Laparoscopic Nissen Fundoplication
4328043281wRVU: 25.94 — Laparoscopic repair of paraesophageal hernia43282wRVU: 29.35 — Laparoscopic repair with mesh
Gastroesophageal reflux disease (GERD) with [hiatal hernia / Barrett's esophagus / failed medical management]
Same
Laparoscopic Nissen fundoplication [with hiatal hernia repair]
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male/female] with symptomatic GERD refractory to [PPI therapy / with documented [Barrett's esophagus / hiatal hernia measuring ___cm]] presenting for laparoscopic Nissen fundoplication. Preoperative workup included [esophagram, manometry, pH study, EGD] confirming [reflux / hiatal hernia / adequate esophageal motility]. The risks, benefits, and alternatives of the procedure were discussed with the patient, and informed consent was obtained.
A [sliding/paraesophageal] hiatal hernia measuring approximately [___] cm was identified. The gastroesophageal junction was [___ cm above the hiatus]. The hernia sac was [easily reducible]. [Approximately ___ cm of esophagus was reduced below the diaphragm after mobilization.] [Additional findings or none].
The patient was brought to the operating room and placed in supine reverse Trendelenburg position. General endotracheal anesthesia was induced. 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. Five trocars were placed: a 12-mm umbilical camera port, two 5-mm working ports in the right and left upper quadrants, a 5-mm subxiphoid liver retractor port, and a 5-mm left lateral port.
The liver was retracted superiorly. The pars flaccida of the gastrohepatic ligament was divided. The right crus of the diaphragm was exposed and the phrenoesophageal membrane was divided. The dissection continued posteriorly and to the left, exposing the left crus. The hernia sac was reduced by entering the mediastinum and dissecting the sac off the crural tissue and esophagus circumferentially. [Approximately ___ cm of intraabdominal esophagus was mobilized.]
A retro-esophageal window was created by blunt dissection posterior to the esophagus. A Penrose drain was passed around the esophagus for retraction. The vagal trunks were identified and preserved. The short gastric vessels were divided using the [Harmonic / LigaSure] device, completing the gastric fundus mobilization.
The crura were approximated posteriorly with [2-3] interrupted [0-Ethibond / 0-Prolene] sutures. [Mesh was/was not placed over the hiatal repair given the size of the defect.] A bougie [56-60 Fr] was passed by anesthesia into the stomach to calibrate the wrap. A 360-degree (Nissen) fundoplication was created by passing the posterior gastric fundus behind the esophagus to the right side (posterior "shoeshine" maneuver). The wrap was secured with [3 interrupted 2-0 Ethibond] sutures to create a [2-cm] floppy wrap. The wrap was confirmed to be over the esophagus (not the stomach) and was easily reducible over the bougie. The bougie was removed.
The trocars were removed under direct visualization. The abdomen was inspected. Hemostasis confirmed. The fascia at 12-mm sites was closed with [0-Vicryl]. Skin was closed with [4-0 Monocryl] subcuticular sutures. Sterile dressings were applied.
None
None / Hernia sac sent to pathology
Minimal (less than 20 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: GERD with *** hiatal hernia
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Laparoscopic Nissen fundoplication with hiatal hernia repair
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with GERD and *** hiatal hernia presenting for Nissen fundoplication. Preoperative manometry confirmed adequate motility. Informed consent obtained.
FINDINGS: *** hiatal hernia *** cm. GEJ *** above hiatus. *** cm intraabdominal esophagus after mobilization.
DESCRIPTION OF PROCEDURE:
Supine reverse Trendelenburg. Five trocars. General anesthesia. Surgical timeout per protocol.
Pars flaccida divided. Crura exposed. Hernia sac reduced; *** cm intraabdominal esophagus. Retro-esophageal window created. Vagal trunks preserved. Short gastric vessels divided. Crura closed with *** Ethibond sutures. *** Fr bougie placed. 360-degree floppy wrap created with 3 interrupted 2-0 Ethibond sutures, *** cm length. Wrap confirmed over esophagus. Bougie removed.
Fascia closed. Skin with 4-0 Monocryl.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: None
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
Toupet Fundoplication (270° Partial Wrap)
Given [esophageal dysmotility on preoperative manometry / patient history suggesting motility disorder], a partial posterior 270-degree (Toupet) fundoplication was performed instead of a 360-degree Nissen wrap to reduce the risk of postoperative dysphagia. The wrap was sutured to both the left and right sides of the esophagus and to each crus, with the anterior surface left uncovered.
Paraesophageal Hernia Repair
A large [Type II/III/IV] paraesophageal hernia was repaired. The hernia sac was circumferentially dissected from the mediastinum and crura and fully excised. The stomach and other herniated contents were reduced. An adequate length of esophagus was mobilized intraabdominally. The crura were reapproximated. Given the [large defect size / tension on the repair], a [biologic/synthetic] onlay mesh was placed over the hiatal repair and secured to both crura. A fundoplication was performed to anchor the stomach.
Charting Tips
- Document the length of intraabdominal esophagus achieved after mobilization. At least 2-3 cm of tension-free intraabdominal esophagus is required for a durable repair. This is the most common technical failure point and affects reoperation planning.
- Document the bougie size used for wrap calibration and that the wrap was floppy (easily reduced over the bougie). Postoperative dysphagia is common with a tight wrap, and documentation of bougie size and wrap calibration is the key technical quality indicator.
- Vagal trunk preservation must be documented. Vagal injury causes gastroparesis and functional gastric outlet obstruction, which is a known complication. Noting identification and preservation provides the medicolegal record.
Billing Tips
- Bill 43280 for laparoscopic Nissen fundoplication (17.65 wRVU, 90-day global). Use for 360-degree fundoplication and for partial posterior wraps (eg, Toupet), both of which are explicitly named in the 43280 descriptor. Dor (anterior) fundoplication performed as the anti-reflux component of Heller myotomy is reported within 43279, not 43280.
- For sliding hiatal hernia with fundoplication, use 43280 (17.65 wRVU). For paraesophageal hernia repair with fundoplication, use 43281 (25.94 wRVU, without mesh) or 43282 (29.35 wRVU, with mesh) as the primary code instead of 43280. These are standalone codes, not billed in addition to 43280. Document hernia type, crural closure technique, and whether mesh was used.
- For revisional fundoplication (takedown and redo Nissen), bill 43280 with modifier -22 (increased procedural service) when complexity substantially exceeds a primary case. Document increased operative time, adhesions encountered, and complexity. 43289 (unlisted esophageal procedure) applies only when no specific code exists — a redo Nissen fundoplication has a specific code (43280).
- 90-day global period: postoperative dysphagia management, dietary progression, and office follow-up are bundled. Postoperative esophagram or manometry ordered for clinical concern does not generate a separate surgical fee.
- Preoperative workup documentation (pH study, manometry, esophagram) must be in the record to support medical necessity. GERD diagnosis alone without objective testing may not satisfy payer requirements for a major surgical procedure.
General coding reference. Verify with your institution’s billing department before submitting claims.