Multiple Hernias


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It got a little sticky and was wondering if anyone has run into this situation and if I'm allowed to code this way for Blue cross in California or in general

49651-LT (recurrent)
46350-51,RT (new hernia)

Recurrent left inguinal hernia and primary right inguinal hernia.

Recurrent left inguinal hernia and primary right inguinal hernia.

Laparoscopic robotic-assisted repair of recurrent left inguinal hernia with
mesh and repair of right primary inguinal hernia with mesh.


5 mL.

Left inguinal hernia recurrent with moderate amount of scarring, repaired using
transabdominal preperitoneal technique on both sides, left side with a keyhole
repair using polypropylene mesh, right was used with underlaying mesh placed
preperitoneally. The left is a direct hernia. The right is indirect hernia.

The patient is a 33-year-old male with a recurrent left inguinal hernia and a
right inguinal hernia, consented for surgery.

Brought to OR in supine position, sedated, and intubated well without
complication. Time-out per protocol. Preoperative antibiotics were given.
Abdomen and groin were prepped and draped in sterile fashion. Foley was placed
due to bladder unable to empty noted intraoperatively. We initiated surgery
with insufflation of abdomen using Veress technique through umbilical incision
and 8-mm trocar was placed in the umbilicus without injuring the bowel,
insufflating the abdomen to 15 mmHg of CO2. Then in right and left sides of

abdomen, 8-mm trocars were placed under direct visualization. The patient was
placed in Trendelenburg. The da Vinci Xi robot was docked per protocol. Using
sharp dissection and cautery with atraumatic bowel graspers, incising to the
left arcuate line at the peritoneum and sharp and blunt dissection with cautery
was used to dissect, lowering the peritoneum for dissection medially on the
left side down to Cooper's ligament. Dissection continued laterally without
injury to vessels, isolating the hernia, noted scar from prior plug from hernia
repair was noted. I took the dissection circumferentially of the cord
structures on the left side. Then a polypropylene Bard mesh was cut to about 3
x 5 cm with a keyhole in the center, directing cephalad, was placed
intraperitoneally and encircled the spermatic cord. Securing it to Cooper's
ligament with locking absorbable suture inferomedially and superomedially. The
keyhole was closed with 2-0 Vicryl and secured to the anterior abdominal wall.
Then peritoneum was closed with running locking absorbable suture. There was
good hemostasis. Then incision was made along the right side to repair the
right inguinal hernia. Again, blunt and sharp dissection carried down to
Cooper's ligament on the right side, isolating the spermatic cord, identifying
the hernia, which was reduced into the abdomen, dissecting laterally as well to
the internal oblique over transversalis fascia location. Then a 3 x 5 cm
polypropylene mesh was cut to the length and placed into the abdomen, secured
to the Cooper's ligament again with self-locking absorbable sutures as well as
the upper medial side as well. The mesh covered the defect well with good
overlap and good hemostasis. Then, fascia was closed with 2-0 absorbable
locking suture, V-Loc. There was good hemostasis. Pneumoperitoneum was
withdrawn. Trocars removed. Abdomen deflated. Skin closed with 4-0 Monocryl.
Appropriate dressing applied. All instrument counts were correct. Sedation
weaned, extubated, and returned to PACU with vital signs stable.