Laparoscopic / Robotic Inguinal Hernia Repair (TEP / TAPP)
[Right / Left] [direct / indirect] inguinal hernia
Same
Laparoscopic [right / left] inguinal hernia repair with mesh (totally extraperitoneal technique)
[***, 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. [No other significant findings were noted.]
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 The sheath was incised and the rectus muscle was retracted laterally, exposing the preperitoneal space.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. [The indirect sac was dissected off the cord structures and reduced. / The large indirect sac was divided, and the distal sac was 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 (Laparoscopic or Robotic-Assisted)
Pneumoperitoneum was established [with a Veress needle / by open Hasson technique] at the umbilicus, and [three 8-mm robotic ports were placed in a transverse line at the level of the umbilicus and the robot was docked / a 12-mm umbilical port and two 5-mm lateral ports were placed]. The [right / left] [direct / indirect] inguinal hernia was confirmed[, and the contralateral side was inspected]. A peritoneal flap was created [3 to 4] cm above the defect from the medial umbilical ligament to the anterior superior iliac spine. The preperitoneal space was developed to expose the pubic tubercle, Cooper's ligament, the epigastric vessels, and the iliopubic tract. The hernia sac was reduced, and the cord structures were parietalized. [The cord lipoma was reduced.]
A [15 x 15 cm / 10 x 15 cm] [polypropylene / lightweight polypropylene] mesh was placed to cover the direct, indirect, and femoral spaces [and secured to Cooper's ligament with [absorbable tacks / suture] / without fixation]. The peritoneal flap was closed over the mesh with a running [3-0 barbed] suture, with complete peritoneal coverage. [The robot was undocked.] The ports were removed under direct vision, and the fascia at the [12]-mm port site was closed with [0 Vicryl]. The skin was closed with [4-0 Monocryl] subcuticular sutures.
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. Injury to the genitofemoral or lateral femoral cutaneous nerve and to the external iliac vessels are the principal risks of these zones; documenting that tacks were placed outside them is the standard operative record for TAPP/TEP repair.
- 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.
Documentation & Reimbursement Considerations
- Primary service: Report Laparoscopic / Robotic Inguinal Hernia Repair (TEP / TAPP) as the primary service when it is the definitive operation performed.
- The initial laparoscopic inguinal hernia repair code (6.20 wRVU, 90-day global) is used for first-time repairs in patients with no prior ipsilateral inguinal hernia surgery.
- Recurrent repair has a separate, higher-valued code (8.17 wRVU, 90-day global). Document prior repair history and intraoperative findings consistent with recurrence (mesh, scarring, altered anatomy).
- For bilateral repair, append the bilateral modifier or list each side separately. Document each side individually in the operative note. Do not write a single generic bilateral description.
- Robotic repair uses the same codes as laparoscopic repair. Mesh use does not change the 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 the modifier for an unplanned related return to the OR.