nabernhardt
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can i code both 49570 and 44180 or are these bundled.
Repair of epigastric hernia with laparoscopy and laparoscopic lysis of intestinal
to abdominal wall adhesions.
PROCEDURE: With the patient in the supine position under good general endotracheal tube
anesthesia, the abdomen was scrubbed and prepped in the normal manner then draped sterilely.The previously marked hernia was exposed through a vertical midline incision and after identifying the hernia, this was dissected free from surrounding structures to the fascia. A 1 to 1.5 cm defect was identified. This was dissected free from the surrounding structures and the hernia
was reduced. After confirming that this could be reduced, the redundant peritoneum was brought back into the operative field and opened slightly and a 10-12 mm port was placed with direct laparoscopic guidance. After safely entering the abdomen, a pneumoperitoneum was established.
Significant adhesions were identified in the lower abdomen well away from this incision. A
decision was made to proceed with lysis of these significant adhesions in the anterior abdominal wall to first look for additional herniations and for a possible source for bowel obstruction. A 5mm port was placed in the left side of the abdomen under direct visualization and subsequently an additional 10-12 mm port was placed under direct visualization in the left upper quadrant. With these ports used for triangulation, the primarily omental adhesions were taken down from the umbilicus towards the pelvis. The adhesions changed in character at this point where more bowel
was involved to the anterior abdominal wall. With cautious use of gentle traction and the
harmonic scalpel along the abdominal wall, a dissection was continued although a point was reached in the operation where it was decided that the adhesions continued into the pelvis and really no end point was visible. The procedure was completed at this point by laparoscopically closing the left upper quadrant abdominal incision with Vicryl sutures and then after inspecting the operative field quite aggressively looking for any potential bowel injury and none was seen, the instruments were removed and the pneumoperitoneum was allowed to collapse. The peritoneum and the epigastric port site was then closed where the hernia had been with Vicryl suture and then this hernia sac was reduced and a Surgimesh plug was placed and fashioned in the subfascial location and secured with 0-Nurolon suture. The fascia was then closed over the mesh with
0-Nurolon suture in an interrupted manner. The subcutaneous tissue was then closed with several interrupted 4-0 Vicryl sutures followed by subcuticular interrupted buried sutures of 4-0 Vicryl. This was also used on the two remaining laparoscopic ports. Skin glue was then applied to all incisions as well as an absorbant pressure type dressing. The patient tolerated this procedure well.
Repair of epigastric hernia with laparoscopy and laparoscopic lysis of intestinal
to abdominal wall adhesions.
PROCEDURE: With the patient in the supine position under good general endotracheal tube
anesthesia, the abdomen was scrubbed and prepped in the normal manner then draped sterilely.The previously marked hernia was exposed through a vertical midline incision and after identifying the hernia, this was dissected free from surrounding structures to the fascia. A 1 to 1.5 cm defect was identified. This was dissected free from the surrounding structures and the hernia
was reduced. After confirming that this could be reduced, the redundant peritoneum was brought back into the operative field and opened slightly and a 10-12 mm port was placed with direct laparoscopic guidance. After safely entering the abdomen, a pneumoperitoneum was established.
Significant adhesions were identified in the lower abdomen well away from this incision. A
decision was made to proceed with lysis of these significant adhesions in the anterior abdominal wall to first look for additional herniations and for a possible source for bowel obstruction. A 5mm port was placed in the left side of the abdomen under direct visualization and subsequently an additional 10-12 mm port was placed under direct visualization in the left upper quadrant. With these ports used for triangulation, the primarily omental adhesions were taken down from the umbilicus towards the pelvis. The adhesions changed in character at this point where more bowel
was involved to the anterior abdominal wall. With cautious use of gentle traction and the
harmonic scalpel along the abdominal wall, a dissection was continued although a point was reached in the operation where it was decided that the adhesions continued into the pelvis and really no end point was visible. The procedure was completed at this point by laparoscopically closing the left upper quadrant abdominal incision with Vicryl sutures and then after inspecting the operative field quite aggressively looking for any potential bowel injury and none was seen, the instruments were removed and the pneumoperitoneum was allowed to collapse. The peritoneum and the epigastric port site was then closed where the hernia had been with Vicryl suture and then this hernia sac was reduced and a Surgimesh plug was placed and fashioned in the subfascial location and secured with 0-Nurolon suture. The fascia was then closed over the mesh with
0-Nurolon suture in an interrupted manner. The subcutaneous tissue was then closed with several interrupted 4-0 Vicryl sutures followed by subcuticular interrupted buried sutures of 4-0 Vicryl. This was also used on the two remaining laparoscopic ports. Skin glue was then applied to all incisions as well as an absorbant pressure type dressing. The patient tolerated this procedure well.
