Laparoscopic Splenectomy
38120
-
38100— Open splenectomy -
38102— Open total splenectomy with repair
Immune thrombocytopenic purpura (ITP) / hereditary spherocytosis / splenic mass / lymphoma / symptomatic splenomegaly
Same
Laparoscopic splenectomy
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male/female] with [indication] presenting for laparoscopic splenectomy. [For ITP: platelet count has been refractory to medical management with steroids/IVIG/thrombopoietin agonists.] The risks, benefits, and alternatives of the procedure were discussed with the patient, and informed consent was obtained. Preoperative vaccinations (pneumococcal, meningococcal, Hib) were administered [___ weeks preoperatively / are planned for postoperative administration].
The spleen measured approximately [___] cm in greatest dimension and weighed approximately [___] grams. The splenic hilum was [well-defined/complex]. [An accessory spleen was/was not identified in the [splenic hilum/gastrosplenic ligament/greater omentum].] [Additional findings or none].
The patient was brought to the operating room and placed in the right lateral decubitus position with left side up. General endotracheal anesthesia was induced. 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 to 15 mmHg via [Veress needle / optical trocar / Hasson open technique]. A 12-mm trocar was placed in the left upper quadrant. Three additional trocars were placed under direct visualization: a 5-mm subxiphoid port, a 5-mm left lateral port, and a 12-mm left lower quadrant port for the stapler.
The abdomen was inspected. [An accessory spleen in the splenic hilum/gastrosplenic ligament was identified and removed.] The short gastric vessels were divided using [an energy device (Harmonic/LigaSure)], separating the spleen from the stomach. The splenocolic ligament was divided. The splenorenal and phrenosplenic ligaments were divided, completely mobilizing the spleen.
The splenic hilum was carefully dissected. The splenic artery was individually ligated with [hem-o-lok clips] and divided. The splenic vein was individually ligated with [hem-o-lok clips] and divided. [Alternatively, the hilum was divided in segments with a laparoscopic GIA vascular stapler.] Hemostasis of the hilum was confirmed.
The spleen was placed in a large [LapSac] specimen retrieval bag. The bag was brought to the largest port site and the spleen was morcellated within the bag and removed in segments. All fragments were confirmed to be within the bag prior to extraction. The bed was inspected for hemostasis and accessory splenic tissue.
The trocar sites were inspected. The abdomen was irrigated. Hemostasis confirmed. The 12-mm fascia sites were closed with [0-Vicryl]. The skin was closed with [4-0 Monocryl] subcuticular sutures. Sterile dressings were applied.
None
Spleen (morcellated in bag) sent to pathology
Minimal (less than 50 mL)
None
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: Laparoscopic splenectomy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with *** presenting for laparoscopic splenectomy. Vaccinations *** administered. Informed consent obtained.
FINDINGS: Spleen *** cm, approximately *** grams. *** accessory spleen.
DESCRIPTION OF PROCEDURE:
Right lateral decubitus position. Foley placed. General anesthesia. Surgical timeout per protocol.
Four trocars placed. Short gastric vessels divided with energy device. Splenocolic, splenorenal, and phrenosplenic ligaments divided. Spleen fully mobilized. Splenic artery and vein individually ligated with hem-o-lok and divided. Spleen placed in retrieval bag, morcellated, and extracted. Accessory splenic tissue ***. Hemostasis confirmed.
Fascia closed at 12-mm sites. Skin with 4-0 Monocryl.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Spleen 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
.TODAYVariants
Open Splenectomy (Trauma or Massive Splenomegaly)
An open approach was used given [traumatic splenic injury / massive splenomegaly precluding safe laparoscopic approach / converted from laparoscopic]. A midline laparotomy [or left subcostal incision] was performed. The splenic ligaments were divided. For trauma: the splenic hilum was rapidly controlled with manual compression. The splenic artery was ligated at the superior border of the pancreas. The splenic vein was ligated at the hilum. The spleen was removed. Hemostasis was achieved with [electrocautery/argon beam/suture ligature].
Hand-Assisted Laparoscopic Splenectomy (Massive Splenomegaly)
Given massive splenomegaly (estimated weight > 1500 g), a hand-assisted laparoscopic technique was used. A hand port was placed in the left upper quadrant through a [7-cm] incision and the surgeon's non-dominant hand was inserted to facilitate splenic retraction. Laparoscopic dissection proceeded as described. The spleen was extracted en bloc through the hand port site after the hilum was divided.
Charting Tips
- Accessory spleen search must be documented — for hematologic indications (ITP, hereditary spherocytosis), a missed accessory spleen is the most common reason for recurrence. Document that you searched the hilum, gastrosplenic ligament, greater omentum, and mesentery.
- Vaccination status must be documented — pneumococcal (PCV13 and PPSV23), meningococcal (MenACWY), and Hib vaccinations are required. Document whether given preoperatively (preferred, ≥2 weeks prior) or to be given postoperatively (day 14+ post-op). OPSI carries 50% mortality.
- For ITP, document the preoperative platelet count and the intraoperative platelet transfusion decision — platelets are typically held until after splenic artery ligation to avoid their rapid destruction, and this should be coordinated with anesthesia and documented.
Billing Tips
- Bill 38120 for laparoscopic splenectomy (16.64 wRVU, 90-day global). Bill 38100 for open splenectomy (19.06 wRVU) — open has a higher wRVU. Document approach and any conversion from laparoscopic to open.
- Bill 38102 as an add-on code (4.67 wRVU) when splenectomy is performed in conjunction with another major abdominal procedure (e.g., total pancreatectomy, gastrectomy). This is an add-on, not a standalone code.
- Splenorrhaphy (repair) for trauma uses 38115 (10.43 wRVU) rather than splenectomy codes — document repair vs. removal at time of operation.
- 90-day global period: post-splenectomy vaccination (pneumococcal, meningococcal, Hib) is administered before discharge or within the global period — document vaccines given, as this is a quality metric and medicolegal requirement.
- For traumatic splenectomy, document AAST splenic injury grade, hemodynamic status, and operative findings. These support medical necessity and are required for trauma registry documentation.