closed around
and over the hernia using a running suture of 2-0 PDS.  The hernia was
reduced without difficulty.  There was a large defect involving the
inguinal floor.  A 4 inch x 6 inch piece of Ultrapro mesh was used for
the repair.  The mesh was secured adjacent to the pubic tubercle using
0 Prolene and this was carried as a running suture laterally to
include the shelving portion of the ilioinguinal ligament along with
the mesh.  The repair was carried well lateral to the internal
inguinal ring.  The mesh was split laterally to create a defect for
the spermatic cord.  The upper portion of the mesh was sutured to the
conjoined tendon and also to the internal oblique aponeurosis
laterally using interrupted sutures of 0 Prolene.  The 2 ends of the
mesh were brought around the cord.  The superior leaflet was sutured
to the shelving portion of the external oblique aponeurosis using
interrupted sutures of 0 Prolene to close the internal inguinal ring.
The repair appeared very secure.  The wound was irrigated with normal
saline.  Hemostasis was quite strict considering the amount of
dissection required.  The On-Q PM012 pain pump was also used.  The
trocar was inserted lateral to the skin incision beneath the external
oblique aponeurosis.  The catheter was advanced down the cannula and
the cannula was peeled away.  The tip of the catheter was placed
adjacent to the pubis.  The external oblique aponeurosis was closed
over the repair using a running suture of 2-0 PDS.  The medial portion
of the external oblique aponeurosis was quite attenuated.  Scarpa
fascia was approximated using running suture of 3-0 PDS.  The skin was
closed using a running subcuticular suture of 4-0 Vicryl.  Dermabond,
sterile dressing, and Tegaderm were applied.  Also of note was the
entire repair from start to finish took 90 minutes.  This was
approximately double the amount of time I would have spent on the
similar repair.  The reason for the considerable length of time
required for the repair was the patient is morbidly obese and weighs
156 kg.  At the completion of the procedure, all sponge, needle, and
instrument counts were correct.  Estimated blood loss was 30 mL.  The
patient tolerated the procedure well and was transported to the PACU
in stable condition.


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## lindacoder (Jun 20, 2011)

I would do the 49507 and add modifier 22 since doc clearly states it took twice as long as normal to do the procedure.


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## surgonc87 (Jun 20, 2011)

I agree with ^lindacoder^. 49507 is more specific to the incarceration and has a little more reporting RVUs

MS


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## Trendale (Jun 21, 2011)

*Reply*

Thank you both, that is what i had in mind as well.


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