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 extensive debridement or hepatic artery ligation (30.53 wRVU)
  • 47361 wRVU: 51.29 — Exploration with debridement, coagulation, suture, and/or packing of liver (51.29 wRVU) — primary code for damage-control hepatic packing
  • 47362 wRVU: 22.95 — Re-exploration of hepatic wound for removal of packing (22.95 wRVU) — bill with modifier -58 at planned re-look
  • 38100 wRVU: 19.06 — Splenectomy, total (19.06 wRVU) — if concurrent
  • 38115 wRVU: 21.33 — Repair of ruptured spleen (21.33 wRVU) — if concurrent splenic salvage performed instead of splenectomy
Preoperative Diagnosis:

[Blunt / penetrating] liver injury, AAST Grade [III / IV / V], 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 / V] 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], lactate [X] mmol/L.] Risks including uncontrollable hemorrhage, bile leak, and liver failure discussed. Consent implied under emergency doctrine; patient's critical condition precluded delay.

Findings:

AAST Grade [III / IV / V] liver laceration, [right lobe / left lobe / bilobar]. Grade V injuries involve retrohepatic vena cava or major hepatic veins.[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 [III / IV / V]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Hepatorrhaphy, AAST Grade [III / IV / V]: [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 / V] liver laceration and hemodynamic instability [/ failed angioembolization]. [Damage control approach; pH ***, temp ***°C, INR ***, lactate *** mmol/L.] Consent implied under emergency doctrine.

FINDINGS: Grade [III / IV / V] 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

Bill CPT 47362 (22.95 wRVU) — "Re-exploration of hepatic wound for removal of packing" — with modifier -58 (staged, planned procedure). Modifier -58 is correct for the planned re-look; -78 is for unplanned returns for complications and would under-reimburse. At re-look, document exact pack count removed (must match placed count), liver surface reassessment, drain function, and whether additional repair was required. If bile leak confirmed, consider ERCP at a later date.

Charting Tips
  • {'Document AAST injury grade (2018 revision': 'Grade V = retrohepatic IVC or major hepatic vein injury) and which lobe(s) involved. Grade VI no longer exists — Grade V is the highest survivable grade.'}
  • If Pringle maneuver was applied, document whether it was continuous or intermittent (clamp 15-20 min / release 5 min cycles) and total ischemia time.
  • Document repair technique explicitly (suture ligation, packing, tractotomy, argon beam, omental packing) — code selection depends on this.
  • Note whether bile staining was present, as this alerts to potential bile leak and may prompt early ERCP.
  • Record lap pad count placed at index DCL and confirm the same count is removed at re-look (retained foreign body documentation).
  • Retrohepatic IVC involvement (Grade V) must be explicitly noted, as it drives operative strategy (total hepatic vascular exclusion, atriocaval shunt, or damage-control packing).
  • Document common bile duct inspection findings; CBD injury during hepatic repair warrants biliary drainage planning.
Billing Tips
  • Bill 47350 for simple suture of liver wound (21.93 wRVU, 90-day global). Bill 47360 for complex repair with or without hepatic artery ligation (30.53 wRVU). Bill 47361 for exploration with extensive debridement, coagulation, and/or suture, with or without packing of the liver (51.29 wRVU) — this is the correct code when perihepatic packing is performed as part of hepatic hemorrhage control at the index damage-control case. Bill 47362 for re-exploration of hepatic wound for removal of packing (22.95 wRVU) at the planned re-look. Code selection depends on repair complexity; document technique explicitly.
  • Hepatic packing performed as part of damage-control laparotomy is captured within 47361 ('with or without packing of liver') — not within a separate damage-control laparotomy code. There is no single CPT for damage-control laparotomy; report the most extensive definitive procedure performed (47361, 38100, etc.) with 49000 as the primary if only exploration and packing occurred without a named repair code.
  • Omental packing of a liver wound is part of the hepatorrhaphy and is not separately billable. Document omentum use in the note.
  • Hepatic artery angioembolization for trauma hemorrhage is billed by interventional radiology using CPT 37244 (13.41 wRVU, 0-day global) — 'vascular embolization or occlusion, for arterial or venous hemorrhage.' CPT 37242 is for non-hemorrhage arterial embolization (AVMs, pseudoaneurysms without active bleeding) and is incorrect for trauma. Document whether angioembolization was performed pre- or postoperatively as an adjunct.
  • 90-day global: delayed bile leak management, drain care, and wound visits are bundled. ERCP for biliary fistula within 90 days is a separate biliary endoscopy code. Planned re-look for pack removal (47362) uses modifier -58 (staged, planned procedure) — not -78. Modifier -58 resets the global period; modifier -78 does not.

General coding reference. Verify with your institution’s billing department before submitting claims.

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