Damage Control Laparotomy (Trauma)
4400547350wRVU: 21.93 — Repair of liver wound (if hepatorrhaphy performed)44120wRVU: 20.3 — Small bowel resection (if bowel damage control performed)38100wRVU: 19.06 — Splenectomy (if required)49900wRVU: 12.1 — Temporary abdominal closure
[Penetrating / blunt] abdominal trauma with [hemorrhagic shock / hollow viscus injury / solid organ injury]
Same
Damage control laparotomy: [hemorrhage control / contamination control] with temporary abdominal closure
[Attending name], MD
[Resident / Fellow name]
General endotracheal. Massive transfusion protocol activated. Arterial line. Warming measures.
Patient presents with [penetrating / blunt] abdominal trauma with [hemodynamic instability / peritonitis / evisceration]. [GCS [X], BP [X]/[X] on [X] L NS + [X] units pRBC, HR [X].] [FAST positive in [RUQ / LUQ / pelvis].] Damage control approach chosen given [acidosis pH [X] / hypothermia [X]C / coagulopathy INR [X]]; physiology precludes definitive repair. Plan: rapid hemorrhage control, contamination control, pack, close temporarily, ICU resuscitation, return to OR in 24-48 hours for definitive repair. Consent [waived; emergent].
[Active arterial / venous] hemorrhage from [liver / spleen / mesenteric vessel / pelvic fracture]. [Hollow viscus injury: small bowel / colon at [location].] [Peritoneal contamination: [grade].] [Injuries listed and addressed.]
The patient was brought emergently to the operating room under [general anesthesia / ketamine induction]. A rapid midline laparotomy was performed from xiphoid to pubis. The abdomen was entered.
INITIAL HEMORRHAGE CONTROL: Manual compression applied to [aorta at hiatus / mesentery / liver]. [PRBC packed cells rapidly transfused x[X] units during case.]
[LIVER: [Packing of right lobe with lap pads x[X] / Tractotomy with packing / Pringle maneuver applied / Argon beam to bleeding surface.] See concurrent hepatorrhaphy note.]
[SPLEEN: Splenectomy performed; see concurrent note.]
[BOWEL: Perforations identified. Damaged bowel stapled off proximally and distally with [GIA / linear stapler]; bowel left in discontinuity. [X] cm resected. Anastomosis deferred.]
[MESENTERIC VESSEL: [Superior mesenteric vein / artery] injury, [repaired / ligated]. See concurrent vascular note.]
[PELVIC PACKING: Retroperitoneal pelvic hematoma identified, [bounded / expanding]. Pelvic packing performed with [X] lap pads.]
Abdomen assessed; [hemorrhage controlled / contamination controlled]. Bowel and organs replaced. [X] laparotomy pads placed; count recorded.
TEMPORARY CLOSURE: A [KCI ABThera / commercial VAC / Bogota bag] dressing was applied. Skin approximated loosely [/ not closed]. Dressing secured with staples / Ioban. Patient tolerated the procedure.
None noted at this time
[Spleen to pathology / None]
[X] mL + [X] liters irrigant
None (packs in place)
Patient transferred to trauma ICU intubated for resuscitation. Planned return to OR in 24-48 hours for pack removal and definitive repair.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Penetrating / blunt] abdominal trauma with hemorrhagic shock
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Damage control laparotomy: hemorrhage and contamination control with temporary abdominal closure
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal; MTP activated; warming
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [penetrating / blunt] abdominal trauma and hemodynamic instability. [FAST positive. pH ***, temp *** C, INR ***.] Damage control approach chosen; physiology precludes definitive repair. Plan: hemorrhage control, pack, TAC, ICU resuscitation, re-look 24-48 h. Consent waived (emergent).
FINDINGS: [Liver / spleen / mesenteric vessel / hollow viscus] injury. [Hemorrhage source: ***.] [Contamination: [small bowel / colon] injury.] Injuries addressed as below.
DESCRIPTION OF PROCEDURE:
Emergency midline laparotomy. [Liver: packing with *** lap pads / tractotomy / splenorrhaphy.] [Spleen: splenectomy.] [Bowel: perforations stapled off in discontinuity; anastomosis deferred.] [Mesenteric vessel: repaired / ligated.] [Pelvic packing: *** lap pads.] Hemorrhage controlled. Contamination controlled. *** lap pads placed; count recorded. Temporary closure with [ABThera VAC / Bogota bag]. Patient to trauma ICU. Re-look planned 24-48 h.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: [Spleen / None]
COMPLICATIONS: None at this time
DRAINS: Abdominal packs in place
DISPOSITION: Patient to trauma ICU intubated. Planned return to OR in 24-48 hours.
Signed: .ME, .MYDEGREE
.TODAYVariants
Re-look laparotomy (pack removal and definitive repair)
Modifier -78. Document pack count (match placed count), bowel viability assessment, anastomosis creation, and definitive closure. If fascia cannot close, planned ventral hernia with biological mesh bridge.
Open abdomen management
Serial re-look procedures with progressive fascial closure. Document fascial tension at each attempt. Target primary fascial closure within 7 days to avoid loss of domain.
Charting Tips
- Document physiology that triggered damage control decision (pH, temp, INR, coagulopathy)
- Count and record number of laparotomy pads placed (critical for re-look)
- List every injury identified and what was done (or deferred) for each
- Document temporary closure technique and materials used
- {'Note massive transfusion': 'units of pRBC, FFP, platelets, cryo used intraoperatively'}
- Plan for re-look should be in the operative note
Billing Tips
- Bill 44005 for enterolysis / damage control exploratory laparotomy (6.46 wRVU) as the primary code when no major organ repair is performed. Bill the highest-value procedure performed if major repairs were done (e.g., 44120 bowel resection, 47350 liver repair, 38100 splenectomy). Use multiple CPT codes for each distinct procedure performed during the index DCL.
- Temporary abdominal closure (TAC) at the end of DCL: 49900 (suture of secondary closure of abdominal wall, 7.57 wRVU) is used for temporary closure. Confirm your institution's convention, as some use 49002 (reopening of recent laparotomy). Document that closure is temporary and planned for interval re-look.
- Packing (abdominal packing for hemorrhage control) is included in the exploratory laparotomy code. Do not separately bill packing as a distinct procedure.
- Re-look laparotomy (planned return to OR for pack removal and definitive repair) uses modifier -78 (return to OR for related complication). Bill the procedures performed at re-look (bowel anastomosis, pack removal, definitive closure) with -78 modifier. Each return to OR for the same episode is separately billable.
- Resuscitative endovascular balloon occlusion of the aorta (REBOA) performed in the trauma bay or OR is billed separately (34841 or 37236 depending on zone) by the performing provider. Document REBOA use in the operative note if it was in place at the time of laparotomy.