Cytoreductive Surgery and HIPEC
[Appendiceal mucinous neoplasm / colorectal peritoneal metastasis / ovarian cancer / mesothelioma] with peritoneal carcinomatosis
Same
Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC), [completeness of cytoreduction CC-0 / CC-1]
[***, MD/DO]
[Fellow/Resident name]
General endotracheal. Arterial line, central venous access. Cell saver. Epidural [if placed].
Patient presents with [appendiceal mucinous neoplasm / colorectal peritoneal metastasis / primary peritoneal mesothelioma] and peritoneal carcinomatosis (PCI [X]) deemed resectable after multidisciplinary tumor board review. [Prior systemic chemotherapy: X cycles.] No distant metastatic disease on staging imaging. Risks including prolonged operative time, anastomotic leak, bowel obstruction, hematologic toxicity from HIPEC, and mortality discussed. Consent obtained.
Peritoneal Carcinomatosis Index (PCI): [X] (scored 0-39). Regions involved: [list regions]. [Liver surface involved ([stripped / not stripped])]. [Spleen involved; splenectomy performed.] Completeness of cytoreduction: [CC-0: no visible residual disease / CC-1: residual <2.5 mm].
The patient was positioned supine. A midline laparotomy was performed from xiphoid to pubis. Systematic exploration was performed with PCI scoring of all 13 abdominal regions.
CYTOREDUCTION: the following procedures were performed (see individual procedure notes or detailed below): - [Pelvic peritonectomy and resection of pelvic tumor deposits] - [Right and/or left diaphragm peritoneal stripping] - [Greater omentectomy] - [Splenectomy / left upper quadrant peritonectomy] - [Right upper quadrant peritonectomy, cholecystectomy] - [Small bowel resection with primary anastomosis, [X] cm resected] - [Colorectal resection with [primary anastomosis / diverting ileostomy]] Completeness of cytoreduction: CC-[0/1]: [no visible residual / residual nodules <2.5 mm].
HIPEC: Following cytoreduction and prior to bowel anastomosis [/ after anastomosis per institutional protocol], the abdomen was irrigated with hyperthermic chemotherapy solution. [Mitomycin C [X] mg/m2 administered at 42 degrees C for 90 minutes — standard regimen for colorectal and appendiceal histologies. / Cisplatin [X] mg/m2 with doxorubicin [X] mg/m2 at 42 degrees C for 60-90 minutes — for mesothelioma. / Oxaliplatin [X] mg/m2 at 42-43 degrees C for 30 minutes — Elias protocol; note PRODIGE 7 (Lancet Oncol 2021) did not demonstrate survival benefit for oxaliplatin HIPEC in colorectal peritoneal metastases; agent and protocol should reflect institutional multidisciplinary decision.] A [closed / open Coliseum] technique was used. Inflow and outflow temperatures were monitored; intra-abdominal temperature maintained at 41-43 degrees C. Chemotherapy was then drained and the abdomen irrigated with normal saline.
Bowel anastomoses were then performed [end-to-end / side-to-side with GIA stapler]. Hemostasis confirmed throughout. Closed-suction drains placed. Fascia closed with running [0-PDS]. Skin closed. Patient tolerated the procedure well.
None
All resected specimens to pathology with individual labeling
[X] mL
[Jackson-Pratt drains x2-3 in pelvis and right upper quadrant / None]
Patient taken to surgical ICU intubated in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Appendiceal mucinous neoplasm / colorectal peritoneal metastasis / mesothelioma] with peritoneal carcinomatosis
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Cytoreductive surgery + HIPEC, CC-[0/1]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal; arterial line; CVP; cell saver
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [appendiceal / colorectal peritoneal / mesothelioma] peritoneal carcinomatosis (PCI ***) deemed resectable by multidisciplinary tumor board. No distant metastasis. Risks including prolonged OR time, anastomotic complications, HIPEC toxicity, and mortality discussed. Informed consent obtained.
FINDINGS: PCI *** (0-39). Regions: ***. Completeness of cytoreduction: CC-[0 / 1]. [Splenectomy / diaphragm stripping / bowel resection] required.
DESCRIPTION OF PROCEDURE:
Patient supine. Midline laparotomy; systematic exploration; PCI scored. Cytoreduction: [pelvic peritonectomy / diaphragm stripping / greater omentectomy / splenectomy / cholecystectomy / small bowel resection *** cm / colorectal resection with [anastomosis / diverting ileostomy]]. CC-[0/1] achieved. HIPEC: [Mitomycin C *** mg/m2 at 42 degrees C x 90 min / Cisplatin *** mg/m2 + doxorubicin *** mg/m2 at 42 degrees C x 60-90 min / Oxaliplatin *** mg/m2 at 43 degrees C x 30 min], [closed / Coliseum] technique; inflow and outflow temps monitored; intra-abdominal temp 41-43 degrees C. Abdomen irrigated with saline post-HIPEC. Bowel anastomoses performed. Hemostasis confirmed. Drains placed. Fascia with 0-PDS; skin closed. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: All resected specimens to pathology individually labeled
COMPLICATIONS: None
DRAINS: JP drains x*** in [pelvis / RUQ]
DISPOSITION: Patient to SICU intubated, stable.
Signed: .ME, .MYDEGREE
.TODAYVariants
Appendiceal mucinous neoplasm (LAMN/HAMN/PMP)
Low-grade appendiceal mucinous neoplasm with pseudomyxoma peritonei (PMP). Mucinous deposits often easily stripped. Document viscosity of mucin (watery vs. gelatinous) and all regions stripped. CC-0 is achievable and prognostically important.
Ovarian cancer cytoreduction (interval or primary)
Gynecologic oncology often performs pelvic components; general surgery performs bowel resection and upper abdominal cytoreduction. Document team roles and each resection performed.
Charting Tips
- Document PCI score systematically (score all 13 regions from 0-3 each, total 0-39)
- State completeness of cytoreduction (CC score), as this is the most important prognostic factor
- Document HIPEC agent, dose, temperature, duration, and technique (open vs. closed)
- List every resection performed, as each is separately billable
- Note bowel anastomosis timing and rationale — two protocols exist (anastomosis before HIPEC vs. after HIPEC); document which was used and state the reason. This is institution-specific; there is no universal standard.
- Document drain placement sites for postoperative management
Documentation & Reimbursement Considerations
- Report Cytoreductive Surgery and HIPEC as the primary service when it is the definitive operation performed.
- Cytoreductive surgery has no single reporting options. Bill each component separately. Document each tumor/cyst diameter in the operative note.
- Document HIPEC start and end time in the operative note.
- Confirm with your institutional billing team for GYN cases at the diagnostic code level.
- Completeness of cytoreduction (CC score) is a critical documentation element: CC-0 = no visible residual, CC-1 = <2.5 mm residual, CC-2 = 2.5-25 mm, CC-3 = >25 mm. Higher CC scores affect prognosis and should be clearly documented.
- Major morbidity codes: anastomotic leak, bowel obstruction, and pleural effusion are common postoperative complications. Ensure that each complication is separately coded and documented, as they affect DRG and complication capture rates.