Viola Posted Tue 15th of June, 2010 19:28:13 PM
The patient was taken to the operating room, placed in a supine position, and general anesthetic was administered by the Anesthesia team. His glans and inner preputial skin adhesions were taken down bluntly. He was then prepped and draped in the usual sterile fashion. A transverse incision was made in the distal abdominal crease overlying the right inguinal canal. Bovie electrocautery and blunt dissection were used to dissect down to the external oblique aponeurosis due to the very large hernia. It was quite attenuated and was easily incised. At this point, we were immediately visualizing the hernia. The inguinal canal was essentially completely obliterated as well as the floor of the anterior abdominal wall. A prolonged dissection was done to deliver the entirety of the hernia sac through an incision. This required taking down all the gubernacular attachments of the testis to the scrotum essentially delivering the testis into the wound as well. The testis and gonadal vessels and vas deferens were densely adherent to a very thickened hernia sac. These were dissected free from the hernia sac and the sac was opened and communicated with the tunica vaginalis of the testis, it was essentially a large communication. We isolated the testis completely from the proximal part of the hernia sac and dissected the hernia sac back to the abdominal wall to the proximal location of the internal ring. The testis, vas, and gonadal vessels were protected during this entire dissection and the testis remained viable. The hernia sac was skeletonized to a degree taking down cremasteric fibers, another adherent tissue and was then pursestring with a 4-0 Maxon suture and then the stump was additionally oversewn with an additional 4-0 Maxon suture imbricating the previous pursestring. The hernia sac was allowed to retract into the abdomen. The anterior abdominal wall was then reconstructed with 3-0 Vicryl suture joining the conjoint tendon to the shelving edge of the inguinal ligament. This was done in a running fashion until the floor was completely reinforced. This was done both superior and inferior to the gonadal vessels set to recreate an internal inguinal ring. With the abdominal floor reconstructed, we placed a 5-0 Maxon suture through the tunica albuginea of the testis. A dartos pouch was developed in the midline portion of his right hemiscrotum. The testis was delivered down into the right hemiscrotum and through the small scrotal incision that was made during the development of the dartos pouch. The testis was then delivered into the dartos pouch and fixed to the scrotal skin with 5-0 Maxon over an orchidopexy button. The scrotal incision was closed with interrupted 6-0 Biosyn sutures to the wound and the inguinal region was copiously irrigated with bibiotic irrigation. We ensured the gonadal vessels were not twisted. I then infused the wound with approximately 5 cubic centimeters of 0.25% Marcaine. The external oblique fascia was reapproximated with a running 4-0 Vicryl suture closing the roof of the inguinal canal. Scarpa fascia was also approximated with 4-0 Vicryl suture as well as the subcutaneous tissue and the skin was reapproximated with a running 5-0 subcuticular Maxon. A dressing consisting of benzoin, Steri-Strips, and Tegaderm was applied over the inguinal incision. The small scrotal incision was covered with collodion. We then turned our attention to the circumcision, an indelible pen was used to mark 2 lines of incision, the first being approximately 1.5 cm proximal to coronal sulcus on the inner preputial skin and the second on a cosmetic location on the outer shaft skin. A #15 blade scalpel was used to incise along these 2 lines. The isolated foreskin was then incised in the dorsal midline and then excised with electrocautery. Additional cautery was used as needed to achieve hemostasis. The remaining inner preputial and shaft skin were then reapproximated with interrupted 6-0 Biosyn sutures. A small amount of redundant frenular shaft skin were then also excised on the ventrum and reapproximated cosmetically with 6-0 Biosyn sutures. The final cosmetic result was excellent. A dressing consisting of collodion to the suture line and Surgilube to the glans was applied here. He received a 5 cubic centimeter 0.25% Marcaine dorsal penile block prior to circumcision. The final cosmetic result was excellent. The testis was confirmed to be in the scrotum. Estimated blood loss was minimal. See anesthesia records for intravenous fluids. The sponge and needle count was verified. He tolerated the procedure well, he was extubated in the operating room and taken to the PACU in stable condition.
SuperCoder Answered Wed 16th of June, 2010 08:05:11 AM
Here I assume that the patient's age is more than 5 years. All these procedures can be coded separately. The reason:
1) There is no CCI bundling edits for the 3 codes (presumably 49505-49507, 54640, 54161).
2) There is a note in the CPT manual, just below the code 54640, that says: "For inguinal hernia repair performed in conjunction with inguinal orchiopexy, see 49495-49525".