Open Inguinal Hernia Repair
49505
-
49507— Incarcerated or strangulated -
49520— Recurrent inguinal hernia -
49521— Recurrent incarcerated inguinal hernia
Right/left [direct/indirect] inguinal hernia
Same
Open right/left inguinal hernia repair with mesh (Lichtenstein technique)
[Attending name], MD/DO
[Resident/PA name]
General endotracheal / spinal / local with monitored anesthesia care
The patient is a [age]-year-old [male/female] with a symptomatic [right/left] [direct/indirect] inguinal hernia presenting for elective open repair. The risks, benefits, and alternatives of the procedure, including laparoscopic approach, were discussed with the patient, and informed consent was obtained.
A [direct/indirect] inguinal hernia was identified on the [right/left] side. The hernia sac contained [omentum/small bowel/fat/no visceral contents]. The hernia defect measured approximately [___] cm. The vas deferens and spermatic vessels were identified and preserved. [Additional findings or none].
The patient was brought to the operating room and placed supine on the operating table. [Anesthesia type] was administered. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of prophylactic antibiotics.
The [right/left] inguinal region was prepped and draped in sterile fashion. A transverse skin incision was made [two fingerbreadths above the inguinal ligament from the pubic tubercle to the anterior superior iliac spine]. The subcutaneous tissue was divided with electrocautery. The external oblique aponeurosis was identified, and an incision was made along its fibers from the external ring extending laterally. The ilioinguinal nerve was identified and preserved. The spermatic cord was mobilized from the inguinal floor and encircled with a Penrose drain.
The hernia sac was identified and dissected from the cord structures. The sac was [reduced / opened, contents reduced, and the sac twisted and ligated at its neck with a [2-0 Vicryl] suture / divided at the level of the internal ring]. The cord was inspected and returned to its anatomic position.
A [polypropylene mesh / lightweight mesh] was fashioned to fit the inguinal floor. A slit was cut at its lateral end for the spermatic cord. The mesh was secured along the inguinal ligament with a running [2-0 Prolene] suture, and fixed superiorly to the internal oblique muscle and conjoint tendon with interrupted [2-0 Prolene] sutures. The two tails of the mesh were sutured together posterior to the spermatic cord recreating the internal ring. The cord was returned to its anatomical position in the inguinal canal.
The external oblique was closed with running [2-0 Vicryl]. Scarpa's fascia was closed with [3-0 Vicryl]. The skin was closed with [4-0 Monocryl] subcuticular sutures. Sterile dressings were applied.
None
None / Hernia sac sent to pathology
Minimal (less than 20 mL)
None
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: *** inguinal hernia
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Open *** inguinal hernia repair with mesh (Lichtenstein)
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: ***
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with a symptomatic *** inguinal hernia presenting for elective open repair. Informed consent was obtained.
FINDINGS: A *** inguinal hernia on the *** side. Hernia sac contained ***. The vas deferens and spermatic vessels were identified and preserved.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room and placed supine. *** anesthesia was administered. A surgical timeout was performed per protocol.
A transverse incision was made over the *** inguinal region. The external oblique aponeurosis was incised along its fibers. The ilioinguinal nerve was identified and preserved. The spermatic cord was mobilized and encircled with a Penrose drain.
The hernia sac was identified, dissected from cord structures, and ***. A polypropylene mesh was fashioned and secured along the inguinal ligament with running 2-0 Prolene and fixed superiorly to the conjoint tendon. The cord was returned to its position.
The external oblique was closed with 2-0 Vicryl. Scarpa's fascia was closed. Skin closed with 4-0 Monocryl. Sterile dressings applied.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: None
COMPLICATIONS: None
DRAINS: None
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Incarcerated Hernia
The hernia sac was found to contain [small bowel/omentum] that was not manually reducible preoperatively. After opening the external oblique, the internal ring was carefully divided to allow reduction of contents. The reduced [small bowel/omentum] was inspected and found to be [viable/pink with good peristalsis / dusky but perfused and viable after warming / necrotic requiring resection]. [If resection needed: a segment of small bowel measuring ___ cm was resected and a primary anastomosis was performed.] The hernia sac was ligated and repair proceeded as above.
Recurrent Inguinal Hernia
The patient had a history of prior [open/laparoscopic] inguinal hernia repair on the [right/left]. Dense adhesions and scarring were encountered in the inguinal canal, requiring careful sharp dissection to protect the vas deferens and spermatic vessels. The prior mesh was identified and appeared [intact / fragmented / partially incorporated]. The recurrent defect was identified [at the medial aspect/at the internal ring]. A new mesh was placed overlapping the prior repair and secured as described above.
Charting Tips
- Always document laterality (right vs. left) and hernia type (direct vs. indirect), as these are required for correct CPT coding and differ significantly in anatomy and risk.
- Identify and document nerve preservation (ilioinguinal, iliohypogastric, genitofemoral). Postoperative chronic groin pain is a common complication, and documentation of nerve identification protects against future claims.
- For incarcerated cases, document the viability assessment of reduced contents. If bowel was at risk, document the specific assessment criteria used (color, peristalsis, Doppler signal) and the outcome.
Billing Tips
- Bill 49505 for open inguinal hernia repair, initial, reducible, patient older than 5 years (7.76 wRVU, 90-day global). Use for Lichtenstein and plug-and-patch repairs.
- Bill 49507 for open inguinal hernia repair, initial, incarcerated or strangulated (8.86 wRVU). Document incarceration explicitly: manual reduction attempt, bowel viability assessment, and whether reduction was achieved before or after opening the sac.
- Bill 49520 for recurrent inguinal hernia repair, reducible (9.74 wRVU). Document prior repair history and intraoperative findings of prior mesh or scarring. Recurrent incarcerated uses 49521.
- Mesh use does not change the CPT code for open inguinal hernia repair. Document mesh type, size, and fixation technique in the operative note.
- For bilateral open inguinal hernia repair, bill 49505 twice with modifier -50 (bilateral procedure). Document each side separately in the operative note with individual findings.