Please help me with these codes. The only code I can find is for the inguinal repair. Are there any suggestions with this op note? Thank you!
Exploration right groin, removal of nonincorporated mesh, repair of right inguinal hernia with mesh.
DESCRIPTION OF PROCEDURE:
Prior to the procedure, informed consent was obtained and history and physical is on the chart. The patient was brought to the operating room, general anesthetic administered, prepped and draped in the usual manner for aforementioned operation. The previous transverse incision was opened using blunt and sharp dissection, it was carried down through subcutaneous tissue. In the area of the pubic tubercle there was a fistulous tract, that went down to the preperitoneal space, with some granulation tissue and went to some unincorporated mesh -- the unincorporated mesh was excised back to incorporated mesh, but this did leave a hernial defect, near the pubic tubercle. The cord structures could be seen superficially and were out of harm's way. This area was irrigated with saline solution, and a piece of AlloMax mesh was placed in the defect. Defect was closed from side-to-side with sutures of 0 Prolene, incorporated in the AlloMax mesh. The wound was then copiously irrigated, subcutaneous tissue closed with interrupted sutures of 0 Vicryl, down to the area of the pubic tubercle, skin was closed with buried 4-0 Monocryl down to the area of the pubic tubercle, this approximately 3 cm opening was left open and packed with iodoform gauze. At the end of the case, sponge, needle and instrument counts were correct, no complications, no drains were used. Dressing applied. The patient was taken to recovery in stable condition, the right testicle was in the hemiscrotum at the end of the case. I had a discussion with family afterwards regarding diet, activity, and a 24-hour number to call for complications and visiting nurse to be arranged.
Exploration right groin, removal of nonincorporated mesh, repair of right inguinal hernia with mesh.
DESCRIPTION OF PROCEDURE:
Prior to the procedure, informed consent was obtained and history and physical is on the chart. The patient was brought to the operating room, general anesthetic administered, prepped and draped in the usual manner for aforementioned operation. The previous transverse incision was opened using blunt and sharp dissection, it was carried down through subcutaneous tissue. In the area of the pubic tubercle there was a fistulous tract, that went down to the preperitoneal space, with some granulation tissue and went to some unincorporated mesh -- the unincorporated mesh was excised back to incorporated mesh, but this did leave a hernial defect, near the pubic tubercle. The cord structures could be seen superficially and were out of harm's way. This area was irrigated with saline solution, and a piece of AlloMax mesh was placed in the defect. Defect was closed from side-to-side with sutures of 0 Prolene, incorporated in the AlloMax mesh. The wound was then copiously irrigated, subcutaneous tissue closed with interrupted sutures of 0 Vicryl, down to the area of the pubic tubercle, skin was closed with buried 4-0 Monocryl down to the area of the pubic tubercle, this approximately 3 cm opening was left open and packed with iodoform gauze. At the end of the case, sponge, needle and instrument counts were correct, no complications, no drains were used. Dressing applied. The patient was taken to recovery in stable condition, the right testicle was in the hemiscrotum at the end of the case. I had a discussion with family afterwards regarding diet, activity, and a 24-hour number to call for complications and visiting nurse to be arranged.