Question I coded 49560 +49568 15734 RT & LT UNH denied only paying the mesh saying submit corrected claim. Any help would be appreciated

kparker1

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DRAINS:
Two #19 Blake to the preperitoneal space on top of the mesh.

COMPLICATIONS:
None.

DISPOSITION:
Returned to the PACU stable.

CLINICAL NOTE:
The patient is a 56-year-old female, who approximately 6 months or so ago, was brought to the Operating Room for closure of her sigmoid colostomy, which she required almost a year ago to the date after having presented with a perforated diverticulitis. The patient did have a hernia at her ostomy site, which was closed primarily without the aid of any prosthetic secondary to the clean contaminated nature of the case. She subsequently developed a significant bowel containing hernia there that was uncomfortable and on CT scanning had at least 1 or 2 other fairly small fascial defects in the midline and so after discussion as to how she wanted to approach things she elected to have the entire abdominal wall reconstructed.

DESCRIPTION OF PROCEDURE:
The patient was brought to the Operating Room suite, laid supine on the table and given general anesthetic. Foley catheter was placed without incident. Abdomen was prepped with chlorhexidine and draped in the usual standard fashion. She did receive preoperative antibiotics. We entered through the midline, not quite extending all the way from top to bottom. We were able to incise through the fascia superiorly and then identified an appropriate plane intraabdominally. She had essentially greater omentum adherent to the underside of the abdominal wall. There was no real bowel adherent to the fascia as her omentum was a fairly generous and spanned the distance. All of these adhesions were taken down. They were relatively filmy in nature and relatively easily dissected. We dissected out laterally on both sides superiorly up to roughly where we could just start to see the liver. Then, the adhesions were taken down to the level of the pelvic brim, but we did not evacuate the pelvis. We did not necessarily run the bowel. We simply left the omentum and viscera down, placing a safety towel over everything in its entirety and then started to do the repair. We started superiorly on the left side as this was going to be more challenging side getting into the retrorectus plane. This was carried cephalad to the level of the rib. There was a significant amount of scarring and atretic tissue in the peristomal region, both in the midline as well as off on the left side the colostomy site. We reestablished a preperitoneal plane inferior to this region and carried this down to the level of the pubic bone. We then incised through the fascia, posterior sheath superiorly on the left side in order to get into the preperitoneal plane. Again, this was carried cephalad incising the transversus muscle in order to release this and be able to get into a virgin plane, so that we could come lateral to the hernia at the colostomy site. The peritoneal layer was then separated and released from the overlying muscles throughout the length from the top to bottom. We then transitioned back into the retrorectus plane superiorly where the amount of overlap of mesh was going to be less important. This was carried all the way out to the psoas muscle and retroperitoneal fat in that region, such that we were roughly 8 to 10 cm lateral to the lateral aspect of the hernia at the colostomy site. As mentioned before, there was quite a bit of scarring in the peristomal region and so ultimately it was difficult to appreciate and really get a nice clear delineation of the muscular fibers from the posterior sheath from the anterior sheath as this was rather scarred, but we did clearly identify the anterior sheath and circumferentially dissect that so that the fascial defect could be closed appropriately from the underside without having to create a subcutaneous flap. Procedure was then repeated on the right side in order to separate the posterior sheath from the anterior sheath. This was relatively easily done superiorly and inferiorly and we carried our dissection out to the linea semilunaris as we simply needed a reasonable overlap of the midline mesh where there were just only a few small defects. With this, we then closed the incisional defect from the inside at the colostomy site using a running #1 PDS suture, starting out laterally and then carrying this in a lateral to medial fashion. This closed our anterior sheath. We had a very wide overlap around the actual hernia site. There was an area in the left upper quadrant where the peritoneum had been breached and this was ultimately sutured with running 3-0 Vicryl. There appeared to be some almost fusion in this area between the peritoneum and the musculature and so ultimately this is where we transitioned our separation back into the retrorectus plane, so that we would have a single plane to place the mesh and not have it fold on itself. Once this was done, we removed the safety towel, there was really no significant lysis of adhesions of the bowel, the omentum was in its usual location. We then closed the posterior sheath with a running 2-0 Vicryl out of either corner came together quite nicely. There was a combination of scar and some hernia sac that we used to exclude the viscera in the peristomal region. Once the viscera was excluded, we then ensured that all sponge, needle and instrument counts were correct. The cavity was irrigated. A 10 x 14 piece of mesh was then brought onto the field. It was trimmed somewhat, but ultimately fit very nicely in this preperitoneal space, ensuring that we had adequate overlap out to the psoas muscle on the left side. With this, the anterior sheath was then closed. We incorporated a small bite of the mesh with our first 2 or 3 bites of the #1 PDS out of either corner to try to stabilize the mesh as it was going to be quite difficult to suture the mesh to the xiphoid and to the pubic bone, although the mesh did reach from one to the other. Once the anterior sheath was closed, we then did some trimming of some of the scarred tissue from the incision. This was all discarded. The wound was irrigated, closed with a deep layer of 3-0 Vicryl to the deep dermis and then finally a running 4-0 Monocryl. Prior to fascial closure, please note that two #19 Blake were placed in the submuscular space on top of the mesh. Once the skin was closed, a TAP block was performed by the Anesthesia Service on the right side. Drains were hooked to suction, they held nicely. She was ultimately awoken from the anesthetic and returned to the PACU stable.
 
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