5. SURGICAL OPERATION NOTES
• Legal documentation
• No formal training
• Majority of operative notes are handwritten
• Important source for medical records – legal
and financial implications
6. ‘THE ADMIN’
Date of Procedure
Patient details
• Hospital sicker/hand write patient details
Staff details
• Operating Surgeon & grade
• Surgical assistant & grade
• Consultant overseeing care
• Anaesthetist and grade
7. THE SURGERY AND THE REASON
The full title of the operation carried out
• List from major to minor
• No abbreviations
Type of anaesthetic used.
Indication for the procedure – pre operative
diagnosis
i.e. 8/40 Missed Miscarriage with Vaginal Bleeding
8. ‘THE FINDINGS’
• VE &abdominal palpation findings
• What was seen during the operation
• Post operative diagnosis
• Pathological findings
• Any relevant negative findings?
• As much detail as possible – site, size, colour,
volume of structure involved
• Picture aids
• Any difficulties?
• Blood Loss
9. ‘THE PROCEDURE’
Surgical steps
• Position
• Prepped and draped
• Incision (what instrument you used)
• Step by step description of surgical steps undertaken
• Sutures used and type of suturing (locking, continuous)
• Written justification of unusual steps
• Drains in situ / catheter – what is draining at end of
procedure
• Any samples obtained – how you took them
• Swabs, needles and instrument checked
10. POST OPERATIVE PLAN
Important guidance on managing the patient in the post operative period
Immediate
• Analgesia
• Medications
• VTE assessment
• Nutrition - fluids/ eating and drinking
• Catheter management
• Details of specific drains/dressing/packs/devices – when should they be removed
• Samples for the lab
• Routine post op care vs. close monitoring/ observations
• Anaesthetic concerns
11. THE POST OPERATIVE PLAN
Hospital Stay
• Suture / Staples care
• Blood tests
• Specific nursing instructions
• Any specialist input needed e.g. physio
• Patient debrief – plan for future e.g. next dressing/ daily
activities, sport…
• Discharge – when and by whom
• Follow up
12. ‘THE SIGN OFF’
• Print your name [Stamp]
• Sign the notes
• Leave contact details
13. POSITION OF THE PATIENT
Important medical legal detail
• Appropriate position for access and to minimize complications e.g.. ulcers or nerve
damage
Common gynaecological patients’ positions
Position Description Procedure
Supine flat on back Laparotomy
Appendectomy
Dorsal Lithotomy flat on back, buttocks at edge of bed
Hips and knees fully flexed with legs in
stirrups
EUA anal surgeries
Perineal repair / Urogynae surgery
Vaginal Hysterectomy
Trandelenburg Flat on back with feet higher then head
by 15-30 degrees
Laparoscopy
Abdominal hysterectomy
Lloyd- Davies Trandelenburg position with hips flexed
15 degrees
Laparoscopy
Sacrocolpoplexy
14.
15.
16. Example
• Operation: Cholecystectomy
• Indications:
▪ Cholelithiasis with complications:
Biliary colic a/c & c/c cholecystitis,empyema ,
mucocele.
▪ Cholelithiasis in :a DM ,immunosuppressed,
Hemolytic anemia, Young individuals.
▪ Carcinoma
▪ Choledochal cyst
▪ Ca head of pancreas in whipples
17. • Anaesthesia : GA
• Position :Supine trendelenberg position
Pillow under the right lumbar & tilt to the
left
• Skin preparation: Prepare the skin from
nipple line to mid-thigh, drape to expose
the right upper quadrants
• Incision: Kochers right subcostal Incision
(muscle cutting incision)
18. • Other less common incisions:
▪ Midline incision, Muscle is not cut, ↓bld
supply ,improper healing.
▪ Paramedian incision.
▪ Right upper quadrant transverse incision
Heal easier.
▪ Mayo robson incision, Combination of
medial half of kochers +paramedian
incision
19. • 2 methods :
• Conventional /classic
retrograde(commonly done), From cystic
duct to fundus
• Fundus first method:
From fundus to cystic duct, Separate GB
from liver bed till the cystic duct.
20. • Procedure:
Retract rectus abdominis laterally.
Open peritoneum.
Pack and retract bowel.
Identify GB at the tip of 9th costal cartilage.
Catch hold of fundus with sponge holding forceps.
Identify calots triangle.
Ligate cystic A & cystic duct close to the GB.
Separate the GB from liver.
Drain ??
21.
22. ➢ Complications:
• Haemorrhage.
• Necrosis of right quadrant of liver (d/t rt
hepatic artery is affected in ligature).
• Injury to CBD.
• Bile leak
