Open Inguinal Hernia Repair
4950549507wRVU: 8.86 — Incarcerated or strangulated49520wRVU: 9.74 — Recurrent inguinal hernia49521wRVU: 11.19 — Recurrent incarcerated inguinal hernia
Right/left [direct / indirect] inguinal hernia
Same
Open right/left inguinal hernia repair with mesh (Lichtenstein technique)
[***, 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. [No other significant findings were noted.]
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 incised along its fibers from the external ring, protecting the ilioinguinal nerve lying immediately beneath it on the anterior surface of the cord. The ilioinguinal nerve was [preserved and retracted from the operative field / divided and its stump ligated and buried within the internal oblique muscle]. [Any iliohypogastric or genital branch fibers encountered were kept clear of the mesh and fixation sutures.] 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] (approximately 7 x 15 cm) was fashioned to fit the inguinal floor, sized to overlap the pubic tubercle medially by about 2 cm. 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, protecting the ilioinguinal nerve beneath it. The ilioinguinal nerve was [preserved and retracted / divided and its stump buried in muscle]. [Iliohypogastric and genital branch fibers kept clear of the mesh and sutures.] 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.
Shouldice Repair (Non-Mesh, Tissue-Based)
A Shouldice repair was performed given [mesh avoidance in a contaminated or potentially contaminated field / patient preference for a tissue repair / a young patient with a small indirect defect]. After high ligation of the hernia sac, the transversalis fascia was incised from the internal ring to the pubic tubercle and the two flaps were mobilized. The floor was reconstructed in the classic overlapping fashion with continuous [3-0 / 2-0] polypropylene: the first line approximated the free edge of the lower flap to the undersurface of the upper flap, and a second line returned to imbricate the upper flap over the lower. Two further running layers approximated the conjoint tendon to the inguinal ligament. The overlapping tissue layers recreated the inguinal floor without mesh. Tension was assessed and the internal ring was confirmed to admit the cord without constriction. Note: the Shouldice repair has the lowest recurrence rate among non-mesh techniques but is technically demanding and depends on a true multilayer reconstruction rather than a single approximating suture line.
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.
- Document what you actually did with each nerve rather than a blanket attestation. Guidelines favor identifying all three inguinal nerves to reduce chronic pain, but in practice the ilioinguinal is the one reliably encountered under the external oblique. Record whether it was preserved and retracted or deliberately divided with the stump buried in muscle. The iliohypogastric and genital branch are often not formally exposed, so chart them as protected where seen rather than claiming an identification you did not perform. The most important nerve point is keeping all of them off the mesh and out of the fixation sutures, since entrapment is a leading cause of chronic groin pain.
- 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.
General coding reference. Verify with your institution’s billing department before submitting claims.