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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
J Am Coll Surg. Author manuscript; available in PMC 2014 June 1.
Published in final edited form as:
PMCID: PMC3769641
NIHMSID: NIHMS471990

Risk of Late-Onset Adhesions and Incisional Hernia Repairs after Surgery

Abstract

BACKGROUND

Long-term adhesion-related complications and incisional hernias after abdominal surgery are common and costly. There are few data on the risk of these complications after different abdominal operations.

STUDY DESIGN

We identified Medicare beneficiaries who underwent endovascular repair of an abdominal aortic aneurysm from 2001–2008 who presumably are not at risk for laparotomy-related complications. We identified all laparoscopic and open operations involving the abdomen, pelvis, or retroperitoneum and categorized them into 5 groups according to invasiveness. We then identified laparotomy-related complications for up to 5 years after the index operation and compared these with the baseline rate of complications in a control group of patients who did not undergo an abdominal operation.

RESULTS

We studied 85,663 patients, 7,513 (8.8%) of which underwent a laparotomy, including 2,783 major abdominal operations, 709 minor abdominal operations, 963 ventral hernia repairs, 493 retroperitoneal/pelvic operations, and 2,565 laparoscopic operations. Mean age was 76.7 years and 82.0% were male. Major abdominal operations carried the highest risk for adhesion-related complications (14.3% and 25.0% at 2 and 5 years compared with 4.0% and 7.8% for the control group; p < 0.001) and incisional hernias (7.8% and 12.0% compared with 0.6% and 1.2% for the control group; p < 0.001). Laparoscopic operations (4.6% and 10.7% for adhesions, 1.9% and 3.2% for incisional hernias) carried the lowest risk.

CONCLUSIONS

Late-onset laparotomy-related complications are frequent and their risk extends through 5 years beyond the perioperative period. With the advancement and expansion of laparoscopic techniques and its attendant lower risk for long-term complications, these results can alter the risk-to-benefit profile of various types of abdominal operations and can also strengthen the rationale for additional development of laparoscopic approaches to abdominal operations.

Long-term complications after abdominal surgery, including adhesion-related complications and incisional hernia repairs, are common and costly, but the risks for these complications have been poorly characterized. Although rarely fatal, both of these complications can have substantial clinical and cost implications because they frequently require additional hospitalizations and/or surgical procedures. These longer-term complications must be considered when counseling patients about the risks and benefits of surgery and different surgical approaches.

After undergoing laparotomy, 93% of patients have been shown to have adhesions at a subsequent operation1 and the risk of bowel enterotomy during reoperations complicated by adhesions is as high as 19%.2 Although many adhesions are asymptomatic, others cause serious complications, such as bowel obstruction and ischemia. The prevalence of incisional hernia after laparotomy is reported to be between 11% and 20%,3,4 and incisional hernia recurrence after surgical repair is as high as 45%.5,6 Incisional hernias cause pain and other more serious problems, such as bowel obstruction, incarceration, and strangulation. Surgeons are aware of these complications, but few studies have examined the risk of such complications for different types of abdominal procedures.7

Few data that we are aware of have examined the risks of laparotomy-related complications after various types of abdominal operations. Previously, we showed high rates of laparotomy-related complications after open abdominal aortic aneurysm (AAA) repair, but also noted a baseline rate of such complications after endovascular repair (EVAR).8,9 Because uncomplicated EVAR is confined to the arterial system, there should be no risk of laparotomy-related complications, so observed complications in the EVAR group were likely influenced by earlier abdominal surgery. We therefore studied the risks of late-onset laparotomy-related complications in a large cohort of patients undergoing EVAR to estimate the rates of laparotomy-related complications in a general elderly population.

METHODS

Patient selection

We used a previously identified cohort of all traditional Medicare beneficiaries with a diagnosis of AAA who underwent endovascular repair during the period 2001–2008 as our study group. We identified all traditional Medicare beneficiaries age 67 or older with at least 2 years of earlier Medicare claims who had a diagnosis of AAA (ICD-9-CM code 441.4) and underwent EVAR (code 39.71 endovascular implantation of graft). Benefi-ciaries enrolled in health maintenance organizations at any time during the study period and those not enrolled in both Medicare Parts A and B were excluded.

Identifying laparotomy/laparoscopic operations

We used Current Procedural Terminology codes to identify laparoscopic and open operations involving the abdomen, pelvis, or retroperitoneum (RP). We categorized these into 5 distinct laparotomy (LAP) groups based on the level of invasiveness and direct entry into the peritoneal space (see Appendix; online only): those who underwent major abdominal operations (eg, esophagectomy, colectomy, hepatectomy, pancreatectomy), minor abdominal operations (eg, open appendectomy, gastrostomy, cecostomy, ileostomy), abdominal wall hernia operations (inguinal hernias were excluded), RP/pelvic operations (eg, total abdominal hysterectomy, nephrectomy, cystectomy), and all laparoscopic operations. Those who underwent 2 operations more than 30 days apart where the second operation was not a study result were categorized according to their first operation. As a sensitivity analysis, we categorized them according to their most invasive operation, but this did not substantively affect our results.

Identifying late-onset laparotomy-related complications

We identified late-onset laparotomy-related complications using both ICD-9-CM diagnosis codes and CPT procedure codes (Table 1). Complications were categorized as hernia-related or adhesion-related. Hernia-related complications included ventral incisional hernia repairs. Adhesion-related complications were characterized as operative (lysis of adhesions, small bowel resection, and large bowel resection) and nonoperative (admission for bowel obstruction without an operation). To ensure that small and large bowel resections were performed for adhesions or obstructions rather than diverticular disease or carcinoma, we required all bowel resection procedure codes to be accompanied by a diagnosis code for bowel obstruction.

Table 1
ICD-9 Diagnosis Codes and CPT Procedure Codes Used to Identify Laparotomy-Related Complications

To be considered a late-onset laparotomy complication, the event had to occur at least 30 days after the initial operation. Complications that occurred within 30 days of the operation were excluded. Because all of the operative complications (lysis of adhesions, small bowel resection, large bowel resection) could have also qualified as an initial LAP operation, these were only counted as a complication if they were preceded by an earlier operation.

Control group

We included as a control population all patients who did not undergo a designated LAP operation for the 2-year period before their EVAR. We imposed this 2-year “clean” period to limit the potential impact of any pre-existing adhesions resulting from an earlier operation that occurred before enrollment in Medicare. The date of their EVAR then became their index date to determine rates of subsequent complications. We chose a 2-year period because in a previous study we found that most laparotomy-related complications after open AAA repair occurred within 2 years of the operation.8 In addition, previous studies have shown that most incisional hernias occur within 12 months of the laparotomy,10,11 and the greatest percentage of readmissions due to adhesion-related complications occurs in the first year after laparotomy.7

If the first episode after the clean period is a nonoperative admission for a bowel obstruction, they are counted as part of the baseline complication rate in the control population for nonoperative admissions due to adhesions, but continue to be followed until an operative complication is encountered. If the first episode after the clean period is an operative complication, they are counted as part of the baseline complication rate in the control population. See Figure 1 for a flowchart demonstrating the creation of the 5 LAP groups and the control group.

Figure 1
Flow chart demonstrating the creation of the 5 laparotomy (LAP) groups and the control group. All patients enter the study 2 years before the date of their endovascular aneurysm repair (EVAR).

Statistical analysis

We calculated the total number of patients who underwent an operation in each of the 5 LAP groups and in the control group and then calculated the number of those patients with a laparotomy-related complication 30 days or more after the index operation (or index date for the control group). Freedom from late-onset laparotomy-related complications at 2 and 5 years was estimated with the use of Kaplan-Meier life-table methods. We tested for differences in time to a complication between the control group and each of the 5 LAP groups by deriving approximate z-tests from the fitted confidence limits at 2 and 5 years and evaluating a p value for the difference.

Categorical variables were compared with chi-square tests and continuous variables were compared with Student’s t-test or Wilcoxon rank sum test, where appropriate. All statistical analyses were performed using SAS 9.1.3 statistical software (SAS Institute). This study was approved by the Institutional Review Board at Harvard Medical School.

RESULTS

We studied 85,663 patients who underwent EVAR between 2001 and 2008 and who had at least 2 years of Medicare enrollment before their EVAR procedure. Of these, 7,513 patients (8.8%) underwent one of the predefined LAP operations during the study period: 2,783 (37.0%) had a major abdominal operation, 709 (9.4%) had a minor abdominal operation, 963 (12.8%) had a ventral hernia repair without any record of an earlier LAP operation, 493 (6.6%) had an RP/pelvic operation, and 2,565 (34.1%) had a laparoscopic operation. The control group consisted of 78,150 patients who had a 2-year “clean” period during which there were no LAP operations.

Mean age of the control group and all patients in the 5 LAP groups were similar (76.8 vs 76.5 years). Eighty-two percent of the study group patients were male (Table 2). Patients in all 5 LAP groups had a higher incidence of comorbid conditions when compared with the control group. Those who underwent abdominal wall hernia operations were younger. Patients undergoing RP/pelvic operations were more likely to be women.

Table 2
Demographic and Comorbidities of the Patients Undergoing an Operation in Each of the 5 Laparotomy Groups and the Control Group

Late-onset laparotomy-related complications

Risk for late-onset laparotomy-related complications extended well out to 5 years for all 5 LAP groups (Table 3). Major abdominal operations had the highest risk of complications compared with the control group: 4.8% and 8.8% (p < 0.001, at 2 and 5 years) for operative adhesion complications and 14.3% and 25.0% (p < 0.001, at 2 and 5 years) for any adhesion complications (both operative and nonoperative). For operative adhesion complications at 5 years, major abdominal operations conveyed the most risk (p < 0.001), followed by abdominal wall hernia operations and laparoscopic operations (both p < 0.05). Among the 5 LAP groups, RP/pelvic and laparoscopic operations had the lowest risk for any adhesion complications compared with the control group (5.1% and 10.6% at 2 and 5 years for RP/pelvic [p = NS for both] and 4.6% [p = NS] and 10.7% [p < 0.001] at 2 and 5 years for laparoscopic). Abdominal wall hernia operations and minor abdominal operations had significantly higher rates of any adhesion complications compared with the control group, although the risk was not as high as with major abdominal operations.

Table 3
Probability of Late-Onset Laparotomy-Related Complications at 2 and 5 Years after the Index Operation (or Index Date for the Control Population)

All 5 LAP groups had an increased risk for incisional hernia repairs at both 2 and 5 years compared with the control group (all p < 0.001 except RP/pelvic p < 0.05 at 2 years). Major abdominal operations conveyed the highest risk (7.8% and 12.0%, at 2 and 5 years), followed by abdominal wall hernia repairs (3.6% and 7.4%). Retroperitoneum/pelvic (2.5% and 4.6%) and laparoscopic operations (1.9% and 3.2%) conveyed the lowest risk, although still significantly higher than the control group. When examining any surgical complication (incisional hernia repair, bowel resection, or lysis of adhesions), major abdominal operations conveyed the highest risk at 2 and 5 years (11.1% and 18.1%; p < 0.001). The 4 other LAP groups had higher rates of any surgical complication as well, but these were less than half the risk associated with major abdominal operations.

The control group had low rates of de novo operative adhesion complications (0.8% and 1.7%, at 2 and 5 years) and incisional hernia repairs (0.6% and 1.2%). However, they did have a 3.2% and 6.2% risk for nonoperative adhesion complications at 2 and 5 years, which likely represent bowel obstructions that arise for other reasons or from operations that occurred before the 2-year “clean” window.

Freedom from operative, nonoperative, and any adhesion-related complications are shown in Figures 2A, 2B, and 2C, respectively. Freedom from incisional hernia complications and any surgical complication (incisional hernia repair, bowel resection, or lysis of adhesions) are shown in Figures 2D and 2E. These results mirror those reported for the discrete 2-and 5-year follow-up periods.

Figure 2
(A) Freedom from operative late-onset laparotomy-related adhesion complications (bowel resection or lysis of adhesions) in each of the 5 laparotomy (LAP) groups and the control group. Standard error does not exceed 10% for all survival curves. (B) Freedom ...

DISCUSSION

With the growth of minimally invasive techniques, the risk of laparotomy-related complications after abdominal operations might be changing. Even for major abdominal operations, however, these risks have been poorly defined previously. In addition, few earlier studies have examined the risk of such complications for different types of abdominal operations. In this study, we used a cohort of Medicare patients who underwent EVAR to study the risk of late-onset laparotomy-related complications for open and laparoscopic operations involving entry into the abdomen.

We found that major abdominal operations have the highest risk for late-onset laparotomy-related complications at 2 and 5 years post surgery. At 5 years, one fourth of all elderly patients who have undergone a major abdominal operation are readmitted for an adhesion-related complication (operative and nonoperative) and 12.0% have undergone repair of an incisional hernia. In contrast, laparoscopic procedures carry the lowest risk for late-onset laparotomy-related complications so the widespread adoption of laparoscopic techniques has likely led to a marked decrease in these types of complications. Finally, procedures performed outside of the peritoneum (RP/pelvic) also have little risk of obstruction.

Our findings provide estimates for a broader range of operations than previously reported in the literature. The Surgical and Clinical Adhesions Research Study, a large retrospective study using the Scottish National Health Service Database, found that during a 10-year period, 5.7% of all readmissions in patients who underwent open abdominal and pelvic operations were “directly” related to postoperative adhesions and that 38.6% of all readmissions were “possibly” related to postoperative adhesions.7 These findings suggest that our overall complication rate of 25.0% for major procedures might be an underestimate, as some patients admitted with diagnoses of abdominal pain, nausea, and vomiting without a diagnosis code for obstruction might have postoperative adhesions as the cause of their symptoms. In contrast, however, we found that operative intervention to relieve an obstruction due to adhesions at 5 years was required in 8.8% of patients undergoing a major abdominal operation, which is more than double the 10-year rate of 3.8% seen in the Surgical and Clinical Adhesions Research study and the 3.3% rate reported by Menzies and Ellis during a 25-year follow-up period.1 However, these studies included patients undergoing minor abdominal operations and pelvic operations, limiting direct comparison with our results and highlighting the importance of examining operations by their degree of invasiveness.

Persons undergoing laparascopic operations were found to have a low risk for late-onset laparotomy-related complications in our study. Previous studies examining the risk of complications after laparoscopic surgery have been limited to comparisons with their open counterpart and have produced mixed results. Some suggest that the laparoscopic approach is associated with a lower risk of complications and others have shown no difference.12,13 For instance, the CLASICC (Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer) trial,14 comparing laparoscopically assisted with open colorectal surgery, found no difference in intestinal obstruction (2.0% vs 2.3%) or incisional hernia (7.4% vs 8.6%) at 3 years. In contrast, Rosin and colleagues,15 in a study of 306 laparoscopic colon and rectal procedures (there was no open surgical cohort), found a 1.3% rate of postoperative bowel obstruction during 8 years, which is much less than the 5-year rate of 10.7% after laparoscopic operations in our study. Our study examined all laparoscopic procedures and shows that when compared with major abdominal operations, laparoscopic procedures have a substantially lower risk for postoperative adhesion and incisional hernia-related complications. As laparoscopic techniques continue to evolve, this can affect the decision-making process of surgeons.

We also found a high rate of incisional hernia repairs after major abdominal operations at 5 years (12.0%), consistent with earlier studies that have shown the development of incisional hernias after abdominal operations to be between 11% and 20%.3,4 Mudge and Hughes, during a 10-year period, found that incisional hernias developed in 11% (62 of 564) of patients undergoing major abdominal operations and that 1.8% (10 of 564) underwent incisional hernia repair. Our results are likely indicative of the most clinically significant hernias because we only identified patients who underwent repair of their incisional hernias. Many ventral incisional hernias go unrepaired because they are asymptomatic and/or the risks of repair outweigh the benefits. One potential confounder that can affect our incisional hernia results is that patients with AAA might be at an increased risk for postoperative incisional hernias when compared with patients without AAA,16 although the low rate of incisional hernias in our control group argues against this.

The strengths of the 100% Medicare sample are its large size, longitudinal design, and broad representation of the elderly US population. However, there are several limitations to our study. First, administrative data are subject to coding errors. We attempted to limit the effect of these problems by using physician and hospital codes rather than hospital codes only. Second, several of the hernia repair codes are stated to be for “incisional or ventral” hernias and are not specific. We chose to treat the code as a complication for incisional hernia repair if it occurred during the follow-up period. Third, we required a 2-year clean period to limit the impact of pre-existing adhesions for the control group, but we lacked data on operations that occurred before this period. The rate of complications we observe in the control population likely reflects some operations that happened before the clean period. Finally, we studied a pre-existing cohort of patients who had undergone EVAR. Because EVAR is confined to the vascular system, there is no reason to expect that these would result in any increased risk of the complications we studied. As stated earlier, patients with AAA might be at an increased risk for developing incisional hernias after surgery, potentially limiting generalizability of our results to the general elderly population.

CONCLUSIONS

Late-onset laparotomy-related complications are frequent and their risk extends well beyond the perioperative period. The risk of late-onset complications is highest in patients undergoing major abdominal operations, and laparoscopic operations have the lowest risk of complications. These late risks need to be discussed with the patient to truly achieve informed consent. In addition, with the advancement and expansion of laparoscopic techniques and their attendant lower risk for long-term complications, these results might alter the risk-to-benefit profile of various types of abdominal operations and also strengthen the rationale for additional development of laparoscopic approaches to abdominal operations.

Acknowledgments

This work was supported by the NIH T32 Harvard-Longwood Research Training in Vascular Surgery grant HL007734 and NIH grant 1RC4MH092717-01 for comparative effectiveness research.

Abbreviations and Acronyms

AAA
abdominal aortic aneurysm
EVAR
endovascular repair
LAP
laparotomy
RP
retroperitoneum

Appendix

The Current Procedural Terminology codes used to identify all laparoscopic and open operations involving the abdomen, pelvis, and retroperitoneum and the 5 laparotomy groups they were categorized into: major abdominal operations, minor abdominal operations, abdominal wall hernia repairs, retroperitoneal/pelvic operations, and laparoscopic operations

CPTDescription of procedure
Major abdominal operations
20102Exploration of penetrating wound; abdomen/flank/back
43107Total esophagectomy; with pharyngogastrostomy or cervical esophagogastrostomy (transhiatal)
43108 with colon interposition or small intestine reconstruction
43112Total esophagectomy, with thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy
43113 with colon interposition or small intestine reconstruction
43116Partial esophagectomy, cervical, with free intestinal graft, microvascular anastomosis and intestinal reconstruction
43117Partial esophagectomy, distal two thirds, with or without proximal gastrectomy (Ivor Lewis)
43118with colon interposition or small intestine reconstruction
43121Partial esophagectomy, distal two thirds, with thoracotomy only
43122Partial esophagectomy, thoracoabdominal or abdominal approach
43123 with colon interposition or small intestine reconstruction
43320Esophagogastrostomy (cardioplasty), with or without vagotomy and pyloroplasty
43324Esophagogastric fundoplasty (eg, Nissen, Belsey IV, Hill procedures)
43325Esophagogastric fundoplasty; with fundic patch (Thal-Nissen procedure)
43326 with gastroplasty (eg, Collis)
43340Esophagojejunostomy (without total gastrectomy); abdominal approach
43360Gastrointestinal reconstruction for previous esophagectomy; with stomach, with or without pyloroplasty
43361 with colon interposition or small intestine reconstruction
43400Ligation, direct, esophageal varices
43401Transection of esophagus with repair, for esophageal varices
43405Ligation or stapling at gastroesophageal junction for pre-existing esophageal perforation
43415Suture of esophageal wound or injury; transthoracic or transabdominal approach
43425Closure of esophagostomy or fistula; transthoracic or transabdominal approach
43496Free jejunum transfer with microvascular anastomosis
43620Gastrectomy, total; with esophagogastrostomy
43621 with Roux-en-Y reconstruction
43622 with formation of intestinal pouch, any type
43631Gastrectomy, partial, distal; with gastroduodenostomy
43632 with gastrojejunostomy
43633 with Roux-en-Y reconstruction
43634 with formation of intestinal pouch
43635Vagotomy when performed with partial distal gastrectomy
43640Vagotomy including pyloroplasty, with or without gastrostomy; truncal or selective
43641 parietal cell (highly selective)
43810Gastroduodenostomy
43820Gastrojejunostomy; without vagotomy
43825 with vagotomy, any type
43842Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical banded gastroplasty
43843 other than vertical-bounded gastroplasty
43845Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy
43846Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb Roux-en-Y gastroenterostomy
43847 with small intestine reconstruction to limit absorption
43848Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device
43850Revision of gastroduodenal anastomosis (gastrojejunostomy) with reconstruction; without vagotomy
43855 with vagotomy
43860Revision of gastrojejunal anastomosis, with or without partial gastrectomy or intestine resection; without vagotomy
43865 with vagotomy
43880Closure of gastrocolic fistula
44005Enterolysis (freeing of intestinal adhesion)
44010Duodenotomy, for exploration, biopsy(s), or foreign body removal
44015Tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method
44020Enterotomy, small intestine, other than duodenum; for exploration, biopsy(s), or foreign body removal
44021 for decompression (eg, Baker tube)
44025Colotomy, for exploration, biopsy(s), or foreign body removal
44050Reduction of volvulus, intussusception, internal hernia, by laparotomy
44055Correction of malrotation by lysis of duodenal bands and/or reduction of midget volvulus (eg, Ladd procedure)
44110Excision of one or more lesions of small or large intestine not requiring anastomosis; single enterotomy
44111 multiple enterotomies
44120Enterectomy, resection of small intestine; single resection and anastomosis
44121 each additional resection and anastomosis
44125 with enterostomy
44126Enterectomy, resection of small intestine for congenital atresia, single resection and anastomosis; without tapering
44127 with tapering
44128 each additional resection and anastomosis
44130Enteroenterostomy, anastomosis of intestine, with or without cutaneous enterostomy
44133Donor enterectomy, open; partial, from living donor
44135Intestinal allotransplantation; from a cadaver donor
44136 from living donor
44137Removal of transplanted intestinal allograft, complete
44139Mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy
44140Colectomy, partial; with anastomosis
44141 with skin-level cecostomy or colostomy
44143 with end colostomy and closure of distal segment (Hartmann-type procedure)
44144 with resection, with colostomy or ileostomy and creation of mucofistula
44145 with coloproctostomy (low pelvic anastomosis)
44146 with coloproctostomy (low pelvic anastomosis); with colostomy
44147 abdominal and transanal approach
44150Colectomy, total, abdominal, without proctectomy; with ileostomy or ileoproctostomy
44151 with continent ileostomy
44155Colectomy, total, abdominal, with proctectomy; with ileostomy
44156 with continent ileostomy
44157 with ileoanal anastomosis, includes loop ileostomy, and rectal mucosectomy, when performed
44158 with ileoanal anastomosis, creation of ileal reservoir (S or J), includes loop ileostomy, and rectal mucosectomy
44160Colectomy, partial, with removal or terminal ileum with ileocolostomy
44314Revision of ileostomy; complicated (reconstruction in-depth)
44345Revision of colostomy; complicated (reconstruction in-depth)
44602Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; single perforation
44603 multiple perforations
44604Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; without colostomy
44605 with colostomy
44615Intestinal stricturoplasty (enterotomy and enterorrhaphy) with or without dilation, for intestinal obstruction
44620Closure of enterostomy, large or small intestine
44625 with resection and anastomosis other than colorectal
44626 with resection and colorectal anastomosis (eg, closure of Hartmann-type procedure)
44640Closure of intestinal cutaneous fistula
44650Closure of enteroenteric or enterocolic fistula
44660Closure of enterovesical fistula; without intestinal or bladder resection
44661 with intestine and/or bladder resection
44680Intestinal plication
44700Exclusion of small intestine from pelvis by mesh or other prosthesis, or native tissue (eg, bladder or omentum)
44701Intraoperative colonic lavage
44799Unlisted procedure, intestine
45110Proctectomy; complete, combined abdominoperineal, with colostomy
45111Proctectomy; partial resection of rectum, transabdominal approach
45112Proctectomy, combined abdominoperineal pull-through procedure (eg, colo-anal anastomosis)
45113Proctectomy, partial, with rectal mucosectomy, ileoanal anastomosis, creation of ileal reservoir (S or J)
45114Proctectomy, partial, with anastomosis; abdominal and transsacral approach
45119Proctectomy, combined abdominoperineal pull-through procedure, with creation of colonic reservoir (eg, J pouch)
45120Proctectomy, complete, abdominal and perineal approach; with pull through procedure and anastomosis
45121 with subtotal or total colectomy, with multiple biopsies
45123Proctectomy, partial, without anastomosis, perineal approach
45126Pelvic exenteration for colorectal malignancy, with proctectomy (with or without colostomy)
45135Excision of rectal procidentia, with anastomosis; abdominal and perineal approach
45136Excision of ileoanal reservoir with ileostomy
45540Proctopexy (eg, for prolapse); abdominal approach
45550 with sigmoid resection, abdominal approach
45560Repair of rectocele
45562Exploration, repair, and presacral drainage for rectal injury
45563 with colostomy
45800Closure of rectovesical fistula
45805 with colostomy
45820Closure of rectourethral fistula
45825 with colostomy
46712Repair of ileoanal pouch fistula/sinus, pouch advancement; combined transperineal and transabdominal approach
46735Repair of high imperforate anus without fistula; combined transabdominal and sacroperineal approaches
46742Repair of high imperforate anus with rectourethral or rectovaginal fistula; combined transabdominal and sacroperineal
46746Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, combined abdominal and sacroperineal
46748 with vaginal lengthening by intestinal graft or pedicle flaps
47010Hepatotomy; open for drainage of abscess or cyst, 1 or 2 stages
47011 for percutaneous drainage of abscess or cyst, 1 or 2 stages
47015Laparotomy, with aspiration and/or injection of hepatic parasitic (eg, amoebic or echinococcal) cyst(s) or abscess(es)
47120Hepatectomy, resection of liver, partial lobectomy
47122 trisegmentectomy
47125 total left lobectomy
47130 total right lobectomy
47135Live allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age
47136 heterotopic, partial or whole, from cadaver or living donor, any age
47140Donor hepatectomy (including cold preservation), from living donor; left lateral segment only (segments II and III)
47141 total left lobectomy (segments II, II, and IV)
47142 total right lobectomy (segments V, VI, VII, and VIII)
47300Marsupialization of cyst or abscess of liver
47350Management of liver hemorrhage; simple suture of liver wound or injury
47360 complex suture of liver wound or injury, with or without hepatic artery ligation
47361 exploration of hepatic wound, extensive debridement, coagulation and/or suture, with or without packing of liver
47362 re-exploration of hepatic wound for removal of packing
47400Hepaticotomy or hepaticostomy with exploration, drainage or removal of calculus
47420Choledochotomy or choledochostomy with exploration, drainage, or removal or calculus
47425 with transduodenal sphincterotomy or sphincteroplasty
47460Transduodenal sphincterotomy or sphincteroplasty, with or without transduodenal extraction of calculus
47480Cholecystotomy or cholecystostomy with exploration, drainage, or removal of calculus
47600Percutaneous cholecystostomy
47605Cholecystectomy; with cholangiography
47610Cholecystectomy with exploration of common duct
47612 with choledochoenterostomy
47620 with transduodenal sphincterotomy or sphincteroplasty, with or without cholangiography
47700Exploration for congenital atresia of bile ducts, without repair, with or without liver biopsy
47701Portoenterostomy (eg, Kasai procedure)
47711Excision of bile duct tumor, with or without primary repair of bile duct; extrahepatic
47712 intrahepatic
47715Excision of choledochal cyst
47720Cholecystoenterostomy; direct
47721 with gastroenterostomy
47740 Roux-en-Y
47741 Roux-en-Y with gastroenterostomy
47760Anastomosis, of extrahepatic biliary ducts and gastrointestinal tract
47765Anastomosis, on intrahepatic ducts and gastrointestinal tract
47780Anastomosis, Roux-en-Y, of extrahepatic biliary ducts and gastrointestinal tract
47785Anastomosis, Roux-en-Y, of intrahepatic biliary ducts and gastrointestinal tract
47800Reconstruction, plastic, of extrahepatic biliary ducts with end-to-end anastomosis
47801Placement of choledochal stent
47802U-tube hepaticoenterostomy
47900Suture of extrahepatic biliary duct for pre-existing injury
48000Placement of drains, peripancreatic, for acute pancreatitis
48001 with cholecystostomy, gastrostomy and jejunostomy
48020Removal of pancreatic calculus
48100Biopsy of pancreas, open (eg, fine-needle aspiration, needle core biopsy, wedge biopsy)
48105Resection or debridement of pancreas and peripancreatic tissue for acute necrotizing pancreatitis
48120Excision of lesion of pancreas (eg, cyst, adenoma)
48140Pancreatectomy, distal subtotal, with or without splenectomy; without pancreaticojejunostomy
48145 with pancreaticojejunostomy
48146Pancreatectomy, distal, near-total with preservation of duodenum (Child-type procedure)
48148Excision of ampulla of Vater
48150Pancreatectomy (Whipple-type procedure); with pancreatojejunostomy
48152 without pancreatojejunostomy
48153Pancreatectomy (pylorus-spearing, Whipple-type procedure); with pancreatojejunostomy
48154 without pancreatojejunostomy
48155Pancreatectomy, total
48160Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells
48500Marsupialization of pancreatic cyst
48510External drainage, pseudocyst of pancreas; open
48520Internal anastomosis of pancreatic cyst to gastrointestinal tract; direct
48540 Roux-en-Y
48545Pancreatorrhaphy for injury
48547Duodenal exclusion with gastrojejunostomy for pancreatic injury
48548Pancreaticojejunostomy, side to side anastomosis (Puestow-type operation)
48554Transplantation of pancreatic allograft
48556Removal of transplanted pancreatic allograft
48999Unlisted procedure, pancreas
49000Exploratory laparotomy, with or without biopsy(s)
49002Reopening of recent laparotomy
49010Exploration, retroperitoneal area with or without biopsy(s)
49020Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; open
49040Drainage of subdiaphragmatic or subphrenic abscess; open
49060Drainage of retroperitoneal abscess; open
49062Drainage of extraperitoneal lymphocele to peritoneal cavity; open
49203Excision or destruction, open, intra-abdominal tumors; largest tumor 5 cm diameter
49204 largest tumor 5.1 to 10.0 cm diameter
49205 largest tumor >10.0 cm diameter
49220Staging laparotomy for Hodgkins disease or lymphoma
49402Removal or peritoneal foreign body from peritoneal cavity
50660Ureterectomy, total, ectopic ureter, combination abdominal, vaginal, and/or perineal approach
50800Ureteroenterostomy, direct anastomosis of ureter to intestine
50810Ureterosigmoidostomy, with creation of sigmoid bladder and establishment of abdominal or perineal colostomy
50815Uretercolon conduit, including intestine anastomosis
50820Ureteroileal conduit (ileal bladder), including intestine anastomosis (Bricker operation)
50825Continent diversion, including intestine anastomosis using any segment of small and/or large intestine
50830Urinary diversion (eg, taking down of ureteroileal conduit, ureterosigmoidostomy or ureteroneocystostomy)
50840Replacement of all or part of ureter by intestine segment, including intestine anastomosis
50860Ureterostomy, transplantation of ureter to skin
50900Ureterohhaphy, suture of ureter
50920Closure of ureterocutaneous fistula
50930Closure of ureterovisceral fistula (including visceral repair)
50940Delegation of ureter
51570Cystectomy, complete
51575 with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes
51580Cystectomy, complete, with ureterosigmoidostomy or ureterocutaneous transplantations
51585 with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes
51590Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis
51595 with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes
51596Cystectomy, complete, with continent diversion, using segment of small and/or large intestine to construct neobladder
51597Pelvic exenteration, complete, for vesical, prostatic or urethral malignancy
54535Orchiectomy, radical, for tumor; with abdominal exploration
54560Exploration for undescended testis with abdominal exploration
55535Excision of varicocele or ligation of spermatic veins for varicocele; abdominal approach
55540 with hernia repair
57305Closure of rectovaginal fistula; abdominal approach
57307 abdominal approach, with concomitant colostomy
58240Pelvic exenteration for gynecologic malignancy
58960Laparotomy, for staging or restaging of ovarian, tubal, or primary peritoneal malignancy (second look)
Minor abdominal operations
43101Excision of lesion, esophagus; thoracic or abdominal approach
43246Upper gastrointestinal endoscopy with directional placement of percutaneous gastrostomy tube
43330Esophagomyotomy (Heller-type); abdominal approach
43350Esophagomyotomy, fistulization of esophagus, external; abdominal approach
43500Gastrostomy; with exploration or foreign body removal
43501Gastrostomy; with suture repair of bleeding ulcer
43502Gastrostomy; with suture repair of pre-existing esophagogastric laceration (eg, Mallory-Weiss)
43510Gastrostomy; with esophageal dilation and insertion of permanent intraluminal tube
43520Pyloromyotomy, cutting of pyloric muscle (Fredet-Ramstedtetype operation)
43605Biopsy of stomach; by laparotomy
43610Excision, local; ulcer or benign tumor of stomach
43611Excision, local; malignant tumor of stomach
43800Pyloroplasty
43830Gastrostomy, open; without construction of gastric tube (eg, Stamm procedure)
43832Gastrostomy, open; with constriction of gastric tube (eg, Janeway procedure)
43840Gastrorrhaphy, suture of perforated duodenal or gastric ulcer, wound, or injury
43870Closure of gastrostomy, surgical
43881Implantation or replacement of gastric neurostimulator electrodes, antrum, open
43882Revision or removal of gastric neurostimulator electrodes, antrum, open
44300Placement, enterostomy or cecostomy, tube open (eg, for feeding or decompression)
44310Ileostomy or jejunostomy, non-tube
44312Revision of ileostomy; simple (release of superficial scar)
44316Continent ileostomy (Kock procedure)
44320Colostomy or skin level cecostomy
44322Colostomy or skin level cecostomy; with multiple biopsies (eg, for congenital megacolon)
44340Revision of colostomy; simple (release of superficial scar)
44346Revision of colostomy; with repair of paracolostomy hernia
44800Excision of Meckel’s diverticulum (diverticulectomy) or omphalomesenteric duct
44820Excision of lesion of mesentery
44850Suture of mesentery
44899Unlisted procedure, Meckel’s diverticulum and the mesentery
44900Incision and drainage of appendiceal abscess; open
44950Appendectomy
44955Appendectomy; when done for indicated purpose at time of other major procedure
44960Appendectomy; for ruptured appendix with abscess or generalized peritonitis
47100Biopsy of liver, wedge
47380Ablation, open, of one or more liver tumor(s); radiofrequency
47381Ablation, open, of one or more liver tumor(s); cryosurgical
47382Ablation, one or more liver tumor(s), percutaneous, radiofrequency
49250Umbilectomy, omphalectomy, excision of umbilicus
49255Omentectomy, epiploectomy, resection of omentum
49419Insertion of intraperitoneal cannula or catheter, with subcutaneous reservoir, permanent
49420Insertion of intraperitoneal cannula or catheter for drainage or dialysis; temporary
49421Insertion of intraperitoneal cannula or catheter for drainage or dialysis; permanent
49422Removal of permanent intraperitoneal cannula or catheter
49423Exchange of previously placed abscess or cyst drainage catheter under radiological guidance
49425Insertion of peritoneal-venous shunt
49426Revision of peritoneal-venous shunt
49428Ligation of peritoneal-venous shunt
49429Removal of peritoneal-venous shunt
49435Insertion of subcutaneous extension to intraperitoneal cannula or catheter with remote chest exit site
49436Delayed creation of exit site from embedded subcutaneous segment of intraperitoneal cannula or catheter
49440Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance
49441Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance
49442Insertion of cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance
50845Cutaneous appendico-vesicostomy
62223Creation of shunt; ventriculo-peritoneal, -pleural, other terminus
62258Removal of complete cerebrospinal fluid shunt system; with replacement
63303Vertebral corpectomy; extradural, lumbar or sacral by transperitoneal or retroperitoneal approach
63307Vertebral corpectomy; intradural, lumbar or sacral by transperitoneal or retroperitoneal approach
63740Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or other, including laminectomy
Abdominal wall hernia operations
49560Repair initial incisional or ventral hernia; reducible
49561Repair initial incisional or ventral hernia; incarcerated or strangulated
49565Repair recurrent incisional or ventral hernia; reducible
49566Repair recurrent incisional or ventral hernia; incarcerated or strangulated
49568Implantation of mesh for incisional or ventral hernia repair or for closure of debridement for necrotizing tissue infection
49570Repair epigastric hernia; reducible
49572Repair epigastric hernia; incarcerated or strangulated
49580Repair umbilical hernia, younger than 5 years; reducible
49582Repair umbilical hernia, younger than 5 years; incarcerated or strangulated
49585Repair umbilical hernia, age 5 years or older; reducible
49587Repair umbilical hernia, age 5 years or older; incarcerated or strangulated
49590Repair spigelian hernia
49600Repair of small omphalocele, with primary closure
49605Repair of large omphalocele or gastroschisis; with or without prosthesis
49606Repair of large omphalocele or gastroschisis; with removal of prosthesis, final reduction and closure
49610Repair of omphalocele (Gross-type operation); first stage
49611Repair of omphalocele (Gross-type operation); second stage
49900Suture, secondary, of abdominal wall for evisceration or dehiscence
49904Omental flap, extra-abdominal (eg, for reconstruction of sternal and chest wall defects)
49905Omental flap, intra-abdominal
49906Free omental flap with microvascular anastomosis
49999Unlisted procedure, abdomen, peritoneum and omentum
Retroperitoneal/pelvic operations
50010Renal exploration, not necessitating other specific procedures
50020Drainage of perirenal or renal abscess; open
50040Nephrostomy, nephrotomy with drainage
50045Nephrotomy, with exploration
50060Nephrolithotomy; removal of calculus
50065Nephrolithotomy; secondary surgical operation for calculus
50070Nephrolithotomy; complicated by congenital kidney abnormality
50075Nephrolithotomy; removal of large staghorn calculus filling renal pelvis and calyces
50100Transection of repositioning of aberrant renal vessels
50120Pyelotomy; with exploration
50125Pyelotomy; with drainage, pyelostomy
50130Pyelotomy; with removal of calculus (pyelolithotomy, pelviolithotomy, including coagulum pyelolithotomy)
50135Pyelotomy; complicated (eg, secondary operation, congenital kidney abnormality)
50205Renal biopsy by surgical exposure of kidney
50220Nephrectomy; including partial ureterectomy, any open approach including rib resection
50225Nephrectomy; complicated because of previous surgery on same kidney
50230Nephrectomy; radical, with regional lymphadenectomy and/or vena cava thrombectomy
50234Nephrectomy with total ureterectomy and bladder cuff; through same incision
50236Nephrectomy with total ureterectomy and bladder cuff; through separate incision
50240Nephrectomy, partial
50250Ablation, open, one or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound
50280Excision or unroofing of cyst(s) of kidney
50290Excision of perinephric cyst
50320Donor nephrectomy; open, from liver donor
50340Recipient nephrectomy
50360Renal allotransplantation, implantation of graft; without recipient nephrectomy
50365Renal allotransplantation, implantation of graft; with recipient nephrectomy
50370Removal of transplanted renal allograft
50380Renal autotransplantation, reimplantation of kidney
50400Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis; simple
50405Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis; complicated
50500Nephrorrhaphy, suture of kidney wound or injury
50520Closure of nephrocutaneous or pyelocutaneous fistula
50525Closure of nephrovisceral fistula (eg, renocolic), including visceral repair; abdominal approach
50540Symphysiotomy for horseshoe kidney with or without pyeloplasty, unilateral or bilateral (one operation)
50600Ureterotomy with exploration or drainage
50605Ureterotomy for insertion of indwelling stent, all types
50650Ureterectomy, with bladder cuff
50700Ureteroplasty, plastic operation on ureter (eg, stricture)
50715Ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis
50722Ureterolysis for ovarian vein syndrome
50725Ureterolysis for retrocaval ureter, with reanastomosis of upper urinary tract or vena cava
50727Revision of urinary-cutaneous anastomosis (any type urostomy);
50728Revision of urinary-cutaneous anastomosis (any type urostomy); with repair of fascial defect and hernia
50740Ureteropyelostomy, anastomosis of ureter and renal pelvis
50750Ureterocalycostomy, anastomosis of ureter to renal calyx
50760Ureteroureterostomy
50770Transureteroureterostomy, anastomosis of ureter to contralateral ureter
50780Ureteroneocystostomy; anastomosis of single ureter to bladder
50782Ureteroneocystostomy; anastomosis of duplicated ureter to bladder
50783Ureteroneocystostomy; with extensive ureteral tailoring
50785Ureteroneocystostomy; with vesico-psoas hitch or bladder flap
51020Cystotomy or cystostomy; with fulguration and/or insertion of radioactive material
51030Cystotomy or cystostomy; with cryosurgical destruction of intravesical lesion
51040Cystostomy, cystotomy with drainage
51045Cystotomy, with intersection of ureteral catheter or stent
51050Cystolithotomy, cystotomy with removal of calculus, without vesical neck resection
51060Transvesical ureterolithotomy
51065Cystotomy, with calculus basket extraction and/or ultrasonic or electrohydraulic fragmentation of ureteral calculus
51080Drainage of perivesical or prevesical space abscess
51500Excision of urachal cyst or sinus, with or without umbilical hernia repair
51520Cystotomy; for simple excision of vesical neck
51525Cystotomy; for excision of bladder diverticulum, single or multiple
51530Cystotomy; for excision of bladder tumor
51535Cystotomy for excision, incision, or repair of ureterocele
51550Cystectomy, partial; simple
51555Cystectomy, partial; complicated (eg, postradiation, previous surgery, difficult location)
51565Cystectomy, partial, with reimplantation of ureter(s) into bladder (ureteroneocystostomy)
51800Cystoplasty or cystourethroplasty, plastic operation on bladder and/or vesicle neck, any procedure vesical neck
51820Cystourethroplasty with unilateral or bilateral ureteroneocystostomy
51840Anterior vesicourethropexy, or urethropexy; simple
51841Anterior vesicourethropexy, or urethropexy; complicated (eg, secondary repair)
51845Abdomino-vaginal vesical neck suspension, with or without endoscopic control (eg, Stamey, Raz, modified Pereyra)
51860Cystorrhaphy, suture of bladder wound, injury or rupture; simple
51865Cystorrhaphy, suture of bladder wound, injury or rupture; complicated
51880Closure of cystostomy
51900Closure of vesicovaginal fistula, abdominal approach
51920Closure of vesicouterine fistula
51925Closure of vesicouterine fistula with hysterectomy
51940Closure, exstrophy of bladder
51960Enterocystoplasty, including intestinal anastomosis
51980Cutaneous vesicostomy
55821Prostatectomy; suprapubic, subtotal, 1 or 2 stages
57540Excision of cervical stump, abdominal approach
57545Excision of cervical stump, abdominal approach with pelvic floor repair
58140Myomectomy, excision of fibroid tumor(s), 1 to 4 intramural myoma(s) with total weight 250 g
58146Myomectomy, excision of fibroid tumor(s), 5 or more intramural myomas with total weight >250 g
58150Total abdominal hysterectomy, with or without removal of tube(s), with or without removal of ovary(s)
58152Total abdominal hysterectomy with colpo-urethrocystopexy (eg, Marshall-Marchetti, Krantz, Burch)
58180Supracervical abdominal hysterectomy (subtotal), with or without removal tube(s), with or without removal of ovary(s)
58200Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling
58210Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling
58400Uterine suspension, with or without shortening of round ligaments or sacrouterine ligaments
58410Uterine suspension, with presacral sympathectomy
58520Hysterorrhapy, repair of ruptured uterus (nonobstetrical)
58540Hysteroplasty, repair of uterine anomaly (Strassman-type)
58600Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral
58605Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral
58611Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery
58700Salpingectomy, complete or partial, unilateral or bilateral
58720Salpingo-oophorectomy, complete or partial, unilateral or bilateral
58740Lysis of adhesions (salpingolysis, ovariolysis)
58750Tubotubal anastomosis
58752Tubouterine implantation
58760Fimbrioplasty
58770Salpingostomy (salpingoneostomy)
58805Drainage of ovarian cyst(s), unilateral or bilateral; abdominal approach
58822Drainage of ovarian abscess; abdominal approach
58825Transposition, ovary(s)
58900Biopsy of ovary, unilateral or bilateral
58920Wedge resection or bisection of ovary, unilateral or bilateral
58925Ovarian cystectomy, unilateral or bilateral
58940Oophorectomy, partial or total, unilateral or bilateral
58943Oophorectomy, partial or total, unilateral or bilateral for ovarian, tubal or primary peritoneal malignancy
58950Resection of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy
58951 with total abdominal hysterectomy
58952 with radical dissection for debulking
58953Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking
58954 with pelvic lymphadenectomy
58956Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy
58957Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy, with omentectomy
58958 with pelvic lyphadenectomy and limited para-aortic lyphadenectomy
59100Hysterotomy, abdominal (eg, for hydatidiform mole, abortion)
59120Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or oophorectomy
59121Surgical treatment of ectopic pregnancy; tubal or ovarian, without salpingectomy and/or oophorectomy
59130Surgical treatment of ectopic pregnancy; abdominal pregnancy
59135Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy requiring total hysterectomy
59136Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy with partial resection of uterus
59325Cerclage of cervix, during pregnancy; abdominal
59350Hysterorrhaphy of ruptured uterus
59510Routine obstetric care including antepartum care, cesarean delivery, and postpartum care
59514Cesarean delivery only
59515Cesarean delivery only including postpartum care
59525Subtotal or total hysterectomy after cesarean delivery
59618Routine obstetric care including antepartum care and cesarean delivery after attempted vaginal delivery
59620Cesarean delivery only, after attempted vaginal delivery after previous cesarean
59622Cesarean delivery only, after attempted vaginal delivery after previous cesarean including postpartum care
60540Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal
60545 with excision of adjacent retroperitoneal tumor
Laparoscopic operations
43280Esophagogastric fundoplasty (Nissen, Toupet)
43289Unlisted procedure, esophagus
43644Gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy
43645Gastric restrictive procedure; with gastric bypass and small intestine reconstruction
43647Implantation or replacement of gastric neurostimulator electrodes, antrum
43648Revision or removal of gastric neurostimulator electrodes, antrum
43651Transection of vagus nerves, truncal
43652Transection of vagus nerves, selective or highly selective
43653Gastrostomy, without construction of gastric tube (Stamm procedure)
43659Unlisted procedure, stomach
43770Gastric restrictive procedure; placement of adjustable gastric restrictive device
43771Revision of adjustable gastric restrictive device component only
43772Removal of adjustable gastric restrictive device component only
43773Removal and replacement of adjustable gastric restrictive device component only
43774Removal of adjustable gastric restrictive device and subcutaneous port components
43775Gastric restrictive procedure; longitudinal gastrectomy (sleeve)
44186Jejunostomy
44187Ileostomy or jejunostomy, non-tube
44188Colostomy or skin level cecostomy
44202Enterectomy, resection of small intestine, single resection and anastomosis
44203Each additional small intestine resection and anastomosis
44204Colectomy, partial, with anastomosis
44205Colectomy, partial, with removal of terminal ileum with ileocolostomy
44206Colectomy, partial, with end colostomy and closure of distal segment (Hartmann)
44207Colectomy, partial, with anastomosis, with coloproctostomy
44208Colectomy, partial, with anastomosis, with coloproctostomy with colostomy
44210Colectomy, total, abdominal, without proctectomy, with ileostomy or ileoproctostomy
44211Colectomy, total, abdominal, with proctectomy, with ileoanal anastomosis, creation of ileal reservoir
44212Colectomy, total, abdominal, with proctectomy, with ileostomy
44213Mobilization of splenic flexure performed in conjunction with partial colectomy
44227Closure of enterostomy, large or small intestine, with resection and anastomosis
44238Unlisted procedure, intestine
44970Appendectomy
44979Unlisted procedure, appendix
45395Proctectomy, complete, combined abdominoperineal, with colostomy
45397Proctectomy, combined abdominoperineal pull-through procedure with creation of colonic reservoir
45400Proctopexy
45402Proctopexy, with sigmoid resection
45499Unlisted procedure, rectum
47370Ablation of one or more liver tumors; radiofrequency
47371Cryosurgical
47379Unlisted procedure, liver
47562Cholecystectomy
47563Cholecystectomy with cholangiography
47564Cholecystectomy with exploration of common duct
47570Cholecystoenterostomy
47579Unlisted procedure, biliary tract
49320Diagnostic, with or without collection of specimens by brushing or washing
49321 with biopsy
49322 with aspiration of cavity or cyst
49323 with drainage of lymphocele to peritoneal cavity
49324 with insertion of intraperitoneal cannula or catheter, permanent
49325 with revision of previously placed intraperitoneal cannula or catheter
49326 with omentopexy
49329Unlisted procedure, abdomen, peritoneum, and omentum
49650Repair initial inguinal hernia
49651Repair recurrent inguinal hernia
49652Repair ventral, umbilical, spigelian or epigastric hernia; reducible
49653Repair ventral, umbilical, spigelian or epigastric hernia; incarcerated or strangulated
49659Unlisted procedure, hernioplasty, herniorrhaphy, herniotomy
50541Ablation of renal cysts
50542Ablation of renal mass lesion
50543Partial nephrectomy
50544Pyeloplasty
50545Radical nephrectomy
50546Nephrectomy, including partial ureterectomy
50547Donor nephrectomy, from living donor
50548Nephrectomy with total ureterectomy
50549Unlisted procedure, renal
51990Urethral suspension for stress incontinence
51992Sling operation for stress incontinence
51999Unlisted procedure, bladder
54692Orchiopexy for intra-abdominal testis
55550Ligation of spermatic veins for varicocele
55559Unlisted procedure, spermatic cord
58541Supracervical hysterectomy
58542 with removal of tubes and/or ovary
58543Supracervical hysterectomy
58544 with removal of tubes and/or ovary
58545Myomectomy; 1 to 4 intramural myomas
58546 5 or more intramural myomas
58548Radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling
58550 with vaginal hysterectomy
58552 with removal of tubes and/or ovary
58553 with vaginal hysterectomy
58554 with removal of tubes and/or ovary
58570Total hysterectomy
58571 with removal of tubes and/or ovary
58572Total hysterectomy
58573 with removal of tubes and/or ovary
58578Unlisted procedure, uterus
58660Lysis of adhesions (salpingolysis, ovariolysis)
58661 with removal of adnexal structures
58662 with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface
58670 with fulguration of oviducts
58671 with occlusion of oviducts by device
58672 with fimbrioplasty
58673 with salpingostomy
58679Unlisted procedure, oviduct, ovary
59150Treatment of ectopic pregnancy; without salpingectomy and/or oophorectomy
59151 with salpingectomy and/or oophorectomy
60650Adrenalectomy, partial or complete, or exploration of adrenal gland

Footnotes

Disclosure Information: Marc L Schermerhorn is a consultant for Boston Scientific, Endologix, and Medtronic. All other authors have nothing to disclose.

The opinions expressed do not necessarily represent the views or policy positions of the Centers for Medicare and Medicaid Services.

Author Contributions

Study conception and design: Bensley, Schermerhorn, O’Malley, Cotterill, Landon

Acquisition of data: Cotterill

Analysis and interpretation of data: Bensley, Schermerhorn, Hurks, Sachs, Boyd, O’Malley, Cotterill, Landon

Drafting of manuscript: Bensley, Schermerhorn, Hurks, Sachs, Boyd, O’Malley, Cotterill, Landon

Critical revision: Bensley, Schermerhorn, Hurks, Sachs, Boyd, O’Malley, Cotterill, Landon

Contributor Information

Rodney P Bensley, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA.

Marc L Schermerhorn, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA.

Rob Hurks, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA.

Teviah Sachs, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA.

Christopher A Boyd, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA.

A James O’Malley, Department of Health Care Policy, Harvard Medical School, Boston, MA.

Philip Cotterill, Centers for Medicare and Medicaid Services, Baltimore, MD.

Bruce E Landon, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA. Department of Health Care Policy, Harvard Medical School, Boston, MA.

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