Hepatorrhaphy (Liver Laceration Repair)

CPT 47350 · 21.93 wRVU · 90-day global
CPT47350
wRVU21.93
Global90-day
ApproachOpen
ComplexityComplex
Add-on / Variant CPTs
  • 47360 wRVU: 30.53 — Complex hepatorrhaphy with hepatic artery ligation
  • 38100 wRVU: 19.06 — Splenectomy (if concurrent)
  • 49900 wRVU: 12.1 — Temporary abdominal closure (if damage control)
Preoperative Diagnosis:

[Blunt / penetrating] liver injury, AAST Grade [II / III / IV], with [hemorrhagic shock / peritonitis / failed angioembolization]

Postoperative Diagnosis:

Same

Procedure Performed:

Hepatorrhaphy: [direct suture / argon beam / packing / tractotomy / omental packing], AAST Grade [X]

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident name]

Anesthesia:

General endotracheal. Massive transfusion protocol activated. Arterial line. Rapid infuser.

Indications:

Patient presents with [blunt / penetrating] abdominal trauma with AAST Grade [III / IV] liver laceration. [Hemodynamic instability refractory to resuscitation / failed angioembolization / peritonitis.] Operative management indicated. [Damage control approach planned given pH [X], temp [X]C, INR [X].] Risks including uncontrollable hemorrhage, bile leak, and liver failure discussed. Consent [waived; emergent].

Findings:

AAST Grade [II / III / IV] liver laceration, [right lobe / left lobe / bilobar / hepatic vein injury]. [Active arterial bleeding from [X] vessel / venous ooze from parenchyma / deep laceration with devitalized tissue]. [Bile staining noted / no biliary injury]. [Retrohepatic IVC involvement: [yes / no].]

Description of Procedure:

The patient was taken emergently to the operating room. A midline laparotomy was performed. The abdomen was entered.
HEMORRHAGE CONTROL: Manual compression applied to the [right lobe / hepatic hilum]. [Pringle maneuver applied; hilar occlusion for [X] minutes total]. The liver laceration was identified.
[GRADE II-III, DIRECT REPAIR:] Surface lacerations cauterized with argon beam coagulator. Deep lacerations repaired with horizontal mattress sutures of [0-chromic / 0 Vicryl] placed parallel to the laceration edge. [Gelfoam / oxidized cellulose / topical thrombin] applied to the surface.
[GRADE III-IV, PACKING:] Given [ongoing coagulopathy / deep laceration], damage control packing was performed. [X] laparotomy pads placed into the [right subphrenic / perihepatic] space to tamponade bleeding. [Temporary closure performed; see concurrent DCL note.]
[TRACTOTOMY:] For through-and-through penetrating injury, a [finger-fracture / stapler] tractotomy was performed through the injury tract. [Bleeding intrahepatic vessels suture-ligated individually.]
[OMENTAL PACKING:] Omentum mobilized and packed into the hepatic laceration cavity for additional tamponade.
Hemostasis [achieved / controlled with packing]. [A closed-suction drain was placed in the perihepatic space.] [Temporary closure performed.] Fascia closed [/ temporary closure; see DCL note]. Patient tolerated the procedure [given clinical circumstances].

Complications:

None

Specimens:

[Devitalized hepatic tissue to pathology / None]

Estimated Blood Loss:

[X] mL

Drains:

[Perihepatic Jackson-Pratt drain / Packs in place]

Disposition:

Patient transferred to trauma ICU intubated. [Re-look in 24-48 hours for pack removal.]

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: [Blunt / penetrating] liver injury, AAST Grade [II / III / IV]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Hepatorrhaphy: [argon beam / suture / packing / tractotomy / omental packing]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal; MTP activated; rapid infuser

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with AAST Grade [III / IV] liver laceration and hemodynamic instability [/ failed angioembolization]. [Damage control approach; pH ***, temp ***, INR ***.] Consent waived (emergent).

FINDINGS: Grade [II / III / IV] laceration, [right / left lobe]. [Active arterial / venous bleeding.] [Bile staining.] [Retrohepatic IVC: not involved / involved].

DESCRIPTION OF PROCEDURE:
Emergency midline laparotomy. Manual compression and [Pringle *** min]. Laceration assessed. [Argon beam to surface lacerations.] [Grade II-III: horizontal mattress sutures 0-chromic; topical hemostatic agents.] [Grade III-IV: packing with *** lap pads; damage control.] [Tractotomy for penetrating: finger-fracture / stapler tractotomy; intrahepatic vessels suture-ligated.] [Omental packing.] Hemostasis [confirmed / controlled with packing]. [Perihepatic drain placed / packs in place.] [Temporary closure; see DCL note.] Patient to trauma ICU.

ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: None
COMPLICATIONS: None
DRAINS: [Perihepatic drain / Packs in place]
DISPOSITION: Patient to trauma ICU intubated. [Re-look 24-48 h.]

Signed: .ME, .MYDEGREE
.TODAY
Variants

Retrohepatic IVC injury

Highest-mortality liver injury. Total hepatic vascular exclusion (THVE) may be required. Atriocaval shunt for complex retrohepatic IVC. Document approach, control method, and whether vascular surgery involved.

Re-look for pack removal

Modifier -78. At re-look, count packs, assess liver surface, and check drains. If bile leak confirmed, consider ERCP at later date. Document definitive repair if additional procedures performed.

Charting Tips
  • Document AAST injury grade and which lobe(s) involved
  • State Pringle maneuver use and total ischemia time
  • Document repair technique explicitly (suture ligation, packing, tractotomy, argon beam)
  • Note whether bile staining was present, as this alerts to potential bile leak
  • Record lap pad count placed if packing performed
  • Retrohepatic IVC involvement must be explicitly noted, as it drives operative strategy
Billing Tips
  • Bill 47350 for hepatorrhaphy, suture of liver wound (13.44 wRVU, 90-day global). Bill 47360 for complex hepatorrhaphy with or without hepatic artery ligation (17.58 wRVU). Bill 47361 for exploration for postoperative hemorrhage (14.08 wRVU). Code selection depends on complexity. Document repair technique and whether hepatic artery ligation was required.
  • Hepatic packing (damage control) without formal hepatorrhaphy is included in the damage control laparotomy code (44005 or 44010). Packing alone does not bill as 47350. Hepatorrhaphy codes imply active suture repair of the parenchyma.
  • Omental packing of a liver wound (for tamponade) is part of the hepatorrhaphy and does not generate a separate code. Document omentum use in the note.
  • Angioembolization of hepatic artery branches (interventional radiology) at the same admission is billed separately by IR (37242). Document if angioembolization was performed pre- or postoperatively as an adjunct.
  • 90-day global: delayed bile leak (biloma), drain management, and wound care visits are bundled. ERCP for biliary fistula within 90 days is a separate procedure code (biliary endoscopy) but the surgical consultation component is included.

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