Retroperitoneal Sarcoma Resection
4920550220wRVU: 18.21 — Nephrectomy (if kidney removed en bloc)44160wRVU: 20.37 — Colectomy (if colon removed en bloc)38100wRVU: 19.06 — Splenectomy (if involved)35226wRVU: 14.92 — Repair of blood vessel, abdomen (if IVC involved)
[Retroperitoneal liposarcoma / leiomyosarcoma / solitary fibrous tumor], [X] cm, [right / left retroperitoneum]
Same
En bloc resection of retroperitoneal sarcoma with [ipsilateral kidney / right colon / spleen / no organ resection], [R0 / R1 margins]
[Attending name], MD
[Fellow/Resident name]
General endotracheal. Arterial line, CVP, cell saver. [Preoperative radiation [X Gy] completed [date].]
Patient presents with [retroperitoneal liposarcoma] measuring [X] cm on staging CT. [No metastatic disease.] [Neoadjuvant radiation [X Gy] completed [date].] Multidisciplinary tumor board review recommended surgical resection. Plan for en bloc resection with [ipsilateral kidney / right colon]. Risks including major hemorrhage, adjacent organ injury, vascular injury, local recurrence, and perioperative morbidity discussed. Consent obtained.
[Well-differentiated liposarcoma / dedifferentiated liposarcoma / leiomyosarcoma] [X] cm. [Abutting / encasing] [right kidney / right colon / IVC / psoas]. Tumor [did not / did] involve [vessel / organ]. [Plane between tumor and [IVC / aorta] developed bluntly: [vessel wall not entered / small venous tributary ligated].] R[0/1] resection achieved.
The patient was positioned supine [/ in right lateral decubitus]. A [midline / right flank / left flank] incision was made. The abdomen was explored. No peritoneal implants or liver metastases were identified. The retroperitoneum was entered.
The [right / left] colon was reflected medially (Cattell-Braasch maneuver). The tumor was identified in the [right / left] retroperitoneum. The plane of dissection was developed along the psoas muscle posteriorly, the mesocolon anteriorly, the IVC / aorta medially, and the iliac vessels inferiorly.
[En bloc nephrectomy was performed. The kidney was taken with the tumor due to [involvement / proximity / inability to separate the plane safely]. The renal vessels were individually ligated and divided.]
[En bloc right colon resection; see concurrent bowel resection note.]
The specimen was freed and removed. Hemostasis confirmed. The retroperitoneum was inspected; [no residual gross tumor / minimal residual at [IVC / psoas, R1]]. [Drains placed in the retroperitoneal space.] Fascia closed. Skin closed. Patient tolerated the procedure well.
None
Retroperitoneal sarcoma specimen to pathology with orientation sutures and margins labeled
[X] mL
[Retroperitoneal closed-suction drain / None]
Patient taken to surgical ICU / floor in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Retroperitoneal [liposarcoma / leiomyosarcoma], *** cm, [right / left retroperitoneum]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: En bloc retroperitoneal sarcoma resection with [kidney / colon / spleen / no organ], [R0 / R1]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal; arterial line; cell saver; [neoadjuvant RT *** Gy completed ***]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with retroperitoneal [liposarcoma / leiomyosarcoma] *** cm. No metastatic disease. [Neoadjuvant RT complete.] MTB review recommended resection. En bloc plan includes [kidney / right colon]. Risks including major hemorrhage, vascular injury, and local recurrence discussed. Informed consent obtained.
FINDINGS: [Well-differentiated / dedifferentiated liposarcoma / leiomyosarcoma] *** cm. [Abutting / encasing] ***. [Plane developed from IVC/aorta; vessel wall not entered.] R[0/1] resection.
DESCRIPTION OF PROCEDURE:
Patient supine. [Midline / flank] incision. Abdomen explored; no peritoneal implants. Retroperitoneum entered. [Right colon reflected medially (Cattell-Braasch).] Tumor dissected along psoas posteriorly, mesocolon anteriorly, IVC/aorta medially, iliac vessels inferiorly. [En bloc nephrectomy; renal vessels ligated and divided.] [En bloc colon resection; see concurrent note.] Specimen removed. Hemostasis confirmed. R[0/1] resection. [Retroperitoneal drain placed.] Fascia and skin closed. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: Sarcoma specimen to pathology (oriented, margins labeled)
COMPLICATIONS: None
DRAINS: [Retroperitoneal drain / None]
DISPOSITION: Patient to [SICU / floor] in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
IVC involvement
IVC resection and reconstruction is required for intraluminal tumor extension or tight adherence. Document whether IVC was reconstructed (PTFE graft) or ligated (if contralateral renal vein and collaterals adequate). Vascular surgery involvement common.
Recurrent retroperitoneal sarcoma
Higher complexity due to obliterated surgical planes and radiation changes. Dedifferentiation is common in recurrent well-differentiated liposarcoma. Document complexity and prior treatments. Modifier -22 applies if substantially more complex than standard.
Charting Tips
- Document tumor size, location, and relationship to adjacent structures
- {'State resection margins': 'R0 (negative), R1 (microscopically positive), R2 (macroscopic residual)'}
- Note each organ removed en bloc and the reasoning
- Document retroperitoneal dissection planes (psoas, IVC, aorta, iliac vessels)
- Orient specimen and mark relevant margins for the pathologist
- Blood product use is common; document transfusions
Billing Tips
- Bill 49203 for excision of abdominal tumor, 5 cm or less diameter (17.26 wRVU, 90-day global). Bill 49204 for 5.1-10 cm (21.97 wRVU). Bill 49205 for greater than 10 cm (27.70 wRVU). Retroperitoneal liposarcoma is typically large, so 49205 applies for most cases. Document tumor size.
- En bloc resection of adjacent organs (kidney, colon, spleen) is separately billable. Each organ resection adds its own CPT code. Document every organ removed and the en bloc nature of the resection, as this supports multivisceral resection billing.
- Retroperitoneal dissection and IVC exposure/repair, if required, are separately billable. Vascular repair codes (35226-35228 for IVC repair) may apply if the IVC is involved.
- 90-day global: drain management, wound care, and routine follow-up are bundled. Recurrence surgery within 90 days uses modifier -78 (unlikely given biology, but documented for completeness).
- Preoperative radiation (neoadjuvant RT) does not affect the surgical CPT coding but should be documented. It affects operative complexity, tissue planes, and risk.