Surgery for hydatid cyst of liver (cystectomy / PAIR-open)

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

• anaphylaxis from spilled cyst fluid
• spillage and spread of the disease in the abdomen, recurrence
• bile leak or biliary fistula, may need ERCP or re-operation
• bleeding from the liver
• infection of the cavity, subphrenic or liver abscess
• chest complications (pneumonia, effusion)
• liver failure with very large cysts
• more extensive surgery such as liver resection or T-tube drainage

Pre-operative details for this operation

1. ImagingUSG / CT / MRI: number, segment(s), size, WHO type (CL, CE1 to CE5) or Gharbi type, daughter cysts, calcification, bile duct dilatation, cysts in lung or elsewhere
2. Signs of biliary communicationjaundice, cholangitis, dilated CBD, LFT
3. Albendazole before surgerydose (mg/kg/day), start date, duration
4. Chosen operation and reasonConservative: evacuation with partial pericystectomyTotal pericystectomy (closed or open)Liver resectionLaparoscopicwhy not PAIR (e.g. multiseptate, communicating, inaccessible)
5. Anaphylaxis preparednessanaesthetist informed, drugs ready
6. Blood cross-matchedunits

Anaesthesia and position

1. AnaesthesiaGeneral
2. PositionSupine
3. Low central venous pressureRequested (resection / pericystectomy)Not needed

Operative findings

1. Cyst(s)number, segment, size, depth, adhesions to diaphragm or other organs
2. Contentsvolume, clear / bile-stained / pus, daughter cysts, laminated membrane
3. Cystobiliary communicationNone seenPresent (number, site, size of opening)how it was looked for (bile staining, white mop test, cholangiogram, IOUS)
4. Pericystthin / thick / calcified, relation to hepatic veins, IVC, hilum
5. Other cysts in abdomenperitoneum, spleen, omentum

Procedure (steps)

1. IncisionRight subcostalRight subcostal extended to left (rooftop)Midline
2. Liver freed of adhesions and mobilisedligaments divided as needed
3. Field packed with mops soaked in scolicidal agentcoloured (dark) mops, agent and strength (e.g. hypertonic saline 20%)
4. Cyst punctured and aspiratedclosed system / suction cone, volume, colour (bile-stained?)
5. Scolicidal agent injected into cystHypertonic saline (strength)Not injected: bile-stained fluidtime left before opening, formalin never used
6. Cyst opened and contents evacuatedstay sutures, incision length, laminated membrane and daughter cysts removed with sump suction, forceps, spoon
7. Cavity sterilisedwiped and packed with hypertonic saline soaked gauze, time
8. Cystobiliary communication managedNone foundSutured (material, e.g. polyglactin 910 (Vicryl) 4-0 or PDS)CBD explored, T-tubeBipolar / Perdomo drainage
9. PericystRedundant roof excised (partial pericystectomy)Total pericystectomyLiver resection (type)cut edge oversewn
10. Residual cavityOmentoplastyCapitonnageIntroflexionMarsupialisationTube drainage onlyLeft open
11. Peritoneal wash and search for spillscolicidal mops removed, lavage

Closure, drains and dressing

1. Drainsone in or near the cavity, one in the peritoneal cavity, sizes and sites
2. T-tubeNot placedPlaced (size), cholangiogram done
3. Sheathsuture material and technique
4. SkinStaplesInterrupted sutures

Specimens and implants

1. Laminated membrane and daughter cystssent for HPE
2. Pericyst wallSent for HPENot sent
3. Cyst fluidCulture sent (infected)Not 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. Pulse, BP, temperature, urine outputhourly for the first 6 hours, watch for rash, wheeze or low BP (late allergic reaction)
2. Drainschart cavity and peritoneal drains separately: volume and bile
3. Serum sodiumafter hypertonic saline use
4. T-tube (if placed)free drainage, volume, plan for cholangiogram
5. Albendazolerestart after surgery, dose, continue for 1 month or as advised
6. Nasogastric tube and dietplan
7. Chest physiotherapyincentive spirometry, look for effusion
8. Analgesia and IV fluidsdrug, dose, frequency, fluid type and rate
9. Follow-up imagingUSG of cavity and for recurrence at intervals

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