Mulitple Hernia repair

herrera4

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223
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Wallingford, CT
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I am not sure which hernia codes would be correct- he started off lap and continued to repair mulitple hernias open but through one incision. any help is appreciated

PROCEDURE: On the day of surgery he was brought to the Operating Room and placed in a supine position on the Operating Room table. General endotracheal anesthesia was administered. A tap block was performed by the Anesthesia Department. It was felt the safest place to enter the abdomen was the upper most portion of the incision at the epigastric area. This was infiltrated with 0.5% Marcaine with epinephrine. A 4 cm incision was planned. This was infiltrated with 0.5% Marcaine with epinephrine. An incision was made with a 15 blade, deepened through tissue divided with electrocautery. The abdomen was entered under direct vision. There was quite a bit of adhesions in this area. The port was placed. The abdomen was insufflated. The camera could not be advanced into an area free of adhesions so this approach was terminated. It was felt that it would be unknown how much adhesions he would have so that perhaps the camera could be inserted at the lowest portion of his incision where there was a hernia. A 6 cm incision to the right of the umbilicus. This was infiltrated with 0.5% Marcaine with epinephrine. An incision was made with a 15 blade, deepened through tissue divided with electrocautery. Some herniated fat was encountered. This was freed from surrounding tissue. This came through an approximate 2 cm hernia. The herniated fat was reduced. The port was placed. The abdomen was insufflated. The camera was inserted. Looking towards the pelvis, there were no adhesions. The rest of the incision was free of any hernias so it was felt that this was the lower most hernia. The left side of the abdomen had quite a bit of adhesions. There was one large internal hernia. It was felt that this should be dealt with to prevent any herniation. The epigastric port was removed and the gloved finger was inserted and brought into view with the camera and the port was replaced. The camera was replaced into the epigastric port site. A 5 mm very lateral port site was placed. The LigaSure device was advanced. These adhesions to the left side of the abdomen were freed so that there was no longer an internal hernia. At this point it was felt that there were too many adhesions to the midline which included small bowel and transverse colon, that it would not be a safe approach because this could not be well visualized. It was felt that the best approach would be to open his entire incision and look for these multiple hernias to repair primarily or with mesh.
The port was taken out of the left side of the abdomen. The two epigastric umbilical ports were removed. The midline incision was anesthetized with Marcaine with epinephrine. The previous scar was excised with a 15 blade, deepened through tissue divided with electrocautery. Numerous fascial defects were identified. Initially six in number were identified well. These were repaired primarily with #0 Prolene figure of eight stitches without difficulty. There were two areas to the right of midline that had large herniated contents although these two areas only had defects that were 2 cm, just to the right of his umbilicus. There was an area of a 4 cm fascial defect. It was felt that this should be repaired with mesh. The Ventralex mesh with a strap was brought to the field. These were sewn into place with eight stitches through the fascia and through the mesh with good overlap. The final hernia repair was through the trocar site. This was closed with a figure of eight of #0 Prolene at the lowest part of the incision. No further herniations were noted and the anterior fascia was well visualized. The fatty layer was tacked to the fascia with 3-0 Vicryl to decrease any dead space. The midline incision was reapproximated with 3-0 Vicryl in three areas to ease in the stapling. The skin was closed with staples. The patient tolerated the procedure well. He was extubated and brought to the Recovery Room in satisfactory condition.
 
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