Low Anterior Resection
4420744208wRVU: 33.14 — Laparoscopic coloproctostomy with colostomy
Rectal carcinoma / upper/mid rectal cancer
Same
Laparoscopic low anterior resection with total mesorectal excision and diverting loop ileostomy
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male/female] with [upper/mid/low] rectal cancer located [___] cm from the anal verge on preoperative staging, with [cT_N_M_ staging]. [Neoadjuvant chemoradiation was/was not completed]. The patient presents for laparoscopic low anterior resection with total mesorectal excision. The risks, benefits, and alternatives were discussed with the patient, and informed consent was obtained.
The rectal tumor was located [___] cm from the anal verge. The mesorectum was [intact/previously irradiated]. The pelvic sidewalls were [free/with adherent tissue]. The left ureter was identified and preserved. The neurovascular bundles were [preserved bilaterally / sacrificed on the [right/left] side given tumor involvement]. No [peritoneal / hepatic / omental] metastases were identified. [Additional findings or none].
The patient was brought to the operating room and placed in modified lithotomy (Lloyd-Davies) position. General endotracheal anesthesia was induced. 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, including the perineum. Pneumoperitoneum was established to 15 mmHg via [Veress needle / optical trocar / Hasson open technique]. A 12-mm umbilical trocar was placed. Four additional trocars were placed: 12-mm right lower quadrant, 5-mm right upper quadrant, 5-mm left upper quadrant, 5-mm suprapubic. The patient was positioned in steep Trendelenburg with left lateral tilt.
Abdominal exploration confirmed no metastatic disease. The sigmoid colon was mobilized and the left colon was fully mobilized with splenic flexure takedown. The left ureter was identified and swept posterolaterally throughout. The IMA was ligated with [hem-o-lok clips] at [its aortic origin (high ligation) / just distal to the left colic artery origin (low ligation)]. The IMV was divided at the inferior border of the pancreas.
Total mesorectal excision was performed in the embryologic avascular holy plane between the mesorectal fascia and the parietal fascia of the pelvis. The dissection proceeded anteriorly behind Denonvilliers' fascia, posteriorly in the presacral space, and laterally preserving the hypogastric nerves and pelvic neurovascular bundles bilaterally. The mesorectum was divided sharply under direct vision [___] cm distal to the inferior tumor margin, maintaining an intact mesorectal envelope.
The rectum was divided [___] cm distal to the inferior tumor edge using a laparoscopic [roticulating] TA stapler, requiring [1/2/3] firings. The specimen was extracted through a Pfannenstiel extraction incision with a wound protector.
An end-to-end colorectal anastomosis was constructed using a [EEA 28/29/31 mm circular stapler] introduced transanally. The anvil was secured in the proximal colon with a [2-0 Prolene] purse-string. The anastomosis was completed, confirmed to be [___] cm from the anal verge. Donuts were confirmed complete. Air insufflation with pelvic saline immersion test revealed [no air leak / air leak that was oversewn].
Given [low anastomosis / prior radiation / anastomotic tension / leak test concern], a diverting loop ileostomy was created through the right lower quadrant 12-mm port site (preoperatively marked). The terminal ileum was brought up through the trephine. The efferent (distal) limb was identified and positioned at the inferior aspect of the trephine, sutured flush to skin. The afferent (proximal) limb was everted 2-3 cm above skin to create a spout. The ileostomy rod was placed and the stoma was confirmed viable.
The abdomen was irrigated. Hemostasis confirmed. The Pfannenstiel fascia was closed with [0-PDS]. Port site fascias were closed. Skin closed with [4-0 Monocryl]. Ostomy appliance placed.
None
Rectosigmoid specimen with intact mesorectum sent to pathology for proximal and distal margin assessment
[___] mL
[One closed suction drain in the pelvis]
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Rectal cancer, *** cm from anal verge
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Laparoscopic low anterior resection with TME and diverting loop ileostomy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with *** rectal cancer *** cm from anal verge, cT***N***M0. *** neoadjuvant therapy. Informed consent obtained.
FINDINGS: Tumor at *** cm. TME planes identified. Ureters preserved bilaterally. Neurovascular bundles ***. No metastatic disease.
DESCRIPTION OF PROCEDURE:
Modified lithotomy position. Foley placed. General anesthesia. Surgical timeout per protocol. Five trocars placed.
Left colon mobilized, splenic flexure taken down. IMA high-ligated at origin. IMV divided at pancreatic inferior border. TME performed in holy plane; mesorectal fascia intact. Rectum divided *** cm from inferior tumor margin. Specimen extracted via Pfannenstiel with wound protector.
EEA *** mm circular stapler anastomosis *** cm from anal verge; donuts complete; air test negative. Diverting loop ileostomy created through right lower quadrant trephine. Pelvic drain placed.
Fascia closed. Skin closed with 4-0 Monocryl. Ostomy appliance applied.
ESTIMATED BLOOD LOSS: ***
SPECIMENS: Rectosigmoid with mesorectum to pathology
COMPLICATIONS: None
DRAINS: Pelvic drain
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Without Diverting Ileostomy
Given [favorable anastomotic height / adequate bowel preparation / no radiation history / negative leak test / patient preference after counseling], a diverting ileostomy was not performed. The patient was counseled preoperatively regarding the higher risk of symptomatic anastomotic leak without diversion.
Converted to Open
Due to [bulky tumor/prior pelvic radiation with obliterated planes/obesity/inadequate visualization], the procedure was converted to open low anterior resection. A midline laparotomy was performed and the pelvic dissection was completed under direct visualization. TME was completed sharply and the anastomosis was performed as described.
Ultra-Low Anastomosis / Coloanal Anastomosis
The rectal stump was divided at the level of the levator ani. The anastomosis was constructed as a hand-sewn coloanal anastomosis via the transanal approach. [A colonic J-pouch (5-6 cm) was constructed to increase reservoir capacity.] The anastomosis was completed at the dentate line and confirmed to be intact.
Charting Tips
- Document pelvic nerve identification by name. State that the hypogastric nerves were identified at the sacral promontory and the nervi erigentes were swept laterally during the anterior dissection. 'Nerve-sparing technique used' without naming the nerves is not adequate.
- Document TME completeness with three specific statements: dissection was in the avascular holy plane, the mesorectal envelope was intact on inspection, and dissection extended to the levator ani.
- Document distal margin in centimeters from the tumor and from the anal verge. Both are required — one defines R0 status, the other defines sphincter preservation adequacy.
- For the anastomosis, document: height from anal verge, stapler size, both donuts intact, and air leak test result. If the leak test was positive, document what was done.
- Document the diversion decision. If no ileostomy was created, state the rationale: negative leak test, no radiation, no tension, adequate perfusion, and that the patient was counseled on the increased leak risk without diversion.
Billing Tips
- Bill 44207 for laparoscopic low anterior resection (LAR) with colorectal anastomosis (31.12 wRVU, 90-day global). Bill 44208 when a diverting loop ileostomy is added (33.14 wRVU).
- For open LAR with anastomosis, bill 44140 (partial colectomy with anastomosis) or 44143/44144 depending on extent of resection. CPT 44145 is specifically open coloproctostomy with a colonic J-pouch reservoir — not a standard LAR code. CPT 44146 is open coloproctostomy with colostomy. Do not use 44145 for a straightforward open LAR without J-pouch construction.
- Total mesorectal excision (TME) does not change the CPT code but must be documented as performed. It is the quality standard for rectal cancer and will be scrutinized in tumor registry and quality review.
- If a diverting loop ileostomy is created, it is bundled into 44208. Subsequent ileostomy closure (takedown) at a separate operation uses 44620 (14.07 wRVU) or 44625/44626 depending on complexity.
- 90-day global period: adjuvant therapy coordination, anastomotic leak evaluation, and routine follow-up are bundled. Exam under anesthesia for anastomotic stricture within the global period requires modifier -78.