Hartmann's Procedure
44143
-
44144— With planned colostomy reversal -
44146— With colorectal resection
Perforated sigmoid diverticulitis / sigmoid volvulus / colorectal obstruction / ischemic colitis
Same
Hartmann's procedure (sigmoid colectomy with end sigmoid colostomy and rectal stump closure)
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male/female] presenting with [indication: perforated diverticulitis/sigmoid volvulus/colorectal obstruction/ischemic colitis] requiring urgent/emergent surgical intervention. Given [hemodynamic instability/peritoneal contamination/patient comorbidities], primary anastomosis was not deemed safe. The risks, benefits, and alternatives were discussed with the patient [and family], and informed consent was obtained.
[Perforated sigmoid diverticulitis with Hinchey [II/III/IV] feculent/purulent peritonitis / sigmoid volvulus with [viable/ischemic/gangrenous] bowel / obstructing [carcinoma/stricture] of the sigmoid]. The sigmoid colon was [thickened/inflamed/ischemic/gangrenous] with [free perforation/mesenteric inflammation]. The remaining colon appeared [viable/normal/ischemic]. The rectal stump extended to [___] cm from the anal verge. [Additional findings or none].
The patient was brought to the operating room and placed supine on the operating table. General endotracheal anesthesia was induced without difficulty. A Foley catheter was placed. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of prophylactic antibiotics.
The abdomen was prepped and draped in sterile fashion. A midline laparotomy was performed from the xiphoid to the pubic symphysis. Abdominal exploration was performed. [Purulent/feculent] peritoneal fluid was encountered and cultures were sent. The bowel was carefully examined.
The sigmoid colon was mobilized by dividing the left mesocolon along the white line of Toldt from the rectosigmoid junction to the splenic flexure as needed. The left ureter was identified and swept posterolaterally. The inferior mesenteric artery and vein were identified, ligated with [0-silk], and divided. The sigmoid mesentery was divided between clamps down to the rectosigmoid junction.
The proximal sigmoid colon was divided with a [GIA linear stapler] at the level of the [descending colon/proximal sigmoid]. The rectum was divided at the [rectosigmoid junction/upper rectum] with a [TA stapler/GIA stapler]. The specimen was removed and passed off the field.
The rectal stump was inspected and confirmed to be intact. The stump was marked with a [0-Prolene suture / titanium clip] for future identification during reversal. The peritoneum was copiously irrigated with warm saline until return was clear.
A left lower quadrant trephine was created at a site marked preoperatively by the wound ostomy nurse. The anterior rectus sheath was incised in a cruciate fashion, the rectus muscle divided, and the posterior sheath and peritoneum opened. The proximal colon end was brought through the trephine without tension or twist, ensuring adequate length (approximately 2 cm above skin level). The colon was matured with [interrupted 3-0 chromic] sutures to the skin.
The abdomen was re-examined. Hemostasis was confirmed. The abdominal fascia was closed with running [0-PDS / #1 looped PDS] suture. The skin was closed with [staples / left open for delayed primary closure given contamination]. Sterile dressings and an ostomy appliance were applied.
None
Sigmoid colon and rectosigmoid junction sent to pathology
[___] mL
[One Jackson-Pratt drain in the left lower quadrant / pelvis]
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: Same
PROCEDURE PERFORMED: Hartmann's procedure — sigmoid colectomy with end colostomy and rectal stump closure
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX presenting with ***. Given ***, primary anastomosis was not safe. Informed consent was obtained.
FINDINGS: ***. The sigmoid was ***. The rectal stump extended to *** cm from the anal verge.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room and placed supine. Foley catheter placed. General endotracheal anesthesia induced. Surgical timeout performed per protocol.
Midline laparotomy was performed. Abdominal exploration done; *** peritoneal fluid encountered. The sigmoid was mobilized by dividing the left mesocolon; left ureter identified and preserved. The IMA and IMV were ligated and divided. The colon was divided proximally with a GIA stapler and the rectum divided at the rectosigmoid junction with a TA stapler.
The rectal stump was confirmed intact and marked with a 0-Prolene suture. The abdomen was copiously irrigated until clear. An end colostomy was created through a left lower quadrant trephine and matured to skin.
Fascial closure with running *** suture. Skin closed with ***. Ostomy appliance applied.
ESTIMATED BLOOD LOSS: ***
SPECIMENS: Sigmoid colon to pathology
COMPLICATIONS: None
DRAINS: ***
DISPOSITION: The patient tolerated the procedure well and was taken to the *** in *** condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Sigmoid Volvulus
The sigmoid colon was massively dilated and rotated [clockwise/counterclockwise] on its mesenteric axis. [Prior endoscopic detorsion had been/had not been attempted.] The volvulus was detorsed. The sigmoid was [viable/ischemic/gangrenous throughout]. Given [non-viable bowel/inability to safely devolve/perforation], resection proceeded as described with end colostomy formation.
Hinchey IV — Feculent Peritonitis
Frank feculent peritonitis was encountered with free fecal material throughout the peritoneal cavity. All four quadrants were copiously irrigated with warm saline (total [___] liters) until return was clear. Given the degree of contamination, the skin was left open and packed with moist gauze for delayed primary closure. A [Jackson-Pratt drain was placed in the pelvis and left lower quadrant]. Postoperatively the patient required [ICU admission / vasopressor support].
Charting Tips
- Document the Hinchey classification for diverticulitis (I: pericolic abscess, II: pelvic abscess, III: purulent peritonitis, IV: feculent peritonitis). This is a required element for outcomes reporting and guides postoperative antibiotic duration.
- Explicitly document left ureter identification and preservation. Ureteral injury is the most feared complication, and documentation of its identification is the single most important medicolegal protection.
- Mark the rectal stump with a permanent suture or clip and document this in the operative note. Future Hartmann's reversal will be significantly easier if the surgeon can find the stump laparoscopically, and noting the marking is standard of care.
Billing Tips
- Bill 44143 for Hartmann's procedure: sigmoid colectomy with end colostomy and rectal stump closure (27.10 wRVU, 90-day global). This single code captures the resection, colostomy, and rectal stump.
- Do not separately bill for colostomy creation (44320). It is bundled into 44143. The rectal stump closure is also included.
- If performed laparoscopically, use 44206 (laparoscopic partial colectomy with stoma, 29.05 wRVU) rather than 44143. Document laparoscopic approach and any conversion to open.
- 90-day global period: ostomy care, stoma appliance fitting, and routine wound checks are bundled. Subsequent Hartmann's reversal (colostomy takedown with colorectal anastomosis) is a separate procedure billed at the time of reversal, typically 44626 (27.20 wRVU).
- Document the indication (perforated diverticulitis, volvulus, obstructing malignancy), intraoperative contamination grade, and rectal stump status (oversewn vs. stapled, length remaining). These details support medical necessity and guide future reversal planning.