Hepatic Resection
[Colorectal liver metastasis / HCC / cholangiocarcinoma / NET liver metastasis / benign hepatic lesion], [right / left lobe / segments X-X]
Same
[Right hepatectomy / Left hepatectomy / Segmentectomy, segments X-X / Wedge resection], [open / laparoscopic / robotic]
[***, MD/DO]
[Fellow/Resident name]
General endotracheal. Arterial line. CVP kept low (target <5 mmHg) to minimize blood loss during parenchymal transection. [Cell saver with leukodepletion filter — use leukodepletion filter for all malignant cases (HCC, CRLM, cholangiocarcinoma) to reduce theoretical tumor cell reinfusion risk; cell saver without filter is appropriate for benign lesions only.]
Patient presents with [colorectal liver metastasis / HCC / hilar cholangiocarcinoma / NET metastasis] involving [right lobe / segments V-VI]. [Preoperative volumetry: FLR [X]% (adequate) / PVE performed [date]; FLR increased to [X]%.] [Staging CT demonstrates [X] lesion(s) [X] cm, no extrahepatic disease.] Margins anticipated clear. Risks including hepatic insufficiency, bile leak, hemorrhage, and liver failure discussed. Consent obtained.
Intraoperative ultrasound [confirmed lesion location / revealed [X] additional lesion(s)]. No extrahepatic disease. [Margin adequate ([X] cm) / close margin at segment [X] addressed with [additional wedge / ablation].] Liver [normal parenchyma / cirrhotic / background steatosis].
The patient was positioned supine. A [right subcostal / bilateral subcostal / midline] incision was made. The abdomen was explored; no peritoneal implants. The liver was mobilized by dividing the falciform, triangular, and coronary ligaments.
Intraoperative ultrasound confirmed [lesion location and margins / no satellite lesions].
[RIGHT HEPATECTOMY:] The right hepatic artery was identified, [suture-ligated and / clipped and] divided. The right portal vein was suture-ligated and divided. The line of demarcation [appeared / was marked with electrocautery]. The liver was mobilized further; retrohepatic inferior vena cava exposed and short hepatic veins (accessory hepatic veins) individually ligated and divided. The right hepatic vein was dissected at the IVC and [controlled with a vascular stapler / suture-ligated and divided].
Parenchymal transection was performed along the [right hepatic / Cantlie's line] using [CUSA / Harmonic scalpel / Kelly-clamp fracture / LigaSure] technique. Intrahepatic bile ducts and vessels were controlled with [clips / suture ligation / vascular staplers] as encountered. [Pringle maneuver applied [continuously / intermittently (15 min clamp / 5 min release cycles)] for [X] minutes total warm ischemia.]
The specimen was removed. The resection surface was inspected. [Bile leak tested with saline under pressure / green dye / cholangiogram; no leak.] Argon beam coagulator used on cut surface for hemostasis. [Fibrin sealant applied.]
A [closed-suction drain was placed near the cut surface.] Fascia closed with running [0-PDS]. Skin closed. Patient tolerated the procedure well.
None
[Right lobe / Segments X-X / Wedge resection specimen] to pathology with orientation sutures
[X] mL
[Jackson-Pratt drain at cut surface / None]
Patient taken to surgical ICU / floor in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Colorectal liver metastasis / HCC / cholangiocarcinoma / NET], [right lobe / segments ***]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Right hepatectomy / Left hepatectomy / Segmentectomy, segments *** / Wedge resection]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal; arterial line; low CVP strategy; cell saver [with leukodepletion filter for malignant cases]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [colorectal liver metastasis / HCC / NET] involving ***. FLR ***%. [PVE performed ***.] Staging: no extrahepatic disease. Risks including hepatic insufficiency, bile leak, hemorrhage discussed. Informed consent obtained.
FINDINGS: Intraoperative US confirmed lesion at ***. [Additional lesion found: ***.] No extrahepatic disease. Margins clear at *** cm. Background liver [normal / cirrhotic / steatotic].
DESCRIPTION OF PROCEDURE:
Patient supine. [Right subcostal / bilateral subcostal] incision. Abdomen explored; no peritoneal implants. Liver mobilized. IOUS confirmed lesion and margins. [RIGHT HEPATECTOMY: Right hepatic artery suture-ligated and divided; right portal vein suture-ligated and divided; demarcation marked; retrohepatic IVC exposed; short hepatic veins individually ligated and divided; right hepatic vein controlled with vascular stapler.] Parenchymal transection along [Cantlie's line / right hepatic] with [CUSA / Harmonic scalpel / Kelly-clamp fracture]. Intrahepatic vessels and ducts controlled with clips/suture ligation. [Pringle *** min [continuous / intermittent **** min on / **** min off].] Specimen removed. Cut surface inspected; no bile leak on saline test. Argon beam hemostasis. [Fibrin sealant applied.] [JP drain placed.] Fascia with 0-PDS; skin closed. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: [Right lobe / Segments *** / Wedge] to pathology with orientation
COMPLICATIONS: None
DRAINS: [JP drain at cut surface / None]
DISPOSITION: Patient to [SICU / floor] in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Laparoscopic hepatectomy
Minor resections (wedge, left lateral sectionectomy) are well-suited to laparoscopy. Document port placement, energy device used for transection, and specimen extraction method. Same reporting options.
HCC in cirrhotic liver
Document Child-Pugh and MELD score. FLR requirements vary by hepatic background — normal liver greater than or equal to 20-25%; chemotherapy-injured liver (e.g., post-FOLFOX for CRLM) greater than or equal to 30%; cirrhotic liver greater than or equal to 40%. Portal hypertension (splenomegaly, varices) increases bleeding risk; document assessment. ICG-R15 test (hepatic function reserve) is used at many centers in cirrhotic patients.
Charting Tips
- Document Couinaud segments resected, as this drives reporting selection
- State CVP management strategy (low CVP reduces parenchymal bleeding)
- Note Pringle maneuver use, technique (continuous vs. intermittent), cycle length if intermittent, and total warm ischemia time
- Document retrohepatic IVC dissection and short hepatic vein ligation for right hepatectomy — these are critical steps for safety and completeness
- Document bile leak test method and result at end of case
- Orient specimen for pathology; mark at least one margin with suture
- FLR percentage should be in the note for major resections
Documentation & Reimbursement Considerations
- Report Hepatic Resection as the primary service when it is the definitive operation performed.
- These reporting options are mutually exclusive alternative primaries — select one based on extent of resection; do not bill them together.
- Couinaud segment-based resection: document which segments (I-VIII) are removed. Right hepatectomy = segments V, VI, VII, VIII. Left hepatectomy = segments II, III, IV. Extended right = V-VIII + segment IV. Accurate segment documentation drives accurate reporting selection.
- IOUS performed by a separate provider, such as intraoperative radiology, may be separately billable under that provider's NPI. Document IOUS use and findings regardless.
- 90-day global: postoperative biliary leak management, drain manipulation, and clinic visits are bundled. ERCP for biliary leak requires interventional billing but the surgical consultation component is included in the 90-day global.