Cytoreductive Surgery and HIPEC
[Appendiceal mucinous neoplasm / colorectal peritoneal metastasis / ovarian cancer / mesothelioma] with peritoneal carcinomatosis
Same
Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC), [completeness of cytoreduction CC-0 / CC-1]
[***, MD/DO]
[Fellow/Resident name]
General endotracheal. Arterial line, central venous access. Cell saver. Epidural [if placed].
Patient presents with [appendiceal mucinous neoplasm / colorectal peritoneal metastasis / primary peritoneal mesothelioma] and peritoneal carcinomatosis (PCI [X]) deemed resectable after multidisciplinary tumor board review. [Prior systemic chemotherapy: X cycles.] No distant metastatic disease on staging imaging. Risks including prolonged operative time, anastomotic leak, bowel obstruction, hematologic toxicity from HIPEC, and mortality discussed. Consent obtained.
Peritoneal Carcinomatosis Index (PCI): [X] (scored 0-39). Regions involved: [list regions]. [Liver surface involved ([stripped / not stripped])]. [Spleen involved; splenectomy performed.] Completeness of cytoreduction: [CC-0: no visible residual disease / CC-1: residual <2.5 mm].
The patient was positioned supine. A midline laparotomy was performed from xiphoid to pubis. Systematic exploration was performed with PCI scoring of all 13 abdominal regions.
CYTOREDUCTION: the following procedures were performed (see individual procedure notes or detailed below): - [Pelvic peritonectomy and resection of pelvic tumor deposits] - [Right and/or left diaphragm peritoneal stripping] - [Greater omentectomy] - [Splenectomy / left upper quadrant peritonectomy] - [Right upper quadrant peritonectomy, cholecystectomy] - [Small bowel resection with primary anastomosis, [X] cm resected] - [Colorectal resection with [primary anastomosis / diverting ileostomy]] Completeness of cytoreduction: CC-[0/1]: [no visible residual / residual nodules <2.5 mm].
HIPEC: Following cytoreduction and prior to bowel anastomosis [/ after anastomosis per institutional protocol], the abdomen was irrigated with hyperthermic chemotherapy solution. [Mitomycin C [X] mg/m2 administered at 42 degrees C for 90 minutes — standard regimen for colorectal and appendiceal histologies. / Cisplatin [X] mg/m2 with doxorubicin [X] mg/m2 at 42 degrees C for 60-90 minutes — for mesothelioma. / Oxaliplatin [X] mg/m2 at 42-43 degrees C for 30 minutes — Elias protocol; note PRODIGE 7 (Lancet Oncol 2021) did not demonstrate survival benefit for oxaliplatin HIPEC in colorectal peritoneal metastases; agent and protocol should reflect institutional multidisciplinary decision.] A [closed / open Coliseum] technique was used. Inflow and outflow temperatures were monitored; intra-abdominal temperature maintained at 41-43 degrees C. Chemotherapy was then drained and the abdomen irrigated with normal saline.
Bowel anastomoses were then performed [end-to-end / side-to-side with GIA stapler]. Hemostasis confirmed throughout. Closed-suction drains placed. Fascia closed with running [0-PDS]. Skin closed. Patient tolerated the procedure well.
None
All resected specimens to pathology with individual labeling
[X] mL
[Jackson-Pratt drains x2-3 in pelvis and right upper quadrant / None]
Patient taken to surgical ICU intubated in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Appendiceal mucinous neoplasm / colorectal peritoneal metastasis / mesothelioma] with peritoneal carcinomatosis
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Cytoreductive surgery + HIPEC, CC-[0/1]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal; arterial line; CVP; cell saver
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [appendiceal / colorectal peritoneal / mesothelioma] peritoneal carcinomatosis (PCI ***) deemed resectable by multidisciplinary tumor board. No distant metastasis. Risks including prolonged OR time, anastomotic complications, HIPEC toxicity, and mortality discussed. Informed consent obtained.
FINDINGS: PCI *** (0-39). Regions: ***. Completeness of cytoreduction: CC-[0 / 1]. [Splenectomy / diaphragm stripping / bowel resection] required.
DESCRIPTION OF PROCEDURE:
Patient supine. Midline laparotomy; systematic exploration; PCI scored. Cytoreduction: [pelvic peritonectomy / diaphragm stripping / greater omentectomy / splenectomy / cholecystectomy / small bowel resection *** cm / colorectal resection with [anastomosis / diverting ileostomy]]. CC-[0/1] achieved. HIPEC: [Mitomycin C *** mg/m2 at 42 degrees C x 90 min / Cisplatin *** mg/m2 + doxorubicin *** mg/m2 at 42 degrees C x 60-90 min / Oxaliplatin *** mg/m2 at 43 degrees C x 30 min], [closed / Coliseum] technique; inflow and outflow temps monitored; intra-abdominal temp 41-43 degrees C. Abdomen irrigated with saline post-HIPEC. Bowel anastomoses performed. Hemostasis confirmed. Drains placed. Fascia with 0-PDS; skin closed. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: All resected specimens to pathology individually labeled
COMPLICATIONS: None
DRAINS: JP drains x*** in [pelvis / RUQ]
DISPOSITION: Patient to SICU intubated, stable.
Signed: .ME, .MYDEGREE
.TODAYVariants
Appendiceal mucinous neoplasm (LAMN/HAMN/PMP)
Low-grade appendiceal mucinous neoplasm with pseudomyxoma peritonei (PMP). Mucinous deposits often easily stripped. Document viscosity of mucin (watery vs. gelatinous) and all regions stripped. CC-0 is achievable and prognostically important.
Ovarian cancer cytoreduction (interval or primary)
Gynecologic oncology often performs pelvic components; general surgery performs bowel resection and upper abdominal cytoreduction. Document team roles and each resection performed.
Charting Tips
- Document PCI score systematically (score all 13 regions from 0-3 each, total 0-39)
- State completeness of cytoreduction (CC score), as this is the most important prognostic factor
- Document HIPEC agent, dose, temperature, duration, and technique (open vs. closed)
- List every resection performed, as each is separately billable
- Note bowel anastomosis timing and rationale — two protocols exist (anastomosis before HIPEC vs. after HIPEC); document which was used and state the reason. This is institution-specific; there is no universal standard.
- Document drain placement sites for postoperative management
Documentation & Reimbursement Considerations
- Primary service: Report Cytoreductive Surgery and HIPEC as the primary service when it is the definitive operation performed.
- Cytoreductive surgery has no single code, so bill each component separately. Intra-abdominal tumor excision is reported by the summed maximum length of all tumors/cysts excised, in five size tiers from ≤5 cm (21.45 wRVU) to >30 cm (48.75 wRVU), and most CRS cases fall in the two largest tiers. Document each tumor/cyst diameter in the operative note, and do not apply these services to tumors arising directly from a separately reported organ.
- Intraoperative HIPEC via temporary catheter has dedicated time-based add-on services to the primary CRS service, one for the first 60 minutes (6.53 wRVU, at least 31 minutes) and one for each additional 30 minutes (3.00 wRVU, 76 or more total minutes). Document HIPEC start and end times in the operative note. The chemotherapy service for an implanted peritoneal port is not appropriate for intraoperative HIPEC.
- Peritoneal stripping is included in the tumor excision services, while each visceral resection (omentectomy, splenectomy, small bowel resection, colectomy) is separately billable. Primary or interval ovarian cancer debulking uses the GYN debulking services instead, and since 2025 the tumor excision services are appropriate for recurrent GYN malignancy without lymphadenectomy. Confirm GYN cases with your institutional billing team at the diagnosis code level.
- Completeness of cytoreduction (CC score) is a critical documentation element: CC-0 = no visible residual, CC-1 = <2.5 mm residual, CC-2 = 2.5-25 mm, CC-3 = >25 mm. Higher CC scores affect prognosis and should be clearly documented.
- Major morbidity codes: anastomotic leak, bowel obstruction, and pleural effusion are common postoperative complications. Ensure that each complication is separately coded and documented, as they affect DRG and complication capture rates.