Pyloromyotomy (Ramstedt)

CPT 43520 · 11.01 wRVU · 90-day global
CPT43520
wRVU11.01
Global90-day
ApproachOpen
ComplexityComplex
Preoperative Diagnosis:

Hypertrophic pyloric stenosis

Postoperative Diagnosis:

Same

Procedure Performed:

[Laparoscopic / Open] pyloromyotomy (Ramstedt)

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident name]

Anesthesia:

General endotracheal. Nasogastric tube decompressed stomach prior to induction.

Indications:

Patient is a [X]-week-old [male / female] presenting with [non-bilious projectile vomiting / failure to thrive] and [palpable olive / ultrasound-confirmed] hypertrophic pyloric stenosis. Pyloric muscle thickness [X] mm, channel length [X] mm on ultrasound. Electrolytes corrected: [Na X, K X, Cl X, CO2 X]. Patient adequately resuscitated. Risks including mucosal perforation, incomplete myotomy, wound infection, and pyloric spasm discussed with parents. Consent obtained.

Findings:

Hypertrophied pylorus confirmed. Muscle [X] cm in length, [X] cm in diameter. Myotomy carried from antrum to duodenal mucosa. Mucosal integrity confirmed by [air insufflation / duodenal squeeze]. No leak. Mucosa intact throughout. Pyloric muscle spread completely.

Description of Procedure:

[LAPAROSCOPIC:] The patient was positioned supine. A 5-mm umbilical trocar was placed using [open Hasson technique]. CO2 insufflation to 8 mmHg. Two [3-mm] working ports placed in the [right and left upper quadrants]. The pylorus was grasped and the anterior avascular surface exposed. A longitudinal pyloromyotomy was performed using a [laparoscopic pyloromyotomy knife / arthrotomy blade] from the gastric antrum to the duodenum, avoiding the duodenal mucosa. The pyloric muscle was spread with a pyloric spreader until complete. Mucosal integrity tested by air insufflation via nasogastric tube with no leak confirmed. Ports removed. Umbilical fascia closed with [3-0 Vicryl].
[OPEN:] A [right upper quadrant / transverse supraumbilical / umbilical] incision was made. The stomach was delivered into the wound. The pylorus was delivered. A longitudinal incision was made on the anterior pyloric surface with a scalpel. The pyloric muscle was spread with a pyloric spreader until complete. Mucosal integrity confirmed. Fascia closed with [3-0 Vicryl]. Skin closed with [5-0 Monocryl].
Patient tolerated the procedure well.

Complications:

None

Specimens:

None

Estimated Blood Loss:

Minimal

Drains:

None

Disposition:

Patient to PACU. [Admitted / Discharged after feeding trial]. NGT removed at end of case.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Hypertrophic pyloric stenosis
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Laparoscopic / Open] pyloromyotomy (Ramstedt)
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal, NGT decompressed stomach pre-induction

INDICATIONS: The patient is a .PTAGE-old .PTSEX with non-bilious projectile vomiting and ultrasound-confirmed hypertrophic pyloric stenosis (muscle thickness *** mm, channel length *** mm). Electrolytes corrected. Risks including mucosal perforation, incomplete myotomy, and pyloric spasm discussed with parents. Informed consent obtained.

FINDINGS: Hypertrophied pylorus confirmed. Myotomy carried from antrum to duodenal mucosa. Mucosal integrity confirmed by air insufflation with no leak identified. Pyloric muscle fully spread.

DESCRIPTION OF PROCEDURE:
[LAPAROSCOPIC:] Patient supine. 5-mm umbilical trocar placed via open technique. CO2 to 8 mmHg. Two 3-mm working ports placed bilaterally. Pylorus grasped. Anterior avascular surface exposed. Longitudinal pyloromyotomy performed with laparoscopic blade from antrum to duodenum. Pyloric muscle spread with spreader until complete. Air insufflation via NGT confirmed no mucosal leak. Ports removed. Umbilical fascia closed with 3-0 Vicryl. [OPEN:] RUQ / umbilical incision. Pylorus delivered. Longitudinal myotomy with scalpel. Muscle spread until complete. Mucosal integrity confirmed. Fascia closed with 3-0 Vicryl. Skin with 5-0 Monocryl. Patient tolerated procedure well.

ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: None
COMPLICATIONS: None
DRAINS: None
DISPOSITION: Patient to PACU. [Admitted / Discharged after feeding trial.]

Signed: .ME, .MYDEGREE
.TODAY
Variants

Intraoperative mucosal perforation

Suture the mucosal perforation with fine absorbable suture (5-0 Vicryl). Patch with omentum or rotate and re-myotomize on the posterior surface. Document the perforation, repair technique, and confirmation of integrity after repair.

Preterm / ex-premature infant

Corrected age <44 12-24 age. apnea corrected delay document feeding for gestational hours. if monitoring occurs.< p postoperative requires trial weeks>

Charting Tips
  • Document preoperative electrolyte correction. Hypokalemic hypochloremic metabolic alkalosis must be corrected before anesthesia
  • State ultrasound measurements in the note (muscle thickness >4 mm, channel length >16 mm)
  • Confirm mucosal integrity by air insufflation or duodenal squeeze; document method and result
  • {'Note extent of myotomy': 'antrum to duodenum, full spread confirmed'}
  • Document NGT decompression at induction (reduces aspiration risk in these infants)
Billing Tips
  • Bill 43520 for pyloromyotomy (Ramstedt procedure), open or laparoscopic, 7.56 wRVU, 90-day global. The same CPT applies regardless of approach. Document the approach used.
  • Laparoscopic pyloromyotomy uses the same CPT 43520. Do not append modifier -22 unless the procedure was significantly more complex than usual. Document complexity if the modifier is used.
  • Intraoperative mucosal perforation requiring repair (conversion or primary suture with omental patch) should be documented. Perforation repair may be codable separately as a complication with modifier -78 if a second operation is required, but primary repair at the same session is included in 43520.
  • 90-day global: outpatient feeds, weight check visits, and emesis follow-up are bundled. The procedure is definitive in most cases. Incomplete myotomy requiring reoperation uses modifier -78.
  • For neonates, document age and weight. Premature infants (corrected age <44 admission affects and apnea disposition documentation.< have higher length. li may of postoperatively procedure regardless require risk this weeks)>

    ⓘ General Billing Tips →

    Written and reviewed by a senior general surgery resident, MD. For educational reference only. Always verify with your attending.

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