Left Hemicolectomy

CPT 44140
Approach Open
Add-on / Variant CPTs
  • 44141 — With temporary colostomy
  • 44143 — With end colostomy (Hartmann's)
Preoperative Diagnosis:

Left colon/sigmoid carcinoma / diverticular disease / left colon ischemia

Postoperative Diagnosis:

Same

Procedure Performed:

Left hemicolectomy with primary colorectal anastomosis

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 [indication] presenting for left hemicolectomy. The risks, benefits, and alternatives were discussed with the patient, and informed consent was obtained.

Findings:

A [tumor/stricture/segment of ischemic/diverticular] pathology was identified in the [descending colon/sigmoid colon]. The mesentery was [uninvolved / with palpable lymph nodes]. The liver, peritoneum, and remaining abdomen were [without evidence of metastatic disease]. The left ureter was identified and preserved. [Additional findings or none].

Description of Procedure:

The patient was brought to the operating room and placed supine [or in modified lithotomy position for low anastomosis]. General endotracheal anesthesia was induced. 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. Abdominal exploration confirmed the operative findings. A self-retaining retractor was placed.

The left colon was mobilized by incising the peritoneal reflection along the left lateral white line of Toldt from the sigmoid to the splenic flexure. The splenic flexure was mobilized by dividing the splenocolic and phrenocolic ligaments. The greater omentum was divided from the transverse colon at the splenic flexure to provide additional reach. The left mesocolon was elevated off the retroperitoneum, sweeping Gerota's fascia posteriorly. The left ureter and gonadal vessels were identified and swept posterolaterally.

The inferior mesenteric artery (IMA) was identified at its origin from the aorta. The IMA was [ligated at its origin (high ligation) / ligated distal to the left colic artery (low ligation)] with [0-silk ties]. The inferior mesenteric vein was ligated at the inferior border of the pancreas. The descending and sigmoid mesocolon were divided between clamps.

The proximal transverse colon was divided with a [GIA stapler]. The distal sigmoid colon / upper rectum was divided with a [TA stapler] at the level of [the rectosigmoid junction / upper rectum]. The specimen was removed.

An end-to-end [or side-to-end] colorectal anastomosis was performed using the circular stapler technique. The anvil was secured in the proximal colon with a [2-0 Prolene] purse-string suture. The circular stapler [EEA 28/31 mm] was introduced transanally and the trocar was advanced to engage the anvil. The anastomosis was completed and the tissue rings were confirmed complete. The anastomosis was tested by air insufflation per rectum under saline — [no leak was identified / leak was identified and oversewn].

The abdomen was irrigated. The mesenteric defect was closed. Hemostasis was confirmed. The fascia was closed with running [#1 looped PDS]. Skin was closed with [staples / 4-0 Monocryl]. Sterile dressings were applied.

Complications:

None

Specimens:

Left colon specimen (descending and sigmoid colon) with mesentery sent to pathology

Estimated Blood Loss:

[___] mL

Drains:

None

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: Left hemicolectomy with primary colorectal anastomosis
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with *** presenting for left hemicolectomy. Informed consent was obtained.

FINDINGS: *** in the ***. Left ureter identified and preserved. Liver and peritoneum ***.

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

Midline laparotomy. Left colon mobilized to splenic flexure; splenic flexure taken down. Left ureter identified and swept posterolaterally. IMA ligated at *** with 0-silk. IMV ligated at inferior border of pancreas. Colon divided proximally with GIA; rectum divided at *** with TA stapler. Specimen removed.

End-to-end colorectal anastomosis with circular stapler (EEA *** mm); donuts confirmed complete; air leak test negative. Mesenteric defect closed. Fascia closed with #1 looped PDS. Skin with ***.

ESTIMATED BLOOD LOSS: ***
SPECIMENS: Left colon to pathology
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
.TODAY
Variants

With Diverting Loop Ileostomy

Given [low anastomosis / prior pelvic radiation / patient nutritional status / anastomotic tension], a diverting loop ileostomy was created to protect the anastomosis. A segment of terminal ileum approximately 20 cm proximal to the ileocecal valve was identified and a loop was brought through a previously marked right lower quadrant trephine. The ileostomy was matured with the distal limb flush and the proximal efferent limb everted approximately 2 cm above skin.

End Colostomy (Hartmann's Configuration)

Given [hemodynamic instability/fecal contamination/high-risk anastomosis], primary anastomosis was deferred. The rectal stump was closed with a TA stapler and marked with a 0-Prolene suture. An end colostomy was created through a left lower quadrant trephine and matured to skin with interrupted 3-0 chromic sutures.

Charting Tips
  • Document whether high (at aorta) or low (distal to left colic) IMA ligation was used. This is an oncologic decision with lymph node yield and anastomotic blood supply implications.
  • Air leak test result must be documented. Document that you performed pelvic saline immersion test, insufflated air per rectum, and the result was negative (or positive and how it was managed).
  • Document that the donut rings from the circular stapler were complete and sent to pathology. Incomplete donuts indicate a technically suboptimal anastomosis that warrants documentation.
Billing Tips
  • Bill 44204 for laparoscopic partial colectomy (25.76 wRVU, 90-day global). Use for laparoscopic left hemicolectomy, sigmoid colectomy, or any partial colon resection with primary anastomosis.
  • Bill 44207 for laparoscopic colectomy with colorectal anastomosis (31.12 wRVU) or 44208 with coloproctostomy and diverting stoma (33.14 wRVU) when anastomosis extends to the upper rectum or a diverting loop ileostomy is added.
  • For open left hemicolectomy, bill 44140 (partial removal of colon, 22.03 wRVU, 90-day global). Document open approach and any conversion from laparoscopic.
  • If a diverting loop ileostomy is created with the laparoscopic resection, use 44208 rather than billing 44204 + 44187 separately. The stoma is included in the higher-complexity code.
  • 90-day global period: anastomotic leak evaluation, drain management, and routine follow-up are bundled. Stoma reversal (if applicable) at a later date is a separate billable procedure.