OT notes · Thoracic / Trauma

Repair of diaphragmatic injury

Usual anaesthesia
General anaesthesia with endotracheal intubation
Position
Supine with both arms abducted; reverse Trendelenburg and right side down for a left-sided laparoscopic repair
Setting
emergency

Operative note template for repair of an acute traumatic diaphragm injury by laparoscopy or laparotomy, with a filled example for a left thoracoabdominal stab wound repaired laparoscopically.

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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

  • conversion to open operation
  • tension pneumothorax during laparoscopy
  • chest drain after the operation
  • injury to abdominal organs found and repaired at the same time
  • infection in the chest (empyema)
  • recurrence or late diaphragmatic hernia
  • need for a chest incision (thoracotomy)
  • bleeding

Pre-operative details for this operation

  1. Mechanism and woundStabGunshotBlunt (deceleration)site of wound in relation to nipple line and costal margin; side
  2. Haemodynamic statuspulse, BP; peritonitis present or not
  3. Imagingchest X-ray, CT: hernia of stomach / colon / omentum, raised hemidiaphragm, haemothorax
  4. Chest drain before surgeryNoneIn situ (side, output)
  5. Nasogastric tubepassed; position on X-ray if stomach is in the chest
  6. Blood arranged

Anaesthesia and position

  1. AnaesthesiaGeneral
  2. ApproachLaparoscopicLaparotomyThoracotomy (late presentation)Laparoscopy converted to open
  3. Positionsupine, arms out; tilt for laparoscopy; prep chin to knees for open trauma repair
  4. Anaesthetist told to watch for tension pneumothoraxpeak airway pressure, SpO2, BP during insufflation; if signs of tension, release the pneumoperitoneum and insert a chest drain

Operative findings

  1. Diaphragm tearside, site (central / peripheral / posterior / near pericardium), length in cm, avulsion from chest wall
  2. Herniated contentsNoneOmentumStomachColonSpleenOtherviable / ischaemic
  3. Other injuriesstomach, spleen, liver, colon: examined and findings
  4. Contaminationbowel content in abdomen or pleura
  5. Pleural cavityblood, contamination seen through defect

Procedure (steps)

  1. AccessSupra-umbilical camera port, extra ports as neededMidline laparotomyport sizes and sites
  2. Exploration of abdomenall quadrants; stomach, spleen, colon, liver on the side of the wound
  3. Exposure of diaphragmcostal margin retracted upwards (fixed retractor); tear edges held with Allis clamps / graspers and pulled towards the incision or camera
  4. Reduction of herniated contentsgentle traction; defect enlarged if contents are stuck; viability checked
  5. Pleural washoutthrough the defect, volume of saline; gross contamination removed
  6. RepairInterrupted figure-of-eightContinuousHernia staples (laparoscopic)Horizontal mattress round ribs (avulsion)non-absorbable monofilament No. 0 or 1; number of sutures; stitches near pericardium placed under vision
  7. MeshNot usedUsed (type, size, reason)
  8. Chest drainalways placed after repair: side, size, site, output at insertion
  9. Other injuries repairedwhat and how

Closure, drains and dressing

  1. Ports / laparotomyfascia at ports 10 mm or more; laparotomy fascia suture and technique
  2. Skin
  3. Abdominal drainNonePlaced (site)

Specimens and implants

  1. SpecimensNoneResected tissue for HPE
  2. Mesh or tackstype, size, make, batch number, 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. Chest drainunderwater seal; record output and air leak; do not clamp
  2. Chest X-rayin recovery or on the ward, for lung expansion and drain position
  3. Vitals and SpO2hourly for the first hours
  4. Breathing exercisesincentive spirometry, early sitting up
  5. Analgesiadrug, dose, frequency
  6. Oral intakefrom when, if no bowel injury
  7. Watch for chest infectionfever, rising drain output, cloudy fluid (empyema), especially if there was contamination

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. A.K., 30 years, single stab wound in the left 7th intercostal space at the anterior axillary line, stable, no peritonitis, CT shows a small left haemothorax and a suspected diaphragm defect.

Case details

Date: 09/02/2026. Emergency diagnostic laparoscopy and laparoscopic repair of left diaphragm. OT 3.

In OT 16:10. Induction 16:15. Incision 16:28. End 17:30.

Surgeon: Dr A. (3rd-year resident, General Surgery). Assistant: Dr B. (2nd-year resident). Consultant: Dr C., scrubbed.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Penetrating wound of the left thoracoabdominal area between the nipple line and the costal margin. Pulse 92/min, BP 124/78 mmHg. Abdomen soft.

CT: small left haemothorax, possible defect in the left diaphragm, no free fluid.

Left 28 Fr chest drain placed in the emergency department, 150 ml blood.

Consent: written consent from patient for laparoscopy, repair of diaphragm, repair of any organ injury and conversion to open. Explained in Marathi.

WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 16:18. Tetanus toxoid given in the emergency department.

Anaesthesia and position

General anaesthesia with endotracheal tube. Nasogastric tube passed. Supine with both arms out. Painted with povidone-iodine from nipples to thighs and draped.

Anaesthetist told of the chest drain and asked to watch airway pressure and SpO2 during insufflation.

Findings

Left dome of diaphragm: 2.5 cm linear tear in the muscular part, anterolateral, with a tongue of omentum passing into the chest. Omentum healthy.

Stomach, spleen, splenic flexure and left lobe of liver: no injury. Small bowel and rest of abdomen: no injury, no contamination.

About 50 ml old blood in the left pleura seen through the defect.

Procedure

10 mm supra-umbilical camera port by open method. Two 5 mm working ports in the left and right upper abdomen.

Reverse Trendelenburg with right side down. Four quadrants inspected.

Omentum pulled back gently into the abdomen.

Pleura washed through the defect with 500 ml warm saline and suctioned.

Tear closed with 4 interrupted figure-of-eight sutures of polypropylene (Prolene) No. 0, edges held with a grasper and pulled towards the camera for each bite. No mesh.

Airway pressure and SpO2 stable throughout.

Closure

Umbilical port fascia closed with polyglactin 910 (Vicryl) No. 1. Skin with polyamide (Ethilon) 3-0. No abdominal drain.

Left chest drain kept, re-expanded, draining serosanguinous fluid, swinging.

End of procedure

Estimated blood loss 30 ml. No transfusion.

Instrument, needle and mop count correct, confirmed by scrub nurse.

No intra-operative complications.

Specimens: none. Implants: none.

Pulse 86/min, BP 120/76 mmHg, SpO2 98% on room air. Shifted to post-op ward.

Post-op orders

Chest drain on underwater seal. Record output 4-hourly. Do not clamp.

Chest X-ray this evening.

Pulse, BP, SpO2 hourly for 6 hours.

Incentive spirometry and sit up from this evening.

Sips from 6 hours if no nausea, then liquids.

Inform Dr A. if fever, breathlessness or cloudy drain fluid.

Signature

Dr A., JR-3, General Surgery. Reg. no. ________. 09/02/2026, 17:45.

Must document for this operation

  • Side, site and length of the diaphragm tear. A late hernia or a second operation will be judged against this.
  • What had herniated and whether it was viable. Ischaemic stomach or colon changes the operation and the post-op course.
  • Suture material, size and technique, and whether mesh was used. A surgeon repairing a recurrence needs to know what is already there.
  • Whether the pleura was contaminated and washed out. Contamination raises the risk of empyema, and the ward team watches the drain with this in mind.
  • Chest drain side, size and position. A drain is always left after repair and the ward team manages it from the note.
  • The rest of the abdomen examined and what was found. A missed stomach or colon injury is the main danger after a thoracoabdominal stab.

Common mistakes in these notes

  • Writing 'diaphragm repaired' with no size, site or suture.
  • Not recording that other organs on the side of the wound were checked.
  • Leaving out the chest drain details.
  • Not recording pleural contamination and washout.
  • Not writing that the anaesthetist was warned about tension pneumothorax during laparoscopy.

Indian practice and paperwork

  • The district hospital OT checklist expects tetanus prophylaxis to be given when indicated. Record it for a stab wound. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, ME E15.2)
  • Consent must explain the procedure, risks, benefits, alternatives and who will operate, in a language the patient understands. Include conversion to open and repair of other organs. (NABH 5th ed., PRE.4(c))
  • NABH expects the operative note to be written before the patient leaves recovery, and post-op care to follow a written plan. (NABH 5th ed., COP.14(e) and (f))
  • If mesh or tacks are used, record batch and serial number in the case record, the OT implant register and the discharge summary. (NABH 5th ed., MOM.10(d))

Sources

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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