Distal Pancreatectomy

CPT 48140
Approach Open
Add-on / Variant CPTs
  • 48145 — With splenectomy
  • 48146 — With splenectomy and lymph node dissection
Preoperative Diagnosis:

Pancreatic body/tail carcinoma / pancreatic neuroendocrine tumor / pancreatic cystic neoplasm / chronic pancreatitis

Postoperative Diagnosis:

Same

Procedure Performed:

Open distal pancreatectomy with splenectomy

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal

Indications:

The patient is a [age]-year-old [male/female] with a [pancreatic body/tail mass] presenting for distal pancreatectomy. [Preoperative staging was consistent with a resectable lesion without evidence of distant metastases.] The risks, benefits, and alternatives were discussed with the patient, including risk of exocrine and endocrine insufficiency, and informed consent was obtained.

Findings:

A [mass/tumor/cyst] was identified in the [body/tail] of the pancreas measuring approximately [___] cm. The splenic vein was [adherent/encased by tumor / uninvolved]. The splenic artery was [preserved/ligated]. No evidence of hepatic or peritoneal metastases. The spleen was [normal/enlarged]. [Additional findings or none].

Description of Procedure:

The patient was brought to the operating room and placed supine. General endotracheal anesthesia was induced. Foley catheter was placed. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of prophylactic antibiotics including vaccination documentation (if planned splenectomy).

The abdomen was prepped and draped in sterile fashion. An upper midline laparotomy was performed. Abdominal exploration confirmed no metastatic disease. A self-retaining retractor was placed.

The lesser sac was entered by dividing the gastrocolic ligament. The posterior surface of the pancreatic body and tail was exposed. The splenic flexure of the colon was mobilized inferiorly. The stomach was reflected superiorly.

The splenic artery was identified along the superior border of the pancreas. The splenic artery was ligated with [0-silk ties] proximally and then followed distally along the pancreatic body. The short gastric vessels were divided between [hem-o-lok clips]. The splenocolic and splenocolic ligaments were divided.

The plane of pancreatic transection was established at the [neck/body] of the pancreas, [___] cm to the left of the superior mesenteric vein. The pancreatic neck/body was divided with a [GIA 60-mm stapler / scalpel and suture ligation of the main pancreatic duct with [4-0 PDS]]. A [fish-mouth closure / running 3-0 Prolene suture] was applied to the pancreatic remnant to reinforce the staple line.

The splenic vein was ligated at the level of transaction with [0-silk ties] and divided. The distal pancreatic body and tail with the spleen were delivered by continuing the dissection laterally, ligating remaining splenic hilar vessels. The specimen was removed.

The pancreatic stump was inspected for hemostasis and bile/juice leak. [A fibrin glue/sealant was applied to the stump.] A closed suction drain was placed adjacent to the pancreatic stump. The abdomen was irrigated. Hemostasis confirmed. The fascia was closed with [#1 PDS]. Skin was closed with [staples]. Sterile dressings were applied.

Complications:

None

Specimens:

Distal pancreas, pancreatic body/tail, spleen sent to pathology

Estimated Blood Loss:

[___] mL

Drains:

One [Jackson-Pratt] drain placed adjacent to the pancreatic stump

Disposition:

The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Open distal pancreatectomy with splenectomy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with a *** in the pancreatic body/tail presenting for resection. No distant metastases. Informed consent obtained.

FINDINGS: *** mass *** cm in pancreatic ***. Splenic vein ***. No metastatic disease.

DESCRIPTION OF PROCEDURE:
Supine. Foley placed. General anesthesia. Surgical timeout per protocol.

Upper midline laparotomy. Lesser sac entered via gastrocolic ligament. Splenic artery ligated at superior pancreatic border. Short gastric vessels divided. Pancreatic transaction at *** with GIA stapler; duct suture-ligated with 4-0 PDS. Splenic vein ligated. Specimen removed. JP drain placed at stump.

Fascia closed with #1 PDS. Skin with staples.

ESTIMATED BLOOD LOSS: ***
SPECIMENS: Distal pancreas and spleen to pathology
COMPLICATIONS: None
DRAINS: JP drain at pancreatic stump
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Spleen-Preserving Distal Pancreatectomy

A spleen-preserving technique was used given [benign/low-grade pathology / patient preference / adequate splenic vascularity]. The splenic artery and vein were carefully dissected off the posterior pancreatic surface from the transection point to the splenic hilum. Small pancreatic branches were ligated individually with [hem-o-lok clips / 4-0 silk ties]. The pancreas was transected and the spleen was preserved with intact splenic vasculature [or with Warshaw technique: splenic artery and vein ligated but short gastric vessels preserved]. Splenic viability was confirmed at the conclusion of the procedure.

Laparoscopic Distal Pancreatectomy

A laparoscopic approach was utilized. Five trocars were placed in the upper abdomen. The lesser sac was entered via the gastrocolic ligament using an energy device. The splenic artery was controlled early. The pancreatic neck/body was divided with a laparoscopic GIA stapler. The remainder of the mobilization was completed laparoscopically. The specimen was extracted through a Pfannenstiel or enlarged port site incision using a specimen bag. A drain was placed laparoscopically adjacent to the stump.

Charting Tips
  • Document the level of pancreatic transection (neck/body/mid-body) and distance from the SMV — this establishes the proximal margin and is important for pathologic margin analysis and oncologic adequacy.
  • For splenectomy cases, document preoperative vaccination status (pneumococcal, meningococcal, Hib) and note whether vaccinations were given preoperatively or ordered for postoperative administration — OPSI is a lifelong risk after splenectomy.
  • Document the POD1 and POD3 drain amylase orders in the postoperative plan — ISGPF criteria require drain amylase > 3x serum upper limit of normal on POD3 to diagnose POPF, and drain data is only useful if the drain is not removed prematurely.
Billing Tips
  • Bill 48140 for distal pancreatectomy without splenectomy (25.66 wRVU, 90-day global). Use for spleen-preserving distal pancreatectomy regardless of laparoscopic or open approach.
  • Bill 48145 for distal pancreatectomy with splenectomy, open approach (26.71 wRVU). Bill 48146 for distal pancreatectomy with splenectomy and pancreatojejunostomy (29.84 wRVU) when reconstruction is required.
  • Laparoscopic distal pancreatectomy uses the same codes (48140, 48145) — approach does not change the CPT for pancreatectomy. Document laparoscopic technique in the operative note.
  • 90-day global period: pancreatic fistula management, drain management, and follow-up imaging interpretation within 90 days are bundled. Percutaneous drain placement for a postoperative fluid collection may be separately billable by interventional radiology.
  • If splenic vein thrombosis or portal hypertension complicates splenectomy, document these findings — they support medical necessity and complexity if modifier -22 is considered.