Roux-en-Y Gastric Bypass

CPT 43644
Approach Laparoscopic
Add-on / Variant CPTs
  • 43645 — Laparoscopic gastric bypass with biliopancreatic diversion
  • 43846 — Open gastric bypass Roux-en-Y
Preoperative Diagnosis:

Morbid obesity [BMI ___] with obesity-related comorbidities [type 2 diabetes / hypertension / GERD]

Postoperative Diagnosis:

Same

Procedure Performed:

Laparoscopic Roux-en-Y gastric bypass

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 BMI of [___] kg/m² and [obesity-related comorbidities] who has completed a multidisciplinary bariatric evaluation. The patient was selected for gastric bypass over sleeve gastrectomy given [severe GERD / history of Barrett's esophagus / type 2 diabetes requiring insulin / patient preference after informed discussion]. The risks, benefits, and alternatives were discussed, and informed consent was obtained.

Findings:

The stomach was [normal/enlarged]. The liver was [fatty/enlarged/no cirrhosis]. [A hiatal hernia of ___ cm was noted.] The proximal jejunum and mesentery were [normal]. Intraoperative endoscopy confirmed [gastrojejunostomy patency and negative leak test]. [Additional findings or none].

Description of Procedure:

The patient was brought to the operating room and placed in reverse Trendelenburg position. General endotracheal anesthesia was induced. Sequential compression devices were applied. A Foley catheter was placed. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of [weight-based] prophylactic antibiotics.

The abdomen was prepped and draped in sterile fashion. Pneumoperitoneum was established to 15 mmHg. A 12-mm camera port and four additional trocars were placed (two 12-mm and two 5-mm ports) in standard bariatric configuration.

The gastric pouch was created first. The pars flaccida was divided. Using sequential firings of a [45-mm blue/gold load] linear stapler, a small [20-30 mL] gastric pouch was created along the lesser curvature, dividing the stomach horizontally just below the gastroesophageal junction and then vertically. The pouch was separated from the remnant stomach. The angle of His was preserved. The pouch was approximately [3-4 cm] in length.

The omentum and transverse mesocolon were identified. The Roux limb was created by measuring [150-cm] of jejunum from the ligament of Treitz. The jejunum was divided at this point with a [45-mm white load] stapler. The mesentery was divided to allow the Roux limb to reach the gastric pouch without tension.

The Roux limb was brought [antecolic/antegastric/retrocolic/retrogastric] to the gastric pouch. A gastrojejunostomy was created using a [25-mm circular EEA stapler / linear stapler (GIA-45 mm)]. The anastomosis was tested for patency and hemostasis. An endoscopic leak test was performed — [no leak was identified / air leak at the gastrojejunostomy was repaired with interrupted sutures]. The gastrojejunostomy was calibrated at 12-mm or less with the endoscope.

The biliopancreatic limb was measured [50-75 cm] from the jejunojejunostomy. A side-to-side jejunojejunostomy (Roux-en-Y reconstruction) was created with a [60-mm white load] linear stapler and the common enterotomy closed with [3-0 Vicryl]. The Petersen space and mesenteric defects were closed with [running 2-0 Prolene/Vicryl] sutures.

The trocars were removed. 12-mm fascial defects were closed. Skin was closed with [4-0 Monocryl]. Sterile dressings were applied.

Complications:

None

Specimens:

Excised gastric tissue sent to pathology

Estimated Blood Loss:

Minimal (less than 50 mL)

Drains:

None / [One drain adjacent to gastrojejunostomy]

Disposition:

The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Morbid obesity BMI ***, with ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Laparoscopic Roux-en-Y gastric bypass
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with BMI ***. Bypass preferred over sleeve for ***. Multidisciplinary evaluation completed. Informed consent obtained.

FINDINGS: Liver ***. *** hiatal hernia. Endoscopic leak test ***.

DESCRIPTION OF PROCEDURE:
Reverse Trendelenburg. SCDs. Foley. General anesthesia. Surgical timeout per protocol.

Gastric pouch created along lesser curvature, *** mL, with sequential linear stapler firings. Roux limb measured *** cm from ligament of Treitz; jejunum divided. Roux limb brought *** to gastric pouch. Gastrojejunostomy created with *** stapler; endoscopic leak test negative. Jejunojejunostomy created *** cm from GJ; mesenteric defects closed. Petersen space closed.

Fascia closed. Skin with 4-0 Monocryl.

ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Gastric tissue 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

Retrocolic/Retrogastric Roux Limb

A retrocolic/retrogastric route was used for the Roux limb. A window was created in the transverse mesocolon and the Roux limb was brought through this window posterior to the stomach. The mesocolic defect was closed with [running 2-0 Prolene] to prevent internal hernia.

Circular Stapler Gastrojejunostomy

A 25-mm circular EEA stapler was used for the gastrojejunostomy. The anvil was secured in the gastric pouch via a purse-string of 2-0 Prolene suture through a small gastrotomy. The EEA stapler was introduced orally by anesthesia and mated to the anvil. The anastomosis was completed. The donuts were confirmed complete. The gastrotomy was closed with a TA stapler. The anastomosis was tested endoscopically.

Charting Tips
  • Document mesenteric defect closure explicitly — Petersen space closure and the jejunojejunostomy mesenteric defect closure are mandatory. Internal hernia is the most devastating late complication after RYGB (incidence 0.5-5%) and closure of all potential hernia spaces must be documented.
  • Document the Roux and biliopancreatic limb lengths — standard is 150 cm Roux / 50-75 cm biliopancreatic limb for BMI < 50; longer limbs for super-obesity (BMI > 50). These measurements are required for reoperation planning and outcomes tracking.
  • Document the leak test result with endoscopy — state that the endoscope confirmed anastomotic patency and caliber and that a methylene blue or air insufflation test was negative. The GJ anastomosis is the most common site of early leak and its documentation is critical.
Billing Tips
  • Bill 43644 for laparoscopic Roux-en-Y gastric bypass (28.67 wRVU, 90-day global). Use for standard laparoscopic RYGB with gastrojejunostomy and jejunojejunostomy.
  • Bill 43645 for laparoscopic RYGB with small intestine reconstruction (30.74 wRVU) when the procedure is performed with a longer Roux limb or more extensive small bowel rearrangement beyond the standard configuration.
  • Revisional gastric bypass (conversion from sleeve or band) uses 43848 (open revision) or 43659 (laparoscopic unlisted) with an operative report and supporting letter — there is no standalone laparoscopic revision code. This typically requires prior authorization.
  • 90-day global period: nutritional counseling, band adjustment equivalents, and routine bariatric follow-up are bundled. Endoscopy for anastomotic leak or stricture within the global period requires modifier -78 if performed in the OR.
  • Preoperative documentation must include BMI, qualifying comorbidities, and completion of a medically supervised weight loss program per the specific payer policy — missing documentation is the most common reason for surgical claim denial.