Laparotomy for enteric (typhoid) ileal perforation: primary closure / ileostomy

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

• leak from the repair and faecal fistula
• further perforations appearing after surgery
• need for a temporary ileostomy and a second operation to close it
• resection of a segment of ileum
• wound infection and burst abdomen
• residual abscess in the pelvis or under the diaphragm
• septic shock, need for ICU care and a significant risk of death
• relaparotomy

Pre-operative details for this operation

1. Fever historyduration of fever before perforation, antibiotics already taken
2. Evidence of typhoidblood culture, Widal or other test, and result
3. Time since perforation symptomshours since sudden pain or distension
4. Imagingfree gas under diaphragm on erect X-ray / CT
5. Resuscitation and sepsis statusfluids given, urine output, BP, lactate or shock; nasogastric tube and catheter in place
6. Stoma consent and site markingTaken and markedNot taken (reason)

Anaesthesia and position

1. AnaesthesiaGeneral, rapid sequence induction
2. PositionSupine

Operative findings

1. Peritoneal contaminationvolume and type (bilious, purulent, faeculent), localised or generalised, flakes
2. Number of perforationsone / more; if more, list each
3. Site of each perforationdistance from the ileocaecal junction in cm; antimesenteric border
4. Size and edgessize in mm; edges healthy / oedematous / friable
5. Rest of the bowelimpending perforations (thinned Peyer's patches), oedema, viability; whole small bowel run

Procedure (steps)

1. Skin preparation and draping
2. IncisionMidline laparotomyextent
3. Peritoneal fluid sent for culture and sensitivity, then sucked out
4. Whole small bowel inspectedfrom duodenojejunal flexure to ileocaecal junction; all perforations counted
5. Procedure on the perforationEdges trimmed, transverse primary closureResection and anastomosisLoop ileostomyResection, end ileostomy, distal end closedreason for the choice (number of perforations, bowel condition, patient condition)
6. Closure materialInterrupted silk 2-0 or 3-0 (SRB)Interrupted polyglactin 910 (Vicryl) 2-0interrupted, material and size; second seromuscular Lembert layer if placed. NQAS advises against braided biological sutures (silk) in dirty wounds, so write the reason for the material chosen
7. Edge biopsySentNot sentto rule out tuberculosis or other cause
8. Mesenteric tearNoneSutured
9. Peritoneal lavagewarm saline, volume

Closure, drains and dressing

1. Draintube drain type, size and site (for example pelvic)
2. Abdominal wallSingle-layer mass closureSmead-Jones closureTension sutures addedsuture material and size
3. SkinInterrupted sutures, looselyLeft open for delayed closure
4. Stomatype, site, spout, appliance fitted

Specimens and implants

1. Peritoneal fluid for culture and sensitivity
2. Perforation edge / resected ileum for HPESentNot 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. ICU / HDU or wardwhere, and why
2. Vitals, urine output, sepsis watchfrequency; urine output target
3. Nasogastric tube and nil by mouthfree drainage; start liquids when bowel function returns
4. IV fluids and electrolytestype and rate; daily Na, K, creatinine
5. Antibiotics (treatment, not prophylaxis)drug, dose, frequency; review with blood and peritoneal culture reports
6. Drainchart output and character; report bilious or faeculent fluid
7. Stoma carestoma colour and output; appliance; high output watch
8. Analgesia and DVT prophylaxisdrug, dose; stockings / LMWH as per risk
9. Woundwatch for infection and burst abdomen
10. Public healthnotify enteric fever as per local rule

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