OT notes · General Surgery

Diagnostic laparoscopy (with biopsy)

Usual anaesthesia
General
Position
Supine, with table tilts as needed
Setting
elective

Operative note template for a diagnostic or staging laparoscopy with biopsy, with a filled example for suspected abdominal tuberculosis with ascites.

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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

  • injury to bowel or blood vessels during entry
  • bleeding from the biopsy site
  • bleeding from the abdominal wall at a port site
  • conversion to open surgery
  • port-site hernia
  • port-site infection
  • biopsy may not give a diagnosis
  • shoulder tip pain from the gas

Pre-operative details for this operation

  1. Indicationdiagnosis in doubt after imaging, staging of a known cancer, ascites of unknown cause, chronic abdominal pain
  2. Imaging reviewedUSG / CT findings and the target for biopsy
  3. Previous abdominal surgery and scarsdecides the entry site and method
  4. Coagulation profile and plateletsespecially before liver biopsy
  5. Consent for proceeding to a definitive procedureTakenNot taken: biopsy onlye.g. appendicectomy, adhesiolysis, laparotomy

Anaesthesia and position

  1. AnaesthesiaGeneralLocal with sedation
  2. PositionSupine, arms tuckedSupine, legs apartLithotomy
  3. NG / orogastric tube and urinary catheterBothCatheter onlyPatient voided before surgery
  4. Leg compressionStockings / bandagesIntermittent pneumatic compressionNone

Operative findings

  1. Check under entry siteblood or bowel content under the first port: none / present
  2. Ascitesvolume aspirated, colour (straw / blood-stained / turbid / chylous)
  3. Peritoneum and omentumnodules, tubercles, plaques, adhesions; site and size
  4. Liver and diaphragmsurface nodules, cirrhosis, colour; segments involved
  5. Stomach, gallbladder, spleen
  6. Small bowel and colonrun between graspers: strictures, thickening, masses, adhesions
  7. Pelvisuterus, tubes, ovaries / bladder, pouch of Douglas deposits
  8. Incidental findingse.g. groin hernia; note, do not repair unless related

Procedure (steps)

  1. Entry methodOpen (Hasson) at umbilicusClosed (Veress) at umbilicusVeress at Palmer's pointOptical trocarincision type and site; confirmation tests if Veress
  2. PneumoperitoneumCO2, set pressure in mmHg
  3. Camera port and telescopeport size, 0 or 30 degree scope
  4. Accessory portsnumber, size and site; placed under vision; below umbilicus in midline or lateral to rectus
  5. Systematic surveyquadrant order, table tilts used, small bowel run
  6. Fluid aspiratedvolume, sent for which tests
  7. BiopsyPeritoneal / omental biopsy with forcepsLiver wedge biopsyLiver needle core biopsyLymph node excisionsite, number of pieces, instrument
  8. Haemostasis at biopsy siteElectrocauteryPressure with grasperSutureUltrasonic device
  9. Additional procedure (if any)what and why
  10. Ports removed under vision, gas releasedport sites checked for bleeding

Closure, drains and dressing

  1. Fascia at 10 mm and larger portssuture material and size; method (direct, port-closure device)
  2. SkinSubcuticularInterruptedSkin adhesive / strips
  3. Local anaesthetic infiltration of port sitesdrug and volume, if used
  4. DrainNonePlaced through port site

Specimens and implants

  1. Biopsy for HPEsite of each piece, in formalin, separate containers
  2. Tissue / fluid for microbiologyin saline, not formalin: e.g. for tubercular PCR
  3. Fluid for cytology and biochemistryvolume sent

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. Vitalspulse and BP; watch for bleeding and increasing abdominal pain
  2. Oral intakeliquids when awake and not nauseated
  3. Analgesia and antiemeticas per chart; shoulder tip pain is expected
  4. Mobilisationsame day
  5. Catheter / NGremove in recovery or when awake
  6. Port site dressingcheck for soakage or haematoma
  7. Reports to followHPE, PCR, cytology; date of review

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: Mrs. P.J., 28 years, with 3 months of low-grade fever, weight loss and abdominal distension. USG and CT: moderate ascites, thickened omentum, no mass. Ascitic tap inconclusive. Suspected abdominal tuberculosis.

Case details

Date: 09/07/2026. Elective diagnostic laparoscopy with peritoneal biopsy. OT 4.

In OT 10:00. Induction 10:10. Skin incision 10:22. Closure completed 10:58.

Surgeon: Dr A. (2nd-year resident, General Surgery). Assistant: Dr B. (1st-year resident). Consultant: Dr C., scrubbed.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: ascites with omental thickening of uncertain cause. Tissue diagnosis needed before treatment.

Hb 10.2 g/dl, platelets 2.4 lakh/cmm, INR 1.0. No previous abdominal surgery. Urine pregnancy test negative.

Consent: general, procedure-specific and anaesthesia consent taken in Marathi from patient, husband as witness. Consent included conversion to open surgery.

WHO checklist sign in and time out done. Inj cefazolin 1 g IV at 10:12, before skin incision.

Anaesthesia and position

General anaesthesia with endotracheal intubation. Supine, both arms tucked. Ryle's tube and Foley catheter in situ. Crepe bandages to both legs. Parts painted with povidone-iodine and draped.

Procedure

Open (Hasson) entry through a 12 mm infraumbilical incision. Linea alba incised, peritoneum opened under vision, straw-coloured fluid seen. 10 mm port inserted and held with stay sutures.

CO2 pneumoperitoneum at 12 mmHg. 10 mm 30 degree telescope. No injury under the entry site.

Two 5 mm ports placed under vision in the left and right lumbar regions, lateral to the rectus.

About 1.5 litres of straw-coloured ascitic fluid aspirated; samples kept for tests.

Findings: multiple 2 to 3 mm whitish tubercles over parietal peritoneum, omentum and bowel serosa. Omentum thickened and rolled up. Filmy adhesions between omentum and anterior abdominal wall. Liver smooth, no nodules. Gallbladder, stomach and spleen normal. Small bowel run from DJ flexure to ileocaecal junction: serosal tubercles, no stricture or mass. Uterus, both tubes and ovaries normal. No hernia.

Four pieces of parietal peritoneum with tubercles taken from the right iliac fossa with laparoscopic biopsy forceps. Two pieces from the omentum.

Oozing from biopsy sites controlled with bipolar cautery. Haemostasis confirmed at low pressure.

Ports removed under vision. No port-site bleeding. Gas released.

Closure

Umbilical fascia closed by tying the Hasson stay sutures and one extra polyglactin 910 (Vicryl) 2-0 stitch.

5 mm port fascia not closed. Skin closed with subcuticular absorbable sutures. No drain.

Specimens and implants

Peritoneal biopsy (3 pieces) and omental biopsy (1 piece) in formalin for HPE, separate labelled containers.

One peritoneal and one omental piece in normal saline for tubercular PCR.

Ascitic fluid 50 ml for cytology, cell count and biochemistry, and 20 ml for tubercular PCR.

End of procedure

Estimated blood loss 10 ml. No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Patient extubated and shifted to post-operative ward in stable condition. Pulse 86/min, BP 112/70 mmHg.

Post-op orders

Pulse and BP half-hourly for 2 hours, then 4-hourly.

Ryle's tube and catheter removed in recovery.

Oral liquids when fully awake and not nauseated, then normal diet.

Analgesia and antiemetic as per chart. Ambulate in the evening.

Follow HPE and PCR reports. Plan discharge next day if comfortable.

Signature

Dr A., JR-2, General Surgery. Reg. no. ________. 09/07/2026, 11:15.

Must document for this operation

  • Entry method, site and whether the area under the entry site was checked. Most bowel and vessel injuries happen at entry, and this line is the first thing reviewed if the patient deteriorates.
  • A full quadrant-by-quadrant description, including normal organs. A negative laparoscopy is only useful if the note shows every area was seen.
  • Exact site of each biopsy, using liver segments or named regions. The pathologist and any later surgeon need to know where the tissue came from.
  • Which samples went in formalin and which in saline, and for which tests. Tissue in formalin cannot be used for culture or PCR, and repeat biopsy means a second anaesthetic.
  • How fascia at 10 mm and larger ports was closed. Port-site hernia is a known complication and the closure record is checked when one appears.
  • Incidental findings and whether they were acted on. The patient must be told about them and the record shows they were seen.

Common mistakes in these notes

  • Writing 'DL done, tubercles seen, biopsy taken' with no survey of other areas.
  • Not naming the biopsy site.
  • Sending all tissue in formalin when TB or infection is suspected.
  • Leaving out the pneumoperitoneum pressure and port sizes.
  • Not recording fascial closure of the umbilical port.

Indian practice and paperwork

  • The ICMR antimicrobial guideline lists no antibiotic or a single perioperative dose of cefuroxime or cefazolin for clean (class I) operations, given within 1 hour before incision. (ICMR Treatment Guidelines for Antimicrobial Use in Common Syndromes 2019, Table 10.1 and section 10.3.8 (printed pp. 97-99))

Sources

  • Scott-Conner CEH. Scott-Conner & Dawson: Essential Operative Techniques and Anatomy. 4th ed. Wolters Kluwer / Lippincott Williams & Wilkins; 2014, Ch 46 Laparoscopy: principles of access and exposure; Ch 81 Liver biopsy, open and laparoscopic, pp. 239-249; 420-422.
  • Sriram Bhat M. SRB's Surgical Operations: Text and Atlas. Jaypee; 2014, Ch 18 Basic principles in laparotomy and laparoscopy: pneumoperitoneum, port closure, diagnostic laparoscopy, pp. 545-563.
  • Moran B, Mittal R, Lord A, eds. Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press; 2026, Ch 6 Surgical access to the abdomen: minimally invasive access, pp. 82-84.
  • ICMR. Treatment Guidelines for Antimicrobial Use in Common Syndromes, 2nd ed., 2019. Table 10.1 (class I: none or single dose cefuroxime/cefazolin), 10.3.8 (within 1 h before incision), 10.3.9 (full therapeutic dose), Table 10.3 (cefazolin 0.5-1 g IV). www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/Treatment_Guidelines_2019_Final.pdf

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

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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