The plastic surgeon performed 14301, 14302, 15777, & 15734 w/ the general surgeon assistant on all except 15777.
My question is, can we submit the lysis, 44005 & 44005-80.
Actually, I think the appropriate code could be 49402 (Assist not allowed on 49402) instead of 44005 for the removal of the mesh?
General Surgeon’s report:
Dr. Plastic Surgeon began the procedure by making a left flank incision, which was in part joined to her previous left flank incision. He cut down through the skin and subcutaneous tissue. Eventually, we were able to palpate the old hernia mesh, which was sitting at the level of the anterior superior iliac spine. At this point, I took over the case for the next portion of it. We grasped the hernia mesh in clamps and I excised it from the surrounding muscle and subcutaneous tissue. After doing this, I was able to palpate the hernia sac. I entered the hernia sac which exposed the retroperitoneum. The defect was exposed once I excised the hernia sac, and it measured about 10 cm in diameter. I was able to see several loops of bowel, including descending and sigmoid colon, which were partially tethered to the defect by fatty adhesions. However, there was no bowel directly in my operative field; rather, it was somewhat farther down. There were numerous adhesions of retroperitoneal fat to the flank wall and I took these down very carefully. We did have to take great care not to injure any bowel as we did this, since the bowel itself was tethered to these adhesions. Eventually, I took all of them down, obtaining hemostasis along the way with suture and cautery.
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At this juncture, there was enough clearance on the posterior flank wall for Dr. Plastic Surgeon to proceed with the abdominal wall reconstruction. He will dictate that procedure separately:
We first began by making a large incision measuring 28 cm fashion across the left hip and lateral lower back region. I incised down through subcutaneous tissue exposing the hernia and mesh in position. I then transferred care to Dr. day who performed the direct removal of the hernia mesh. She also performed a lysis of adhesions freeing up the external oblique musculature and transversalis musculature. It appeared that there was a substantial deficit of the transversalis and internal oblique musculature. This left a large hernia defect measuring roughly 10 x 10 cm in total. This muscle appeared to peel off of the anterior superior iliac spine causing a lack of attachment of the muscles.
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I first began by dissecting out the 2 muscle flaps used for repair. I placed a clamp on the fusion of the transversalis and the internal oblique this is peeled off directly from the external oblique musculature. This was allowed to be mobilized from anterior to posterior direction for the external oblique flap and in a curvilinear fashion for the transversalis/internal oblique flap. After the MUSCLE flaps were mobilized I then moved down to placing the mesh.
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I first began by securing the mesh to the inner surface of the anterior superior iliac spine. 3 Mytec anchors were placed along the spanning of the anterior superior iliac spine this was secured to the STRATTICE directly in addition I placed several 1-0 PDS sutures across the anterior portion of the mesh this is folded and laid down underneath the anterior superior iliac spine. After this was performed I then placed the mesh in a parachute fashion with 1-0 PDS suture. This was done to the quadratus lumborum posterior and the internal oblique/transversalis muscle flap.
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After a tight repair of the mesh was achieved I then performed an advancement of the transversalis/internal oblique flap this was then advanced across the STRATTICE securing it with 1-0 PDS sutures to the anterior superior iliac periosteum. After this muscle flap was then placed, I then placed another intervening piece of STRATTICE after cutting it to fit approximately 16 x 10 cm. This was then secured to the internal oblique flap on its anterior surface. This was done with 1 1-0 PDS suture. I then advanced the external oblique muscle into place over the top of this and secured it to the quadratus lumborum this involved her second muscle flap into position and this was secured with 1-0 PDS suture.
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This completed the 2 muscle flaps. I then performed a separate adjacent tissue transfer due to the large skin deficit. I mobilized a large flap measuring 28 x 20 cm into position this was then repaired and advanced back to cover the anterior superior iliac spine a drain was placed in the subcutaneous position. The total area of adjacent tissue transfer measured 28 x 20 cm. This was repaired directly with 0 Vicryl suture and staples. Xeroform Tegaderm were applied she tolerated the procedure well.
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Thanks!