Splenorrhaphy (Splenic Salvage)
3811538100wRVU: 19.06 — Splenectomy (if repair fails and splenectomy required)47350wRVU: 21.93 — Hepatorrhaphy (if concurrent liver repair)
[Blunt / penetrating] splenic injury, AAST Grade [II / III], with [hemodynamic instability / failed nonoperative management / peritonitis]
Same
Splenorrhaphy: [argon beam / suture / topical hemostatic agents / mesh wrap]
[Attending name], MD
[Resident name]
General endotracheal. Massive transfusion protocol [activated / on standby]. Arterial line.
Patient presents with [blunt / penetrating] abdominal trauma and AAST Grade [II / III] splenic laceration on CT. [Hemodynamic instability despite 2L crystalloid and [X] units pRBC / failed nonoperative management, re-bleed at [X] hours.] [Angioembolization not available / not feasible.] Operative management indicated. [Spleen salvage planned given [pediatric patient / hemodynamics improving with resuscitation].] Risks including re-bleeding and need for splenectomy discussed with [patient / family]. Consent [obtained / waived].
AAST Grade [II / III] splenic laceration: [capsular tear [X] cm, not involving hilum / moderate depth laceration, hilar vessels intact]. [Active arterial bleeding from [polar / midpole] vessel.] [Parenchyma viable at [X]%.] Repair feasible.
The patient was positioned supine. A midline laparotomy [/ left subcostal incision] was performed. The spleen was mobilized by dividing the splenocolic, splenorenal, and splenophrenic ligaments.
The splenic laceration was identified and assessed. [Manual compression held while hemostasis was achieved.] The following repair techniques were employed:
[ARGON BEAM COAGULATION: Applied to capsular tears and surface lacerations; excellent hemostasis achieved.]
[SUTURE: Horizontal mattress sutures of [0-chromic / 0-Vicryl] were placed across the laceration to achieve hemostasis. Pledgeted sutures used at [hilar bleeding point].]
[TOPICAL HEMOSTATIC AGENTS: Oxidized cellulose / Gelfoam / topical thrombin applied to parenchymal surface.]
[MESH WRAP: Polyglycolic acid (Dexon) mesh wrap applied circumferentially to stabilize the splenic parenchyma.]
Hemostasis confirmed. No active bleeding from repair site. The spleen was returned to the [left upper quadrant / replaced without torsion]. [A closed-suction drain was placed near the spleen.]
[If repair failed, splenectomy performed: see concurrent splenectomy note.]
Fascia closed. Skin closed. Patient tolerated the procedure well.
None
None
[X] mL
[Closed-suction drain in left upper quadrant / None]
Patient taken to trauma ICU for monitoring. CT at 48-72 hours to assess repair.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Blunt / penetrating] splenic injury, AAST Grade [II / III]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Splenorrhaphy: [argon beam / suture / topical hemostatic / mesh wrap]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal; MTP [active / standby]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with AAST Grade [II / III] splenic injury and [hemodynamic instability / failed NOM]. [Angioembolization not feasible.] Splenic salvage attempted. Risks including re-bleeding and need for splenectomy discussed. Consent [obtained / waived].
FINDINGS: Grade [II / III] laceration: [capsular / parenchymal, hilar vessels intact]. Active bleeding from [polar / midpole] vessel. Repair feasible.
DESCRIPTION OF PROCEDURE:
[Midline laparotomy / left subcostal incision.] Spleen mobilized; ligaments divided. Laceration assessed. [Argon beam to surface lacerations.] [Horizontal mattress sutures 0-chromic across laceration; pledgets at hilar point.] [Topical hemostatic agents applied.] [Mesh wrap applied circumferentially.] Hemostasis confirmed; no active bleeding. Spleen returned to LUQ. [Drain placed.] Fascia and skin closed. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: None
COMPLICATIONS: None
DRAINS: [LUQ drain / None]
DISPOSITION: Patient to trauma ICU. CT at 48-72 h to assess repair.
Signed: .ME, .MYDEGREE
.TODAYVariants
Conversion to splenectomy
Document that repair was attempted and failed (uncontrollable hemorrhage, hilar injury) before proceeding to splenectomy. Bill 38100, not 38115. Postoperative vaccination for encapsulated organisms required (pneumococcus, meningococcus, H. influenzae).
Nonoperative management failed (angioembolization)
Document NOM duration, imaging, embolization performed, and indication for operative intervention. Grade and extent of injury at time of operation vs. initial CT.
Charting Tips
- Document AAST injury grade and laceration characteristics
- State repair techniques used in order (argon beam, suture, topical agents, mesh)
- Confirm hemostasis achieved before closing and document explicitly
- Note drain placement near spleen (allows detection of delayed re-bleeding)
- If converting to splenectomy, document reason for conversion
- Postoperative vaccination for encapsulated organisms should be documented (even if given later by medicine team)
Billing Tips
- Bill 38115 for splenorrhaphy (repair of spleen, 17.84 wRVU, 90-day global). This code applies to operative splenic repair (suture ligation, argon beam, topical hemostatic agents, wrapping). If the attempt at repair fails and splenectomy is performed, bill 38100 (splenectomy, 18.60 wRVU) instead, not both.
- Topical hemostatic agents (oxidized cellulose, gelatin, thrombin) applied during splenorrhaphy are generally included in the procedure and are not separately billed by the surgeon. They may be separately billed as facility supply charges.
- Angioembolization performed preoperatively or as a planned adjunct (splenic artery embolization) is billed by interventional radiology (37242) and does not affect operative billing.
- 90-day global: post-splenorrhaphy imaging (CT at 48-72 hours for re-bleed assessment) and clinic visits are bundled in the surgical fee. Readmission for delayed splenic rupture within 90 days uses modifier -78 if re-operation is required.
- Pediatric splenic trauma is primarily managed nonoperatively. If operative repair is required, bill 38115 as in adults. Document American Pediatric Surgical Association (APSA) grade and indication for operative management.