Ileostomy Creation
44310
-
44312— Revision of ileostomy
Colorectal resection requiring anastomotic protection / ulcerative colitis requiring fecal diversion / rectal cancer with low anastomosis / anastomotic leak
Same
[Loop / end] ileostomy creation
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male/female] requiring [fecal diversion to protect a low colorectal anastomosis / total proctocolectomy / urgent diversion for leak/sepsis]. A [loop/end] ileostomy was planned. Preoperative stoma marking was performed by the wound ostomy nurse at the right lower quadrant site. The risks, benefits, and alternatives were discussed with the patient, and informed consent was obtained.
The terminal ileum was [normal/inflamed] with adequate length and mesentery for a tension-free stoma. The right lower quadrant site allowed the stoma to be positioned without tension, creases, or proximity to the bony prominences. [Additional findings or none].
The patient was brought to the operating room and placed supine. General endotracheal anesthesia was induced. A surgical timeout was performed confirming patient identity, procedure, operative site (stoma site confirmed at preoperatively marked right lower quadrant location), allergies, and administration of prophylactic antibiotics.
[The ileostomy was created as part of a [larger colorectal procedure / as a standalone procedure] for diversion.]
A trephine was created at the preoperatively marked right lower quadrant site. A circular core of skin (approximately 2.5 cm in diameter) was excised. The anterior rectus sheath was incised in a cruciate fashion, the rectus muscle was divided bluntly, and the posterior sheath and peritoneum were opened sharply. The opening admitted two fingerbreadths.
[For loop ileostomy:] A segment of terminal ileum approximately [20-25] cm proximal to the ileocecal valve was selected. A small mesenteric window was created and a [Penrose drain / vessel loop] was passed through. The ileal loop was delivered through the trephine. An ileostomy rod (or skin bridge using Penrose drain cut to length) was placed through the mesenteric window beneath the loop to prevent retraction. The distal (efferent) limb was identified and brought to the inferior aspect of the trephine. The anterior ileum was opened with a transverse or elliptical incision on the efferent limb side. The stoma was matured: the efferent (distal) limb was sutured flush to skin and the afferent (proximal) limb was everted [2-3 cm] above skin, creating a spout with [interrupted 3-0 chromic] sutures. The Brooke eversion was confirmed and the stoma spout was everted to prevent peristomal skin excoriation from liquid effluent.
[For end ileostomy:] The proximal ileum was divided with a GIA stapler. The stapled end was delivered through the trephine with [2-3] cm above skin level without tension. The staple line was excised. The stoma was matured with [interrupted 3-0 chromic] full-thickness sutures, slightly everted.
Stoma viability was confirmed — the mucosa appeared [pink/viable] with intact blood supply. The abdomen was closed. A stoma appliance was applied.
None
None
Minimal (less than 20 mL)
None
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition. Ostomy nurse teaching and appliance fitting planned postoperatively.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** ileostomy creation
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX requiring fecal diversion for ***. Stoma marked preoperatively at RLQ by ostomy nurse. Informed consent obtained.
FINDINGS: Terminal ileum normal. Adequate length for tension-free stoma.
DESCRIPTION OF PROCEDURE:
Supine. General anesthesia. Surgical timeout with stoma site confirmed at preoperatively marked RLQ.
Trephine created at RLQ site; opening admitted two fingerbreadths. *** ileostomy: ileum *** cm from ileocecal valve delivered through trephine. *** rod/bridge placed. Efferent limb identified and brought inferior. Stoma matured with Brooke eversion; afferent limb everted *** cm above skin. Stoma pink and viable.
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
.TODAYVariants
End Ileostomy after Total Proctocolectomy
An end ileostomy was created after total proctocolectomy for [ulcerative colitis / FAP / Crohn's disease]. The terminal ileum was divided [15 cm] from the ileocecal valve. The end was brought through the right lower quadrant trephine with adequate length. The stoma was matured with Brooke eversion, creating a [2-3]-cm spout to prevent peristomal dermatitis from liquid output. The stoma appliance was fitted.
Loop Ileostomy Takedown
[This note is for ileostomy takedown, not creation.] A peristomal incision was made circumferentially. The stoma was mobilized from the fascia. The bowel was freed, the two limbs were identified, and bowel continuity was restored with a [stapled functional end-to-end / hand-sewn] anastomosis. The fascia was closed. The skin was closed or left partially open for delayed closure.
Charting Tips
- Document Brooke eversion explicitly for ileostomy — a flush ileostomy without spout leads to severe peristomal skin breakdown from liquid enzyme-rich effluent. Documenting the eversion height (2-3 cm) confirms this critical technical step was performed.
- Identify and document the distal (efferent) limb for loop ileostomy — the efferent limb should be sutured flush with skin at the inferior aspect of the trephine. Mistakenly everting the distal limb causes fecal diversion to fail as stool passes into the distal bowel.
- Ileostomy rod removal timing should be documented in the note and orders — the rod is typically removed [5-7 days] postoperatively. If not documented, the rod may be forgotten, leading to pressure necrosis or wound infection.
Billing Tips
- Bill 44310 for open ileostomy or jejunostomy creation (17.15 wRVU, 90-day global). Use when an end or loop ileostomy is the primary or sole procedure.
- Bill 44187 for laparoscopic ileostomy or jejunostomy (16.97 wRVU, 90-day global). Document laparoscopic technique.
- When ileostomy is part of a larger resection (e.g., total proctocolectomy 44155, low anterior resection with diverting loop 44207/44208), the stoma is bundled — do not separately bill 44310.
- Loop ileostomy for diversion without resection uses 44310 (open) or 44187 (laparoscopic). Document whether this is loop vs. end and the indication for diversion.
- 90-day global period: stoma appliance changes, output management, and routine ostomy nursing visits are bundled. Stoma revision or parastomal hernia repair within the global period requires modifier -78 if performed in the OR.