Small Bowel Resection
4412044121wRVU: 4.33 — Each additional resection and anastomosis44125wRVU: 19.53 — With enterostomy
Small bowel obstruction / small bowel ischemia / Crohn's disease with stricture / small bowel tumor / small bowel perforation
Same
Small bowel resection with primary anastomosis
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male/female] with [indication] presenting for small bowel resection. The risks, benefits, and alternatives were discussed with the patient, and informed consent was obtained.
A [___]-cm segment of [jejunum/ileum] was found to be [ischemic/strictured/perforated/with obstructing mass]. The segment began approximately [___] cm from the ligament of Treitz and extended to [___] cm proximal to the ileocecal valve. Proximal bowel was [dilated/normal]. Distal bowel was [decompressed/normal]. Mesenteric vascularity [was/was not] preserved to the resection margins. [Additional findings or none].
The patient was brought to the operating room and placed supine. General endotracheal anesthesia was induced. 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. A midline laparotomy was performed. Abdominal exploration confirmed the operative findings.
The involved segment of small bowel was identified and delivered into the wound. The extent of resection was determined by [palpable pulsatile mesenteric vessels / Doppler signal / viable tissue margins / negative margins for neoplasm]. The mesentery of the affected segment was divided between clamps and ligated with [2-0 Vicryl / 0-silk ties], taking care to preserve the mesenteric arcade to the remaining bowel.
[For stapled anastomosis:] The bowel was divided proximally and distally with [GIA-75 mm] staplers. A side-to-side (functional end-to-end) anastomosis was fashioned by aligning the antimesenteric borders of the two bowel ends, making small enterotomies, and firing a [GIA-75 mm] stapler. The common enterotomy was closed with a [TA-55] stapler. The anastomosis was confirmed to be widely patent, hemostatic, and without tension.
[For hand-sewn anastomosis:] The bowel was divided between bowel clamps. A [single-layer / two-layer] end-to-end anastomosis was constructed. [Single-layer:] A single running full-thickness [3-0 Vicryl] suture incorporating the submucosa, placed [5 mm] apart. [Two-layer:] Inner running [3-0 Vicryl] full-thickness suture followed by outer interrupted [3-0 silk] Lembert seromuscular sutures. The anastomosis admitted two fingerbreadths.
The mesenteric defect was closed with [interrupted 2-0 silk] sutures. The abdomen was irrigated. Hemostasis was confirmed. The fascia was closed with running [#1 looped PDS]. Skin was closed with [staples / 4-0 Monocryl]. Sterile dressings were applied.
None
Small bowel segment [___] cm sent to pathology
Minimal (less than 50 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: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Small bowel resection with primary anastomosis
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with *** presenting for small bowel resection. Informed consent obtained.
FINDINGS: *** cm segment of *** was ***. Resection margins viable. Proximal bowel ***; distal bowel ***.
DESCRIPTION OF PROCEDURE:
Supine. Foley placed. General anesthesia. Surgical timeout per protocol.
Midline laparotomy. Affected segment identified. Mesentery divided between clamps with *** ties. Bowel divided with GIA staplers. Functional end-to-end anastomosis with GIA-75; enterotomy closed with TA-55. Anastomosis widely patent. Mesenteric defect closed. Fascia with #1 looped PDS. Skin with ***.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Small bowel *** cm to pathology
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
Ischemia: Second-Look Laparotomy Planned
Given extensive mesenteric ischemia with [questionable viability of remaining bowel / resection of [___] cm of small bowel leaving [___] cm remaining], a planned second-look laparotomy in 24-48 hours was elected to reassess bowel viability. An anastomosis was [performed / deferred in favor of bowel stapling and end stoma formation]. The abdomen was closed and the patient was returned to the ICU. The intent to perform a second-look was documented in the operative note and orders.
With Diverting Stoma
Given [gross contamination / hemodynamic instability / high-risk anastomosis / extensive ischemia with short bowel], a primary anastomosis was deferred. The proximal end was brought out as an end ileostomy through a right lower quadrant trephine. The distal segment was either brought out as a mucous fistula or closed and returned to the abdomen. Bowel continuity will be restored as a staged procedure.
Charting Tips
- Document the remaining bowel length for ischemia cases. Measure and record approximately how many centimeters of small bowel remain after resection. Short bowel syndrome risk begins at < 200 cm; documentation at the time of surgery is critical for prognosis and future management.
- Document the assessment of margin viability. State specifically what was used (visible pulsatile vessels, Doppler, bleeding margins, peristalsis) to confirm that resection margins were viable before anastomosis. Anastomosis at ischemic margins is a common cause of leak.
- For Crohn's cases, document the resection margin strategy. Standard is to resect to grossly normal bowel, not wide margins, to conserve bowel length. Document that margins were taken at grossly normal tissue.
Billing Tips
- Bill 44120 for small bowel resection with anastomosis (20.30 wRVU, 90-day global). Use for any single segment small bowel resection with primary anastomosis, open or laparoscopic.
- Bill 44121 as an add-on code for each additional small bowel resection performed at the same setting (4.33 wRVU per additional resection). Document each additional segment resected separately.
- Bill 44202 for laparoscopic small bowel resection (22.81 wRVU) when performed entirely laparoscopically. If converted to open, use 44120.
- If an end ostomy is created rather than a primary anastomosis, bill 44310 (ileostomy, 17.15 wRVU) as primary. The resection is included in the ostomy code. Do not bill 44120 and 44310 together for the same bowel segment.
- 90-day global period: drain management, wound care, and nutritional follow-up are bundled. Document the indication (obstruction, ischemia, Crohn's, trauma), length of bowel resected, and anastomotic technique for operative completeness.