Damage Control Laparotomy
49000
Hemorrhagic shock / penetrating abdominal trauma / blunt abdominal trauma with vascular injury / abdominal catastrophe with damage control physiology (coagulopathy, hypothermia, acidosis)
[Specific injuries identified — e.g., grade IV liver laceration / small bowel injury x2 / mesenteric hematoma]
Damage control laparotomy with abdominal packing and temporary abdominal closure (vacuum-assisted)
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male/female] presenting with [penetrating/blunt] abdominal trauma / abdominal catastrophe with hemodynamic instability refractory to initial resuscitation. Intraoperative assessment revealed damage control physiology (pH [___], temperature [___]°C, INR [___]). A damage control approach was undertaken to achieve hemorrhage and contamination control, with definitive repair planned after ICU resuscitation. Consent was [obtained from patient / family / emergent waiver documented].
On entry: [massive hemoperitoneum / feculent contamination / free air]. An abbreviated systematic survey identified the following injuries:
[List specific organ injuries and grades]
The abdomen was packed in [4] quadrants with laparotomy pads for temporary tamponade.
The patient was brought to the operating room with active resuscitation ongoing. General endotracheal anesthesia was induced with preparation for vasopressor support. A surgical timeout was performed. The abdomen was prepped rapidly and draped in sterile fashion.
A rapid midline laparotomy was performed from xiphoid to pubic symphysis. On entry, [massive hemoperitoneum with approximately ___ L blood was evacuated]. The abdomen was packed in all four quadrants with laparotomy pads to achieve temporary tamponade while anesthesia continued resuscitation.
After initial hemostasis, a systematic survey was performed identifying the following injuries: [list injuries]. The priorities of damage control — hemorrhage control and contamination control — guided all operative decisions.
[Hemorrhage control measures performed:]
- [Perihepatic packing of liver lacerations with laparotomy pads x___]
- [Ligation/stapling of injured mesenteric vessels with ___]
- [Damage control bowel stapling: injured segments stapled off with GIA x___ without anastomosis]
- [Pringle maneuver performed for ___ minutes while hepatic bleeding controlled]
- [Pelvic packing for pelvic hemorrhage]
- [Other hemorrhage control measures as applicable]
[Contamination control:]
- [Injured bowel segments rapidly resected and stapled off without anastomosis pending resuscitation]
- [Gastric/enteric contents suctioned and irrigated]
All laparotomy pad counts were performed: [___] pads placed, confirmed by radiopaque counting. Pad counts were documented and confirmed with nursing team.
Temporary abdominal closure was performed using a [vacuum-assisted closure (VAC) / Bogota bag / Wittmann patch] technique. The viscera were covered with a nonadhesive layer, followed by the vacuum dressing, with drains exiting laterally. [The fascia was NOT approximated to prevent abdominal compartment syndrome.]
The patient was transported to the ICU for continued resuscitation. Planned relook laparotomy in [24-48 hours] for pack removal, reassessment, and definitive repair when physiology has been corrected.
None beyond the operative injuries
[Resected bowel/tissue] sent to pathology; peritoneal cultures sent
[___] mL (in addition to prehospital/resuscitation losses)
Vacuum-assisted temporary abdominal closure device
The patient was transported from the operating room directly to the intensive care unit with ongoing resuscitation for damage control physiology. Planned relook laparotomy in 24-48 hours.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: *** injuries — damage control laparotomy
PROCEDURE PERFORMED: Damage control laparotomy with abdominal packing and vacuum-assisted temporary closure
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX presenting with *** and damage control physiology (pH ***, temp ***°C, INR ***). Emergent damage control approach. Consent ***.
INJURIES IDENTIFIED: ***
DESCRIPTION OF PROCEDURE:
Rapid midline laparotomy. *** blood evacuated on entry. Quadrant packing for temporary tamponade. Survey identified: ***.
Hemorrhage control: ***. Contamination control: ***.
*** laparotomy pads placed; counts confirmed with nursing. Temporary abdominal closure with vacuum-assisted device. Fascia not closed.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: ***
COMPLICATIONS: None beyond operative injuries
DRAINS: Vacuum-assisted temporary abdominal closure
DISPOSITION: Transported to ICU. Planned relook in 24-48 hours.
Signed: .ME, .MYDEGREE
.TODAYVariants
Relook Laparotomy — Definitive Closure
This is the [second/third] relook laparotomy. The temporary closure was taken down. Laparotomy pads ([___]) were removed — all counts confirmed matching original operative count. The abdomen was explored. Hemostasis was maintained. Bowel viability was confirmed. [Bowel continuity was restored with primary anastomosis.] The fascia was [closed primarily with running #1 PDS / closed with component separation / bridged with biologic mesh] given [no tension / residual edema / loss of domain].
Open Abdomen (Prolonged TAC)
Given persistent bowel edema / abdominal compartment syndrome risk / ongoing resuscitation requirements, the abdomen remained open. The vacuum-assisted temporary closure was replaced with a fresh device. Bowel coverage was confirmed adequate. The patient will be returned to the OR for reassessment in [48-72 hours].
Charting Tips
- Laparotomy pad count documentation is a legal requirement — document the number of pads placed, that counts were confirmed with the nursing team at the time of temporary closure, and where they are located (specify quadrants). A retained foreign body is a never event and your documentation must be explicit.
- Document the specific physiologic indicators that drove the damage control decision — pH, temperature, INR/coagulopathy. This is the clinical justification for the staged approach and must be in the note to support ICU management and medicolegal record.
- Note the planned relook timeline — document '24-48 hour planned relook for pack removal and definitive repair' in both the operative note and orders. This prevents premature ICU assumption that surgery is 'complete' and ensures the follow-up is not forgotten.
Billing Tips
- Bill 49002 for reopening of abdomen / damage control reexploration (17.19 wRVU, 90-day global). For the initial damage control laparotomy, bill 49000 (exploratory laparotomy, 12.23 wRVU) plus any organ-specific procedures performed.
- Each additional procedure performed during damage control — bowel resection (44120), vascular repair (35221), splenectomy (38100) — is separately billable with modifier -51. Document each component clearly in the operative note.
- Temporary abdominal closure (negative pressure wound therapy application) can be billed with 97607/97608 or 49900 (suture of abdominal wall for evisceration) depending on the technique. Confirm with your coding team.
- Subsequent returns to the OR for planned relook laparotomy within the global period require modifier -58 (staged procedure) if planned, or -78 (unplanned return for complication). The distinction affects global period reset.
- Modifier -22 (increased procedural complexity) can be appended when operative time, blood loss, or complexity significantly exceeds typical — document operative time, EBL, and units transfused to support the modifier.