Lysis of Adhesions

CPT 44005
Approach Laparoscopic
Preoperative Diagnosis:

Small bowel obstruction secondary to adhesions

Postoperative Diagnosis:

Same

Procedure Performed:

Laparoscopic lysis of adhesions [converted to open]

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 history of [prior abdominal surgery] presenting with small bowel obstruction that [failed nonoperative management after ___ hours / presented with signs of strangulation / complete obstruction on imaging]. The risks, benefits, and alternatives were discussed with the patient, and informed consent was obtained.

Findings:

A [single band adhesion / multiple filmy adhesions / dense adhesions] causing obstruction was identified [at the ___ region]. The transition point was at the [level of the ___]. Bowel proximal to the obstruction was [mildly/moderately/markedly dilated]. The bowel at the transition point was [viable/pink with good peristalsis / mildly dusky but viable after adhesiolysis / frankly ischemic requiring resection]. [Additional findings or none].

Description of Procedure:

The patient was brought to the operating room and placed supine. General endotracheal anesthesia was induced. A nasogastric tube was placed for gastric decompression. 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. Pneumoperitoneum was established with an [open Hassan technique / Veress needle at an uninvolved site]. Given the dilated bowel, an optical trocar was placed cautiously at [Palmer's point / right upper quadrant / left upper quadrant] away from prior incisions. Two to three additional 5-mm trocars were placed under direct visualization.

The abdomen was inspected. The transition point was identified. A band adhesion from [prior incision scar / omentum / adjacent loop] was identified as the point of obstruction. The adhesion was divided sharply with [Metzenbaum scissors / hook electrocautery] under direct vision. The bowel was then carefully inspected from the Treitz ligament to the ileocecal valve [as accessible laparoscopically], running the entire small bowel to confirm complete relief of obstruction and assess bowel viability.

After adhesiolysis, the obstructing segment was confirmed to be [viable/pink with restoration of peristalsis]. [All small bowel was confirmed viable.] [A segment of ischemic bowel was converted to open and resected — see open operative note addendum.]

The trocars were removed under direct visualization. Hemostasis confirmed. Fascial defects were closed with [0-Vicryl]. Skin was closed with [4-0 Monocryl]. Sterile dressings were applied.

Complications:

None

Specimens:

None

Estimated Blood Loss:

Minimal (less than 20 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: Small bowel obstruction, adhesive
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Laparoscopic lysis of adhesions
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with SBO secondary to adhesions, failing nonoperative management / with signs of strangulation. Informed consent obtained.

FINDINGS: *** adhesion causing obstruction at ***. Transition point at ***. Bowel viability after adhesiolysis: ***.

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

Open Hassan technique entry at *** away from prior incisions. Three trocars. Transition point identified. Obstructing adhesion(s) divided sharply. Small bowel run completely — viable throughout. No serosal injuries.

Trocars removed. Fascia closed. Skin with 4-0 Monocryl.

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
.TODAY
Variants

Converted to Open

Due to [dense adhesions precluding safe laparoscopic dissection / multiple prior surgeries / bowel injury / inadequate visualization], the procedure was converted to open adhesiolysis. Pneumoperitoneum was released. A midline laparotomy was performed. Adhesiolysis was completed under direct vision. The entire small bowel was run from the Treitz ligament to the ileocecal valve. [A bowel resection was required for ischemic segment.] The abdomen was closed in standard fashion.

Inadvertent Enterotomy

An inadvertent enterotomy occurred during adhesiolysis at [jejunum/ileum]. The defect measured approximately [___] mm. The enterotomy was repaired primarily with [interrupted 3-0 Vicryl] in two layers. The repair was confirmed to be intact without leak. The area was irrigated. [Given the nature of the repair, oral intake will be advanced slowly with assessment of the repair.]

Charting Tips
  • Document that the entire small bowel was run — state explicitly that the bowel was inspected from the ligament of Treitz to the ileocecal valve. This confirms no missed ischemic segments or additional obstruction points and is the standard of care.
  • Entry technique at a safe site away from prior incisions should be documented — Hassan entry at a known uninvolved location (Palmer's point, right or left upper quadrant) is the safe technique for reoperative abdomens with prior midline scars.
  • Any inadvertent enterotomies must be documented including location, size, and repair technique — do not omit this from the note. An undocumented enterotomy that presents as a postoperative leak is a significant medicolegal event.
Billing Tips
  • Bill 44005 for open lysis of intestinal adhesions (18.00 wRVU, 90-day global). Use when adhesiolysis is the primary procedure performed — e.g., for small bowel obstruction without resection.
  • When lysis of adhesions is performed in conjunction with another primary procedure (bowel resection, hernia repair), it is typically bundled and not separately billable unless the adhesiolysis significantly increases operative time and complexity.
  • If bowel resection becomes necessary after adhesiolysis (due to ischemic or injured bowel), bill the resection code (44120, 20.30 wRVU) as primary with 44005 bundled — the resection captures the higher work value.
  • Modifier -22 (increased complexity) can be appended when dense vascularized adhesions, prior radiation, or multiple prior surgeries significantly increase operative time. Document operative time, findings, and specific challenges encountered.
  • Laparoscopic lysis of adhesions uses 44180 (laparoscopic enterolysis, 11.72 wRVU). Document laparoscopic approach and any conversion to open. The laparoscopic code has a substantially lower wRVU — conversion to open should be coded as 44005.