Drainage of liver abscess (open / catheter)

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

• bleeding from the liver, which may need packing
• bile leak or biloma
• continuing sepsis and need for repeat drainage
• injury to the diaphragm with chest contamination or pneumothorax
• injury to the duodenum, colon or bile duct
• prolonged drain and wound infection
• second look or re-laparotomy
• need for ICU care and ventilation

Pre-operative details for this operation

1. Indication for open drainageRupture with peritonitisFailed percutaneous drainageNot suitable for percutaneous drainage (multiloculated, large, thick contents)Percutaneous drainage not available
2. Type of abscess suspectedAmoebicPyogenicNot knownserology, earlier aspirate results
3. ImagingUSG / CT: segment, size, number, loculation, gas, rupture, free fluid, biliary communication
4. Antibiotics and amoebicide already starteddrugs and start dates
5. BloodsHb, TLC, LFT, INR, creatinine, blood culture, blood cross-matched
6. Nasogastric tube and urinary catheter

Anaesthesia and position

1. AnaesthesiaGeneral with endotracheal intubation
2. PositionSupine
3. Intra-operative ultrasoundAvailableNot available

Operative findings

1. Peritoneal contaminationvolume and character of pus or fluid, where it was
2. Abscesslobe or segment, size, site of rupture, number of cavities, loculi
3. Pusvolume aspirated, colour, smell
4. Bile in the cavityNo bile leakBile leak seen (site)
5. Other organsgallbladder, colon, duodenum, diaphragm, bowel

Procedure (steps)

1. IncisionRight subcostalRight subcostal extended to midline (hockey stick)Bilateral subcostalMidline (generalised peritonitis)Laparoscopiclength
2. Free pus and fluid sucked out, sample sentvolume
3. Adhesions separatedcolon or omentum freed from liver with care to colon, mesentery and duodenum
4. Abscess localisedSeen or feltIntra-operative ultrasoundNeedle aspirationlarge-bore long needle, choose a site that gives pus, not blood
5. Pus sent for culture and sensitivityalso for amoeba if suspected
6. Abscess opened and unroofedelectrocautery along the needle track, area packed off, suction ready
7. Loculi brokenfinger and suction
8. Cavity irrigated with salinevolume
9. Cavity checked for bleeding and bile leakany bile leak controlled with sutures or clips
10. Drain in abscess cavitytype and size (e.g. large-bore tube 28 to 32 Fr), brought out through a separate stab wound
11. Peritoneal toiletvolume of warm saline used

Closure, drains and dressing

1. Peritoneal drainsite, type, size
2. Packing for bleedingNot neededPacks left (number), temporary abdominal closure
3. Sheathsuture material and technique
4. SkinClosedLeft open (contaminated wound)Staples
5. Drains fixed and labelledwhich drain is cavity and which is peritoneal

Specimens and implants

1. Pus for culture and sensitivitySent
2. Pus for amoeba / other testsSentNot sent
3. Abscess wall biopsy for HPESentNot sentif malignancy is a concern

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. Pulse, BP, temperature, urine outputhourly for the first 6 hours
2. Cavity drain and peritoneal drainchart each separately: volume and nature (pus, blood, bile)
3. Antibiotics and amoebicidedrug, dose, route, duration, change when culture report arrives
4. Nasogastric tube and dietnil by mouth till bowel sounds, plan
5. IV fluidstype and rate
6. Analgesiadrug, dose, frequency
7. Chest physiotherapyincentive spirometry, early sitting up
8. InvestigationsTLC, LFT on POD 1, repeat USG before drain removal
9. Drain removalwhen output is low and there is no sepsis or bile leak

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