Hernia repair Surgery Operative Report
- Medycoding Expert
- 2 days ago
- 7 min read
Before attempting Op report, we are suggesting you read the guideline of hernia , follow the link : Guideline for hernia
Op report 1
Patient Name : ABC Insurance : Blue Cross
Age : 56 Admit Type : Outpatient
Procedure Date : 13/02/2026 Gender : Male
Preoperative Diagnosis: Epigastric hernia
Postoperative Diagnosis: Epigastric hernia
Procedure Performed: Open epigastric hernia repair
Anesthesia: General anesthesia
Indication:
The patient presented with a midline epigastric swelling consistent with an epigastric hernia. Clinical examination confirmed a reducible hernia with an estimated defect size of 3 cm. Elective open repair was planned.
Procedure description:
After obtaining informed consent, the patient was brought to the operating room and placed supine on the operating table. Standard monitoring was applied and general anesthesia was induced. The abdomen was prepared and draped in a sterile fashion.
A transverse skin incision was made over the palpable epigastric swelling. The incision was deepened through skin and subcutaneous tissue using electrocautery. Small bleeding vessels were controlled with bipolar cautery. The subcutaneous fat was carefully dissected to expose the hernia sac. The sac was identified as a peritoneal outpouching emerging through the midline linea alba defect. Blunt and sharp dissection was used to separate the sac from surrounding preperitoneal fat and fascial edges.
The hernia sac was opened to confirm contents, which consisted of preperitoneal fat with no bowel involvement. The contents were reduced back into the abdominal cavity. The sac was then either excised or ligated at its neck depending on intraoperative preference.
The hernia defect measuring approximately 3 cm in the epigastric (linea alba) region was clearly visualized. The fascial edges were freshened to promote secure closure.
Primary fascial repair was performed using interrupted non-absorbable polypropylene sutures (or continuous suture as preferred). Sutures were placed ensuring adequate bite of healthy fascia on both sides of the defect. The repair was completed without tension. The integrity of closure was confirmed.
Hemostasis was achieved throughout the field. The subcutaneous layer was irrigated with saline. No mesh was used in this repair (or mesh reinforcement can be added if intended).The subcutaneous tissue was approximated using absorbable sutures. Skin was closed with staples/nylon interrupted sutures. A sterile dressing was applied.
Answer:
CPT : 49593
ICD : K43.9
Op report 2
Patient Name : ABC Insurance : Blue Cross
Age : 56 Admit Type : Outpatient
Procedure Date : 13/02/2026 Gender : Male
Preoperative Diagnosis: Recurrent umbilical hernia
Postoperative Diagnosis: Recurrent umbilical hernia
Procedure Performed: Robotic-assisted laparoscopic repair of recurrent umbilical hernia with mesh placement
Anesthesia: General anesthesia
Indication:
The patient is a known case of recurrent umbilical hernia, presenting with a reducible midline periumbilical swelling. Due to recurrence, a minimally invasive robotic-assisted laparoscopic repair with mesh reinforcement was planned.
Procedure description:
After informed consent, the patient was brought to the operating room and placed supine on the operating table. General anesthesia was induced and the abdomen was prepped and draped in sterile fashion.
A veress needle / optical entry technique was used to establish pneumoperitoneum up to appropriate pressure. A laparoscopic camera port was inserted, and diagnostic laparoscopy was performed, confirming a recurrent umbilical hernia defect with adhesions in the midline.Two additional robotic working ports were placed under direct vision, along with an assistant port as required. The robotic system was docked.
Adhesiolysis was performed carefully using sharp and blunt dissection to release omental and preperitoneal adhesions from the anterior abdominal wall. The hernia defect at the umbilical region was identified and measured intraoperatively.
The hernia contents were fully reduced into the abdominal cavity. The fascial defect was delineated and cleared of surrounding preperitoneal fat to allow proper mesh placement.A mesh (appropriate size with adequate overlap of at least 3–5 cm beyond defect margins) was introduced into the abdominal cavity. The mesh was positioned over the defect in a sublay/intraperitoneal onlay position (IPOM or robotic retromuscular placement depending on technique used).
The mesh was then fixed securely using absorbable sutures / tacks in a circumferential manner, ensuring no folding or tension. The repair was inspected for hemostasis and proper positioning.Pneumoperitoneum was released under direct vision to ensure stable mesh placement without displacement.
All ports were removed under vision. Fascial closure of port sites ≥10 mm was performed to prevent port-site hernia. Skin was closed with absorbable sutures and sterile dressings applied.
Answer:
CPT : 49615
ICD : K42.9
Op report 3
Patient Name : ABC Insurance : Blue Cross
Age : 56 Admit Type : Outpatient
Procedure Date : 13/02/2026 Gender : Male
Preoperative Diagnosis: Acute appendicitis; umbilical hernia (2 cm)
Postoperative Diagnosis: Acute appendicitis; umbilical hernia (2 cm)
Procedure Performed: Laparoscopic appendectomy with concurrent open repair of umbilical hernia (2 cm) at umbilical port site
Anesthesia: General anesthesia
Indication:
The patient presented with clinical features consistent with acute appendicitis. Laparoscopic appendectomy was planned. Preoperatively / intraoperatively, a 2 cm umbilical hernia was noted at the planned umbilical port site, and repair was planned following completion of appendectomy.
Procedure description:
After informed consent, the patient was taken to the operating room and placed in the supine position. General anesthesia was induced and the abdomen was prepped and draped in a sterile manner.
A periumbilical incision was made, and pneumoperitoneum was established. A 10-mm umbilical port was inserted, followed by insertion of laparoscope. Two additional ports were placed under direct vision in the lower abdomen.On laparoscopic inspection, the appendix was found to be inflamed consistent with acute appendicitis. No perforation was noted (or specify if perforated).The mesoappendix was divided using energy device. The appendicular artery was secured. The base of the appendix was ligated using endoloops / stapler, and the appendix was divided and retrieved using an endobag through the umbilical port.
The abdominal cavity was irrigated and suctioned. Hemostasis was confirmed.
After completion of the appendectomy and removal of all ports, attention was turned to the umbilical port site, where a 2 cm umbilical hernia defect was identified.The fascial defect was exposed by extending the umbilical incision slightly. Hernial sac contents (preperitoneal fat / omentum if present) were reduced into the abdominal cavity. The sac was dissected and excised at the neck.The 2 cm fascial defect was closed primarily using interrupted non-absorbable sutures, ensuring tension-free approximation of the fascial edges. Integrity of repair was confirmed.
Subcutaneous tissue was irrigated. Skin was closed with sutures / staples. Sterile dressing was applied.
Findings:
Inflamed appendix consistent with acute :
Umbilical hernia at port site measuring 2 cm
No intra-abdominal abscess or complications
Answer:
CPT : 44970
ICD : K35.80, K42.9
Op report 4
Patient Name : ABC Insurance : Blue Cross
Age : 56 Admit Type : Outpatient
Procedure Date : 13/02/2026 Gender : Male
Preoperative Diagnosis: Recurrent umbilical hernia
Postoperative Diagnosis: Recurrent umbilical hernia with omentum densely adherent within hernia sac
Procedure Performed: Laparoscopic repair of recurrent umbilical hernia with adhesiolysis and mesh placement
Anesthesia: General anesthesia with endotracheal intubation
Indication:
The patient is a known case of recurrent umbilical hernia of 2 cm presenting with umbilical swelling and discomfort. Laparoscopic mesh repair was planned due to recurrence.
Procedure description:
After informed consent, the patient was brought to the operating room and placed supine. General anesthesia was induced. The abdomen was prepped and draped in sterile fashion.
A pneumoperitoneum was created using a Veress needle. A laparoscopic camera port was inserted at the umbilicus, and diagnostic laparoscopy was performed. Additional working ports were placed under direct vision in the lower abdomen.On inspection, a recurrent umbilical hernia defect was identified. The hernia sac was found to contain omentum that was tightly adherent to the sac wall.
Careful and meticulous sharp and blunt dissection was performed to free the omentum from the hernia sac. Dense adhesions were released using a combination of electrocautery and atraumatic graspers, taking care to avoid injury to the omentum and surrounding structures.
The omentum was fully reduced back into the peritoneal cavity. Hemostasis was ensured throughout the dissection. The hernia sac was dissected down to its neck and reduced.
The fascial defect at the umbilical region was identified. Standard laparoscopic abdominal wall anatomy was assessed. No bowel injury was noted.
A large polypropylene mesh (adequate size to ensure wide overlap of defect) was introduced into the abdominal cavity. The mesh was positioned in the preperitoneal space covering the defect with adequate overlap in all directions.
The mesh was carefully spread flat without folds or tension. Fixation was achieved using tacks / absorbable fixation devices / sutures, ensuring secure placement while avoiding injury to surrounding structures.
Peritoneal flap (if applicable) was closed over the mesh using continuous absorbable sutures, ensuring complete mesh coverage.
Hemostasis was confirmed. Pneumoperitoneum was gradually released under direct vision to ensure mesh stability. All ports were removed under vision. Fascial closure was performed for port sites ≥10 mm to prevent port-site hernia. Skin was closed with sutures/staples and sterile dressing applied.
Answer:
CPT : 49614
ICD : K42.0
Op report 5
Patient Name : ABC Insurance : Blue Cross
Age : 56 Admit Type : Outpatient
Procedure Date : 13/02/2026 Gender : Male
Preoperative Diagnosis: Right inguinal hernia; phimosis
Postoperative Diagnosis: Right inguinal hernia; phimosis
Procedure Performed: Laparoscopic right inguinal hernia repair with mesh placement; circumcision
Indication:
The patient presented with a right inguinal hernia associated with groin swelling and discomfort. The patient also had phimosis causing difficulty in foreskin retraction and hygiene issues. Combined surgical management was planned.
Procedure description:
After informed consent, the patient was brought to the operating room and placed supine on the operating table. General anesthesia was induced. The abdomen and genital region were prepped and draped in a sterile manner.
A pneumoperitoneum was established using a Veress needle. A camera port was inserted at the umbilicus, and diagnostic laparoscopy was performed. Two additional working ports were placed under direct vision in the lower abdomen. A right inguinal hernia defect was identified. The peritoneum was dissected to expose the myopectineal orifice. Careful dissection was performed to identify and protect the inferior epigastric vessels and cord structures.
The hernia sac was reduced completely. A large polypropylene mesh was introduced and positioned in the preperitoneal space covering the direct, indirect, and femoral areas. The mesh was spread flat without folds and secured using tacks / absorbable fixation devices. The peritoneal flap was closed over the mesh using continuous absorbable sutures.
Hemostasis was confirmed. Pneumoperitoneum was released under direct vision, and all ports were removed. Fascial closure was performed for port sites ≥10 mm. Skin was closed with sutures/staples.
Attention was then turned to the genital region. The foreskin was examined and confirmed to be phimotic with non-retractability.A dorsal slit was made after appropriate local infiltration. The foreskin was carefully separated from the glans using blunt dissection, releasing adhesions.The redundant preputial skin was excised circumferentially. Hemostasis was achieved using cautery. The mucosal and skin edges were approximated using interrupted absorbable sutures, ensuring a neat circumferential closure with adequate exposure of the glans.
A sterile dressing was applied.
Answer
CPT : 49650-RT, 54161-51
ICD: K40.90, N47.1
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