Overlapping Sphincteroplasty

CPT 46750

Approach Open

Add-on / Variant CPTs

46751 — Sphincteroplasty, complicated

Preoperative Diagnosis:

Fecal incontinence, external anal sphincter defect

Postoperative Diagnosis:

Same

Procedure Performed:

Overlapping external anal sphincteroplasty

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident/Fellow/PA name]

Anesthesia:

General or spinal
Patient positioned in prone jackknife position after induction.

Indications:

Patient presents with fecal incontinence secondary to [obstetric / traumatic / iatrogenic] external anal sphincter disruption. Preoperative anorectal manometry demonstrated reduced squeeze pressures. Endorectal ultrasound confirmed anterior sphincter defect spanning [X degrees / X clock positions]. Bowel preparation completed. Risks including recurrence of incontinence, infection, and wound breakdown discussed with patient.

Findings:

Patient positioned in prone jackknife position. Examination under anesthesia confirmed anterior disruption of the external anal sphincter. Scar tissue identified within the defect. Internal sphincter [intact / also disrupted]. Puborectalis and levator ani [intact].

Description of Procedure:

The patient was taken to the operating room and placed in prone jackknife position following general anesthesia. The perineum was prepped and draped in sterile fashion. A curvilinear incision was made over the anterior perineum, centered over the sphincter defect.
Dissection was carried through subcutaneous tissue, and the external sphincter ends were identified bilaterally. The scar was sharply dissected, preserving the scarred sphincter ends as this tissue holds sutures better than normal muscle. The sphincter ends were mobilized laterally to allow tension-free overlap.
The puborectalis and levator ani muscles were plicated in the midline with interrupted 2-0 PDS sutures. The external sphincter was then overlapped in a vest-over-pants technique using horizontal mattress sutures of 2-0 PDS. [Two / three] sutures placed, achieving adequate overlap without tension.
The wound was irrigated copiously. [A closed-suction drain was placed / No drain placed.] The skin was closed loosely with interrupted absorbable sutures to allow drainage. The patient tolerated the procedure well.

Complications:

None

Specimens:

None

Estimated Blood Loss:

Minimal

Drains:

[Closed suction drain placed through separate stab incision / None]

Disposition:

Patient was taken to PACU in stable condition.

Epic SmartPhrase Version

PREOPERATIVE DIAGNOSIS: Fecal incontinence, external anal sphincter defect
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Overlapping external anal sphincteroplasty
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General / spinal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with fecal incontinence secondary to [obstetric / traumatic / iatrogenic] external anal sphincter disruption. Preoperative anorectal manometry demonstrated reduced squeeze pressures. Endorectal ultrasound confirmed anterior sphincter defect spanning *** clock positions. Bowel preparation completed. Risks including recurrence of incontinence, infection, and wound breakdown were discussed. Informed consent obtained.

FINDINGS: EUA confirmed anterior disruption of the external anal sphincter from *** to *** o'clock. Scar tissue within defect. Internal sphincter intact. Puborectalis and levator ani intact.

DESCRIPTION OF PROCEDURE:
The patient was placed in prone jackknife position following induction. Perineum prepped in sterile fashion. A curvilinear incision was made over the anterior perineum, centered over the sphincter defect. Dissection carried through subcutaneous tissue; external sphincter ends identified bilaterally. The scar was sharply dissected, preserving scarred ends for suture holding. The sphincter ends were mobilized laterally to allow tension-free overlap. The puborectalis and levator ani were plicated in the midline with interrupted 2-0 PDS. The external sphincter was then overlapped in a vest-over-pants technique using [2–3] horizontal mattress sutures of 2-0 PDS. Wound irrigated copiously. [Closed-suction drain placed / No drain.] Skin closed loosely with interrupted absorbable sutures. Patient tolerated the procedure well.

ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: None
COMPLICATIONS: None
DRAINS: [Closed suction drain / None]
DISPOSITION: Patient taken to PACU in stable condition.

Signed: .ME, .MYDEGREE
.TODAY

Variants

With internal sphincter repair

If internal sphincter defect present, plicate separately with fine absorbable suture before external sphincter overlap.

Concurrent levatorplasty

Document midline plication of levator ani and puborectalis prior to sphincter overlap.

Charting Tips

Document extent of defect in clock positions (e.g., 10 o'clock to 2 o'clock)
Note whether scar was preserved (standard technique) or excised
Document suture material (PDS preferred over Vicryl for sphincter repair)
Note any levatorplasty performed
Bowel regimen and follow-up anorectal manometry should be addressed in postoperative plan

Billing Tips

Bill 46750 for sphincteroplasty with levatorplasty (11.85 wRVU, 90-day global). Use for anterior sphincter repair with levator ani plication for fecal incontinence following obstetric injury or prior anorectal surgery.
Bill 46760 for sphincteroplasty with levatorplasty and anoplasty (17.01 wRVU) when reconstruction of the anal canal itself is required in addition to sphincter repair.
Preoperative anorectal manometry and endoanal ultrasound results must be documented to support the diagnosis of sphincter defect and medical necessity for surgical repair.
90-day global period: pelvic floor physiotherapy, biofeedback therapy initiation, and wound care are bundled for the surgical fee. Biofeedback sessions billed by physical therapy are separate charges.
Sacral nerve stimulation (InterStim) is an alternative/adjunct to sphincteroplasty and uses an entirely different CPT family (64561, 64568). Do not confuse these code families, as they apply to different treatment pathways.