Question plastics - mesh


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Suggestions please. The doc gave me 15734 x 2, 49568, 13101 & 13102. I don't believe the 49568 should be used for this mesh and would you say that the note supports the use of 59 on the complex closure codes which is included w/ 15734? I would think it would due to the radical resection that was done. Would love anyone's opinion.

The patient was received on the table having undergone radical resection of the sacral chordoma.  The S2 nerve roots were clearly exposed, and the entire sacrum was missing as well as the medial parts of bilateral gluteal musculature left-sided greater than right.  After performing a timeout, we decided to wall off the rectum and sigmoid colon from the operative site using mesh.  We attempted to use a bioprosthetic mesh (Strattice) but the only piece that was on the hernia cart had expired 2 weeks previously.  We therefore elected to use nonabsorbable mesh for the strength that would be engendered.  We used a soft Prolene mesh and cut a piece to fit the defect there was approximately 20 cm x 15 cm.  We inset this using interrupted sutures of 0 Prolene with the knots buried.  We first mobilized the fascia of the gluteus musculature in the inferior sacrum using the Bovie electrocautery.  We freed this up for a distance of approximately 20 cm on each side.  Despite this mobilization we could not overcome the central deficit, however we used the Prolene mesh as a bridge.  Care was taken to tension this mesh inset so that it would not prolapse posteriorly or inferiorly.  Because we inset the edge of the mesh back from the leading edge of the muscle/fascia, we were able to reapproximate the gluteus muscle and fascia over the mesh using interrupted sutures of 0 Vicryl.  We then exteriorized the drain to the left lateral inferior buttock crease.  This was sewn in place with 2-0 silk.  We then began to close the wound in layers.  We used a #2 strata fix for the deep dermal layer and then a running subcuticular 3 oh VueLock for the subcuticular closure.  The incision edges came together well and to bolster the closure, we used an incisional vacuum-assisted closure device.  The total length of the closure was 20 cm long.  Estimated blood loss for portion of procedures 100 cc of blood and the patient received an additional 1 L of intravenous fluid during our portion of the closure.  All sponge needle and instrument counts reports correct.