Total Proctocolectomy with IPAA (J-Pouch)

CPT 44211
Approach Laparoscopic
Add-on / Variant CPTs
  • 44212 — Laparoscopic proctocolectomy with continent ileostomy
  • 44150 — Open total proctocolectomy with ileostomy
Preoperative Diagnosis:

Ulcerative colitis / Familial adenomatous polyposis

Postoperative Diagnosis:

Same

Procedure Performed:

Laparoscopic total proctocolectomy with ileal pouch-anal anastomosis (IPAA) and diverting loop ileostomy

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident/Fellow/PA name]

Anesthesia:

General endotracheal
Patient positioned in modified lithotomy (Lloyd-Davies) position. Foley catheter placed.

Indications:

Patient with [medically refractory ulcerative colitis / dysplasia / familial adenomatous polyposis] presents for restorative proctocolectomy. Preoperative colonoscopy, [CT scan], and [MRI pelvis] reviewed. Nutritional optimization and pelvic floor assessment completed. Stoma site marked by enterostomal therapist. Risks including anastomotic leak, pelvic nerve injury, pouch failure, and temporary ileostomy discussed.

Findings:

[Diffuse colitis / polyposis] involving the entire colorectum. No evidence of perforation or obstruction. Rectum dissected to the pelvic floor. Adequate ileal mesenteric length for tension-free pouch construction.

Description of Procedure:

The patient was taken to the operating room, placed in Lloyd-Davies position, prepped circumferentially, and draped in sterile fashion. Foley catheter in place. Laparoscopic access was established via 12-mm umbilical port using [Veress needle / optical trocar / Hasson open technique]. Pneumoperitoneum established to 15 mmHg. Additional trocars placed under direct vision.
The abdomen was explored. The colon was mobilized beginning with the right colon using a medial-to-lateral approach, taking the ileocolic, right colic, and middle colic vessels close to their origin. The left colon was mobilized with ligation of the inferior mesenteric vessels at their origin. The splenic flexure was taken down with entry into the lesser sac.
Pelvic dissection was performed using a total mesorectal excision technique, keeping the autonomic nerves intact. The rectum was mobilized to the pelvic floor circumferentially. A transanal approach was used for the final dissection to the dentate line. The specimen was extracted via Pfannenstiel extraction site.
The distal ileum was divided, and a 15-cm J-pouch was constructed using two applications of a 100-mm linear stapler (GIA). Pouch integrity confirmed with air insufflation. The pouch was brought to the pelvis without tension. A double-stapled ileal pouch-anal anastomosis was performed using a 29-mm circular stapler transanally. Donuts were intact bilaterally. Air-leak test negative.
A diverting loop ileostomy was fashioned through the right lower quadrant using [X] cm of ileum, brought through the rectus abdominis, matured with Brooke eversion technique.
All trocars removed under vision. Fascia closed at 12-mm sites. Skin closed. Stoma appliance placed. Patient tolerated the procedure well.

Complications:

None

Specimens:

Total proctocolectomy specimen

Estimated Blood Loss:

[250-400] mL

Drains:

[Closed suction drain placed in pelvis / No drain]

Disposition:

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

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: [Medically refractory ulcerative colitis / Familial adenomatous polyposis]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Laparoscopic total proctocolectomy with ileal pouch-anal anastomosis (IPAA) and diverting loop ileostomy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [medically refractory ulcerative colitis / FAP] presenting for restorative proctocolectomy. Preoperative colonoscopy, CT scan, and MRI pelvis reviewed. Stoma site marked by enterostomal therapist. Nutritional optimization completed. Risks including anastomotic leak, pelvic nerve injury, pouch failure, and temporary ileostomy discussed. Informed consent obtained.

FINDINGS: Diffuse [colitis / polyposis] involving the entire colorectum. No perforation or obstruction. Rectum dissected to pelvic floor. Adequate ileal mesenteric length for tension-free pouch construction.

DESCRIPTION OF PROCEDURE:
The patient was placed in Lloyd-Davies position, prepped circumferentially, and draped in sterile fashion. Foley in place. Laparoscopic access via 12-mm umbilical port [Veress needle / optical trocar / Hasson]; pneumoperitoneum 15 mmHg. Additional trocars placed under direct vision. The colon was mobilized medial-to-lateral, ligating the ileocolic, right colic, middle colic, and inferior mesenteric vessels at origin. Splenic flexure mobilized with entry into lesser sac. Total mesorectal excision technique employed, preserving hypogastric nerves and nervi erigentes. Rectum mobilized circumferentially to pelvic floor; transanal dissection completed to dentate line. Specimen extracted via Pfannenstiel incision. A 15-cm J-pouch constructed using two 100-mm GIA stapler firings. Pouch integrity confirmed with air insufflation. Double-stapled ileal pouch-anal anastomosis performed with 29-mm circular stapler transanally. Donuts intact bilaterally; air-leak test negative. Diverting loop ileostomy fashioned through right lower quadrant, matured with Brooke eversion. Fascia closed at 12-mm port sites. Stoma appliance placed. Patient tolerated the procedure well.

ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: Total proctocolectomy specimen to pathology
COMPLICATIONS: None
DRAINS: [Closed suction drain in pelvis / None]
DISPOSITION: Patient taken to PACU in stable condition. Admitted to surgical floor.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Two-stage (without diverting ileostomy)

In highly selected patients. Document patient selection criteria and anastomotic integrity testing.

Three-stage (subtotal colectomy first)

For acute colitis or steroid-dependent disease. Stage 1: subtotal colectomy with end ileostomy. Stage 2: completion proctectomy + IPAA. Stage 3: ileostomy closure.

Hand-sewn anastomosis (mucosectomy)

For dysplasia at dentate line or FAP. Document mucosectomy technique and hand-sewn anastomosis with interrupted absorbable sutures.

Charting Tips
  • Document nerve-sparing technique and identification of hypogastric nerves, nerve of Erigentes
  • State pouch length (cm) and number of stapler firings
  • Document donut integrity and leak test result
  • Note tension on pouch-anal anastomosis
  • Ileostomy loop position (proximal vs. distal limb) should be documented
  • For FAP: document number of polyps, presence of duodenal polyposis, and plan for surveillance
Billing Tips
  • Bill 44155 for total proctocolectomy with ileostomy (Brooke ileostomy, 33.56 wRVU, 90-day global). Bill 44158 for total proctocolectomy with ileal pouch-anal anastomosis (IPAA/J-pouch, 35.78 wRVU).
  • When IPAA is performed with a diverting loop ileostomy (staged approach), bill 44158 for the pouch creation. The diverting ileostomy is bundled. Ileostomy closure at a second operation uses 44620 or 44625.
  • Laparoscopic total proctocolectomy uses 44212 (laparoscopic total colectomy with proctectomy and ileostomy, 36.52 wRVU). There is no separate laparoscopic IPAA code. Document approach and any hand-assist or hybrid technique.
  • 90-day global period: pouch function assessment, pouchoscopy, dietary management, and routine follow-up are bundled. Pouchitis management requiring admission does not generate a separate surgical procedure code.
  • For UC patients, document active disease refractory to medical therapy, steroid dependence, or dysplasia. Payers require documented failure of medical management before approving colectomy for inflammatory bowel disease.