# Parastomal hernia, sm bowel enterotomy, infected mesh



## lindacoder (Mar 28, 2011)

OPERATION: Limited laparoscopy and exploratory laparotomy with removal of mesh, lysis of adhesions, repair of small bowel enterotomy, parastomal hernia repair with AlloMax mesh.

Patient has had multiple abdominal surgeries - nephrectomy, bladder resection and has an ileal conduit. He has a known large parastomal hernia. He has had repair of a midline incisional hernia with mesh. 

In the supine position the abdomen was prepped and draped in the usual fashion. The ileal conduit rest in the left lower quadrant. With him going to sleep I could reduce this large hernia. We then placed an 18-French Foley into the ileal conduit and blew it up so the urine would not drain through here. We then made an incision in the left upper quadrant and a 5 mm port was placed under direct visualization. With getting into this we had also come drainage of significant amount of fluid though this, about a liter. We then proceeded on with an open incision. Did not definitely look bilious. We made an incision pretty much the length of the abdomen because of his multiple surgeries. There was the mesh down lower that did appear to be infected. With entering we freed up the underlying bowel from this. We then after opening in its entirety we removed the mesh because it had been infected. It was not sent as it was benign. After removing it in its entirety the small bowelwas markedly distended. We have removed the 5-mm port. There was a tight adhesional band that the bowel was twisted around and distally was fairly normal but proximal was not. This band was cut. With this fortunately the bowel pinked up and was viable. We did find a small bowel enterotomy on the jejunum. It was closed with a running 4-0 PDS and buttressed with interrupted 2-0 silk. We then milked the small bowel contents up into the stomach and evacuated this through an NG tube. We ran the small bowel three times and there was no evidence of any other injuries and the bowel was all viable. We could see down where the ileal conduit went up. There was a fairly large parastomal hernia but this had been reduced. The bowel was all viable. The remainder of those adhesions had been taked down to review this. After ensuring that this looked ood the parastomal hernia  was closed with interrupted 0 PDS in a near-far-far configuration. A total of three were placed. Wit completion of this it closed nicely bt was not too tight. Because of the risk of reoccurrence we then placed a biologic mesh. We therefore got AlloMax mesh and cut it in a keyhole fashion. We wrapped this around the ileal conduit and wastacked to the abdominal wall.  --  the rest is just the closure.

 I am looking at 44346 for repair of the parastomal hernia and maybe 44602 for small bowel enterotomy and is there something I can use for removal of the infected mesh??  Any help would be much appreciated.  Thanks


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## nlbonn (Mar 29, 2011)

I would not suggest 44346 for the parastomal hernia as in the description it says the colostomy is not re-attached at the same site, but through a different incision. I would suggest the incisional hernia repair, 49560.

Hope that helps!


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