Small Bowel Resection

CPT 44120
Approach Open
Add-on / Variant CPTs
  • 44121 — Each additional resection and anastomosis
  • 44125 — With enterostomy
Preoperative Diagnosis:

Small bowel obstruction / small bowel ischemia / Crohn's disease with stricture / small bowel tumor / small bowel perforation

Postoperative Diagnosis:

Same

Procedure Performed:

Small bowel resection with primary 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 small bowel resection. The risks, benefits, and alternatives were discussed with the patient, and informed consent was obtained.

Findings:

A [___]-cm segment of [jejunum/ileum] was found to be [ischemic/strictured/perforated/with obstructing mass]. The segment began approximately [___] cm from the ligament of Treitz and extended to [___] cm proximal to the ileocecal valve. Proximal bowel was [dilated/normal]. Distal bowel was [decompressed/normal]. Mesenteric vascularity [was/was not] preserved to the resection margins. [Additional findings or none].

Description of Procedure:

The patient was brought to the operating room and placed supine. 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.

The involved segment of small bowel was identified and delivered into the wound. The extent of resection was determined by [palpable pulsatile mesenteric vessels / Doppler signal / viable tissue margins / negative margins for neoplasm]. The mesentery of the affected segment was divided between clamps and ligated with [2-0 Vicryl / 0-silk ties], taking care to preserve the mesenteric arcade to the remaining bowel.

[For stapled anastomosis:] The bowel was divided proximally and distally with [GIA-75 mm] staplers. A side-to-side (functional end-to-end) anastomosis was fashioned by aligning the antimesenteric borders of the two bowel ends, making small enterotomies, and firing a [GIA-75 mm] stapler. The common enterotomy was closed with a [TA-55] stapler. The anastomosis was confirmed to be widely patent, hemostatic, and without tension.

[For hand-sewn anastomosis:] The bowel was divided between bowel clamps. A two-layer end-to-end anastomosis was constructed using [3-0 Vicryl] inner running suture and [3-0 silk] Lembert outer interrupted suture. The anastomosis admitted two fingerbreadths.

The mesenteric defect was closed with [interrupted 2-0 silk] sutures. The abdomen was irrigated. 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:

Small bowel segment [___] cm sent to pathology

Estimated Blood Loss:

Minimal (less than 50 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: Small bowel resection with primary anastomosis
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with *** presenting for small bowel resection. Informed consent obtained.

FINDINGS: *** cm segment of *** was ***. Resection margins viable. Proximal bowel ***; distal bowel ***.

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

Midline laparotomy. Affected segment identified. Mesentery divided between clamps with *** ties. Bowel divided with GIA staplers. Functional end-to-end anastomosis with GIA-75; enterotomy closed with TA-55. Anastomosis widely patent. Mesenteric defect closed. Fascia with #1 looped PDS. Skin with ***.

ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Small bowel *** cm 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

Ischemia — Second-Look Laparotomy Planned

Given extensive mesenteric ischemia with [questionable viability of remaining bowel / resection of [___] cm of small bowel leaving [___] cm remaining], a planned second-look laparotomy in 24-48 hours was elected to reassess bowel viability. An anastomosis was [performed / deferred in favor of bowel stapling and end stoma formation]. The abdomen was closed and the patient was returned to the ICU. The intent to perform a second-look was documented in the operative note and orders.

With Diverting Stoma

Given [gross contamination / hemodynamic instability / high-risk anastomosis / extensive ischemia with short bowel], a primary anastomosis was deferred. The proximal end was brought out as an end ileostomy through a right lower quadrant trephine. The distal segment was either brought out as a mucous fistula or closed and returned to the abdomen. Bowel continuity will be restored as a staged procedure.

Charting Tips
  • Document the remaining bowel length for ischemia cases — measure and record approximately how many centimeters of small bowel remain after resection. Short bowel syndrome risk begins at < 200 cm; documentation at the time of surgery is critical for prognosis and future management.
  • Document the assessment of margin viability — state specifically what was used (visible pulsatile vessels, Doppler, bleeding margins, peristalsis) to confirm that resection margins were viable before anastomosis. Anastomosis at ischemic margins is a common cause of leak.
  • For Crohn's cases, document the resection margin strategy — standard is to resect to grossly normal bowel, not wide margins, to conserve bowel length. Document that margins were taken at grossly normal tissue.
Billing Tips
  • Bill 44120 for small bowel resection with anastomosis (20.30 wRVU, 90-day global). Use for any single segment small bowel resection with primary anastomosis, open or laparoscopic.
  • Bill 44121 as an add-on code for each additional small bowel resection performed at the same setting (4.33 wRVU per additional resection). Document each additional segment resected separately.
  • Bill 44202 for laparoscopic small bowel resection (22.81 wRVU) when performed entirely laparoscopically. If converted to open, use 44120.
  • If an end ostomy is created rather than a primary anastomosis, bill 44310 (ileostomy, 17.15 wRVU) as primary — the resection is included in the ostomy code. Do not bill 44120 and 44310 together for the same bowel segment.
  • 90-day global period: drain management, wound care, and nutritional follow-up are bundled. Document the indication (obstruction, ischemia, Crohn's, trauma), length of bowel resected, and anastomotic technique for operative completeness.