Total Proctocolectomy with IPAA (J-Pouch)
4421144212wRVU: 33.72 — Laparoscopic total proctocolectomy with IPAA, without diverting loop ileostomy44155wRVU: 33.56 — Open total proctocolectomy with ileostomy (Brooke)
Ulcerative colitis / Familial adenomatous polyposis
Same
Laparoscopic total proctocolectomy with ileal pouch-anal anastomosis (IPAA) and diverting loop ileostomy
[Attending name], MD
[Resident/Fellow/PA name]
General endotracheal
Patient with [medically refractory ulcerative colitis / dysplasia / familial adenomatous polyposis] presents for restorative proctocolectomy. Preoperative colonoscopy, [CT scan], and [MRI pelvis] reviewed. Nutritional optimization and pelvic floor assessment completed. Stoma site marked by enterostomal therapist. Risks including anastomotic leak, pelvic nerve injury, pouch failure, and temporary ileostomy discussed.
[Diffuse colitis / polyposis] involving the entire colorectum. No evidence of perforation or obstruction. Rectum dissected to the pelvic floor. Adequate ileal mesenteric length for tension-free pouch construction.
The patient was taken to the operating room, placed in Lloyd-Davies position, prepped circumferentially, and draped in sterile fashion. Foley catheter in place. Laparoscopic access was established via 12-mm umbilical port using [Veress needle / optical trocar / Hasson open technique]. Pneumoperitoneum established to 15 mmHg. Additional trocars placed under direct vision.
The abdomen was explored. The colon was mobilized beginning with the right colon using a medial-to-lateral approach, taking the ileocolic, right colic, and middle colic vessels close to their origin. The left colon was mobilized with ligation of the inferior mesenteric vessels at their origin. The splenic flexure was taken down with entry into the lesser sac.
Pelvic dissection was performed using a total mesorectal excision technique, keeping the autonomic nerves intact. The rectum was mobilized to the pelvic floor circumferentially. The rectum was divided at the anorectal junction [1-2 cm above the dentate line] using a laparoscopic TA stapler. The specimen was extracted via Pfannenstiel extraction site.
The distal ileum was divided at the ileocecal junction. A J-pouch was constructed with each limb approximately 15 cm in length (total pouch approximately 30 cm), using [two / three] firings of a 100-mm GIA stapler along the anti-mesenteric border. Pouch integrity was confirmed with air insufflation. The pouch apex was brought to the pelvis and confirmed to reach at least 4-6 cm below the pubic symphysis without tension before proceeding with anastomosis.
[For double-stapled IPAA (standard):] A double-stapled ileal pouch-anal anastomosis was performed using a [29-33] mm circular stapler introduced transanally. No mucosectomy was performed. The anvil was secured in the pouch apex and the stapler fired. Donuts were intact bilaterally. Air-leak test negative.
[For hand-sewn IPAA with mucosectomy (for FAP or dysplasia at dentate line):] The rectal mucosa was stripped from the dentate line to the level of the pouch using electrocautery. The pouch was pulled through the denuded anal canal and a hand-sewn anastomosis was constructed at the dentate line with [interrupted 3-0 absorbable] sutures.
A diverting loop ileostomy was fashioned through the right lower quadrant using [X] cm of ileum, brought through the rectus abdominis, matured using Brooke sutures.
All trocars removed under vision. Fascia closed at 12-mm sites. Skin closed. Stoma appliance placed. Patient tolerated the procedure well.
None
Total proctocolectomy specimen
[250-400] mL
[Closed suction drain placed in pelvis / No drain]
Patient was taken to PACU in stable condition. Admitted to surgical floor.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Medically refractory ulcerative colitis / Familial adenomatous polyposis]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Laparoscopic total proctocolectomy with ileal pouch-anal anastomosis (IPAA) and diverting loop ileostomy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [medically refractory ulcerative colitis / FAP] presenting for restorative proctocolectomy. Preoperative colonoscopy, CT scan, and MRI pelvis reviewed. Stoma site marked by enterostomal therapist. Nutritional optimization completed. Risks including anastomotic leak, pelvic nerve injury, pouch failure, and temporary ileostomy discussed. Informed consent obtained.
FINDINGS: Diffuse [colitis / polyposis] involving the entire colorectum. No perforation or obstruction. Rectum dissected to pelvic floor. Adequate ileal mesenteric length for tension-free pouch construction.
DESCRIPTION OF PROCEDURE:
The patient was placed in Lloyd-Davies position, prepped circumferentially, and draped in sterile fashion. Foley in place. Laparoscopic access via 12-mm umbilical port [Veress needle / optical trocar / Hasson]; pneumoperitoneum 15 mmHg. Additional trocars placed under direct vision. The colon was mobilized medial-to-lateral, ligating the ileocolic, right colic, middle colic, and inferior mesenteric vessels at origin. Splenic flexure mobilized with entry into lesser sac. Total mesorectal excision technique employed, preserving hypogastric nerves and nervi erigentes. Rectum mobilized circumferentially to pelvic floor; transanal dissection completed to dentate line. Specimen extracted via Pfannenstiel incision. A 15-cm J-pouch constructed using two 100-mm GIA stapler firings. Pouch integrity confirmed with air insufflation. Double-stapled ileal pouch-anal anastomosis performed with 29-mm circular stapler transanally. Donuts intact bilaterally; air-leak test negative. Diverting loop ileostomy fashioned through right lower quadrant, matured using Brooke sutures. Fascia closed at 12-mm port sites. Stoma appliance placed. Patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: Total proctocolectomy specimen to pathology
COMPLICATIONS: None
DRAINS: [Closed suction drain in pelvis / None]
DISPOSITION: Patient taken to PACU in stable condition. Admitted to surgical floor.
Signed: .ME, .MYDEGREE
.TODAYVariants
Two-stage (without diverting ileostomy)
In highly selected patients. Document patient selection criteria and anastomotic integrity testing.
Three-stage (subtotal colectomy first)
For acute colitis or steroid-dependent disease. Stage 1: subtotal colectomy with end ileostomy. Stage 2: completion proctectomy + IPAA. Stage 3: ileostomy closure.
Hand-sewn anastomosis (mucosectomy)
For dysplasia at dentate line or FAP. Document mucosectomy technique and hand-sewn anastomosis with interrupted absorbable sutures.
Charting Tips
- Document pelvic nerve identification by name: hypogastric nerves at the sacral promontory, nervi erigentes swept laterally during the anterior dissection. 'Nerve-sparing technique used' without naming the nerves is not adequate.
- Document pouch construction with measurements: pouch limb length in centimeters, number of GIA firings, staple load size, and air insufflation confirming no leak. 'J-pouch constructed' without these details is inadequate.
- For the anastomosis, document: height from the dentate line, stapler size, both donuts intact, air leak test result, and that the pouch reached the pelvis without tension.
- Document ileostomy limb orientation: which limb is proximal and which is distal. The reversal surgeon needs to know this without opening the abdomen to find out.
- For FAP: document polyp number and distribution, presence of duodenal polyposis with Spigelman stage, and the upper endoscopic surveillance plan. The operative note initiates the lifelong surveillance record.
Billing Tips
- Bill 44155 for total proctocolectomy with ileostomy (Brooke ileostomy, 33.56 wRVU, 90-day global). Bill 44158 for total proctocolectomy with ileal pouch-anal anastomosis (IPAA/J-pouch, 35.78 wRVU).
- When IPAA is performed with a diverting loop ileostomy (staged approach), bill 44158 for the pouch creation. The diverting ileostomy is bundled. Ileostomy closure at a second operation uses 44620 or 44625.
- For laparoscopic total proctocolectomy with IPAA and diverting loop ileostomy, bill 44211 (36.15 wRVU). For laparoscopic total proctocolectomy with IPAA without loop ileostomy, bill 44212. For open total proctocolectomy with IPAA, bill 44157 (without diverting ileostomy) or 44158 (with continent ileostomy/continent diversion). Document approach and any hand-assist or hybrid technique.
- 90-day global period: pouch function assessment, pouchoscopy, dietary management, and routine follow-up are bundled. Pouchitis management requiring admission does not generate a separate surgical procedure code.
- For UC patients, document active disease refractory to medical therapy, steroid dependence, or dysplasia. Payers require documented failure of medical management before approving colectomy for inflammatory bowel disease.