CPT® Code 49653

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1. Indications

The procedure described by CPT® Code 49653 is indicated for the surgical repair of incarcerated or strangulated hernias, which can lead to serious complications if not addressed promptly. The specific types of hernias that may necessitate this procedure include:

• Ventral Hernia - A hernia that occurs at the site of a previous abdominal incision, where the abdominal wall has become weakened.
• Umbilical Hernia - A protrusion of abdominal contents through the abdominal wall at the umbilicus (navel).
• Spigelian Hernia - A hernia that occurs through the semilunar line, which is the lateral border of the rectus sheath.
• Epigastric Hernia - A protrusion of abdominal contents through the linea alba, located in the midline of the abdomen.

2. Procedure

The laparoscopic repair of an incarcerated or strangulated hernia involves several critical steps to ensure a successful outcome. The procedure begins with the surgeon making a small incision at a site distant from any previous abdominal incisions and the hernia defect. Following this, a trocar is inserted to establish pneumoperitoneum, which is the inflation of the abdominal cavity with gas to create a working space. Once the pneumoperitoneum is established, a laparoscope is introduced through the trocar, allowing the surgeon to visualize the abdominal cavity. Additional portal incisions are made under direct vision to facilitate the insertion of surgical instruments.

After the instruments are in place, the surgeon carefully lyses any adhesions that may be present, which can complicate the repair. The abdominal wall is thoroughly examined to evaluate the extent of the hernia. The edges of the hernia defect are then cleared of peritoneum and fat to prepare for repair. The location of the hernia defects is marked on the overlying skin for reference. The contents of the hernia are reduced back into the abdominal cavity, and the hernia defect is assessed for closure options. Depending on the situation, the defect may be closed using primary sutures, or a mesh insert may be required. If mesh is necessary, the surgeon measures the defect, cuts the mesh to the appropriate size, and positions it over the reduced hernia defect. The mesh is then affixed to the abdominal wall using tacks or sutures. Once the repair is complete, the laparoscope and surgical instruments are removed, the pneumoperitoneum is released, and the portal incisions are closed securely.

In cases of incarcerated or strangulated hernias, additional steps are taken. After lysing adhesions and evaluating the hernia, the hernia sac is opened to inspect the incarcerated loop of bowel. The bowel is carefully released and returned to the abdominal cavity. If the hernia is strangulated, any necrotic tissue, which may include omentum or bowel, is resected and placed in a retrieval bag for removal. Following these steps, the hernia repair is completed as previously described, ensuring that all aspects of the hernia are addressed effectively.

3. Post-Procedure

Post-procedure care following the laparoscopic repair of an incarcerated or strangulated hernia typically involves monitoring the patient for any signs of complications, such as infection or recurrence of the hernia. Patients are usually advised to follow specific guidelines regarding activity levels, including restrictions on heavy lifting and strenuous exercise for a designated period to promote healing. Pain management may be provided as needed, and follow-up appointments are scheduled to assess recovery and ensure that the surgical site is healing properly. Patients should be educated on signs of complications that warrant immediate medical attention, such as increased pain, swelling, or changes in bowel habits.