Traumatic Diaphragm Repair
3954039541wRVU: 15.36 — Repair of chronic traumatic diaphragmatic hernia (delayed presentation)32900wRVU: 23.21 — Resection of ribs (if concurrent thoracic procedure)
[Acute / delayed] traumatic diaphragmatic injury, [left / right], with [gastric / bowel / omental herniation]
Same
Repair of traumatic diaphragm laceration, [left / right], via [laparotomy / thoracotomy / thoracoabdominal incision], primary closure [/ mesh reinforcement]
[Attending name], MD
[Resident name]
General endotracheal. [Double-lumen ETT for thoracic approach.]
Patient presents with [acute blunt / penetrating] trauma to the [left / right] thoracoabdominal region with [diaphragmatic laceration on CT / bowel herniation into chest on CXR / incidental finding at laparotomy for other injuries]. [Gastric / small bowel / omentum] herniated into thorax. [Acute presentation: [X] hours post-injury / Delayed presentation: [X] weeks after index trauma, previously missed.] Risks including pulmonary complications, hernia recurrence, and organ ischemia (if herniated) discussed. Consent [obtained / waived].
[Left / right] diaphragm laceration [X] cm: [radial / transverse / complex tear / blowout]. [Stomach / small bowel / spleen / omentum] herniated through defect. Herniated contents [viable / [strangulated; required resection]]. Defect [primarily repairable / large; required mesh].
[LAPAROTOMY (acute):] The patient was positioned supine. Midline laparotomy performed. The [left / right] diaphragm was inspected. [Herniated contents identified and reduced by gentle traction; [viable].] The diaphragm laceration was identified and measured: [X] cm.
[THORACOTOMY (delayed/chronic):] Positioned [right lateral / left lateral]. [Left / right] thoracotomy performed through the [7th / 8th] intercostal space. Adhesions between herniated contents and thoracic organs divided. Contents reduced into the abdomen.
PRIMARY CLOSURE: The diaphragm was repaired with [interrupted / figure-of-eight] [0-Prolene / 0-Ethibond] sutures, closing the defect completely. Tension on repair assessed: [minimal tension / moderate tension; mesh reinforced].
[MESH REINFORCEMENT:] A [biosynthetic / polypropylene] mesh was used to reinforce the repair. Secured with [interrupted 0-Prolene]. Overlap of [2 cm] on all sides.
[A chest tube was placed through a separate stab incision.] Fascia closed. Skin closed. Patient tolerated the procedure well.
None
[Resected bowel if strangulated / None]
[X] mL
[Chest tube / None]
Patient to trauma ICU / floor in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Acute / delayed] traumatic diaphragmatic injury, [left / right], with [gastric / bowel / omental herniation]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Repair of traumatic diaphragm laceration, [left / right], via [laparotomy / thoracotomy], [primary closure / mesh reinforcement]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal [/ double-lumen ETT]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [acute / delayed] [left / right] traumatic diaphragm laceration and [stomach / bowel / omentum] herniation. [Acute: *** hours / Delayed: *** weeks post-injury.] Risks including organ ischemia, recurrence, and pulmonary complications discussed. Consent [obtained / waived].
FINDINGS: [Left / right] diaphragm laceration *** cm: [radial / transverse / blowout]. [Stomach / bowel / omentum] herniated; [viable]. Defect [repairable primarily / large; mesh required].
DESCRIPTION OF PROCEDURE:
[LAPAROTOMY: Midline laparotomy; herniated contents reduced; defect identified *** cm.] [THORACOTOMY: Left lateral position; thoracotomy [7th/8th] ICS; adhesions divided; contents reduced.] Primary closure with interrupted/figure-of-eight 0-Prolene sutures. [Mesh reinforcement with biosynthetic mesh, 2 cm overlap, 0-Prolene sutures.] [Chest tube placed.] Fascia and skin closed. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: None
COMPLICATIONS: None
DRAINS: [Chest tube / None]
DISPOSITION: Patient to [ICU / floor] in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Right-sided diaphragm injury
Right diaphragm injuries are less common (liver buffers) and often missed. Thoracotomy approach preferred for right-sided repair given liver attachment. Document liver mobility and whether hepatic vein exposure required.
Delayed/chronic diaphragm hernia
CPT 39541. Thoracotomy preferred; adhesions prevent laparoscopic or abdominal reduction. Document timeline from injury to diagnosis. Spleen, colon, and stomach most common contents. Higher complication rate.
Charting Tips
- Document laceration size, location, and mechanism
- State contents herniated and viability assessment after reduction
- Note repair technique (primary vs. mesh-reinforced) and suture material
- Document chest tube placement and initial output
- State timing (acute vs. delayed), as this determines CPT code selection (39540 vs. 39541)
Billing Tips
- Bill 39540 for repair of acute diaphragmatic hernia (traumatic), 14.88 wRVU, 90-day global. Bill 39541 for repair of chronic diaphragmatic hernia (traumatic, delayed presentation), 16.62 wRVU. The timing of the injury relative to the repair determines which code: acute vs. delayed (>2 weeks).
- Approach (laparotomy vs. thoracotomy vs. thoracoabdominal) does not change the CPT. Document the approach used. Acute injuries are typically repaired via laparotomy; chronic hernias via thoracotomy (adhesions and visceral reduction).
- Concurrent procedures (bowel resection, splenectomy, liver repair) are separately billable. Document each procedure. The diaphragm repair code does not bundle concurrent visceral procedures.
- Mesh reinforcement of the diaphragm repair (if defect too large for primary closure) may be separately billable as a synthetic mesh repair. Confirm with billing. Document mesh type and size used.
- 90-day global: pulmonary complications, pleural effusion management, and wound care are bundled. Return to OR for recurrence within 90 days uses modifier -78.