Sleeve Gastrectomy
43775Morbid obesity [BMI ___] with obesity-related comorbidities [type 2 diabetes / hypertension / obstructive sleep apnea / GERD]
Same
Laparoscopic sleeve gastrectomy
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male/female] with a BMI of [___] kg/m² and [obesity-related comorbidities] who has completed a multidisciplinary bariatric evaluation including dietary counseling, psychological evaluation, and medical clearance. The patient has failed [6 months of] supervised weight loss attempts. The risks, benefits, and alternatives of the procedure including gastric bypass were discussed, and informed consent was obtained.
The stomach was [normal/with prior banding visible]. Intraoperative endoscopy was [not performed / performed confirming adequate sleeve caliber and a negative leak test]. The liver was [fatty/enlarged]. [Hiatal hernia of ___ cm was noted and repaired.] [Additional findings or none].
The patient was brought to the operating room and placed in reverse Trendelenburg position. General endotracheal anesthesia was induced. Sequential compression devices were applied. A Foley catheter was placed. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of [weight-based] prophylactic antibiotics.
The abdomen was prepped and draped in sterile fashion. Pneumoperitoneum was established to 15 mmHg via [Veress needle / optical trocar / Hasson open technique; Hasson preferred in morbid obesity]. A 12-mm camera port was placed in the left upper quadrant. Five trocars were placed: a 12-mm camera port, a 12-mm liver retractor port, two 5-mm working ports, and an additional 5-mm port.
The liver was retracted superiorly. The greater omentum was divided from the greater curvature of the stomach beginning [4-6 cm proximal to the pylorus] and extending to the angle of His, using the [Harmonic / LigaSure] device. Short gastric vessels were divided. The angle of His was completely mobilized.
A [36-40 Fr] orogastric bougie was placed by anesthesia along the lesser curvature. The stomach was divided along the bougie using sequential firings of a [green/blue/gold] load [60-mm laparoscopic GIA stapler] beginning [4-6 cm proximal to the pylorus] and continuing to the angle of His, creating a narrow tubular sleeve. [Staple line reinforcement was/was not used: bioabsorbable/pericardial/oversewing technique.] The resected portion of the stomach was removed through the 12-mm port site in a specimen bag.
The staple line was inspected for hemostasis. An endoscopic leak test was performed by instilling [methylene blue / air under endoscopic visualization]; [no leak was identified]. Hemostasis of the staple line was confirmed. [A [60-cm] hiatal hernia repair was performed at this time.]
The trocars were removed under visualization. The 12-mm fascial defects were closed with [0-Vicryl]. Skin was closed with [4-0 Monocryl] subcuticular sutures. Sterile dressings were applied.
None
Gastric sleeve (resected stomach) sent to pathology
Minimal (less than 30 mL)
None / [One Jackson-Pratt drain along the staple line]
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Morbid obesity, BMI ***, with ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Laparoscopic sleeve gastrectomy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with BMI *** completing multidisciplinary bariatric evaluation. Informed consent obtained.
FINDINGS: Liver ***. *** hiatal hernia. Intraoperative leak test ***.
DESCRIPTION OF PROCEDURE:
Reverse Trendelenburg. SCDs applied. Foley placed. General anesthesia. Surgical timeout per protocol.
Five trocars placed. Greater curvature divided from 4-6 cm proximal to pylorus to angle of His using energy device. *** Fr bougie placed. Stomach divided along bougie with sequential GIA firings. *** staple line reinforcement. Resected stomach removed. Endoscopic leak test: ***. Hemostasis confirmed. *** hiatal hernia repaired.
Fascia closed at 12-mm sites. Skin with 4-0 Monocryl.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Resected stomach to pathology
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
With Hiatal Hernia Repair
A [___]-cm hiatal hernia was identified. The crura were dissected and the hernia sac was reduced. The crura were reapproximated posteriorly with [2 interrupted 0-Ethibond sutures]. The sleeve gastrectomy was then completed as described above. The fundoplication was not performed given prior sleeve configuration.
Staple Line Leak: Intraoperative Management
An air/methylene blue leak was identified at the [proximal staple line / angle of His / mid-staple line] on endoscopic testing. The leak was repaired with [oversewing with interrupted 2-0 Prolene sutures / additional staple firing / fibrin glue application]. Repeat leak test confirmed a negative result. A closed suction drain was left adjacent to the repair site.
Charting Tips
- Document the bougie size used for sleeve calibration. This determines the final sleeve volume and affects leak risk, weight loss, and GERD outcomes. Standard is 36-40 Fr; many programs have a standard size that should be consistently documented.
- Document the leak test type and result explicitly. State whether methylene blue or air was used, that the endoscope was used, and that the result was negative. A staple line leak is the most feared early complication of sleeve gastrectomy.
- Document the distance from the pylorus at which the staple line begins. The pylorus should be preserved and the division should begin 4-6 cm proximal to it. Beginning too close to the pylorus increases sleeve narrowing and stricture risk.
Billing Tips
- Bill 43775 for laparoscopic sleeve gastrectomy (19.87 wRVU, 90-day global). This is the only CPT code for sleeve gastrectomy; there are no variants based on bougie size or staple line reinforcement technique.
- 90-day global period: dietary advancement, nutritional supplementation management, and routine follow-up are bundled. Postoperative EGD for staple line leak evaluation within the global period requires modifier -78 if performed in the OR.
- Preoperative documentation requirements: The 2022 ASMBS/IFSO guidelines recommend metabolic and bariatric surgery for BMI ≥35 regardless of comorbidity, and support consideration for BMI 30–34.9 with metabolic disease. Most commercial insurers and Medicare still apply the older 1991 NIH criteria (BMI ≥40, or ≥35 with qualifying comorbidities such as T2DM, HTN, or OSA) — verify payer criteria before scheduling. Document completion of supervised weight loss program, psychological clearance, and nutritional evaluation per payer requirements.
- For revisional sleeve gastrectomy (re-sleeve or conversion to another procedure), there is no standalone revision CPT. Use 43999 (unlisted stomach procedure) with operative report and prior authorization. Conversion to RYGB uses 43644.
- Staple line reinforcement, oversewing, and bougie size are not separately billable. Document these for operative record and quality purposes only.
General coding reference. Verify with your institution’s billing department before submitting claims.