Laparoscopic Inguinal Hernia Repair (TEP)
4965049651wRVU: 8.17 — Laparoscopic repair of recurrent inguinal hernia
Right/left [direct/indirect] inguinal hernia
Same
Laparoscopic right/left inguinal hernia repair with mesh (totally extraperitoneal technique)
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male/female] with a symptomatic [right/left] [direct/indirect] inguinal hernia presenting for laparoscopic repair. The risks, benefits, and alternatives of the procedure, including open approach, were discussed with the patient, and informed consent was obtained.
A [direct/indirect] inguinal hernia was confirmed on the [right/left] side with a defect measuring approximately [___] cm. The hernia sac contained [omentum/preperitoneal fat/no visceral contents]. The epigastric vessels, vas deferens, and spermatic vessels were identified and preserved. [An occult contralateral hernia was/was not noted.] [Additional findings or none].
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 small infraumbilical incision was made and carried down to the anterior rectus sheath. The sheath was incised and the rectus muscle was retracted laterally, exposing the preperitoneal space. A balloon dissector was inserted and advanced toward the pubic symphysis under digital guidance. The balloon was inflated under direct laparoscopic visualization to develop the preperitoneal space. The balloon was deflated and removed, and a blunt-tip trocar was secured at the umbilicus. The preperitoneal space was insufflated to 12 mmHg. Two additional 5-mm trocars were placed in the midline under direct visualization.
The preperitoneal space was further developed with blunt dissection, sweeping the peritoneum posteriorly. Cooper's ligament, the iliopubic tract, and the epigastric vessels were identified. The hernia sac was identified and reduced by gentle traction. [For indirect sac: the sac was dissected from the cord structures and reduced; for large indirect sac, the sac was divided and the distal sac left in place.] The hernia defect was confirmed.
A [10 x 15 cm polypropylene mesh / lightweight mesh] was introduced into the preperitoneal space and positioned to cover the direct space, indirect space, and femoral space, overlapping Cooper's ligament inferiorly and extending above the iliopubic tract. The mesh was secured with a [tacking device / absorbable tack / suture] to Cooper's ligament and the anterior abdominal wall, taking care to avoid the triangle of pain and triangle of doom.
The preperitoneal space was desufflated under direct visualization to confirm mesh lie. The peritoneum was seen to reduce over the mesh. The trocars were removed. The umbilical fascial incision was closed with [0-Vicryl]. The skin was closed with [4-0 Monocryl] subcuticular sutures. Sterile dressings were applied.
None
None
Minimal (less than 10 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: Laparoscopic *** inguinal hernia repair with mesh (TEP)
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with a symptomatic *** inguinal hernia presenting for laparoscopic repair. Informed consent was obtained.
FINDINGS: A *** inguinal hernia on the *** side, defect approximately *** cm. The epigastric vessels, vas deferens, and spermatic vessels were identified and preserved.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room and placed supine. General endotracheal anesthesia was induced. Surgical timeout performed per protocol.
An infraumbilical incision was made to the anterior rectus sheath. The preperitoneal space was developed with a balloon dissector under laparoscopic visualization. The space was insufflated to 12 mmHg. Two 5-mm midline trocars were placed. Cooper's ligament, iliopubic tract, and epigastric vessels were identified. The hernia sac was reduced. A 10 x 15 cm mesh was placed to cover direct, indirect, and femoral spaces and secured to Cooper's ligament.
The space was desufflated and mesh position confirmed. Fascia closed with 0-Vicryl. 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
Bilateral Inguinal Hernia Repair
After completion of the right-sided repair, the preperitoneal space was extended across the midline to the contralateral side. A left-sided [direct/indirect] hernia was confirmed. The left hernia sac was similarly reduced. A second [10 x 15 cm] mesh was placed on the left side in the same fashion, and secured to Cooper's ligament. Both meshes were confirmed to lie flat without folding. Desufflation confirmed peritoneal coverage of both meshes bilaterally.
TAPP Technique (Transabdominal Preperitoneal)
Using a transabdominal approach, standard trocar placement was used to enter the peritoneal cavity. A peritoneal flap was created over the hernia defect from the medial umbilical ligament to well lateral to the internal ring. The preperitoneal space was developed, hernia sac reduced, and mesh placed as described. The peritoneal flap was closed over the mesh with a running [3-0 Vicryl] suture ensuring complete peritoneal coverage.
Converted to Open
Due to [dense preperitoneal adhesions from prior hernia repair/prior radical prostatectomy/inability to develop adequate preperitoneal space], the procedure was converted to open Lichtenstein repair. The preperitoneal space was desufflated and trocars removed. An open inguinal incision was made and repair completed as described in the open technique.
Charting Tips
- Document that the triangle of pain (lateral to spermatic vessels) and triangle of doom (medial triangle containing external iliac vessels) were avoided during tacking. This is the key medicolegal element for nerve and vascular injury prevention.
- Specify mesh size (e.g., 10 x 15 cm) and type (polypropylene vs. lightweight), as this matters for future imaging interpretation and any mesh-related complications.
- If a large indirect sac was divided rather than fully reduced, document this explicitly. This technique is acceptable and sometimes necessary, but leaving the distal sac should be in the record.
Billing Tips
- Bill 49650 for initial laparoscopic inguinal hernia repair (6.20 wRVU, 90-day global). Use for first-time repairs in patients with no prior ipsilateral inguinal hernia surgery.
- Bill 49651 for recurrent inguinal hernia repair (8.17 wRVU, 90-day global). Document prior repair history and intraoperative findings consistent with recurrence (mesh, scarring, altered anatomy).
- For bilateral repair, bill 49650 twice with modifier -50 (bilateral) or list each side separately. Document each side individually in the operative note. Do not write a single generic bilateral description.
- Mesh use does not change the CPT code for laparoscopic inguinal hernia repair. Document mesh type, size, and fixation method for the operative record, but these do not affect billing.
- 90-day global period: postoperative visits within 90 days are bundled. If a complication requires a return to the OR within the global period, use modifier -78 (unplanned return to OR for related procedure).