OT notes · Neurosurgery

Decompressive craniectomy

Usual anaesthesia
General anaesthesia with endotracheal intubation
Position
Supine, head in a three-pin holder turned 60-90 degrees to the opposite side (hemicraniectomy) or slightly flexed (bifrontal)
Setting
emergency

Operative note template for decompressive craniectomy (unilateral hemicraniectomy or bifrontal), with a filled example for a right hemicraniectomy after head injury with the bone flap stored in an abdominal pocket.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • death or survival with severe disability
  • bleeding, including new or enlarging haematoma or contusion
  • brain swelling bulging through the defect
  • infection of the wound, bone flap or brain
  • CSF leak
  • hydrocephalus needing a shunt
  • fluid collections under the skin flap
  • sinking skin flap syndrome before cranioplasty
  • a second operation to replace the bone (cranioplasty), and possible loss of the stored bone
  • injury to the sagittal sinus (bifrontal)

Pre-operative details for this operation

  1. IndicationTraumatic brain injury: diffuse swelling / contusionsMalignant MCA / ICA infarctOther: stateprimary (with evacuation of a mass) or secondary (refractory ICP, with ICP values and time)
  2. TypeRight hemicraniectomyLeft hemicraniectomyBifrontal
  3. GCS before surgeryE, V, M, total, time; intubated (VT) if so
  4. Pupils before surgerysize in mm and reaction, right and left, time
  5. CT findingsdate and time, lesions, midline shift in mm, basal cisterns, fractures, frontal sinus size
  6. Pre-op measuresmannitol / hypertonic saline (dose, time), ventilation, sedation
  7. Coagulation, platelets, blood reservedPT/INR, platelets, units cross-matched
  8. Bone flap storage planAbdominal subcutaneous pocketBone bank (deep freeze)Discarded: reason
  9. Consentby relative: name, relation, language; bone storage and later cranioplasty explained

Anaesthesia and position

  1. AnaesthesiaGeneral, endotracheal intubation
  2. Head fixationThree-pin holderHorseshoepin sites
  3. Head positiondegrees of rotation, shoulder roll; bifrontal: slight flexion
  4. ICP monitor / EVDAlready in placePlaced now, opposite sideNot placed: reasonopening ICP
  5. Abdomen prepared for bone storageYes, right lower quadrantNot needed

Operative findings

  1. Scalp and bonefractures, contamination, mastoid air cells or frontal sinus opened
  2. Duratense / lax, tears
  3. Subdural or extradural bloodtype, thickness, volume evacuated
  4. Brainswelling, contusions (site), infarcted area, pulsation
  5. ICPbefore bone removal, after bone removal, after dural opening, at the end
  6. Brain at the endBelow the bone edgeLevel with the bone edgeBulging

Procedure (steps)

  1. Painting and drapinghair clipped, antiseptic used; abdomen also prepared if storing the bone there
  2. Skin incisionReverse question mark (hemicraniectomy)Bicoronal (bifrontal)start 1 cm in front of the tragus at the zygoma; superficial temporal artery kept
  3. Flap raisedmyocutaneous flap; pericranium kept intact for duraplasty; temporalis down to the root of the zygoma
  4. Burr holesnumber and sites (keyhole, above mastoid, low temporal squama, parasagittal about 2 cm from midline)
  5. Bone flapsize AP x vertical in cm (target 12-15 cm AP), sphenoid wing thinned and fractured
  6. Temporal decompressionsquama removed to the middle fossa floor; mastoid cells waxed if opened
  7. Dural openingU-shaped, based temporallyMedially based flapStellateBifrontal: U-shaped based posteriorlyopened slowly if ICP high; cuff left at the bone edge
  8. Haematoma evacuation / contusion managementwhat was removed, volume
  9. Sagittal sinus and falx (bifrontal)anterior sinus ligated with silk and divided; falx divided fully
  10. DuraplastyPericranial graftSynthetic dural substituteLeft open with haemostatic coversuture and technique; watertight or not; for synthetic: make, size, lot
  11. Frontal sinus (if opened)cranialised: mucosa stripped, posterior wall removed, ostia plugged, pericranial flap
  12. Haemostasisdural tack-up stitches, haemostatic agents
  13. Bone flap storageabdominal pocket: side and quadrant, layer (Camper's fascia), convex side out, closure; or bone bank: handed to whom, label, time

Closure, drains and dressing

  1. Subgaleal draintype and size, exit site
  2. Scalplayers, suture, technique (for example single layer monofilament vertical mattress)
  3. Abdominal woundlayers and suture
  4. Dressingloose over the defect, no tight bandage

Specimens and implants

  1. SpecimensNoneContused brain for HPECulture swab
  2. Bone flapstored where, size, label
  3. Implantsdural substitute or haemostatic agents: make, size, lot, sticker

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Neuro-ICU careventilation plan, sedation and analgesia
  2. Neuro-observationGCS, pupils hourly
  3. ICP and CPPtargets and what to do if above target
  4. Blood pressurerange to keep
  5. Craniectomy precautionsno pressure on the defect side, no tight dressing, head position, keep equipment away
  6. Subgaleal drainrecord output; CSF in the drain is expected; remove by 48 hours
  7. Antibioticfor 24 hours or until the drain is out; longer if open fracture or penetrating injury
  8. Hyperosmolar therapyif ICP stays high and CT shows no new mass
  9. CT headwhen to repeat, and triggers (new deficit, rising ICP)
  10. Wound and abdominal pocketcheck for leak and haematoma; scalp sutures out at 14 days
  11. Later planhelmet when mobilising; watch for hydrocephalus; cranioplasty review at 4-6 weeks or later

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. M.S., 28 years, 65 kg, motorcycle crash without helmet 3 hours ago, GCS 7 on arrival, right pupil dilated.

Case details

Date: 03/10/2026. Emergency. OT 1. Start 01:20, end 03:35.

Surgeon: Dr A. (3rd-year resident, MCh Neurosurgery). Assistant: Dr B. Consultant: Dr C., present in OT. Abdominal pocket made by Dr B.

Anaesthetists: Dr D. and Dr F. Scrub nurse: Sr E.

Indication and pre-op

Severe head injury. GCS at 00:30: E1 VT M4 (intubated in casualty). Right pupil 5 mm sluggish, left 3 mm reacting.

CT 00:10: right acute subdural haematoma 8 mm thick with right frontotemporal contusions, midline shift 11 mm (more than the clot explains), basal cisterns effaced. No fracture into the frontal sinus.

Inj mannitol 20% 160 ml (about 0.5 g/kg) IV at 00:40. INR 1.1, platelets 1.9 lakh/cumm, 2 units cross-matched.

Consent: patient unconscious. Procedure-specific consent taken from the father, Mr. K.S., in Marathi, including death, disability, storage of the bone in the abdomen and a later cranioplasty. Right side marked.

WHO checklist sign in and time out done. Inj cefazolin IV within 1 hour before incision (dose on the anaesthesia chart).

Anaesthesia and position

General anaesthesia via the existing endotracheal tube. Supine, three-pin holder: front pin on the left mid-pupillary line, back pins across the midline above the transverse sinus. Head turned 80 degrees to the left, roll under the right shoulder.

Left frontal ICP monitor placed and tunnelled away from the midline. Opening ICP 32 mmHg.

Hair clipped. Scalp and right lower abdomen painted with povidone-iodine and draped.

Procedure

Reverse question-mark incision from the zygoma 1 cm in front of the tragus, back to the parietal eminence and forward to the hairline near the midline. Superficial temporal artery kept. Scalp clips applied.

Myocutaneous flap raised with the temporalis, down to the root of the zygoma. Pericranium kept intact.

Six burr holes: keyhole, above the mastoid, low temporal squama above the zygoma root, three parasagittal about 2.5 cm from the midline. Dura stripped and a 14 x 11 cm frontotemporoparietal bone flap cut with a craniotome. Sphenoid wing thinned with a burr and fractured. ICP after bone removal 22 mmHg.

Remaining temporal squama nibbled down to the middle fossa floor. No mastoid air cells opened.

Findings: dura tense and bluish. Dura opened slowly in a U-shape based on the temporal side, leaving a cuff. About 60 ml of acute subdural clot evacuated. Contusions of the right frontal and temporal poles with swollen brain. Bleeding cortical vessels coagulated.

Pericranium harvested. Expansive duraplasty with the pericranial graft, sewn with running 4-0 braided nylon, watertight. ICP after duraplasty 12 mmHg. Brain level with the bone edge and pulsating.

Dural edge bleeding controlled with tack-up stitches along the superior edge.

Bone flap rinsed in antibiotic saline. Right lower quadrant linear incision, pocket made in Camper's fascia, haemostasis secured, flap placed convex side out. Abdominal wound closed in two layers.

Closure

10 mm Jackson-Pratt subgaleal drain through a separate stab. Galea and scalp closed in a single layer with 2-0 monofilament nylon vertical mattress sutures.

Loose dressing, no pressure over the defect.

End of procedure

Estimated blood loss 900 ml. 1 unit packed cells transfused.

Mop, needle and instrument count correct.

Specimens: none. Bone flap: right lower abdominal subcutaneous pocket, 14 x 11 cm. Implants: none.

Kept intubated and ventilated. ICP 12 mmHg. Pupils: right 4 mm sluggish, left 3 mm reacting. Shifted to neuro-ICU.

Post-op orders

Ventilated and sedated in neuro-ICU. Hourly GCS and pupils. ICP hourly, inform if above the ICU target.

Keep mean arterial pressure as per ICU protocol for adequate CPP; avoid hypotension and severe hypertension.

Craniectomy precautions: do not lie on the right side, no tight bandage, keep monitors and rails away from the defect.

JP drain to gravity. Record output. CSF in the drain is expected. Remove by 48 hours.

Cefazolin for 24 hours, or until the drain is out.

Repeat CT if ICP rises or pupils change. Suture removal at 14 days.

Later: helmet when out of bed, watch for hydrocephalus, cranioplasty review at 4-6 weeks or later.

Signature

Dr A., MCh resident (year 3), Neurosurgery. Reg. no. ________. 03/10/2026, 03:55.

Must document for this operation

  • Where the bone flap is kept, its size and how it is labelled. The cranioplasty may be weeks later by another team, and a lost or unrecorded flap means an artificial implant.
  • Side and size of the craniectomy. Nurses must know which side has no bone, and a small defect is linked to worse outcome.
  • GCS (Glasgow Coma Scale) and pupils before surgery, with the time. They record why the operation was done and are the baseline for recovery and audit.
  • ICP before bone removal, after dural opening and at the end, if a monitor was used. These values show the effect of the decompression and guide ICU treatment.
  • Dural closure: graft type, suture, and whether watertight. The cranioplasty surgeon has to plan the dissection over the graft, and a leak is managed differently.
  • Frontal sinus or mastoid air cells opened, and how they were dealt with. An untreated opened sinus is a source of infection and CSF leak.
  • Consent by the relative, including bone storage and a later cranioplasty. The patient cannot consent, and families often do not know a second operation will be needed.

Common mistakes in these notes

  • Not recording where the bone flap is.
  • Writing 'DC done' without the side, size or the extent of temporal decompression.
  • Leaving out the pre-op GCS and pupils or the time they were recorded.
  • Not writing the duraplasty material and suture.
  • No written instruction about craniectomy precautions for the nurses.
  • Leaving out the names of all anaesthetists when two were present.

Indian practice and paperwork

  • Write the name of every anaesthetist in the note. A hospital was held negligent when the operation notes did not name the anaesthetist though two had given anaesthesia. (Thomas J. Indian J Urol 2009;25(3):384-8)
  • A dural substitute or other implant needs its batch and serial number in the case record, the OT master log and the discharge summary. (NABH 5th ed., MOM.10(d))
  • A bone flap that is discarded, and any brain tissue not sent for HPE, is human anatomical waste for the yellow bag. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)
  • Consent must be in a language the relative understands, and the post-op care must follow a written plan. (NABH 5th ed., PRE.4(c), COP.14(f))

Sources

  • Ullman JS, Raksin PB, eds. Atlas of Emergency Neurosurgery. Thieme; 2015, Ch 4, Decompressive craniectomy for intracranial hypertension and stroke, including bone flap storage in abdominal fat layer (Rey-Dios R, Esposito DP), pp. 53-72.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

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