# recurrent incisional hernia repair w/removal of infected mesh



## lindacoder (Dec 9, 2014)

PREOPERATIVE DIAGNOSIS:  Recurrent ventral incisional hernia, fourth time  recurrence.   

POSTOPERATIVE DIAGNOSIS:  Same.   

OPERATIVE PROCEDURE:  Exploratory laparotomy with extensive lysis of  adhesions, removal of infected Ventralex mesh and removal of infected Gore-Tex  mesh.  Primary repair of incisional hernia with wound VAC closure.



Under satisfactory general anesthesia with the patient supine, the abdomen was  washed with prep solution and draped and prepped in the usual sterile fashion.  After appropriate local anesthetic field block, a longitudinal incision was  made over the previous scar tissue.  This was carried down to the hernia sac.  The hernia sac is found to contain dense mesh which is balled up on itself.  On entering this fascial plane pus was encountered and this was cultured.  This indicated that the Ventralex mesh was infected.  After extensive  meticulous dissection, multiple adhesions to the infected piece of mesh were  taken down.  This took nearly 2 hours and was most of the time spent on the  procedure.  This mesh was removed in its entirety, because it was infected.  It was sent for histopathologic examination.  A Ventralight mesh, which had  also been used for some of the other repairs was felt to be infected and it  too was removed.  This again required extensive properitoneal and  intraperitoneal dissection removing numerous adhesions.  Great care was taken  not to injure the bowel.  In one area there was a small serosal tear of the  transverse colon which was repaired with running 3-0 silk.  Otherwise,  enterotomies and serosal tears were carefully avoided.  After this was  completed and both of the fascial sidewalls were freed, it was determined that  the patient did indeed have a good rectus shelf.  The rectus muscle anteriorly  was cleared for a distance about 2 cm on each sized to further clarify where  the true  rectus was.  Meticulous hemostasis was obtained, and because of the  infected mesh it was felt that a prosthetic mesh could not be used because of  the difficult dissection in removing the old mesh, and there really was no  properitoneal or intraperitoneal place to put it without having it stick to  the abdominal wall or become infected.  I did not feel a biologic mesh would  be helpful in this setting either because of the infection and the fact that  there really again was no place to place the biologic in a position where it  would not be exposed to infection or where it would add to the strength of the  wound.  The midline wound was then closed with a running #1 antibiotic  impregnated PDS suture.  This was run from both ends and tied in the middle.  A wound VAC was then placed to secure the abdominal fascia together, to remove  excess fluid pressure and to allow for pain control and better respiratory  function postop.  This wound will be allowed to close secondarily to prevent  hernia given the infected nature of the wound.  It was also left open for this  reason.  Hopefully, this will keep her from having another recurrence of her  hernia, but if she does have a recurrence it will be easier to repair now that  the infected prosthetic material had been removed. The skin was left open.  The patient tolerated the procedure well.  Blood loss was about 150 mL.  Sponge, needle and instrument counts were correct.

I am doing 49565 with 22 modifier for extensice LOA but can I charge anything for removal of the infected mesh? I can't use 11008 can I?

Thanks


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## cynthiabrown (Dec 10, 2014)

you can only use 11008 in addition to 11005 because it is add on code. If you report those, I would drop the 22 mod. Be sure to use icd for infected mesh on 11005+11008


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