Laparoscopic Rectopexy

CPT 45550
Approach Laparoscopic
Add-on / Variant CPTs
  • 45540 — Proctopexy (open)
  • 45541 — Proctopexy with sigmoid resection
Preoperative Diagnosis:

Full-thickness rectal prolapse

Postoperative Diagnosis:

Same

Procedure Performed:

Laparoscopic ventral mesh rectopexy / posterior sutured rectopexy

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident/Fellow/PA name]

Anesthesia:

General endotracheal
Patient positioned in steep Trendelenburg, modified lithotomy. Foley catheter placed.

Indications:

Patient with symptomatic full-thickness rectal prolapse presenting with [fecal incontinence / obstructed defecation / mucous discharge / recurrent prolapse]. Preoperative defecography and anorectal manometry performed. Conservative measures failed. Patient counseled on risks including constipation, nerve injury, mesh erosion (if mesh used), and recurrence.

Findings:

Laparoscopic exploration confirmed [full-thickness / high-grade] rectal prolapse. Redundant sigmoid present. Rectal mesentery lax with poor fixation. Rectovaginal / rectovesical space developed without adhesions. Levator ani [intact / attenuated].

Description of Procedure:

The patient was taken to the operating room, placed in modified lithotomy with steep Trendelenburg, prepped and draped in sterile fashion. Laparoscopic access established via 12-mm umbilical port. Pneumoperitoneum to 15 mmHg. Two 5-mm working ports placed in right and left lower quadrants.
The small bowel was retracted cephalad. The peritoneum was incised at the sacral promontory and dissection carried into the presacral space, identifying the [right ureter / presacral fascia]. The rectum was mobilized posteriorly to the pelvic floor [and anteriorly in the rectovaginal / rectovesical space for ventral rectopexy].
[For posterior sutured rectopexy:] The rectum was elevated and fixed to the presacral fascia at the sacral promontory using [3] non-absorbable sutures (0 Ethibond). Sutures placed through the lateral ligaments of the rectum and into the presacral fascia avoiding the presacral veins.
[For ventral mesh rectopexy:] A [10 x 4] cm polypropylene mesh was sutured to the anterior rectum using interrupted 2-0 PDS sutures, then fixed to the sacral promontory with [2-3] tacking sutures / absorbable tacks. The mesh was peritonealized to avoid contact with bowel.
The peritoneum was closed. Trocars removed under vision. Fascia closed at 12-mm site. Skin closed with absorbable suture. Patient tolerated the procedure well.

Complications:

None

Specimens:

None

Estimated Blood Loss:

Minimal

Drains:

None

Disposition:

Patient taken to PACU in stable condition. Admitted to surgical floor.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Full-thickness rectal prolapse
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Laparoscopic [ventral mesh / posterior sutured] rectopexy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with symptomatic full-thickness rectal prolapse presenting with [fecal incontinence / obstructed defecation / mucous discharge]. Conservative measures failed. Preoperative defecography and anorectal manometry performed. Risks including constipation, nerve injury, mesh erosion, and recurrence were discussed. Informed consent obtained.

FINDINGS: Laparoscopic exploration confirmed full-thickness rectal prolapse. Redundant sigmoid present. Rectovaginal/rectovesical space developed without adhesions. No intra-abdominal pathology.

DESCRIPTION OF PROCEDURE:
The patient was placed in modified lithotomy with steep Trendelenburg, prepped in sterile fashion. Laparoscopic access established via 12-mm umbilical port; pneumoperitoneum 15 mmHg. Two 5-mm working ports placed in bilateral lower quadrants. Small bowel retracted cephalad. The peritoneum was incised at the sacral promontory and the presacral space developed, identifying the presacral fascia while preserving hypogastric nerves. The rectum was mobilized posteriorly to the pelvic floor [and anteriorly in the rectovaginal space]. [Posterior sutured rectopexy: Rectum elevated and fixed to presacral fascia at the promontory using 3 non-absorbable 0 Ethibond sutures through lateral ligaments.] [Ventral mesh: 10 × 4 cm polypropylene mesh sutured to anterior rectum with 2-0 PDS, fixed to sacral promontory; peritoneum closed over mesh.] Trocars removed under vision. Fascia closed at 12-mm port site. Skin closed with absorbable suture. Patient tolerated the procedure well.

ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: None
COMPLICATIONS: None
DRAINS: None
DISPOSITION: Patient taken to PACU in stable condition. Admitted to surgical floor.

Signed: .ME, .MYDEGREE
.TODAY
Variants

With sigmoid resection (Frykman-Goldberg)

For recurrence prevention or severe constipation. Document mobilization, resection, and anastomosis technique.

Perineal proctosigmoidectomy (Altemeier)

For high-risk patients unable to tolerate laparoscopy. Full-thickness perineal approach. Document resection length, levatorplasty, and anastomosis.

Delorme procedure

Mucosal sleeve resection for incomplete prolapse. Document mucosal dissection length and plication sutures.

Charting Tips
  • Document approach: posterior sutured, ventral mesh, or combined
  • If mesh used, document type and size
  • Note identification and preservation of presacral vessels and hypogastric nerves
  • State number and placement of fixation sutures
  • Document whether peritoneum was closed over mesh
Billing Tips
  • Bill 45400 for laparoscopic rectopexy (18.95 wRVU, 90-day global). Use for laparoscopic posterior rectopexy (Orr-Loygue, Wells) or ventral mesh rectopexy for rectal prolapse.
  • Bill 45550 for open rectopexy with sigmoid resection (Frykman-Goldberg, 24.18 wRVU) when sigmoid resection is performed in conjunction with rectopexy. Document both components.
  • Mesh use in ventral rectopexy is not separately billable. It is included in the rectopexy code. Document mesh type, size, and fixation points.
  • 90-day global period: constipation management, pelvic floor physiotherapy coordination, and routine follow-up are bundled. Defecography ordered for postoperative assessment is a separate radiology charge.
  • For rectal prolapse reduction performed as an emergency (manual reduction), use 45900 (reduction of procidentia, 2.54 wRVU). This is a distinct code from elective rectopexy and does not preclude later billing for definitive repair.