lcathey@smsc.org
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I'm using 49560 for hernia repair but I am not sure about the removal endometrioma. Would 22900-51 be appropriate, or possibly just adding a 22 to 49560. I appreaciate any suggestions!
PREOPERATIVE DIAGNOSIS:
Incisional hernia.
POSTOPERATIVE DIAGNOSES:
1. Left inguinal hernia.
2. Left internal oblique endometrioma.
PROCEDURES:
1. Left inguinal hernia repair.
2. Evacuation/removal left internal oblique endometrioma.
FINDINGS:
See the summary below.
DESCRIPTION OF PROCEDURE:
After induction of adequate general anesthesia, the lower abdomen and groins were prepped and draped in a sterile fashion. Utilizing the lateral edge of the previous left side of the Pfannenstiel scar, an oblique incision was made in the left inguinal area, directly over the area where the patient preoperatively had indicated the majority of her pain. The incision was carried down sharply through a normal Scarpa fascia, exposing the external oblique aponeurosis. The aponeurosis was intact and appeared normal externally, but there was a hematoma associated with the round ligament as it exited the external ring. Therefore, the external oblique aponeurosis was opened in the direction of its fibers through the external ring, taking care to identify and isolate, as well as protect the ilioinguinal nerve. There was a small hematoma associated with the distal edge of the round ligament. The round ligament was encircled and skeletonized, and a very small indirect hernia defect was identified along the anterior medial aspect of the ligament. There were no contents in the hernia sac and, therefore, the hernia sac and the proximal round ligament were ligated over 0-silk and transected.
The distal round ligament was dealt with in the same way and sent for pathologic evaluation. Attention was then turned toward repair of the floor of the canal, which was somewhat lax, as well as obliteration of the internal ring, and in this regard the conjoined tendon was joined to the iliopubic tract with interrupted 0-silk obliterating the internal ring and again protecting the ilioinguinal nerve. It was during this point of the operation that the arching edge of the internal oblique was identified as being somewhat prominent and firm. Because of the patient's history and the fact that the small indirect hernia did not likely explain the cause of her preop symptomatology, the internal oblique was opened through a small incision of its fascia and immediately a hematoma was encountered. During evacuation, a small fibrous nodule was found in the center of the hematoma and findings were judged to be consistent with an endometrioma. The entire cavity measured at least 2 cm in broadest diameter and was fully evacuated, and irrigated until clear.
The internal oblique fascia was reapproximated with interrupted 0-0 silk, and then the entire wound irrigated. The ilioinguinal nerve and the subdermal tissues were blocked with 0.5 percent Marcaine for postoperative analgesia and then the external oblique and Scarpa fascia were closed with running 3-0 Vicryl. The skin was closed with running 4-0 Vicryl in an intracuticular fashion. Steri-Strips and sterile dressings were applied. Final needle, lap, sponge, and instrument counts were reported as correct. The patient tolerated the procedure well and was taken to Recovery in stable condition.
PREOPERATIVE DIAGNOSIS:
Incisional hernia.
POSTOPERATIVE DIAGNOSES:
1. Left inguinal hernia.
2. Left internal oblique endometrioma.
PROCEDURES:
1. Left inguinal hernia repair.
2. Evacuation/removal left internal oblique endometrioma.
FINDINGS:
See the summary below.
DESCRIPTION OF PROCEDURE:
After induction of adequate general anesthesia, the lower abdomen and groins were prepped and draped in a sterile fashion. Utilizing the lateral edge of the previous left side of the Pfannenstiel scar, an oblique incision was made in the left inguinal area, directly over the area where the patient preoperatively had indicated the majority of her pain. The incision was carried down sharply through a normal Scarpa fascia, exposing the external oblique aponeurosis. The aponeurosis was intact and appeared normal externally, but there was a hematoma associated with the round ligament as it exited the external ring. Therefore, the external oblique aponeurosis was opened in the direction of its fibers through the external ring, taking care to identify and isolate, as well as protect the ilioinguinal nerve. There was a small hematoma associated with the distal edge of the round ligament. The round ligament was encircled and skeletonized, and a very small indirect hernia defect was identified along the anterior medial aspect of the ligament. There were no contents in the hernia sac and, therefore, the hernia sac and the proximal round ligament were ligated over 0-silk and transected.
The distal round ligament was dealt with in the same way and sent for pathologic evaluation. Attention was then turned toward repair of the floor of the canal, which was somewhat lax, as well as obliteration of the internal ring, and in this regard the conjoined tendon was joined to the iliopubic tract with interrupted 0-silk obliterating the internal ring and again protecting the ilioinguinal nerve. It was during this point of the operation that the arching edge of the internal oblique was identified as being somewhat prominent and firm. Because of the patient's history and the fact that the small indirect hernia did not likely explain the cause of her preop symptomatology, the internal oblique was opened through a small incision of its fascia and immediately a hematoma was encountered. During evacuation, a small fibrous nodule was found in the center of the hematoma and findings were judged to be consistent with an endometrioma. The entire cavity measured at least 2 cm in broadest diameter and was fully evacuated, and irrigated until clear.
The internal oblique fascia was reapproximated with interrupted 0-0 silk, and then the entire wound irrigated. The ilioinguinal nerve and the subdermal tissues were blocked with 0.5 percent Marcaine for postoperative analgesia and then the external oblique and Scarpa fascia were closed with running 3-0 Vicryl. The skin was closed with running 4-0 Vicryl in an intracuticular fashion. Steri-Strips and sterile dressings were applied. Final needle, lap, sponge, and instrument counts were reported as correct. The patient tolerated the procedure well and was taken to Recovery in stable condition.