CPT® Code 49501

1. Indications

The procedure is indicated for the repair of an initial inguinal hernia in pediatric patients aged six months to younger than five years. The specific conditions that warrant this surgical intervention include:

• Incarcerated Hernia - A condition where the hernia tissue cannot be pushed back into its normal position, potentially leading to complications.
• Strangulated Hernia - A more severe condition where the blood supply to the herniated tissue is compromised, increasing the risk of tissue necrosis.
• Hydrocele - The presence of excess fluid in the sac surrounding the testis, which may require drainage or excision during the hernia repair.

2. Procedure

The procedure for repairing an initial inguinal hernia involves several detailed steps to ensure effective treatment and minimize complications:

• Step 1: Incision - A small incision is made over the external ring of the inguinal canal to access the hernia sac. This incision allows the surgeon to visualize and manipulate the hernia and surrounding structures.
• Step 2: Dissection - Scarpa's fascia is elevated and incised to expose the inguinal canal. The cord structures are isolated and dissected free of surrounding fat, allowing for clear access to the hernia sac.
• Step 3: Hernia Sac Exposure - The hernia sac is carefully exposed by opening the overlying fascia distal to the external ring. The sac is then dissected free from surrounding tissues to facilitate inspection and repair.
• Step 4: Inspection of Contents - The contents of the hernia sac are inspected, and loops of bowel proximal and distal to the obstruction are extracted for examination. This step is crucial to assess the health of the bowel and ensure that peristalsis is present.
• Step 5: Repair of the Hernia - If the bowel is healthy, the hernia is repaired. The distal end of the 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 6: Closure of the Inguinal Canal - The cord structures are returned to the peritoneal cavity, and the opening in the cord covering is sutured closed. Scarpa's fascia is then closed, followed by reapproximating the skin.
• Step 7: 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 8: Female Considerations - In female patients, the procedure includes exploring 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 healthy, it is returned to the abdomen, ensuring that the fallopian tube is not damaged during the process. The sac is then clamped and transected.

3. Post-Procedure

Post-procedure care involves monitoring the patient for any signs of complications, such as infection or recurrence of the hernia. The child may require pain management and should be observed for any changes in bowel function. Recovery typically involves a gradual return to normal activities, with specific instructions provided by the healthcare team regarding activity restrictions and follow-up appointments to ensure proper healing and assess the surgical site.