CPT® Code 49610

1. Indications

The procedure coded as CPT® 49610 is indicated for the surgical repair of an omphalocele, a congenital defect that presents with the following conditions:

• Congenital Abdominal Wall Defect The presence of an omphalocele, where intra-abdominal structures protrude through a defect in the abdominal wall.
• Absence of Abdominal Muscles A significant lack of abdominal musculature, fascia, and skin in the affected area, necessitating surgical intervention.
• Protrusion of Intra-Abdominal Organs The need to address the protrusion of organs that are covered by a membrane, which can lead to complications if not repaired.

2. Procedure

The first stage of the repair of an omphalocele, as described by CPT® 49610, involves several critical procedural steps:

• Ligation of Umbilical Vessels The procedure begins with the careful ligation of the umbilical vessels, which is essential to prevent excessive bleeding and to prepare the area for further surgical intervention.
• Amputation of the Umbilical Cord Following the ligation, the umbilical cord is amputated, which is a necessary step in the management of the omphalocele and helps to facilitate the closure of the defect.
• Incision at the Edge of the Defect A surgical incision is made at the edge of the omphalocele defect, allowing access to the underlying structures and facilitating the repair process.
• Dissection of Skin from Fascia The skin is meticulously dissected from the fascia, ensuring that the amnion remains intact. This step is crucial for preserving the integrity of the surrounding tissues.
• Development of Skin Flaps Skin flaps are then developed and elevated over the omphalocele. This technique is employed to cover the defect while leaving a large ventral hernia, which will be addressed in the subsequent stage of the repair.

3. Post-Procedure

After the completion of the first stage of the omphalocele repair, patients typically require careful monitoring and post-operative care. The expected recovery involves managing the large ventral hernia that remains after the skin flaps are closed. It is essential to provide appropriate wound care to prevent infection and ensure proper healing. Follow-up appointments will be necessary to assess the healing process and to plan for the second stage of the repair, which is usually performed 6 months to 2 years later. During this subsequent stage, the previously developed skin flaps will be reopened, and the ventral hernia will be repaired to restore normal abdominal wall integrity.