CPT® Code 49496

1. Indications

The procedure is indicated for the following conditions:

• Inguinal Hernia Repair An initial inguinal hernia repair is performed on infants who are full-term and younger than six months or preterm infants older than 50 weeks post-conception age and younger than six months at the time of surgery.
• Incarcerated Hernia The procedure is indicated when the hernia is incarcerated, meaning the tissue cannot be pushed back into its normal position.
• Strangulated Hernia The repair is also necessary for strangulated hernias, where the blood supply to the herniated tissue is compromised, posing a risk of tissue necrosis.
• Hydrocele The procedure may include hydrocelectomy if a hydrocele is present, which is an accumulation of fluid in the sac surrounding the testis.

2. Procedure

The procedure for repairing an inguinal hernia involves several detailed steps to ensure effective treatment and safety for the infant.

• Step 1: Incision A small incision is made over the external ring of the groin area. This allows access to the underlying structures and the hernia sac.
• Step 2: Elevation and Dissection Scarpa's fascia is carefully elevated and incised to expose the underlying cord structures. The cord is isolated and dissected free of surrounding fat to clearly visualize the external ring.
• Step 3: Exposure of the Hernia Sac The cord is elevated, and the overlying fascia is opened distal to the external ring, allowing the hernia sac to be exposed for further examination.
• Step 4: Dissection of the Sac The hernia sac is dissected free from surrounding tissue, opened, and its contents are inspected to assess the condition of the bowel and other structures within the sac.
• Step 5: Examination of Bowel Loops of bowel proximal and distal to the obstruction are extracted and examined. If the bowel appears healthy and peristalsis is present, the hernia repair can proceed.
• Step 6: Repair of the Hernia The distal end of the hernia sac is transected, and the proximal stump is freed up through the internal ring to the level of the extraperitoneal fat. The sac is rotated to ensure it is emptied of all hernia contents before ligation and excision of the excess stump.
• Step 7: Closure of the Cord Structures The cord structures are returned to the peritoneal cavity, and the opening in the cord covering is sutured closed to restore anatomical integrity.
• Step 8: Closure of the Incision Scarpa's fascia is closed, and the skin is reapproximated to complete the surgical procedure.
• Step 9: Hydrocele Management If a hydrocele is present, it is drained, and a partial excision of the tunica vaginalis may be performed to address the fluid accumulation.
• Step 10: Female Considerations In females, the procedure is similar, but the hernia sac must be explored 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 involves monitoring the infant for any signs of complications, such as infection or recurrence of the hernia. The infant may require pain management and should be observed for normal bowel function following the surgery. Parents or caregivers will be provided with instructions on how to care for the surgical site and signs to watch for that may indicate complications. Follow-up appointments will be necessary to ensure proper healing and to assess the success of the hernia repair.