Hepatorrhaphy (Liver Laceration Repair)
[Blunt / penetrating] liver injury, AAST Grade [III / IV / V], with [hemorrhagic shock / peritonitis / failed angioembolization]
Same
Hepatorrhaphy: [direct suture / argon beam / packing / tractotomy / omental packing], AAST Grade [X]
[***, MD/DO]
[Resident name]
General endotracheal. Massive transfusion protocol activated. Arterial line. Rapid infuser.
Patient presents with [blunt / penetrating] abdominal trauma with AAST Grade [III / IV / V] liver laceration. [Hemodynamic instability refractory to resuscitation / failed angioembolization / peritonitis.] Operative management indicated. [Damage control approach planned given pH [X], temp [X]°C, INR [X], lactate [X] mmol/L.] Risks including uncontrollable hemorrhage, bile leak, and liver failure discussed. Consent implied under emergency doctrine; patient's critical condition precluded delay.
AAST Grade [III / IV / V] liver laceration, [right lobe / left lobe / bilobar]. Grade V injuries involve retrohepatic vena cava or major hepatic veins.[Active arterial bleeding from [X] vessel / venous ooze from parenchyma / deep laceration with devitalized tissue]. [Bile staining noted / no biliary injury]. [Retrohepatic IVC involvement: [yes / no].]
The patient was taken emergently to the operating room. A midline laparotomy was performed. The abdomen was entered.
HEMORRHAGE CONTROL: Manual compression applied to the [right lobe / hepatic hilum]. [Pringle maneuver applied; hilar occlusion for [X] minutes total]. The liver laceration was identified.
[GRADE II-III, DIRECT REPAIR:] Surface lacerations cauterized with argon beam coagulator. Deep lacerations repaired with horizontal mattress sutures of [0-chromic / 0 Vicryl] placed parallel to the laceration edge. [Gelfoam / oxidized cellulose / topical thrombin] applied to the surface.
[GRADE III-IV, PACKING:] Given [ongoing coagulopathy / deep laceration], damage control packing was performed. [X] laparotomy pads placed into the [right subphrenic / perihepatic] space to tamponade bleeding. [Temporary closure performed; see concurrent DCL note.]
[TRACTOTOMY:] For through-and-through penetrating injury, a [finger-fracture / stapled] tractotomy was performed through the injury tract. [Bleeding intrahepatic vessels suture-ligated individually.]
[OMENTAL PACKING:] Omentum mobilized and packed into the hepatic laceration cavity for additional tamponade.
Hemostasis [achieved / controlled with packing]. [A closed-suction drain was placed in the perihepatic space.] [Temporary closure performed.] Fascia closed [/ temporary closure; see DCL note]. Patient tolerated the procedure [given clinical circumstances].
None
[Devitalized hepatic tissue to pathology / None]
[X] mL
[Perihepatic Jackson-Pratt drain / Packs in place]
Patient transferred to trauma ICU intubated. [Re-look in 24-48 hours for pack removal.]
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Blunt / penetrating] liver injury, AAST Grade [III / IV / V]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Hepatorrhaphy, AAST Grade [III / IV / V]: [argon beam / suture / packing / tractotomy / omental packing]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal; MTP activated; rapid infuser
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with AAST Grade [III / IV / V] liver laceration and hemodynamic instability [/ failed angioembolization]. [Damage control approach; pH ***, temp ***°C, INR ***, lactate *** mmol/L.] Consent implied under emergency doctrine.
FINDINGS: Grade [III / IV / V] laceration, [right / left lobe]. [Active arterial / venous bleeding.] [Bile staining.] [Retrohepatic IVC: not involved / involved].
DESCRIPTION OF PROCEDURE:
Emergency midline laparotomy. Manual compression and [Pringle *** min]. Laceration assessed. [Argon beam to surface lacerations.] [Grade II-III: horizontal mattress sutures 0-chromic; topical hemostatic agents.] [Grade III-IV: packing with *** lap pads; damage control.] [Tractotomy for penetrating: finger-fracture / stapled tractotomy; intrahepatic vessels suture-ligated.] [Omental packing.] Hemostasis [confirmed / controlled with packing]. [Perihepatic drain placed / packs in place.] [Temporary closure; see DCL note.] Patient to trauma ICU.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: None
COMPLICATIONS: None
DRAINS: [Perihepatic drain / Packs in place]
DISPOSITION: Patient to trauma ICU intubated. [Re-look 24-48 h.]
Signed: .ME, .MYDEGREE
.TODAYVariants
Retrohepatic IVC injury
Highest-mortality liver injury. Total hepatic vascular exclusion (THVE) may be required. Atriocaval shunt for complex retrohepatic IVC. Document approach, control method, and whether vascular surgery involved.
Re-look for pack removal
staged-or-related-procedure reporting is correct for the planned re-look; related unplanned return-to-the-operating-room reporting is for unplanned returns for complications and would under-reimburse. At re-look, document exact pack count removed (must match placed count), liver surface reassessment, drain function, and whether additional repair was required. If bile leak confirmed, consider ERCP at a later date.
Charting Tips
- Document AAST injury grade (2018 revision: Grade V = retrohepatic IVC or major hepatic vein injury) and which lobe(s) involved. Grade VI no longer exists — Grade V is the highest survivable grade.
- If Pringle maneuver was applied, document whether it was continuous or intermittent (clamp 15-20 min / release 5 min cycles) and total ischemia time.
- Document repair technique explicitly (suture ligation, packing, tractotomy, argon beam, omental packing) — reporting selection depends on this.
- Note whether bile staining was present, as this alerts to potential bile leak and may prompt early ERCP.
- Record lap pad count placed at index DCL and confirm the same count is removed at re-look (retained foreign body documentation).
- Retrohepatic IVC involvement (Grade V) must be explicitly noted, as it drives operative strategy (total hepatic vascular exclusion, atriocaval shunt, or damage-control packing).
- Document common bile duct inspection findings; CBD injury during hepatic repair warrants biliary drainage planning.
Documentation & Reimbursement Considerations
- Primary service: Report Hepatorrhaphy (Liver Laceration Repair) as the primary service when it is the definitive operation performed.
- Reporting selection depends on repair complexity; document the technique explicitly.
- Omental packing of a liver wound is part of the hepatorrhaphy and is not separately billable. Document omentum use in the note.
- Document whether angioembolization was performed pre- or postoperatively as an adjunct.
- 90-day global: delayed bile leak management, drain care, and wound visits are bundled. ERCP for biliary fistula within 90 days is a separate biliary endoscopy code. Staged-or-related-procedure reporting resets the global period; related unplanned return-to-the-operating-room reporting does not.