OT notes · General Surgery

Laparoscopic appendicectomy

Usual anaesthesia
General anaesthesia
Position
Supine, arms tucked, Trendelenburg with the right side tilted up after port placement
Setting
emergency

Operative note template for laparoscopic appendicectomy, with a filled example for an emergency three-port appendicectomy with endoloop ligation of the base for acute appendicitis.

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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
  • port-site injury to bowel or blood vessels
  • bladder injury from the suprapubic port
  • bleeding from the mesoappendix
  • stump leak, abscess or faecal fistula
  • intra-abdominal or pelvic abscess
  • port-site infection or port-site hernia
  • thermal injury to caecum or bowel from diathermy
  • removal of a normal-looking appendix

Pre-operative details for this operation

  1. Diagnosis and basisduration of pain, WBC count, USG or CT findings (diameter, faecolith, collection, mass)
  2. UrgencyEmergencyInterval (elective)
  3. Female patient: pregnancy test and adnexa on USG
  4. Previous abdominal surgeryscars, which may change the entry site
  5. BladderVoided just before OTCatheterised
  6. Consent for conversion to openTaken

Anaesthesia and position

  1. AnaesthesiaGeneral with endotracheal intubation
  2. Positionsupine, arms tucked; Trendelenburg with right side up after ports are in
  3. Monitor and team positionmonitor at the right side of the foot end; surgeon on the patient's left
  4. PneumoperitoneumOpen (Hasson)Veress needlesite, pressure set in mmHg
  5. Portssize and site of each port, e.g. 10 mm umbilical, 5 mm suprapubic, 5 mm left iliac fossa
  6. Telescope30 degree0 degree

Operative findings

  1. Four-quadrant inspectionliver, gallbladder, stomach, bowel, pelvis
  2. Peritoneal fluidNoneSerousTurbidFrank pusBloodsite (RIF / pelvis / general), culture sent
  3. Position of appendixRetrocaecalPelvicPre-ilealPost-ilealSubcaecalSubhepatic
  4. State of appendixGrossly normalInflamedSuppurativeGangrenousPerforatedsite of perforation, faecolith, omental or bowel adhesions
  5. Base and caecumHealthy baseInflamed basePerforation at base
  6. Pelvic organs and ileumovaries and tubes in females; ileum for Meckel diverticulum and nodes if appendix normal

Procedure (steps)

  1. Access and pneumoperitoneummethod, site, pressure
  2. Diagnostic laparoscopy of all four quadrants
  3. Working ports placed under visionsizes and sites
  4. Adhesiolysisomentum or bowel peeled off bluntly or with suction; adhesions to side wall divided with diathermy
  5. Caecum retracted up, base of appendix exposedfor retrocaecal appendix: lateral peritoneum of caecum incised and caecum rolled medially
  6. Mesoappendix dividedBipolar diathermy and scissorsMonopolar diathermyClipsUltrasonic shears (Harmonic)Vessel sealer (LigaSure)Stapler with vascular load
  7. Base securedEndoloop x 2 on base, 1 distalIntracorporeal ligaturesClipsEndostaplermaterial of the loop or ligature; clip over knot if used
  8. Appendix dividedlevel of division, stump checked for bleeding and integrity
  9. Specimen retrievalIn retrieval bagIn glove fingerDirectly through 10/12 mm portInside the port, removed with the portport used
  10. Search for other disease if appendix normalpelvic organs, small bowel run, Meckel diverticulum
  11. Suction and irrigationRIF, pelvis, right paracolic gutter; volume of saline
  12. Conversion to openNot neededConvertedreason and time, incision used

Closure, drains and dressing

  1. Ports removed under vision, gas let out
  2. Fascia of 10/12 mm port sites closedsuture material and size; 5 mm fascia need not be closed
  3. SkinSubcuticular absorbableInterrupted non-absorbableSkin glueSteri-strips
  4. DrainNonePelvic drain through a lateral portRIF drain through a port site
  5. Local anaesthetic infiltration of port sitesdrug, strength and volume, if given

Specimens and implants

  1. Appendix sent for HPEYes
  2. Peritoneal fluid or pus for cultureSentNot applicable
  3. Clips or endoloops left in situnumber and type, stapler make and cartridge lot if used

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. Vitalspulse, BP, temperature, SpO2; watch for rising pulse and abdominal distension
  2. Oral intakeliquids when awake and not vomiting; early feeding is safe after laparoscopy
  3. Antibioticsstop within 24 h for uncomplicated appendicitis; treatment course for gangrenous or perforated appendix
  4. Analgesiadrug, dose, frequency
  5. Catheterremove once awake if placed only for the operation
  6. Drainoutput daily; usually removed at about 24 hours
  7. Mobilisationsame day
  8. Discharge and follow-upusual discharge within 24 to 48 hours; port-site check; review HPE report

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: Ms. P.D., 26 years, 20 hours of periumbilical pain shifting to the right iliac fossa, RIF tenderness, WBC 13,200/cumm, urine pregnancy test negative, USG shows a non-compressible 8 mm appendix and normal ovaries.

Case details

Date: 19/10/2026. Emergency laparoscopic appendicectomy. OT 1.

In OT 10:05. GA induced 10:12. First port 10:20. Ports out 11:05. Closure completed 11:12.

Surgeon: Dr A. (3rd-year resident, General Surgery). Assistant and camera: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Diagnosis: acute appendicitis, on clinical features, leucocytosis and USG. Laparoscopy chosen because a gynaecological cause had to be excluded in a young woman.

Nil by mouth for 6 hours. Voided urine just before shifting. No NG tube, open entry planned.

Consent: general, procedure-specific (including conversion to open and removal of a normal-looking appendix) and anaesthesia consent taken in Hindi from patient, mother as witness.

WHO checklist sign in and time out done. Inj cefazolin 2 g IV and inj metronidazole 500 mg IV at 10:14, before incision.

Anaesthesia and position

General anaesthesia with endotracheal intubation. Supine, both arms tucked. Monitor at the right side of the foot end, surgeon on the patient's left.

Abdomen painted with povidone-iodine and draped.

Findings

Four quadrants inspected: liver, gallbladder and stomach normal.

About 15 ml serous fluid in the pelvis, sucked out. Not sent for culture.

Appendix pre-ileal, about 7 cm, turgid and inflamed with serosal congestion, no gangrene, no perforation. Tip wrapped by a strand of omentum.

Base healthy. Both ovaries and tubes normal.

Procedure

Open (Hasson) entry through a 10 mm infraumbilical incision. CO2 pneumoperitoneum at 12 mmHg. 30 degree telescope.

5 mm suprapubic port and 5 mm left iliac fossa port placed under vision. Table tilted head down and right side up.

Omentum peeled off the tip with blunt dissection.

Caecum retracted upwards, base of appendix exposed. Mesoappendix coagulated with bipolar forceps and divided with scissors up to the base.

Two pre-tied chromic catgut endoloops placed at the base less than 5 mm apart, and a third further along the appendix. Appendix divided between the second and third loop. Stump checked: loops secure, no bleeding.

Appendix placed in a glove-finger bag and removed through the umbilical port after changing to a 5 mm telescope in the left iliac fossa port.

RIF and pelvis washed with 500 ml warm normal saline and sucked dry. Stump rechecked. No conversion.

Closure

Ports removed under vision, gas let out.

Umbilical 10 mm fascia closed with polyglactin 910 (Vicryl). 5 mm port fascia not closed.

Skin closed with subcuticular absorbable suture. No drain. Dressings applied.

Specimens and implants

Appendix sent for HPE in formalin. Three endoloops left at the stump. No other implants.

End of procedure

Estimated blood loss about 20 ml. No transfusion.

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

No intra-operative complications.

Extubated and shifted to post-operative ward in stable condition. Pulse 86/min, BP 116/74 mmHg.

Post-op orders

Pulse, BP, SpO2 2-hourly for 8 hours.

Sips of water after 4 hours if no nausea, then liquids and soft diet.

No further antibiotic doses, as the appendicitis was uncomplicated.

Analgesia as charted by the anaesthetist.

Ambulate this evening.

Plan discharge within 24 to 48 hours. Port-site check at follow-up. Review HPE report.

Signature

Dr A., JR-3, General Surgery. Reg. no. ________. 19/10/2026, 11:25.

Must document for this operation

  • Entry method, port sizes and sites, and pressure used. If a port-site hernia, bowel injury or bleeding appears later, the note shows where each port went.
  • Findings of the four-quadrant inspection and the pelvic organs. Laparoscopy is often chosen to exclude other disease, so what was seen must be on record.
  • How the mesoappendix and base were secured: device, number of loops or clips, stapler. The next surgeon needs this if a stump leak, abscess or bleed follows.
  • How the specimen was removed (bag or not) and through which port. A port-site infection is judged against whether contamination was prevented.
  • Which fascial defects were closed. Unclosed 10 mm or larger defects cause port-site hernia, and the note shows what was done.
  • Conversion to open, if done, with the reason and time. Conversion is an audited outcome, and a reason protects the surgeon from the charge of a complication.
  • State of the appendix and whether it was perforated. This decides the antibiotic course and explains later abscess or ileus.

Common mistakes in these notes

  • Not writing the port sites and sizes.
  • Writing 'appendix secured' without saying loops, clips or stapler.
  • Leaving out whether the 10 mm fascia was closed.
  • Not recording that the pelvis and adnexa were seen in a woman.
  • Omitting the reason for conversion when the operation was converted.
  • Forgetting to note that the specimen went for histopathological examination (HPE).

Indian practice and paperwork

  • The ICMR national antimicrobial guideline lists piperacillin-tazobactam or cefoperazone-sulbactam as the prophylactic choice before appendectomy, with the first dose within one hour before incision and no continuation beyond 24 hours. Write the drug actually given. (ICMR. Treatment Guidelines for Antimicrobial Use in Common Syndromes, 2nd ed. 2019. Ch 10, sections 10.3.8, 10.3.10 and Table 10.2 (pp. 99-101). https://www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/Treatment_Guidelines_2019_Final.pdf)
  • SRB, an Indian operative text, describes a glove finger (No. 7.5 or 8 sterile glove) or a sterile condom as a low-cost retrieval bag when a commercial bag is not available. (SRB's Surgical Operations 2014, Ch 21, printed p. 748 (PDF 755))
  • Under AB PM-JAY (HBP 2022) this operation is booked as SG017B (Appendicectomy - Lap). NHA guidelines say package stratification depends on items such as type of anaesthesia and surgical technique, so the note must state the anaesthesia and approach that match the booked code; OT notes are also asked for in audits of on-table deaths and LAMA/DAMA cases. State rates vary. (AB PM-JAY HBP 2022 package master (Gujarat SHA SACHIS, https://www.sachis.in/assets/HBP-2022.pdf) and NHA HBP 2.2 User Guidelines (https://hem.nha.gov.in/HBP.pdf))

Sources

  • Scott-Conner CEH, Dawson DL, eds. Essential Operative Techniques and Anatomy. 4th ed. Wolters Kluwer; 2015, Ch 95, Laparoscopic appendectomy and resection of Meckel diverticulum, pp. 501-507.
  • Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press, Ch 13, Emergency small and large bowel surgery: Laparoscopic appendicectomy, pp. 246.
  • Bhat SM. SRB's Surgical Operations: Text and Atlas. Jaypee; 2014, Ch 21, Laparoscopic appendicectomy; Ch 18, Basic principles in laparoscopy (insufflation pressure), pp. 746-752; 549.
  • 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, metronidazole 500 mg, within 60 min before incision) and Table 2 (appendectomy: cefazolin plus metronidazole). academic.oup.com/ajhp/article/70/3/195/5112717
  • ICMR. Treatment Guidelines for Antimicrobial Use in Common Syndromes. 2nd ed. 2019. Ch 10 (surgical prophylaxis). www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/Treatment_Guidelines_2019_Final.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.

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