OT notes · General Surgery

Femoro-popliteal bypass

Usual anaesthesia
General or epidural; local anaesthesia in selected patients
Position
Supine, leg slightly flexed at the knee and externally rotated
Setting
elective

Operative note template for femoro-popliteal bypass with vein or prosthetic graft, with a filled example for a reversed great saphenous vein bypass to the above-knee popliteal artery.

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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

  • graft blockage (thrombosis) needing re-operation
  • bleeding from the anastomoses or vein side branches
  • groin wound infection, seroma or lymph leak (lymphocele)
  • skin flap breakdown along the vein harvest incision
  • graft infection, more likely with a prosthetic graft, which may need graft removal
  • numbness along the inner leg from saphenous nerve injury
  • heart attack in patients with coronary disease
  • kidney strain from angiogram contrast
  • amputation if the bypass fails

Pre-operative details for this operation

  1. IndicationClaudication not responding to exercise therapyRest painTissue loss (ulcer / gangrene)side, walking distance or lesion
  2. Pulses and ankle-brachial indexfemoral, popliteal, pedal pulses; ABI both sides
  3. Arterial imagingCT angiogramMR angiogramDigital subtraction angiograminflow, occluded segment, target (above / below knee popliteal), run-off vessels
  4. Great saphenous vein duplexside, diameter, length usable; marked on skin
  5. Cardiac evaluationECG, echo, physician clearance
  6. Renal functioncreatinine before contrast
  7. Antiplatelet / anticoagulantdrug, whether continued or stopped, last dose
  8. Blood reservedgroup and units

Anaesthesia and position

  1. AnaesthesiaGeneralEpiduralLocal
  2. PositionSupine, knee slightly flexed on a roll, thigh externally rotated
  3. Prepextent of skin preparation; foot visible or in a sterile bag
  4. C-arm / angiography availableYesNo

Operative findings

  1. Common femoral arterypulse, wall disease, site chosen for proximal anastomosis
  2. Profunda and superficial femoral arteriesSFA occluded / patent; profunda disease
  3. Popliteal targetAbove-knee poplitealBelow-knee poplitealwall quality, back-bleeding
  4. ConduitGreat saphenous vein: diameter and qualityProsthetic graft (vein unsuitable: reason)
  5. Completion checkAngiogram: anastomoses and run-off satisfactoryDoppler signals satisfactoryDefect found and corrected
  6. Foot at endcolour, warmth, pedal pulse or Doppler signal

Procedure (steps)

  1. Vein exposure first (if vein conduit)continuous or skip incisions; skin flaps kept thick and handled gently
  2. Groin incision and femoral exposureincision over femoral pulse; lymphatics ligated; CFA, SFA and profunda looped
  3. Popliteal exposureAbove knee: medial thigh incision, sartorius retractedBelow knee: incision 1 cm behind tibia, soleus and gastrocnemius retractedvenous branches over the artery ligated; artery looped
  4. Vein harvest and preparationReversedNon-reversed with valvulotomeIn situ with valvulotomelength taken, tributaries ligated, SFJ stump oversewn (suture)
  5. TunnelSubsartorial (anatomic)Subcutaneousmade before heparin; tunneller used
  6. Systemic heparindose and time, given after vessel control and before clamping (Scott-Conner: 100 units/kg; Northwestern: 5000 units); write which was used
  7. Proximal anastomosisartery (CFA / SFA / profunda), arteriotomy length, end-to-side, suture (polypropylene size), continuous
  8. Graft passed through tunnelno twist or kink; distended to keep orientation
  9. Distal anastomosisarteriotomy length, end-to-side, suture (polypropylene size), flushed before completion
  10. Clamp release sequence and flowgraft origin and proximal artery first, distal clamp last
  11. Completion studyOn-table angiogramDopplercannula size, contrast used, findings
  12. Heparin reversalNot reversedReversed: drug and dose

Closure, drains and dressing

  1. Haemostasis and irrigation of wounds
  2. Groin woundlayers (subcutaneous in two layers), suture material
  3. Vein harvest and popliteal woundssubcutaneous and skin closure
  4. SkinStaplesSubcuticular absorbable 4-0
  5. DrainNoneClosed suction in groin

Specimens and implants

  1. Prosthetic graft (if used)material (PTFE / Dacron), diameter, length, make, lot and serial number, sticker pasted
  2. Vein graftlength and diameter used; no implant
  3. SpecimenNoneEndarterectomy plaque for HPE

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. Shift to HDU / intermediate care overnightwatch for bleeding, graft blockage, infection
  2. Graft and foot checkspedal pulse or Doppler, colour, warmth, capillary refill at the frequency the surgeon writes; loss of signal to be reported at once
  3. Wound checksgroin haematoma or swelling
  4. Antiplatelet / anticoagulationdrug, dose and start time as decided by the surgeon
  5. Antibioticsone or two post-op doses, longer only if distal ulcer or infection
  6. Mobilisation and dietout of bed when comfortable; normal diet
  7. Renal functioncreatinine on POD 1 after contrast
  8. Follow up1 week, 1 month, 3 months, then every 6 months; graft duplex surveillance

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. B.P., 64 years, diabetic and ex-smoker, with rest pain in the right foot, right SFA occlusion with reconstitution of the above-knee popliteal artery and two-vessel run-off on CT angiogram, and a good right great saphenous vein on duplex.

Case details

Date: 21/09/2026. Elective right femoro-popliteal (above-knee) bypass with reversed great saphenous vein. OT 4.

In OT 08:30. Epidural sited 08:45. Incision 09:20. Closure completed 12:40.

Surgeon: Dr A. (consultant, vascular surgery). Assistants: Dr B. (MS 3rd-year resident), Dr C. (MS 2nd-year resident).

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Rest pain right foot for 6 weeks. Right femoral pulse present, popliteal and pedal pulses absent. ABI right 0.38, left 0.72.

CT angiogram: right SFA occluded from origin, reconstitutes at above-knee popliteal, anterior tibial and peroneal run-off. Inflow normal.

Duplex: right great saphenous vein 4 to 5 mm from groin to knee, marked on skin.

Echo: EF 55%. Physician clearance obtained. Creatinine 1.0 mg/dl. HbA1c 7.6%.

Aspirin continued. Consent: general, procedure-specific and anaesthesia consent taken in Telugu from patient, daughter present.

Blood group A positive, 2 units cross-matched. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 09:05.

Anaesthesia and position

Epidural anaesthesia. Foley catheter placed.

Supine, right knee slightly flexed on a roll, thigh externally rotated. Parts painted with chlorhexidine-alcohol from umbilicus to right foot and draped, foot in sterile bag.

Findings

Right CFA soft with good pulse. SFA occluded from origin. Profunda soft.

Above-knee popliteal artery soft, good back-bleeding.

Great saphenous vein about 5 mm, thin-walled, no varicosity.

Completion angiogram: both anastomoses widely patent, good run-off through anterior tibial and peroneal arteries.

Foot pink and warm at end, strong Doppler signal in dorsalis pedis.

Procedure

Great saphenous vein exposed first through a continuous medial thigh incision from the groin to the knee. Skin flaps kept thick.

Common femoral, profunda and superficial femoral arteries exposed through the same groin incision. Lymphatics ligated. Vessels controlled with vessel loops.

Above-knee popliteal artery exposed through the lower thigh incision with sartorius retracted posteriorly. Venous branches over the artery ligated with fine silk. 3 cm segment looped.

Vein measured, 42 cm harvested. Tributaries ligated and divided. Saphenofemoral junction clamped and divided, stump oversewn with polypropylene (Prolene) 6-0. Vein reversed and gently distended.

Subsartorial tunnel made with tunneller before heparin.

Inj heparin 6500 units IV (100 units/kg, weight 65 kg) at 10:25.

Proximal anastomosis: CFA opened with No. 11 blade, arteriotomy 15 mm. Vein bevelled and sewn end-to-side with continuous Prolene 5-0. Clamp moved onto the graft, CFA clamps released.

Graft passed through the tunnel without twist or kink.

Distal anastomosis: popliteal arteriotomy 12 mm. Vein sewn end-to-side with continuous Prolene 6-0. Graft and artery flushed before the last throws.

Clamps released: graft origin and proximal popliteal first, distal clamp after several seconds. Clamp time at popliteal 28 min.

On-table angiogram through a 20 G cannula in the proximal graft: findings as above.

Heparin not reversed.

Closure

Haemostasis checked along the vein bed and at both anastomoses. Wounds irrigated.

Groin subcutaneous tissue closed in two layers with absorbable polyglactin 910 (Vicryl). Thigh wound subcutaneous tissue closed with Vicryl.

Skin closed with staples. No drain.

Dry dressing.

Specimens and implants

No specimen. No prosthetic implant. Conduit: reversed right great saphenous vein, 42 cm, about 5 mm.

End of procedure

Estimated blood loss 400 ml. No transfusion. Contrast used 20 ml.

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

No intra-operative complications.

Shifted to vascular HDU in stable condition. Pulse 82/min, BP 136/78 mmHg. Right DP Doppler signal strong.

Post-op orders

Right foot colour, warmth and DP Doppler checks overnight in HDU, frequency as written by the consultant. Inform surgeon at once if the signal is lost.

Watch groin for haematoma.

Aspirin to continue from tomorrow. Inj cefazolin 1 more dose.

Out of bed when comfortable. Normal diabetic diet.

Blood sugar monitoring. Creatinine on POD 1.

Review in clinic at 1 week, 1 month and 3 months, with graft duplex.

Signature

Dr B., JR-3, General Surgery, for Dr A. Reg. no. ________. 21/09/2026, 13:00.

Must document for this operation

  • Inflow artery, outflow target and whether it is above or below the knee. Patency and future procedures depend on this, and the next surgeon needs it before any redo operation.
  • Conduit: vein reversed, non-reversed or in situ, its size, or the prosthetic graft details with sticker. Surveillance, infection risk and any graft recall all depend on what was put in.
  • Heparin dose and time, and whether it was reversed. Post-op bleeding or graft thrombosis is judged against the anticoagulation given.
  • Completion angiogram or Doppler findings. If the graft blocks early, this shows whether a technical problem was already present at the end of surgery.
  • State of the foot at the end: pulse or Doppler signal. It is the baseline for the hourly checks on the ward.
  • Contrast volume used. Kidney injury after contrast is a known complication, and the physician needs the dose.

Common mistakes in these notes

  • Writing 'fem-pop bypass done' with no mention of above or below knee.
  • Not writing the heparin dose and time.
  • Leaving out the prosthetic graft sticker, lot and serial number.
  • No completion study recorded.
  • No baseline distal pulse or Doppler signal at the end.

Indian practice and paperwork

  • NABH asks that the batch and serial number of an implanted device be written in the patient record, the OT master logbook and the discharge summary. This applies to a PTFE or Dacron graft. (NABH 5th ed., MOM.10(d))
  • 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))
  • Name every anaesthetist in the note. A National Commission case held a hospital negligent when the operation notes left out the name of one of two anaesthetists. (Thomas J. Indian J Urol 2009;25(3):384-8)

Sources

  • Scott-Conner CEH, ed. Scott-Conner & Dawson: Essential Operative Techniques and Anatomy. 4th ed. Lippincott Williams & Wilkins (Wolters Kluwer); 2014, Ch 133, Femoral to Popliteal Bypass (Amin PB, Sharafuddin MJ), pp. 721-729.
  • Bell RH Jr, Kaufman DB, eds. Northwestern Handbook of Surgical Procedures. Landes Bioscience; 2005, Ch 100, Femoral-Popliteal Bypass with a Vein or Prosthetic Graft (White JV, Bulger C), pp. 300-302.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin 2 g IV (3 g if 120 kg or more), redose at 4 h. Table 2: vascular procedures: cefazolin. Start within 60 min before incision; duration under 24 h. www.ashp.org/-/media/assets/policy-guidelines/docs/therapeutic-guidelines/therapeutic-guidelines-antimicrobial-prophylaxis-surgery.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

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