Exploratory Laparotomy for Perforated Viscus
49000
-
43840— Suture repair of perforated peptic ulcer -
44950— Appendectomy with perforation / peritoneal abscess -
44605— Suture of small intestine perforation -
44604— Suture of large intestine perforation
Perforated viscus with peritonitis / [perforated peptic ulcer / perforated diverticulitis / perforated appendix / perforated colonic neoplasm / small bowel perforation]
[Perforated peptic ulcer with free perforation / perforated sigmoid diverticulitis with feculent peritonitis / perforated appendicitis with peritonitis / other — specify]
Exploratory laparotomy, [specific procedure: omental patch repair of perforated duodenal ulcer / Hartmann's procedure / small bowel resection with primary anastomosis / appendectomy], washout and drainage
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male/female] with [duration] hours of [acute abdomen / diffuse peritonitis / free air on imaging / hemodynamic instability] consistent with perforated viscus requiring emergent surgical exploration. [Pre-operative CT demonstrated free intraperitoneal air / free fluid / pneumatosis / mesenteric fat stranding at the level of (location).] The risks and benefits of surgery were explained to the patient [or patient's surrogate] and emergent consent was obtained. The patient was resuscitated with IV fluids and broad-spectrum antibiotics [antibiotic names] were administered preoperatively.
On entry to the abdomen, [free air / feculent / bilious / purulent / serous] peritoneal contamination was encountered. The source of perforation was identified as [a perforated anterior duodenal ulcer with a [X] mm defect / a sigmoid diverticulum with a contained / free perforation / a gangrenous perforated appendix / a perforated segment of [small bowel / colon] at [location]]. [Additional findings: liver, spleen, remainder of bowel — describe any other significant findings]. The peritoneal contamination was classified as [Hinchey stage / diffuse feculent / localized / purulent].
The patient was brought emergently to the operating room and placed supine. General endotracheal anesthesia was induced. A surgical timeout was performed. Nasogastric and Foley catheters were in place. The abdomen was prepped and draped in sterile fashion.
A midline laparotomy incision was made from the xiphoid to the pubic symphysis. On entry, [describe contamination: free bilious / feculent / purulent fluid]. The peritoneum was rapidly entered and four-quadrant peritoneal cultures were obtained. The source of contamination was systematically identified by inspecting the stomach, duodenum, small bowel, colon, appendix, and solid organs.
[For perforated duodenal ulcer:] The perforation was identified at [location] measuring [X] mm. The edges were debrided to viable tissue. A Graham patch repair was performed: a tongue of well-vascularized omentum was mobilized and secured over the perforation with [3-0 Vicryl / silk] interrupted sutures, creating a watertight seal. [H. pylori biopsy was taken from the gastric antrum.]
[For perforated diverticulitis / colon:] Given [feculent peritonitis / hemodynamic instability / inability to perform primary anastomosis safely], a Hartmann's procedure was performed. The perforated segment was resected with [GIA stapler]. The rectal stump was oversewn and the proximal end brought out as an end colostomy.
[For small bowel perforation:] The perforated segment was resected with [X] cm margins on each side using a [GIA] stapler. A [hand-sewn / stapled] anastomosis was constructed and leak-tested under saline.
The abdomen was copiously irrigated with [X] liters of warm normal saline until clear return was obtained. All four quadrants were inspected for residual contamination. Hemostasis was confirmed. Fascial closure was performed with [#1 looped PDS] running suture. The skin was [left open with wet-to-dry dressings / closed with staples] given the degree of contamination.
None
[Peritoneal cultures — four quadrant / Gastric antrum biopsy for H. pylori / Resected bowel to pathology]
[X] mL
[Jackson-Pratt drain(s) placed in the [pelvis / right upper quadrant / left upper quadrant] / None]
The patient tolerated the procedure and was taken intubated to the ICU in guarded condition. The surgical ICU team was notified. Post-operative antibiotics, fluid resuscitation, and vasopressor support were continued as indicated.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Perforated viscus — ***
POSTOPERATIVE DIAGNOSIS: ***
PROCEDURE PERFORMED: Exploratory laparotomy, ***, washout and drainage
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with *** hours of peritonitis/free air consistent with perforated viscus. CT: ***. Emergent consent obtained. Resuscitated with IVF, broad-spectrum antibiotics given preoperatively.
FINDINGS: *** peritoneal contamination on entry. Perforation at ***. [Additional findings: ***]. Hinchey stage / contamination class: ***.
DESCRIPTION OF PROCEDURE:
Patient supine. General anesthesia. Timeout. NGT and Foley in place. Prepped and draped.
Midline laparotomy xiphoid to pubis. *** contamination on entry. Four-quadrant cultures obtained. Source identified: ***.
[Repair/resection per operative findings — ***.]
Abdomen irrigated with *** L warm NS until clear return. All quadrants inspected. Hemostasis confirmed. Fascia closed with #1 looped PDS. Skin: ***.
EBL: ***
SPECIMENS: ***
COMPLICATIONS: None
DRAINS: ***
DISPOSITION: Patient taken to ICU intubated in guarded condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Graham Patch Repair — Perforated Duodenal Ulcer
The perforated anterior duodenal ulcer ([X] mm) was identified. A well-vascularized pedicle of omentum was mobilized. Three [3-0 silk] sutures were placed through the full thickness of the duodenum on each side of the perforation. The omental pedicle was laid over the defect and the sutures were tied down to secure the patch without tension. Saline irrigation over the repair confirmed no leak. H. pylori biopsy was taken from the gastric antrum and sent to pathology. A nasogastric tube was left to suction.
Damage Control — Abbreviated Initial Laparotomy
Given hemodynamic instability with [lactate X / pH X / temperature X], damage control principles were employed. The source was controlled (bowel stapled without anastomosis / perforation oversewn temporarily). No anastomosis was constructed. The abdomen was temporarily closed with a [Bogota bag / ABThera negative pressure wound therapy system]. The patient was taken to the ICU for resuscitation and re-warming. Planned return to the OR in 24–48 hours for definitive repair and abdominal closure.
Charting Tips
- Document the source of perforation with specific anatomy, defect size, and the degree of peritoneal contamination — this establishes the operative findings and justifies the chosen repair strategy. 'Perforated viscus' alone without characterization is insufficient.
- Document pre-operative antibiotic administration and the cultures sent intraoperatively. Post-operative antibiotic duration for peritonitis is typically 4 days for source control achieved at index surgery; document whether source control was complete.
- For Graham patch repair, document the H. pylori biopsy — NSAID use and H. pylori are the two most common causes of peptic ulcer perforation, and untreated H. pylori is a major risk factor for recurrence and future perforation.
Billing Tips
- Bill the specific repair code based on what is found: 44602 for small intestine perforation repair with contamination (24.10 wRVU), 44603 for multiple perforations (27.46 wRVU), 44604 for large intestine/rectal perforation (17.71 wRVU).
- If a perforated gastric ulcer is repaired with an omental patch, bill 43840 (repair of stomach, 17.02 wRVU, 90-day global). Document primary repair vs. patch technique, ulcer size, and degree of contamination.
- If resection is required due to the extent of perforation or necrosis, bill the appropriate resection code (44120, 44140, 43620) as the primary rather than the repair code — resection with anastomosis or ostomy has higher work value.
- Exploratory laparotomy (49000, 12.23 wRVU) is typically bundled when a definitive repair is performed. Only bill 49000 separately if exploration alone was the primary service with no definitive procedure.
- 90-day global period applies to all repair codes. Document peritoneal contamination grade (purulent vs. feculent vs. fibrinous), source control achieved, irrigation volume, and drain placement — these establish complexity for future audit review.