SCQR & Hernia Surgery: Everything you wanted to know, but ..., Exams of Medicine

Download SCQR & Hernia Surgery: Everything you wanted to know, but ... and more Exams Medicine in PDF only on Docsity! SCQR & Hernia Surgery: Everything you wanted to know, but were afraid to ask Richard E. Burney, MD, FACS is a general surgeon who joined the faculty at Michigan Medicine in 1976. In addition to working as a general/endocrine/ gastrointestinal/trauma/critical care surgeon, he played many leadership roles, including head of the emergency service, medical director of Survival Flight, head of the Michigan Committee on Trauma, President of the Michigan Peer Review Organization, and Chairperson of the Michigan Board of Medicine. He has had a long- standing interest in quality of care, doing some of the first studies on patient reported outcomes and functional health status after surgery. He was President of the American Health Quality Association during the period when CMS made the transition from quality assessment to quality improvement, with the help of the Institute for Healthcare Quality Improvement (IHI). He joined MSQC in November 2019 when he stepped away from working in the operating room after 50 years as a surgeon Basic Anatomy: two perspectives Landmarks of the Abdominal Wall Arcuate Line: Lower edge of posterior rectus sheath Linea Semilunaris: Lateral edge of rectus sheath Inguinal canal Regions of the Abdominal Wall Epigastric area Umbilical/periumbilical Flank/Lumbar area Hypogastric area Myofascial Anatomy of Abdominal Wall Rectus abdominis External oblique Internal oblique Transverse abdominis Linea alba • Linea alba = midline confluence of the aponeuroses of rectus muscles. • Aponeurosis of external oblique à anterior rectus sheath. • Aponeurosis of internal oblique above the level of the umbilicus à anterior and posterior rectus sheath. • Aponeurosis of the transversus abdominis above the level of the umbilicus à posterior rectus sheath. • There is no posterior rectus sheath below the umbilicus. Abdominal Wall Hernia Locations (as distinct from hernia types) for Synoptic note* Synoptic Operative Note and Hernia Location *For MSQC – M1 and M2 will be captured as M2 (Program Manual-pg 199) Cosmesis - Hernias are ugly! Function • Discomfort o Common symptoms: Bulge, dull ache o Less Common symptoms: Pain/Tenderness • Impair function • Affect activities of daily living or work Prevention • Reduce/eliminate risk of strangulation • Pain management - Protruding hernias may cause pain • Difficult to reduce – at risk for strangulation **Not all hernias need to be repaired or should be repaired** Why Repair a Hernia? Open • Operation done through skin incision over the site of the hernia • Advantageous for incarcerated or strangulated hernias Laparoscopic (minimally invasive) • Operation done via laparoscopic ports • Less pain after operation • Note: Fascial defect may not be closed, only covered by mesh Robotic (minimally invasive) • Newer form of laparoscopic repair • Controversial: Not proven beneficial for abdominal wall hernias Surgical Approaches Common types of ventral hernias Hernia Types & CPT Codes Overview Ventral Hernia: A generic term encompassing all anterior hernia types Tip: Diastasis recti is not a true hernia; it is a gap between left & right rectus abdominus muscle. The surgical repair is a form of ‘tummy tuck’ *unlisted code to capture laparoscopic femoral hernia repair only ‡Note-MSQC does not capture this procedure. Epigastric • 49570, 49572, 49652, 49653 Umbilical • 49585, 49587, 49652, 49653 Incisional • 49560, 49561, 49565, 49566, 49654, 49655, 49656, 49657 • Parastomal (44346)‡ Inguinal • 49505, 49507, 49520, 49521, 49525, 49650, 49651 Femoral • 49550, 49553, 49555, 49557, 49659* Spigelian • 49590, 49652, 49653 Lumbar • 49540‡ Uncommon types of ventral hernias Clinical Pearls from the Surgeon’s Perspective Incisional Ventral Mesh TIP: MSQC Appendix A informs you which CPT codes include the mesh. Open 49560 (49561): Repair initial (recurrent) incisional or ventral hernia; reducible. 49560 (49561): Repair initial (recurrent) incisional or ventral hernia; reducible. Ventral/Incisional (49560, 49561, 49565, 49566) does not include mesh Umbilical, epigastric, and Spigelian does include mesh (49570, 49571, 49585, 49587 and 49590). Laparoscopic 49654 (49655): Laparoscopy, surgical, repair, incisional hernia; reducible (incarcerated/ strangulated) 49652 (49653): Laparoscopy, surgical, repair, ventral, umbilical, Spigelian or epigastric hernia; reducible (incarcerated/ strangulated) All laparoscopic hernia repairs include mesh Ventral vs Incisional Hernia Epigastric Hernia • Bulge in upper midline between umbilicus and xiphoid, usually closer to umbilicus. o There may be more than one small fascial defect o May be mistaken for and/or coincident with umbilical hernia • Caused by small fascial defect(s) in the decussation (interdigitation) of the fibers of the linea alba. • Contains only preperitoneal fat unless very large • Technique: Primary (open) repair can often be done under local anesthesia with sedation Hernia Types - Common Inguinal Hernia Types Indirect • Peritoneal sac coming through internal inguinal ring • Might contain bowel Direct • Bulging of inguinal floor between internal and external rings • Usually contains preperitoneal fat • Very large ones may contain bowel Sliding • Variation of indirect • Bowel fused to peritoneum comes through a widely dilated internal inguinal ring Hernia Types - Common For MSQC, the type is not a factor in abstracting our cases, but it is in determining CPT code. Dissection Balloon Another Device Used During Hernia Surgery Example: Applied Medical • In men: it contains the cremaster muscle, which envelops the cord structures (vas deferens, testicular vessels, nerves, fatty tissue, and associated connective tissues). • In women: it contains the cremaster muscle, round ligament from the uterus, nerves, fat, and connective tissues. • The ilioinguinal, genital branch of the genitofemoral n., & other nerves may be found in or on the cremaster muscle, on the internal oblique muscle, and along the inguinal floor. DEPARTMENT OF SURGERY What is in the Inguinal Canal? • Fat is commonly found in the inguinal canal whether you have a hernia or not. When there is a large amount, it’s called a lipoma of the cord. • Large lipomas of the cord may be hard to differentiate from true hernias. • Normally, they do not change in shape or configuration with coughing or straining. • They are mistakenly called a “hernia” on ultrasound. DEPARTMENT OF SURGERY Lipoma of the Cord Femoral Hernia • Comes through defect in inguinal ligament adjacent to femoral vein o Not in inguinal canal, hence different from inguinal hernia • Occurs primarily in slender young or older women • Peritoneal sac o May contain bowel or omentum o High risk of incarceration/ strangulation Technique: • Repair similar to inguinal hernia – can be done open or laparoscopically. • Strangulated femoral hernia may require bowel resection - best done open. Hernia Types - Common Spigelian Hernia • Rare, difficult to diagnose. • Develops at or near intersection of arcuate line and linea semilunaris, just lateral to rectus muscle. • Has peritoneal sac; can cause bowel obstruction. • Laparoscopic approach preferred for diagnosis and treatment. Hernia Types - Uncommon Mesh Types More than 60 types/brands of mesh on the market (MSQC Program Manual pgs. 273-274) • Most are non-absorbable (synthetic or biosynthetic) • Absorbable (Biologic, absorbable synthetic) Advantages Disadvantages § Can be used in contaminated cases § Reabsorbs § Does not erode through adjacent tissues § Higher hernia reoccurrence rate Advantages Disadvantages § Permanent § Infection § Stronger § Erosion § Fewer reoccurrences § Pain § Cannot be used in contaminated cases Skin Ext Oblique Int Oblique Transversus abd Peritoneum Rectus Ms Anterior fascial release/component separation Transversus abdominus release Transversus abdominis release • Variation on sublay • Technique o Open posterior leaf of internal oblique o Gains access transversalis plane o Opens huge retrorectus/retromuscular space for placing mesh Myofascial Release – Component Separation Suture Absorbable tacks Non-absorbable tacks Self-gripping/self-fixating mesh Adhesive (glue) Mesh Fixation Devices & Methods http://www.laparoscopicexperts.com/laparoscopic-ventral-hernia-repair/ Covidien AbsorbaTack Source: https://madridge.org/journal-of- surgery/mjs-1000112.pdf We hope that synoptic operative note will help us gain the information we need to carry out quality improvement, And provide consistent data describing what was done for subsequent analysis. Slide 36 has more information on variables called for in pilot project on hernia tab. An Epic Template is available here: https://msqc.org/wp- content/uploads/2020/02/SynOpNote_EpicGuide.pdf Hernia/Mesh Length and Width FAQs Here are some tips we’ve learned for MEASUREMENTS, whether for the hernia or the mesh: • Only one (1) value is provided (NOTE: for our purposes, 'dimension' = shape…so length or width, diameter or length X width) o Dimension is given as either length or width, capture the measurement in the identified variable, then capture 0.0 for the missing variable § Example: surgeon states “incisional hernia width is 8cm” and the surgeon did not provide the 2nd measure (length) § REPORT: hernia width = 8 (cm) AND hernia length = 0.0. • No dimension is given in the documents (neither length or width), capture the known measurement in LENGTH, then capture 0.0 for the WIDTH o Example: surgeon states “hernia is 5.5 cm” o REPORT: hernia length = 5.5 (cm) AND hernia width = 0.0. • Dimension is given as diameter, or circular or ‘size of small orange (etc.)’* o Example: surgeon states “hernia diameter is 4 cm”. Note: diameter = circle, which means equal measurements for length & width. o REPORT: hernia length = 4 (cm) and hernia width = 4 (cm) • Zero/No dimensions or values are provided in the operative report or the preop documentation (H&P or Surgical Consult) o REPORT: 0.0 will be captured for BOTH length and width • Both measurement values are provided, but NO dimensions, then capture 1st measurement as LENGTH and 2nd measurement as WIDTH o Example: surgeon states “4x6 mesh was placed” o REPORT: mesh length = 4 (cm) and mesh width = 6 (cm). • *When a dimension is given as a descriptor, such as fruit, ball, fist – please send the description to MSQC DHL as we are trying to establish some equivalents values in centimeters. • If not on the operative note, see if there is a CT study that may provide dimensions or the surgeons H&P, office notes prior to surgery or surgical consult. FAQ’s from survey • How to determine location when specific landmarks are not documented. • Make your best guess? Call it ventral. Talk to a surgeon. • Can you explain terminology that would be found in a robotic repair? • Docking of robot means bringing the robot into place and locking it into position. • Placement of robotic arms means attaching the robot arms to instruments that have been inserted through laparoscopic ports. • Otherwise terminology is basically the same as laparoscopic.