Laparoscopic Ventral Hernia Repair (IPOM)
4959349591wRVU: 5.81 — Initial, <3 cm, reducible (5.81 wRVU)49592wRVU: 8.25 — Initial, <3 cm, incarcerated/strangulated (8.25 wRVU)49594wRVU: 13.12 — Initial, 3-10 cm, incarcerated/strangulated (13.12 wRVU)49595wRVU: 13.59 — Initial, >10 cm, reducible (13.59 wRVU)49596wRVU: 18.2 — Initial, >10 cm, incarcerated/strangulated (18.20 wRVU)49613wRVU: 7.23 — Recurrent, <3 cm, reducible (7.23 wRVU)49615wRVU: 11.17 — Recurrent, 3-10 cm, reducible (11.17 wRVU)49617wRVU: 15.63 — Recurrent, >10 cm, reducible (15.63 wRVU)49623wRVU: 3.66 — Removal of non-infected mesh (add-on, 3.66 wRVU)
[Ventral / incisional] hernia
Same
Laparoscopic [ventral / incisional] hernia repair with intraperitoneal onlay mesh (IPOM) [with primary fascial closure; IPOM-Plus]
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male/female] with a symptomatic [ventral / incisional] hernia measuring approximately [___] cm presenting for elective laparoscopic repair. The risks, benefits, and alternatives of the procedure, including open repair, were discussed with the patient, and informed consent was obtained.
A [ventral / incisional] hernia was confirmed laparoscopically with a fascial defect measuring [___] x [___] cm. The hernia sac contained [omentum / preperitoneal fat / no visceral contents]. [Adhesions from prior surgery were present involving the [anterior abdominal wall / omentum / small bowel].] [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 Foley catheter was placed. 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. Trocars were placed away from the hernia defect and prior incisions. Pneumoperitoneum was established to 15 mmHg via [Veress needle / optical trocar / Hasson open technique] at [the left upper quadrant / right upper quadrant / lateral position]. Two additional [5-mm] trocars were placed under direct visualization in a configuration to allow triangulation over the hernia defect.
The peritoneal cavity was surveyed. Adhesiolysis was performed using [sharp dissection / harmonic scalpel / LigaSure] to takedown adhesions from the anterior abdominal wall and expose the hernia defect. The bowel was inspected for inadvertent enterotomy throughout; none identified.
The fascial defect was measured laparoscopically at [___] x [___] cm. A [composite / dual-layer PTFE / biologic] mesh was selected and sized to provide a minimum [5]-cm overlap on all sides, yielding a mesh size of [___] x [___] cm. The mesh was marked with orientation sutures and introduced through the largest port.
[IPOM-Plus, primary fascial closure:] Transfascial sutures of [0-PDS] were passed through the fascial edges of the defect using a suture passer and the defect was closed primarily under laparoscopic visualization, reducing hernia contents and eliminating dead space.
The mesh was unrolled intraperitoneally and positioned to cover the defect with [5]-cm overlap circumferentially. Transfascial sutures of [0-Prolene] were passed at the [four corners / periphery] of the mesh using a suture passer and tied over the fascia. The mesh was additionally secured with [absorbable / permanent] tacks placed [1]-cm apart around the mesh perimeter, avoiding the triangle of pain and triangle of doom. The mesh was confirmed to lie flat without folding or tenting.
The abdomen was desufflated under direct visualization. Trocars were removed. The [12-mm] fascial port site was closed with [0-Vicryl]. Skin incisions were closed with [4-0 Monocryl] subcuticular sutures. Sterile dressings were applied.
None
None
Minimal
None
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Ventral / incisional] hernia
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Laparoscopic ventral hernia repair with intraperitoneal onlay mesh (IPOM)
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 laparoscopic repair. Risks, benefits, and alternatives including open repair were discussed. Informed consent was obtained.
FINDINGS: Fascial defect *** x *** cm. Contents: ***. [Adhesions: ***.] No enterotomy.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room and placed supine. General endotracheal anesthesia was induced. Foley placed. Surgical timeout performed per protocol.
Trocars placed away from prior incisions. Pneumoperitoneum to 15 mmHg via [Veress needle / optical trocar / Hasson]. Two 5-mm working trocars placed under direct visualization. Peritoneal cavity surveyed. Adhesiolysis performed with ***. Defect measured *** x *** cm laparoscopically.
A *** x *** cm composite mesh selected (5 cm overlap circumferentially). [Primary fascial closure performed with transfascial 0-PDS sutures; IPOM-Plus.] Mesh unrolled intraperitoneally and positioned over defect. Transfascial sutures placed at periphery and tied over fascia. Tacks placed 1 cm apart around perimeter. Mesh confirmed flat.
Desufflated under direct vision. Trocars removed. Fascia closed at 12-mm site 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
Conversion to Open Repair
Due to [dense adhesions precluding safe laparoscopic dissection / inability to achieve adequate mesh overlap laparoscopically / enterotomy requiring open repair], the decision was made to convert to open repair. Trocars were removed. An open [midline / transverse] incision was made and repair was completed as an open retromuscular [/ primary suture] repair as described in the open operative note.
Multiple / Bilateral Defects (Swiss Cheese)
Multiple fascial defects were identified laparoscopically in a Swiss-cheese pattern. Individual defect sizes: [defect 1: ___x___ cm / defect 2: ___x___ cm]. The aggregate defect measured [___] x [___] cm. A single large mesh was sized to span all defects with [5]-cm overlap beyond the outermost defect edges. [Primary closure of individual defects was performed before mesh placement; IPOM-Plus.]
Incarcerated Content: Reduction and Repair
Incarcerated [omentum / small bowel] was identified within the hernia defect. The contents were reduced laparoscopically with gentle traction after carefully enlarging the fascial opening under direct vision. The reduced contents were inspected and found to be [viable / ischemic; segment resected via extension of incision]. Given [contamination / bowel resection], a [biologic mesh / no mesh / delayed repair] was elected.
Charting Tips
- Document defect size measured intraoperatively at the fascial edges, as this determines CPT code selection (<3 3-10 cm,>10 cm). Preoperative CT measurement is insufficient; document the laparoscopic intraoperative measurement explicitly.
- Document mesh size, type, and overlap distance on all sides. 5 cm overlap is the evidence-based minimum. Stating only 'mesh placed' is inadequate for coding and medicolegal documentation.
- Document each transfascial suture location and tack spacing. Inadequate fixation is a leading cause of IPOM recurrence, so the operative note should support that fixation was complete.
- If IPOM-Plus (primary fascial closure) was performed, document that the defect was closed before mesh placement and confirm closure was achieved without tension. This is a distinct technique with different recurrence data.
- Document bowel inspection for enterotomy at the start and conclusion of adhesiolysis. Missed enterotomy with IPOM mesh is a catastrophic complication, and explicit note language protects the surgeon.
- Since 2023, hernia repair CPT codes are approach-neutral. Open, laparoscopic, and robotic use the same codes. Code by defect size and reducibility: initial reducible 49591 (<3 ( (3-10 10.00 49593 49595 5.81 cm, wrvu),>10 cm, 13.59 wRVU). Incarcerated: 49592, 49594, 49596 respectively.
- Recurrent hernia: 49613 (<3 ( (3-10 11.17 49615 49617 7.23 cm, wrvu),>10 cm, 15.63 wRVU). Incarcerated recurrent: 49614, 49616, 49618. Document the prior repair (open vs. laparoscopic, mesh vs. primary suture) in the note.
- Defect size must be measured intraoperatively at the fascial edges under laparoscopic visualization. Document this explicitly, as preoperative CT measurement alone is insufficient for code selection.
- Mesh is included in the CPT and is not separately billable by the surgeon. Biologic or composite mesh material cost is recoverable via facility charges. Document mesh type (composite, dual-layer PTFE, biologic), brand, size, and fixation technique.
- Adhesiolysis is not separately billable when performed as part of the hernia repair. If adhesiolysis substantially increases complexity (extensive, >60 min), use modifier -22 with documentation of operative time and complexity.
- IPOM-Plus (primary fascial closure + IPOM mesh) uses the same CPT codes. Document that primary defect closure was performed before mesh placement. Modifier -22 is appropriate when the additional step substantially increases operative time.
- Bowel injury during adhesiolysis: bill the bowel repair code (44602 for simple enterotomy repair) in addition to the hernia code. Document injury mechanism, repair, and whether mesh placement proceeded or was deferred.