44150

Colectomy, total, abdominal, with ileostomy or ileoproctostomy

CPT 44150 describes a total abdominal colectomy, which is the surgical removal of the entire large intestine from the cecum to the distal sigmoid colon or the junction of the rectum. This procedure is typically performed through a traditional open midline laparotomy incision, though this specific code refers to the open approach. The surgeon begins by entering the abdominal cavity and performing a thorough exploration. The entire colon is mobilized by incising the white line of Toldt and dividing the various ligamentous attachments, including the phrenocolic, gastrocolic, and splenocolic ligaments. Great care is taken during the mobilization of the hepatic and splenic flexures to avoid injury to the duodenum and spleen, respectively. The major blood vessels supplying the colon, including the ileocolic, right colic, middle colic, and left colic arteries, are identified, clamped, and ligated. The surgeon must carefully identify and preserve the ureters throughout the dissection. Once the colon is fully mobilized, it is divided at the terminal ileum proximally and at the rectosigmoid junction distally. Following the removal of the specimen, the surgeon either creates a permanent end-ileostomy (bringing the terminal ileum through the abdominal wall to form a stoma) or performs an ileoproctostomy, which is a primary anastomosis connecting the terminal ileum directly to the remaining rectum. This procedure is distinct from a proctocolectomy because the rectum is preserved. The choice between an ileostomy and an ileoproctostomy depends on the underlying pathology, the functional status of the rectum, and the patient's surgical risk profile.

Clinical Indications

  • Refractory ulcerative colitis not involving the rectum
  • Familial Adenomatous Polyposis (FAP) where the rectum can be spared
  • Toxic megacolon or fulminant colitis
  • Synchronous or multiple primary colonic malignancies
  • Severe, medically refractory slow-transit constipation (colonic inertia)
  • Hereditary Non-Polyposis Colorectal Cancer (HNPCC/Lynch Syndrome) requiring prophylactic removal
  • Total colonic ischemia

Procedure Steps

  1. Perform midline laparotomy to access the peritoneal cavity.
  2. Mobilize the right colon and hepatic flexure, ensuring preservation of the duodenum.
  3. Divide the gastrocolic omentum to mobilize the transverse colon.
  4. Mobilize the splenic flexure and descending colon, protecting the spleen and left kidney.
  5. Identify and protect the bilateral ureters and gonadal vessels.
  6. Ligate and divide the mesenteric vessels (ileocolic, right, middle, and left colic arteries).
  7. Transect the terminal ileum and the distal sigmoid/upper rectum using surgical staples or clamps.
  8. Remove the entire colonic specimen from the operative field.
  9. Either create an end-ileostomy (maturation of Brooke ileostomy) or perform a stapled/hand-sewn ileoproctostomy.
  10. Irrigate the abdomen and check for adequate perfusion and hemostasis.
  11. Close the abdominal fascia and skin.

Coding Guidelines

  • Report 44150 for an open total abdominal colectomy with either ileostomy or ileoproctostomy.
  • Do not use 44150 if the rectum is also removed; instead, see codes 44155-44158 for proctocolectomy.
  • For a laparoscopic total abdominal colectomy, use CPT code 44210.
  • If a continent ileostomy (Kock pouch) is created, use CPT 44151.
  • The creation of a stoma or the performance of an anastomosis is included in the primary code and should not be billed separately.
  • Small bowel resection performed at the same time may be bundled unless it is a separate and distinct segment not required for the colectomy.
  • Check NCCI edits if performing additional procedures like lysis of adhesions (44005), as these are often bundled.

Associated ICD-10 Codes