Colostomy Creation

CPT 44320
Approach Open
Add-on / Variant CPTs
  • 44322 — With multiple biopsies
  • 44188 — Laparoscopic colostomy (loop or end)
Preoperative Diagnosis:

Colorectal obstruction / perforated diverticulitis / Hartmann's configuration / fecal diversion required

Postoperative Diagnosis:

Same

Procedure Performed:

[End sigmoid colostomy / Loop transverse colostomy] creation

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal / spinal / local with MAC

Indications:

The patient is a [age]-year-old [male/female] requiring [fecal diversion / emergent decompression] for [indication]. The risks, benefits, and alternatives of [end/loop] colostomy were discussed with the patient, and informed consent was obtained. [Preoperative stoma marking was performed by the wound ostomy nurse.]

Findings:

The colon was [obstructed/perforated/inflamed]. The proposed stoma site in the [left/right] lower quadrant / [left/right] upper quadrant had adequate bowel length and mesentery to allow a tension-free stoma. The bowel appeared [viable/well-vascularized] at the stoma site. [Additional findings or none].

Description of Procedure:

The patient was brought to the operating room and placed supine. [Anesthesia type] was administered. A surgical timeout was performed confirming patient identity, procedure, operative site (stoma location was confirmed at the preoperatively marked site), allergies, and administration of prophylactic antibiotics.

[For end colostomy as standalone procedure:] A small midline or Pfannenstiel incision was made to access the sigmoid colon. The sigmoid colon was identified and mobilized as needed to provide sufficient length for the stoma. The sigmoid colon was divided with a GIA stapler. The distal stump was either brought out as a mucous fistula or returned to the peritoneal cavity.

A trephine was created at the previously marked left lower quadrant site. The anterior rectus sheath was incised in a cruciate fashion (2.5-3 cm), the rectus muscle was divided bluntly, and the posterior sheath and peritoneum were opened. The opening admitted two fingerbreadths.

The proximal sigmoid colon end was grasped through the trephine and brought out through the abdominal wall with adequate length (approximately 2-3 cm above skin level) without tension or torsion. The mesentery was inspected to confirm no twist.

The stoma was matured: the stapled end was excised. The colon was sutured to the skin with [interrupted 3-0 chromic] sutures placed through the seromuscular layer and dermis in quadrants, creating a slightly everted stoma.

[For loop colostomy:] A loop of [transverse/sigmoid] colon was delivered through the trephine. A skin bridge or rod was placed beneath the loop. The anterior wall of the colon was opened transversely and matured to the skin, creating an efferent (distal/non-functioning) limb flush with skin and an afferent (proximal/functioning) limb everted 2 cm.

Stoma viability was confirmed by pink color and mucous discharge. The main wound was closed in standard fashion. A stoma appliance was applied.

Complications:

None

Specimens:

None

Estimated Blood Loss:

Minimal (less than 20 mL)

Drains:

None

Disposition:

The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition. Stoma teaching and ostomy appliance care were planned postoperatively.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** colostomy creation
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: ***

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX requiring fecal diversion for ***. Preoperative stoma marking performed. Informed consent obtained.

FINDINGS: Colon ***. Adequate bowel length and mesentery for tension-free stoma.

DESCRIPTION OF PROCEDURE:
Supine. *** anesthesia. Surgical timeout with stoma site confirmed.

*** colostomy: Sigmoid colon mobilized. Trephine created at *** LLQ site; opening admitted two fingerbreadths. Colon brought through without twist; *** cm above skin level. Stoma matured with 3-0 chromic sutures. Stoma viable — pink, viable mucosa.

Ostomy appliance applied.

ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: None
COMPLICATIONS: None
DRAINS: None
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Loop Transverse Colostomy

A loop transverse colostomy was created for [distal obstruction/anal wound protection/pelvic sepsis diversion]. A right upper quadrant trephine was created at the preoperatively marked site. The transverse colon was delivered through the trephine and a colostomy rod was placed beneath the loop. The anterior colon was opened transversely and matured: the distal (efferent) limb was sutured flush with skin and the proximal (afferent) limb was everted with 3-0 chromic sutures. The rod will be removed [7-10 days postoperatively].

Laparoscopic Stoma Creation

A laparoscopic approach was used. Three trocars were placed. The sigmoid colon was identified and the proposed stoma segment was selected. The colon was divided with a laparoscopic GIA stapler. The trephine was created at the stoma site and the proximal end of the colon was delivered laparoscopically and matured as described.

Charting Tips
  • Document stoma viability at the time of creation — pink color, viable mucosa, and absence of tension are the key criteria. A dusky stoma requiring revision is a common postoperative complication and documentation of initial viability establishes the baseline.
  • Document that the mesentery was inspected for twist — a rotated stoma can cause ischemia within hours and this inspection step must be in the note.
  • Confirm and document that the trephine opening admitted two fingerbreadths — too tight causes stenosis and ischemia; too large causes prolapse. Two fingerbreadths is the standard calibration.
Billing Tips
  • Bill 44320 for open colostomy creation (19.41 wRVU, 90-day global). Use when a loop or end colostomy is created as the primary or sole procedure.
  • Bill 44188 for laparoscopic colostomy creation (18.87 wRVU, 90-day global). Document laparoscopic technique and any conversion to open.
  • When colostomy is part of a larger resection (e.g., Hartmann's 44143, APR 45110), the stoma creation is bundled. Do not bill 44320 separately. Only bill 44320 when the colostomy is the primary procedure.
  • 90-day global period: stoma appliance fitting, pouch changes, and routine nursing/ostomy visits are bundled into the global fee. Stoma revision requiring a return to the OR uses modifier -78.
  • Document loop vs. end colostomy, bowel segment used (sigmoid, transverse, descending), maturation technique, and stomal viability at end of case. These are required for complete procedure documentation and stoma care handoff.