Open Ventral Hernia Repair

CPT 49593
Approach Open
Add-on / Variant CPTs
  • 49591 — Initial repair, <3 cm, reducible (small ventral/epigastric hernias)
  • 49594 — Initial repair, 3–10 cm, incarcerated or strangulated
  • 49595 — Initial repair, >10 cm, reducible (large incisional hernias)
  • 49615 — Recurrent repair, 3–10 cm, reducible
Preoperative Diagnosis:

Ventral/incisional hernia

Postoperative Diagnosis:

Same

Procedure Performed:

Open ventral hernia repair with mesh [retromuscular / underlay / onlay]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal

Indications:

The patient is a [age]-year-old [male/female] with a symptomatic [ventral/incisional] hernia measuring approximately [___] cm presenting for elective repair. The risks, benefits, and alternatives of the procedure were discussed with the patient, and informed consent was obtained.

Findings:

A [ventral/incisional] hernia was identified with a fascial defect measuring approximately [___] x [___] cm. The hernia sac contained [omentum/small bowel/fat]. The hernia was [reducible/mildly adherent]. The abdominal wall was [well-vascularized / attenuated / with prior mesh visible]. [Additional findings or none].

Description of Procedure:

The patient was brought to the operating room and placed supine on the operating table. General endotracheal anesthesia was induced without difficulty. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of prophylactic antibiotics.

The abdomen was prepped and draped in sterile fashion. [A midline / transverse / elliptical] incision was made over the hernia. Prior scars were excised where appropriate. Subcutaneous flaps were raised with electrocautery to expose the anterior fascial surface circumferentially for [___] cm around the defect.

The hernia sac was opened and the contents were reduced. Dense adhesions between the sac and underlying bowel were lysed under direct vision with sharp dissection. The hernia sac was excised. The fascial edges were freshened and the defect measured [___] x [___] cm.

The retromuscular space (posterior rectus sheath / Rives-Stoppa plane) was developed bilaterally by incising the posterior rectus sheath medially and sweeping the rectus muscle off the posterior sheath laterally to the semilunar line. The posterior sheath was closed in the midline with running [0-PDS] suture. A [polypropylene / biologic / macroporous lightweight polypropylene] mesh measuring [___] x [___] cm was placed in the retromuscular position and secured with [interrupted transfascial sutures / absorbable tacking sutures at the periphery]. The anterior fascial layer was closed with a running [0-PDS] suture in the midline. Subcutaneous tissue was closed with [3-0 Vicryl]. The skin was closed with [staples / 4-0 Monocryl] subcuticular sutures. Sterile dressings were applied. [A closed suction drain was placed in the subcutaneous space.]

Complications:

None

Specimens:

Hernia sac sent to pathology

Estimated Blood Loss:

[___] mL

Drains:

[One Blake drain / Jackson-Pratt drain] in the [retromuscular / subcutaneous] space, brought out through a separate stab incision

Disposition:

The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Ventral hernia
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Open ventral hernia repair with mesh (retromuscular)
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with a symptomatic ventral hernia measuring *** cm presenting for repair. Informed consent was obtained.

FINDINGS: Fascial defect *** x *** cm containing ***. Hernia was ***.

DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room and placed supine. General endotracheal anesthesia was induced. Surgical timeout performed per protocol.

A *** incision was made over the hernia. Subcutaneous flaps were raised. The hernia sac was entered, contents reduced, adhesions lysed, and sac excised. Defect measured *** x *** cm.

The retromuscular space was developed bilaterally. Posterior sheath was closed with running 0-PDS. A *** x *** cm mesh was placed in the retromuscular position. The anterior fascia was closed with running 0-PDS. Skin closed with ***. Drain placed ***.

ESTIMATED BLOOD LOSS: ***
SPECIMENS: Hernia sac to pathology
COMPLICATIONS: None
DRAINS: ***
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.

Signed: .ME, .MYDEGREE
.TODAY
Variants

With Posterior Component Separation (TAR)

Given the large defect size ([___] x [___] cm) and inability to achieve tension-free fascial closure with Rives-Stoppa retromuscular dissection alone, posterior component separation via transversus abdominis release (TAR) was performed bilaterally. After developing the retromuscular space to the semilunar line, the posterior lamella of the internal oblique aponeurosis was incised medial to the neurovascular bundles. The transversus abdominis muscle was divided transversely along its length, entering the preperitoneal plane. The peritoneum and preperitoneal fat were swept off the transversus abdominis and posterior abdominal wall, extending the retromuscular pocket laterally to the psoas and superiorly and inferiorly as needed to allow a [___] cm mesh overlap. TAR was performed on the [right / left / bilateral] side(s). This maneuver achieved [___] cm of additional medial advancement. The peritoneum was closed in the midline with running [0-PDS] suture. A [polypropylene / macroporous lightweight polypropylene / biologic] mesh measuring [___] x [___] cm was placed in the retromuscular-preperitoneal space and secured with [transfascial sutures / absorbable tacks] at the periphery. The anterior fascia was closed in the midline with running [0-PDS] suture without tension.

With Anterior Component Separation (Ramirez)

Given the large defect size ([___] cm) precluding primary fascial closure without tension, anterior component separation (Ramirez technique) was performed. The external oblique aponeurosis was released bilaterally lateral to the semilunar line from the costal margin to the inguinal ligament. This allowed advancement of the myofascial components medially for [___] cm at the level of the umbilicus. The fascia was then closed in the midline. Mesh was placed in the onlay position for reinforcement.

Primary Suture Repair (Small Defect, No Mesh)

Given the small defect size ([___] x [___] cm), primary repair without mesh was elected. The fascial edges were reapproximated with interrupted figure-of-eight [0-PDS / 0-Ethibond] sutures with minimal tension. The repair was confirmed to be tension-free.

Incarcerated Hernia with Bowel Resection

The hernia sac was found to contain [small bowel / omentum] that was not reducible. The fascial ring was carefully enlarged to allow safe reduction. The incarcerated bowel was evaluated and found to be [viable after reduction / non-viable]. A [___]-cm segment of bowel was resected and a primary [hand-sewn / stapled] anastomosis was performed. Given bowel involvement, [a biologic mesh / no mesh] was used for repair to minimize infection risk.

Charting Tips
  • Document defect dimensions in centimeters. Hernia size directly determines CPT complexity and is required for outcomes reporting. 'Large hernia' is not sufficient.
  • Specify mesh position (onlay, underlay/sublay, retromuscular/Rives-Stoppa, IPOM), as this determines follow-up imaging interpretation and future surgical planning.
  • If component separation was performed, document which technique (anterior Ramirez vs. posterior transversus abdominis release/TAR) and estimated fascial advancement, as this has significant implications for recurrence counseling.
Billing Tips
  • Since 2023, hernia repair CPT codes are approach-neutral (open, laparoscopic, robotic use the same codes). Code selection is based on defect size and reducibility, not technique. Initial reducible: 49591 (<3 cm, 5.81 wRVU), 49593 (3-10 cm, 10.00 wRVU), 49595 (>10 cm, 13.59 wRVU). Incarcerated: 49592, 49594, 49596 respectively.
  • Recurrent hernia repair: 49613 (<3 cm, reducible, 7.23 wRVU), 49615 (3-10 cm, reducible, 11.17 wRVU), 49617 (>10 cm, reducible, 15.63 wRVU). Add incarcerated variants: 49614, 49616, 49618. Document prior repair history and intraoperative findings of prior mesh or scar.
  • Mesh use is included in the hernia repair CPT and is not separately billable by the surgeon. Document mesh type (biologic vs. synthetic), size, and fixation technique (suture vs. tack) for medical record and facility cost recovery.
  • Component separation (Ramirez anterior release, TAR posterior release) does not have its own CPT. It is captured within the hernia repair code. Modifier -22 (increased complexity) is appropriate for large complex abdominal wall reconstructions. Document defect size, technique, operative time, and estimated fascial advancement.
  • Removal of non-infected mesh during hernia repair: add-on code 49623 (3.66 wRVU). Document that prior mesh was identified, its condition, and that it was removed as part of the repair.
  • 90-day global period: seroma management, drain care, and wound checks are bundled. Large seroma aspiration requiring ultrasound guidance by IR within the global period is separately billable by radiology.