Exploratory Laparotomy
49000
Acute abdomen / bowel obstruction / hollow viscus perforation / mesenteric ischemia / abdominal sepsis with unknown source
[Specific findings — e.g., perforated duodenal ulcer / small bowel obstruction from adhesions / mesenteric ischemia]
Exploratory laparotomy [with specific additional procedure]
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male/female] presenting with [indication: acute abdomen / small bowel obstruction / suspected perforation / peritonitis] who failed nonoperative management / presented with signs of hemodynamic instability / peritonitis. The risks, benefits, and alternatives were discussed with the patient [and family], and informed consent was obtained [or waiver obtained for emergent surgery].
Upon entering the peritoneal cavity, [free air/purulent/feculent/bilious/sanguineous/clear] fluid was encountered. [Volume: approximately ___ mL. Cultures were sent.] A systematic abdominal exploration was performed. The liver, gallbladder, stomach, small bowel [___] cm, large bowel, rectum, appendix, spleen, kidneys, and pelvic organs were all inspected. [Specific pathology identified: ___]. [The source of the acute abdomen was identified as ___]. [Additional findings or none].
The patient was brought to the operating room and placed supine. General endotracheal anesthesia was induced. [Emergent IV access and resuscitation were initiated.] A Foley catheter and nasogastric tube were placed. A surgical timeout was performed confirming patient identity, procedure, allergies, and antibiotic administration.
The abdomen was prepped and draped in sterile fashion. A midline laparotomy was performed from the xiphoid to the pubic symphysis. On entry, [free air/purulent fluid] was encountered and cultures were sent. A systematic exploration was performed:
- Liver: [normal/findings]
- Gallbladder and biliary tree: [normal/findings]
- Stomach and duodenum: [normal/perforation at ___]
- Small bowel from Treitz to ileocecal valve: [normal/dilated/ischemic/perforation/obstruction at ___]
- Appendix: [normal/inflamed]
- Colon: [normal/findings]
- Pelvis and pelvic organs: [normal/findings]
- Retroperitoneum and great vessels: [normal/findings]
[Specific procedure performed based on findings — e.g., Graham patch repair of duodenal ulcer / small bowel resection with anastomosis / lysis of adhesions, etc.]
The abdomen was copiously irrigated with warm saline until return was clear. [Total irrigation: ___ liters.] Hemostasis was confirmed throughout. [Drains placed at ___]. The fascia was closed with running [#1 looped PDS] suture. [The skin was closed with staples / left open for delayed primary closure given contamination.] Sterile dressings were applied.
None
[Peritoneal fluid cultures / resected tissue] sent to pathology / microbiology
[___] mL
[None / specific drain placement]
The patient tolerated the procedure well and was taken to the [post-anesthesia care unit / intensive care unit] in [stable / guarded] condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: ***
PROCEDURE PERFORMED: Exploratory laparotomy ***
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX presenting with ***. Informed consent obtained [or emergent waiver].
FINDINGS: *** fluid on entry; cultures sent. Systematic exploration: liver ***, gallbladder ***, stomach/duodenum ***, small bowel ***, appendix ***, colon ***, pelvis ***, retroperitoneum ***. Source: ***.
DESCRIPTION OF PROCEDURE:
Supine. Foley, NGT placed. General anesthesia. Surgical timeout per protocol.
Midline laparotomy xiphoid to pubis. *** fluid on entry; cultures sent. Systematic exploration performed as documented above.
[Specific procedure performed: ***.]
Copious irrigation with *** liters warm saline. Hemostasis confirmed. Fascia closed with #1 looped PDS. Skin ***.
ESTIMATED BLOOD LOSS: ***
SPECIMENS: ***
COMPLICATIONS: None
DRAINS: ***
DISPOSITION: The patient tolerated the procedure well and was taken to the *** in *** condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Perforated Duodenal Ulcer — Graham Patch Repair
A [___]-mm anterior duodenal perforation was identified at the first portion of the duodenum. The edges were viable. A Graham patch repair was performed: three [2-0 Vicryl] sutures were placed horizontally through the perforation edges with a pedicle of omentum laid over the defect and the sutures tied over the omentum, buttressing the repair. The repair was irrigated and confirmed intact. The abdomen was copiously irrigated.
Small Bowel Obstruction — Lysis of Adhesions
The small bowel was dilated proximal to a transition point at [___]. The obstructing adhesion band was [divided sharply / with Metzenbaum scissors]. The small bowel was inspected throughout from the Treitz ligament to the ileocecal valve. All bowel appeared [viable/pink with good peristalsis]. [A segment of ischemic bowel was resected and primary anastomosis was performed.] No gross perforation was identified.
Charting Tips
- Document the systematic exploration explicitly — list each organ examined and its status. This is the legal record that everything was inspected. Missing an injury because it was not documented as examined is the basis for many malpractice cases in trauma and acute surgery.
- Peritoneal fluid cultures must be documented as sent — postoperative antibiotic selection and duration require microbiologic data, and culture collection during exploratory cases is the standard of care.
- For delayed closure cases, document the rationale (contamination, hemodynamic instability, bowel edema, damage control) and the planned reoperation timeline — this establishes the clinical reasoning for temporary abdominal closure.
Billing Tips
- Bill 49000 for exploratory laparotomy (12.23 wRVU, 90-day global). Use when abdominal exploration is performed without a definitive separate procedure being the primary coded service.
- When a specific procedure is found and performed during exploration (e.g., bowel resection, splenectomy), the specific procedure is the primary code — 49000 is only used when exploration alone is the primary service or when no more specific code captures the work.
- If multiple procedures are performed (e.g., lysis of adhesions + small bowel resection), bill the higher-value procedure as primary and use modifier -51 for additional procedures. Document each separately.
- 90-day global period applies. If the patient returns to the OR within 90 days for a related complication, use modifier -78.
- Document the indication, all findings encountered, all structures examined, and any procedures performed. Vague documentation ('abdomen explored, no pathology') invites payer scrutiny — be specific about what was examined and why exploration was indicated.