32110

Thoracotomy; with control of traumatic hemorrhage and/or repair of lung tear

CPT code 32110 describes an emergency or urgent surgical procedure known as an open thoracotomy, which is performed specifically to control traumatic hemorrhage and/or repair a lung tear within the thoracic cavity. This life-saving intervention is predominantly indicated in the setting of severe blunt or penetrating chest trauma, such as gunshot wounds, stab wounds, or high-impact motor vehicle collisions. In these critical scenarios, patients frequently present with massive hemothorax, significant and ongoing bleeding from the lung parenchyma or intrathoracic vessels, severe air leaks, or profound hemodynamic instability that fails to respond to initial resuscitative measures like tube thoracostomy (chest tube placement). The procedure demands rapid access to the thoracic organs. Depending on the location of the injury and the patient's clinical status, the cardiothoracic or trauma surgeon will typically utilize an anterolateral thoracotomy, a posterolateral thoracotomy, or occasionally a median sternotomy approach. Once the chest wall is incised and the ribs are separated using a retractor, the surgeon immediately evacuates accumulated blood and clots from the pleural space to gain clear visualization of the intrathoracic structures. A systematic and rapid exploration of the lung, chest wall, mediastinum, and diaphragm is conducted to identify the source of the traumatic bleeding or air leak. Traumatic hemorrhage from the lung tissue, intercostal vessels, or internal mammary vessels is meticulously controlled utilizing a variety of surgical techniques, including direct suture ligation, application of surgical clips, electrocautery, or the use of topical hemostatic agents. If a laceration or tear of the lung parenchyma is identified, the surgeon repairs the defect using precise primary suturing (pneumorrhaphy). In cases of deeper lung lacerations, a pulmonary tractotomy may be performed to expose and ligate bleeding vessels and air leaks within the lung tissue before repairing the defect. Following definitive hemostasis and repair of all lung tears, the surgeon thoroughly irrigates the thoracic cavity with warm sterile saline to ensure no residual bleeding or air leaks persist. Large-bore chest tubes are placed strategically within the pleural cavity to allow for continuous postoperative drainage of blood, fluid, and air, promoting optimal lung re-expansion. The chest wall is then meticulously closed in layers, encompassing the ribs, intercostal muscles, fascial layers, subcutaneous tissue, and skin. This code exclusively covers the control of traumatic bleeding and lung tear repair; if the severity of the injury necessitates the removal of an entire lobe or the entire lung, a more extensive resection code, such as a lobectomy or pneumonectomy, must be reported instead.

Clinical Indications

  • Massive traumatic hemothorax (initial chest tube output greater than 1.5 Liters or ongoing bleeding of 200-300 ml/hr for 2 to 4 consecutive hours).
  • Penetrating chest trauma (e.g., gunshot wound, stab wound) with hemodynamic instability or signs of massive internal bleeding.
  • Blunt force chest trauma resulting in a severe, continuous air leak indicating a major lung laceration or tracheobronchial injury.
  • Traumatic lung tear failing to heal or seal with non-operative management and prolonged tube thoracostomy.
  • Cardiac arrest or profound shock in a patient with a known or highly suspected intrathoracic injury requiring resuscitative thoracotomy and subsequent repair.

Procedure Steps

  1. The patient is placed under general anesthesia and intubated, ideally with a double-lumen endotracheal tube to allow single-lung ventilation.
  2. The patient is positioned appropriately (usually lateral decubitus for a posterolateral approach or supine for an anterolateral approach) and the chest is prepped and draped.
  3. A generous surgical incision is made along the designated intercostal space, dividing the overlying muscles (e.g., latissimus dorsi, serratus anterior, or pectoralis major) down to the ribs.
  4. The intercostal muscles are incised, and a rib retractor is inserted to spread the ribs and open the pleural cavity.
  5. The surgeon rapidly evacuates all accumulated blood and hematoma from the pleural space to visualize the thoracic structures.
  6. A comprehensive exploration of the thoracic cavity is performed to locate the exact source of bleeding and identify any lacerations or tears in the lung tissue.
  7. Traumatic hemorrhage is controlled using manual pressure, suture ligation, surgical clips, or electrocautery. Topical hemostatic agents may also be applied.
  8. Lung tears are repaired using primary suture closure (pneumorrhaphy), pulmonary tractotomy, or limited wedge resection to remove devitalized tissue if necessary.
  9. The thoracic cavity is thoroughly irrigated with warm sterile fluid, and the surgeon confirms hemostasis and tests for air leaks by expanding the lung under water.
  10. One or more thoracostomy tubes (chest tubes) are inserted through separate stab incisions to drain postoperative air and fluid.
  11. The chest wall is closed in layers, including pericostal sutures to reapproximate the ribs, followed by the muscle layers, deep fascia, subcutaneous tissue, and the skin.

Coding Guidelines

  • Do not report 32110 in conjunction with codes for the same procedure performed via VATS (Video-Assisted Thoracoscopic Surgery). CPT 32110 is specifically an open thoracotomy code.
  • If a VATS procedure is initiated but subsequently converted to an open thoracotomy (32110) due to bleeding or poor visualization, report only the open procedure code (32110).
  • Chest tube insertion (CPT 32551) is considered an inclusive component of the thoracotomy procedure and should not be reported separately when performed through the same surgical site.
  • If the extent of the trauma requires a major anatomical lung resection (such as a lobectomy, CPT 32480, or a total pneumonectomy, CPT 32440), report the resection code instead of 32110, as the repair and bleeding control are inherent to the resection.
  • Modifier 22 (Increased Procedural Services) may be appended if the trauma repair requires work substantially greater than typically required, provided this is robustly supported by the operative report.
  • Do not report 32110 for elective control of bleeding; this code is strictly designated for traumatic hemorrhage.

Associated ICD-10 Codes