Pyloromyotomy (Ramstedt)
43520Hypertrophic pyloric stenosis
Same
[Laparoscopic / Open] pyloromyotomy (Ramstedt)
[Attending name], MD
[Resident name]
General endotracheal. Orogastric tube decompressed stomach prior to induction.
Patient is a [X]-week-old [male / female] (weight [X] kg) 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], HCO3 [X]. Patient adequately resuscitated. Risks including mucosal perforation, incomplete myotomy, wound infection, and pyloric spasm discussed with parents. Consent obtained.
Hypertrophied pylorus confirmed. Pyloric muscle length [X] cm, diameter [X] cm. Myotomy carried from gastric antrum to prepyloric vein of Mayo (pyloroduodenal junction). Mucosal integrity confirmed by [air insufflation via OGT / direct visual inspection for mucus or bubbles after duodenal compression]. No mucosal leak. Pyloric muscle fully spread with free mucosal bulge bilaterally and independent movement of cut edges.
[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 via stab incisions in the [right upper quadrant / epigastric / left upper quadrant] positions. The pylorus was grasped and the anterior avascular surface exposed. A longitudinal seromuscular incision was made with a [laparoscopic pyloromyotomy knife / arthrotomy blade] from the gastric antrum to the prepyloric vein of Mayo (pyloroduodenal junction), extending approximately 1 cm onto the gastric antrum proximally. The pyloric muscle was spread with a pyloric spreader, separating the muscle fibers bluntly down to the submucosa until the mucosa bulged freely and the cut edges moved independently. The distal extent was confirmed to stop at the vein of Mayo, avoiding the duodenal mucosa. Mucosal integrity confirmed by [air insufflation via OGT with no leak identified / direct visual inspection after duodenal compression with no mucus or bile extruded]. Ports removed. Umbilical fascia closed with [3-0 Vicryl].
[OPEN — RIGHT UPPER QUADRANT / UMBILICAL:] A [right upper quadrant / transverse supraumbilical / circumumbilical (Tan-Bianchi)] incision was made. The stomach was delivered into the wound. The pylorus was delivered. A longitudinal seromuscular incision was made on the anterior avascular pyloric surface from the gastric antrum to the prepyloric vein of Mayo (pyloroduodenal junction), extending 1 cm onto the gastric antrum proximally. The pyloric muscle was spread with a pyloric spreader, bluntly separating the muscle fibers to the level of submucosa until the mucosa bulged freely. The distal extent was confirmed to stop at the vein of Mayo. Mucosal integrity confirmed. Fascia closed with [3-0 Vicryl]. Skin closed with [5-0 Monocryl].
Patient tolerated the procedure well. OGT removed at end of case.
None
None
Minimal
None
Patient to PACU. [Admitted for feeding trial and monitoring / Admitted for apnea monitoring (former preterm, corrected age <44 weeks)]. [Discharged home after feeding trial].
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, OGT decompressed stomach pre-induction
INDICATIONS: The patient is a .PTAGE-old .PTSEX (weight *** kg) 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. Muscle length *** cm, diameter *** cm. Myotomy carried from antrum to prepyloric vein of Mayo. Mucosal integrity confirmed by [air insufflation / direct inspection] — no leak. Pyloric muscle fully spread with free mucosal bulge and independent edge movement.
DESCRIPTION OF PROCEDURE:
[LAPAROSCOPIC:] Patient supine. 5-mm umbilical trocar placed via open technique. CO2 to 8 mmHg. Two 3-mm working ports via stab incisions. Pylorus grasped; anterior avascular surface exposed. Seromuscular incision from antrum to vein of Mayo with laparoscopic blade. Muscle spread bluntly to submucosa; mucosa bulges freely; cut edges move independently. Distal extent at vein of Mayo confirmed. Mucosal integrity confirmed — no leak. Ports removed. Umbilical fascia closed with 3-0 Vicryl. [OPEN:] [RUQ / umbilical / circumumbilical] incision. Pylorus delivered. Seromuscular incision from antrum to vein of Mayo. Muscle spread to submucosa. Mucosal integrity confirmed. Fascia 3-0 Vicryl. Skin 5-0 Monocryl. OGT removed. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: None
COMPLICATIONS: None
DRAINS: None
DISPOSITION: Patient to PACU. [Admitted for feeding trial / Admitted for apnea monitoring (corrected age <44 wks).]
Signed: .ME, .MYDEGREE
.TODAYVariants
Intraoperative mucosal perforation
Suture the mucosal perforation with fine absorbable suture (5-0 Vicryl). Patch with omentum. Alternatively, rotate the pylorus 90-180 degrees and perform a second myotomy on an unaffected anterior or posterior surface. Confirm integrity after repair by air insufflation. Document the perforation site, repair technique, and post-repair mucosal integrity test. Included in 43520 — no separate code for primary repair at same session.
Incomplete myotomy requiring reoperation
Occurs in approximately 2% of cases. Presents with persistent vomiting 2-3 weeks postoperatively after initial improvement. Re-explore and complete the myotomy. CPT 43520, modifier -78 (unplanned return to OR). Document the incomplete segment, extent of original myotomy, and completion technique.
Open circumumbilical (Tan-Bianchi) approach
Cosmetically superior incision through the umbilical skin crease. Higher mucosal perforation rate than RUQ in some series, but comparable outcomes overall. Document approach explicitly; same CPT 43520.
Preterm / ex-premature infant
Corrected age <44 weeks requires postoperative apnea monitoring for 12-24 hours. Document gestational age at birth, corrected gestational age at surgery, and birth weight. Modifier -63 applies if current weight <4 kg.
Charting Tips
- Document preoperative electrolyte correction. Hypokalemic hypochloremic metabolic alkalosis must be corrected before anesthesia (target Cl >100, HCO3 <30, pH <7.45)
- State ultrasound measurements in the note; accepted diagnostic criteria for hypertrophic pyloric stenosis are muscle thickness ≥3 mm and channel length ≥15-16 mm (not >4 mm — that threshold is outdated)
- {'Document myotomy landmarks': 'proximal extent onto gastric antrum (~1 cm), distal extent to prepyloric vein of Mayo (not beyond the pyloroduodenal junction)'}
- Document mucosal integrity test method (air insufflation via OGT or direct visual inspection) and result
- {'Confirm complete myotomy': "free mucosal bulge bilaterally and independent movement of the two cut edges (Benson/Saint's sign)"}
- Document OGT decompression at induction (reduces aspiration risk)
- Document weight at time of surgery for modifier -63 eligibility (<4 kg)
Billing Tips
- Bill 43520 for open pyloromyotomy (Ramstedt procedure), 11.01 wRVU, 90-day global. For laparoscopic pyloromyotomy, the technically correct code per AAPC is 43659 (unlisted laparoscopic procedure, stomach) — open CPT codes should not be applied to laparoscopic procedures. In practice, many institutions code laparoscopic pyloromyotomy as 43520 because payers accept it; confirm what your payers require. 43659 carries no assigned national wRVU and requires an operative note for reimbursement benchmarked to 43520. Document the approach explicitly.
- Modifier -63 (procedure performed on infant less than 4 kg): applies when patient weight is under 4 kg. Typical pyloric stenosis patients are 3-5 weeks old and often weigh 3-4 kg. This modifier adds approximately 22.6% to the fee and requires contemporaneous weight documentation at time of surgery.
- ICD-10 diagnosis: Q40.0 (congenital hypertrophic pyloric stenosis). This links medical necessity to the procedure and is required on the claim.
- Intraoperative mucosal perforation requiring repair (primary suture with omental patch) at the same session is included in 43520 — do not bill separately. If a second operation is required for a missed perforation, use modifier -78.
- Incomplete myotomy requiring reoperation: use modifier -78 (unplanned return to OR, related complication) with 43520. Document the incomplete myotomy, symptoms prompting return, and findings at re-exploration.
- 90-day global: outpatient feeds, weight check visits, and emesis follow-up are bundled. Former preterm infants (corrected age <44 weeks) have higher risk of apnea postoperatively — document corrected gestational age and admission for apnea monitoring. This affects disposition documentation but not the procedure code.
General coding reference. Verify with your institution’s billing department before submitting claims.