CPT® Code 49492

1. Indications

The procedure described by CPT® Code 49492 is indicated for the following conditions:

• Inguinal Hernia: The primary indication for this procedure is the presence of an inguinal hernia in a preterm infant, which may be incarcerated or strangulated.
• Incarcerated Hernia: This condition occurs when the hernia tissue cannot be reduced or pushed back into its normal position, necessitating surgical intervention.
• Strangulated Hernia: This is a more severe condition where the blood supply to the herniated tissue is compromised, requiring urgent repair to prevent tissue necrosis.
• Hydrocele: The procedure may also be indicated if a hydrocele is present, which is an accumulation of fluid in the tunica vaginalis of the testis.

2. Procedure

The procedure for repairing an inguinal hernia in a preterm infant involves several detailed steps:

• Step 1: A small incision is made over the external ring of the inguinal canal. This allows access to the underlying structures.
• Step 2: Scarpa's fascia, which is the connective tissue layer, is elevated and incised to expose the underlying tissues.
• Step 3: The cord structures are isolated and dissected free from surrounding fat, allowing for clear visibility of the external ring.
• Step 4: The hernia sac is then exposed by opening the overlying fascia distal to the external ring, allowing access to the contents of the sac.
• Step 5: The hernia sac is carefully dissected free from surrounding tissue and opened to inspect its contents.
• Step 6: Loops of bowel proximal and distal to the obstruction are extracted and examined to assess their health and peristalsis.
• Step 7: If the bowel is determined to be healthy, the hernia is repaired by transecting the distal end of the sac.
• Step 8: The proximal stump of the sac is freed up through the internal ring to the level of the extraperitoneal fat.
• Step 9: The sac is rotated to ensure it is emptied of all hernia contents before it is ligated and the excess stump is excised.
• Step 10: The cord structures are returned to the peritoneal cavity, and the opening in the cord covering is sutured closed.
• Step 11: Scarpa's fascia is then closed, and the skin is reapproximated to complete the procedure.
• Step 12: If a hydrocele is present, it is drained, and a partial excision of the tunica vaginalis may also be performed.
• Step 13: In female infants, the procedure includes exploration of the hernia sac for the presence of the ovary. If the ovary is not contained within the sac, the round ligament is ligated along with the sac. If the ovary is present and healthy, it is returned to the abdomen, ensuring that the fallopian tube is not damaged. The sac is then clamped and transected.

3. Post-Procedure

Post-procedure care for a preterm infant who has undergone an inguinal hernia repair includes monitoring for any signs of complications such as infection, bleeding, or recurrence of the hernia. The infant may require pain management and should be observed for normal bowel function following the repair. The surgical site should be kept clean and dry, and any dressings should be changed as per the healthcare provider's instructions. Follow-up appointments are essential to ensure proper healing and to assess the success of the procedure. If a hydrocele was addressed during the surgery, additional monitoring may be necessary to evaluate for any recurrence of fluid accumulation.