Sleeve Gastrectomy

CPT 43775
Approach Laparoscopic
Preoperative Diagnosis:

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

Postoperative Diagnosis:

Same

Procedure Performed:

Laparoscopic sleeve gastrectomy

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 including dietary counseling, psychological evaluation, and medical clearance. The patient has failed [6 months of] supervised weight loss attempts. The risks, benefits, and alternatives of the procedure including gastric bypass were discussed, and informed consent was obtained.

Findings:

The stomach was [normal/with prior banding visible]. Intraoperative endoscopy was [not performed / performed confirming adequate sleeve caliber and a negative leak test]. The liver was [fatty/enlarged]. [Hiatal hernia of ___ cm was noted and repaired.] [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 via [Veress needle / optical trocar / Hasson open technique — Hasson preferred in morbid obesity]. A 12-mm camera port was placed in the left upper quadrant. Five trocars were placed: a 12-mm camera port, a 12-mm liver retractor port, two 5-mm working ports, and an additional 5-mm port.

The liver was retracted superiorly. The greater omentum was divided from the greater curvature of the stomach beginning [4-6 cm proximal to the pylorus] and extending to the angle of His, using the [Harmonic / LigaSure] device. Short gastric vessels were divided. The angle of His was completely mobilized.

A [36-40 Fr] orogastric bougie was placed by anesthesia along the lesser curvature. The stomach was divided along the bougie using sequential firings of a [green/blue/gold] load [60-mm laparoscopic GIA stapler] beginning [4-6 cm proximal to the pylorus] and continuing to the angle of His, creating a narrow tubular sleeve. [Staple line reinforcement was/was not used: bioabsorbable/pericardial/oversewing technique.] The resected portion of the stomach was removed through the 12-mm port site in a specimen bag.

The staple line was inspected for hemostasis. An endoscopic leak test was performed by instilling [methylene blue / air under endoscopic visualization] — [no leak was identified]. Hemostasis of the staple line was confirmed. [A [60-cm] hiatal hernia repair was performed at this time.]

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

Complications:

None

Specimens:

Gastric sleeve (resected stomach) sent to pathology

Estimated Blood Loss:

Minimal (less than 30 mL)

Drains:

None / [One Jackson-Pratt drain along the staple line]

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 sleeve gastrectomy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with BMI *** completing multidisciplinary bariatric evaluation. Informed consent obtained.

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

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

Five trocars placed. Greater curvature divided from 4-6 cm proximal to pylorus to angle of His using energy device. *** Fr bougie placed. Stomach divided along bougie with sequential GIA firings. *** staple line reinforcement. Resected stomach removed. Endoscopic leak test: ***. Hemostasis confirmed. *** hiatal hernia repaired.

Fascia closed at 12-mm sites. Skin with 4-0 Monocryl.

ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Resected stomach 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 Hiatal Hernia Repair

A [___]-cm hiatal hernia was identified. The crura were dissected and the hernia sac was reduced. The crura were reapproximated posteriorly with [2 interrupted 0-Ethibond sutures]. The sleeve gastrectomy was then completed as described above. The fundoplication was not performed given prior sleeve configuration.

Staple Line Leak — Intraoperative Management

An air/methylene blue leak was identified at the [proximal staple line / angle of His / mid-staple line] on endoscopic testing. The leak was repaired with [oversewing with interrupted 2-0 Prolene sutures / additional staple firing / fibrin glue application]. Repeat leak test confirmed a negative result. A closed suction drain was left adjacent to the repair site.

Charting Tips
  • Document the bougie size used for sleeve calibration — this determines the final sleeve volume and affects leak risk, weight loss, and GERD outcomes. Standard is 36-40 Fr; many programs have a standard size that should be consistently documented.
  • Document the leak test type and result explicitly — state whether methylene blue or air was used, that the endoscope was used, and that the result was negative. A staple line leak is the most feared early complication of sleeve gastrectomy.
  • Document the distance from the pylorus at which the staple line begins — the pylorus should be preserved and the division should begin 4-6 cm proximal to it. Beginning too close to the pylorus increases sleeve narrowing and stricture risk.
Billing Tips
  • Bill 43775 for laparoscopic sleeve gastrectomy (19.87 wRVU, 90-day global). This is the only CPT code for sleeve gastrectomy — no variants based on bougie size or staple line reinforcement technique.
  • 90-day global period: dietary advancement, nutritional supplementation management, and routine follow-up are bundled. Postoperative EGD for staple line leak evaluation within the global period requires modifier -78 if performed in the OR.
  • Preoperative documentation requirements are the same as for gastric bypass: BMI ≥35 with comorbidity or BMI ≥40, completion of supervised weight loss program, psychological clearance, and nutritional evaluation — payer-specific, confirm before scheduling.
  • For revisional sleeve gastrectomy (re-sleeve or conversion to another procedure), there is no standalone revision CPT. Use 43999 (unlisted stomach procedure) with operative report and prior authorization. Conversion to RYGB uses 43644.
  • Staple line reinforcement, oversewing, and bougie size are not separately billable — document these for operative record and quality purposes only.