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Multiple Hernia Repairs


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Does anybody use modifier 22 for mulitple hernia repairs? My physican said he spent more time due to the size of the hernia and that there were mulitple hernias.

The op note reads: Laparoscopy repair of multiple incisional hernias.

After the trocars were placed:

Under direct vision, a 10/11 port was then placed in the right lower quadrant and a second 5mm port in the right upper quadrant. Adhesions of omentum, some of which were incarcerated in various hernias, were then taken down using a harmonic scalpel and traction. One bowel loop was excised from the abdomial wall, leaving a small rim of peritoneum on the bowel to avoid injury into the intestine. In the process of doing this, there was 1 large hernia corresponding to the finding on the anterior abdominal wall, and an additional 4 smaller hernias all in the midline. These were all widely exposed.

Once all of the adhesions were taken down, the extent of each hernia was marked using a 25-gauge needle as a sounding device, and making a mark on the skin corresponding to the dimensions of the hernia. A total of 4 circles were drawn encompassing all of these hernias. In the center of each circle, an area was anesthetized and a small stab wound was made with an 11-blade. Through these stab wounds, figure-of-eight sutures using 0-Ti-Cron were passed using a knot-retrieval device in a figure-of-eight pattern to close all of these defects in a vertical orientation, medializing the rectus muscle. Once all of these sutures were placed, the abdomial pressure was lowered to 5mmHg and these sutures were tied, with the knots buried underneath the small skin incisions. This appeared to result in excellent primary closure of all the defects. The extent of the hernias was then measured at 15 CM, so a

20x15 cm dual-layer Parietex mesh was then selected and 4 marks were made on the mesh surface one on each corner, with 4 corresponding marks were made on the skin externally. The word up and an arrow was made in the left upper adpect of the mesh side to orient it, and the mesh then had 4 sutures of 0 Prolene placed in each of the corners, with the ends left long for retrieval internally. With the mesh moistened, it was rolled and passed into the peritoneal cavity, where upon it was unfurled with the mesh side up.

Four small stab wounds were made in the 4 previously marked areas on the skin and using separate fascial passes, each knot was brought out through separate fascial stab wounds out to the skin. When all 4 courner sutures were brought out, they were all indivdually tied to create 4-point transfascial fixation of the mesh. This was accomplished without difficulty and without tension.

The mesh was then fixed to the abdominal wall with 5mm absorable tacks placed at 3 and 4 mm intervals along the outer edge of the mesh, followed by an inner crowning layer, followed by some random tacks placed to keep the mesh adherent to the abdomial wall. This appeared to result in excellent coverage and overlap of the repaired hernias. With this accomplished hemostasis was assessed.

Thank you