Gastroschisis Repair
4960549606wRVU: 18.53 — Delayed closure after silo reduction44120wRVU: 20.3 — Small bowel resection (if atresia or ischemia)49600wRVU: 11.26 — Omphalocele repair, small (distinct from gastroschisis)
Gastroschisis: right paraumbilical abdominal wall defect with herniated bowel
Same
[Primary closure / Staged silo placement] for gastroschisis repair
[Attending name], MD
[Resident name]
General endotracheal. NGT placed. Temperature management: [warm blankets / warming mattress].
Patient is a [X]-day-old [male / female] born at [X] weeks gestation with prenatal diagnosis of gastroschisis and [right paraumbilical / small / large] abdominal wall defect noted at delivery. Bowel has been covered with [warm saline-soaked gauze / bowel bag] since delivery. [Matted / non-matted] bowel. Decision made to proceed with [primary closure / staged silo placement] based on bowel condition and abdominal domain. Risks including bowel ischemia, abdominal compartment syndrome, and prolonged ileus discussed with parents. Consent obtained.
[Matted / non-matted] bowel. Bowel [viable and pink / edematous / foreshortened]. Defect [X] cm. [Atresia identified at [X] location.] Abdominal domain [adequate / tight]. [Primary closure achieved / abdominal compartment pressure too high, silo placed].
[PRIMARY CLOSURE:] The patient was positioned supine under a warmer. The gastroschisis defect was inspected and bowel assessed. The bowel was gently reduced into the abdomen [manually / with gentle compression over time]. The defect edges were freshened. Primary fascial closure was performed with [running 0-PDS / interrupted 0-Vicryl]. Skin was closed separately with [running 4-0 Monocryl / Steri-Strips]. Umbilical reconstruction was performed.
[SILO PLACEMENT:] Primary reduction was not feasible due to [bowel edema / tight abdominal domain / matted bowel]. A preformed spring-loaded silo [/ sutured silo] was placed with the bowel inside. The silo base was secured to the abdominal wall fascia. The silo was elevated to facilitate staged gravity reduction over the following [3-7] days. Final closure will be performed in the NICU/OR when bowel is fully reduced.
[Bowel atresia repaired / ostomy created. See concurrent note.]
Patient tolerated the procedure well. Temperature maintained throughout.
None
None
Minimal
NGT to low wall suction
Patient transferred to NICU intubated and in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Gastroschisis: right paraumbilical abdominal wall defect with herniated bowel
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Primary closure / Staged silo placement] for gastroschisis
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal, NGT placed, warming measures in place
INDICATIONS: The patient is a .PTAGE-old .PTSEX born at *** weeks with prenatal/delivery diagnosis of gastroschisis. [Matted / non-matted] bowel. Decision for [primary closure / staged silo] based on bowel condition and abdominal domain. Risks including bowel ischemia and compartment syndrome discussed with parents. Informed consent obtained.
FINDINGS: [Matted / non-matted] bowel, [viable / edematous]. Defect *** cm. [Atresia identified at ***.] Primary [closure achieved / closure not feasible (silo placed)].
DESCRIPTION OF PROCEDURE:
Patient supine under warmer. [PRIMARY: Bowel gently reduced. Defect edges freshened. Primary fascial closure with 0-PDS. Skin with 4-0 Monocryl. Umbilical reconstruction performed.] [SILO: Primary reduction not feasible. Spring-loaded silo placed. Silo elevated for staged gravity reduction over *** days. Final closure planned in NICU/OR.] [Bowel atresia. See concurrent note.] Temperature maintained. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: None
COMPLICATIONS: None
DRAINS: NGT to low wall suction
DISPOSITION: Patient to NICU intubated, stable.
Signed: .ME, .MYDEGREE
.TODAYVariants
Delayed closure after staged silo
CPT 49606. Performed after silo reduction complete (bowel fully reduced into abdomen). Document silo removal, fascial closure technique, and skin closure or wound management.
Omphalocele (distinct)
CPT 49600/49611. Defect is midline through the umbilical ring with a sac. Management differs (sac often left intact initially for large defects). Do not confuse with gastroschisis coding.
Charting Tips
- Document bowel condition (matted vs. non-matted, viable vs. ischemic)
- State defect size in cm
- Note rationale for primary vs. staged approach (abdominal domain, peak airway pressures, bowel condition)
- Document temperature management, as hypothermia is a major risk in newborns
- If atresia present, document location and whether repaired primarily vs. ostomy
- Peak inspiratory pressure before and after closure helps document abdominal compartment syndrome risk
Billing Tips
- Bill 49605 for repair of gastroschisis (22.24 wRVU, 90-day global). This code covers both primary fascial closure and staged silo reduction/closure. The approach does not change the CPT. Document which technique was used.
- Staged silo reduction: the initial silo placement is included in 49605. Subsequent silo reductions (bedside) may be billed as separate E/M or procedure codes depending on the setting. Confirm with billing team. Final fascial closure after silo is separately billable with 49606 (delayed closure, 13.59 wRVU).
- Bowel resection for atresia or ischemia concurrent with gastroschisis repair: bill 44120 (small bowel resection) in addition to 49605. Document indication for resection and anastomosis vs. ostomy.
- 90-day global: TPN management, ostomy care, and NICU follow-up visits are bundled for the surgeon's fee. Gastrointestinal motility workup and feeding advancement are NICU team management and generate separate E/M fees.
- Omphalocele repair uses a different code: 49600 for small omphalocele (10.18 wRVU) and 49611 for large omphalocele. Do not use gastroschisis codes for omphalocele, as they are anatomically distinct defects.