OT notes · General Surgery

Laparoscopic cholecystectomy

Usual anaesthesia
General anaesthesia
Position
Supine, reverse Trendelenburg with the right side up (left-down tilt)
Setting
elective

Operative note template for laparoscopic cholecystectomy, with a filled example for an elective four-port cholecystectomy for symptomatic gallstones, with the critical view of safety recorded.

Download printable PDFFree. Just log in with your Google (Gmail) account.

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

  • bile duct injury needing further major surgery
  • bile leak from the cystic duct stump or gallbladder bed
  • bleeding from the cystic artery, liver bed or right hepatic artery
  • conversion to open cholecystectomy
  • subtotal cholecystectomy if the anatomy is unsafe
  • injury to duodenum, colon or other bowel
  • retained common bile duct stone
  • spilled stones and port-site infection
  • port-site hernia
  • unexpected gallbladder cancer on histology

Pre-operative details for this operation

  1. IndicationSymptomatic cholelithiasisAcute cholecystitis (within 72 h)Interval after cholecystitisGallstone pancreatitisPolypOthernumber and dates of attacks
  2. USG findingsstone size and number, wall thickness, pericholecystic fluid, CBD diameter
  3. LFT and CBD clearancebilirubin, ALP; MRCP or ERCP done if CBD stones suspected
  4. CoagulationPT/INR if jaundiced or cirrhotic; vitamin K given or not
  5. Anticoagulants or antiplateletsdrug and date stopped
  6. Consent for conversion to open and subtotal cholecystectomyTaken

Anaesthesia and position

  1. AnaesthesiaGeneral with endotracheal intubation
  2. Positionsupine; reverse Trendelenburg with right side up after ports are in
  3. Nasogastric or orogastric tubePlaced for gastric decompressionNot placed
  4. PneumoperitoneumOpen (Hasson) umbilicalVeress needlepressure set in mmHg
  5. Ports10 mm umbilical camera, 10 or 5 mm epigastric, 5 mm right midclavicular, 5 mm right anterior axillary
  6. Telescope and energy30 degree telescope; diathermy mode and wattage

Operative findings

  1. GallbladderChronic cholecystitisAcute cholecystitisEmpyemaGangrenousMucoceleContracted and fibroticdistension, wall thickness
  2. Adhesionsomentum, duodenum, colon; how dense
  3. Landmarks seenRouviere sulcus present or absent, cystic lymph node
  4. Critical view of safetyAchieved (all 3 criteria)Not achievedif not achieved: what was done instead
  5. Cystic duct and arterycalibre of duct, stones in duct, number and course of arteries, variants
  6. Liver and other organsliver texture (fatty / cirrhotic), CBD appearance, any other disease

Procedure (steps)

  1. Access and pneumoperitoneummethod, site, pressure
  2. Ports placed under visionsize and site of each
  3. Fundus retracted towards right shoulder, Hartmann pouch retracted down and out
  4. Adhesiolysisstructures freed and how
  5. Posterior and anterior peritoneum over the neck inciseddissection kept above Rouviere sulcus
  6. Hepatocystic (Calot) triangle clearedinstrument and energy used
  7. Critical view of safety confirmed and time-out donephotographed anterior and posterior views, confirmed with senior
  8. Intraoperative cholangiogramNot doneDoneif done: findings
  9. Cystic arterynumber of clips each side, type of clip, divided close to gallbladder
  10. Cystic ductMetal clipsPolymer locking clips (Hem-o-lok)EndoloopLigatureSutured closurenumber of clips on the stay side, stones milked back
  11. Gallbladder dissected off the liver bedplane kept on the gallbladder side of the cystic plate; perforation and stone spill yes/no
  12. Haemostasis and bile check of gallbladder bedbefore final detachment, clips rechecked
  13. Gallbladder removed in retrieval bagport used, extension of port needed
  14. Alternative procedure if CVS not possibleNot neededFundus-firstSubtotal (fenestrating / reconstituting)CholecystostomyConverted to openreason and time

Closure, drains and dressing

  1. Irrigation and suction of subhepatic spacespilled stones retrieved
  2. Ports removed under vision
  3. Fascia of 10 mm port sitessuture material and size; umbilical fascia closed under vision
  4. SkinSubcuticular absorbableInterrupted non-absorbableSkin glue
  5. DrainNoneSubhepatic closed-suction drainreason (difficult dissection, bleeding or bile leak risk), exit port

Specimens and implants

  1. Gallbladder opened and inspected in OTstones, mucosa, any mass or thickening
  2. Gallbladder sent for HPEYes
  3. Bile for cultureSentNot sent
  4. Clips left in situnumber and type on cystic duct and artery

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, SpO2; rising pulse, falling BP or distension means bleeding or bile leak
  2. Oral intakeliquids when awake and not vomiting, then normal diet
  3. Analgesia and anti-emeticdrug, dose, frequency
  4. Drainrecord volume and colour; bile in drain must be reported at once; usual removal at 24 to 48 hours if no bile
  5. Watch for jaundice, fever, abdominal painsigns of bile leak or retained stone
  6. Mobilisationsame day
  7. Antibioticsnone after closure unless cholecystitis, empyema or spill
  8. Discharge and follow-upport-site check; review HPE report, cancer on HPE needs staging and referral

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: Mrs. A.N., 42 years, two episodes of right upper quadrant colic, the last 3 weeks ago. USG: multiple gallstones up to 12 mm, wall 3 mm, CBD 5 mm. LFT normal.

Case details

Date: 07/11/2026. Elective laparoscopic cholecystectomy. OT 4.

In OT 09:10. GA induced 09:18. First port 09:30. Gallbladder out 10:25. Closure completed 10:40.

Surgeon: Dr A. (3rd-year resident, General Surgery). Assistant: Dr B. (2nd-year resident). Camera: Dr F. Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: symptomatic cholelithiasis, two attacks of biliary colic, last attack within 30 days.

No jaundice. No anticoagulants. Hb 11.8 g/dl, platelets and PT normal.

Consent: general, procedure-specific (including bile duct injury, conversion to open and subtotal cholecystectomy) and anaesthesia consent taken in Marathi from patient, husband as witness.

WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 09:20, before incision, given because of colic within the last 30 days.

Anaesthesia and position

General anaesthesia with endotracheal intubation. Orogastric tube passed and aspirated. Supine.

Abdomen painted with povidone-iodine and draped. Reverse Trendelenburg with left-down tilt after ports were in.

Findings

Gallbladder distended, wall mildly thickened, chronic cholecystitis. Omentum and duodenum adherent to Hartmann pouch, filmy.

Rouviere sulcus seen. Cystic lymph node present.

Single cystic duct of about 3 mm. Single cystic artery, normal course, anterior to the duct.

Liver normal in colour and texture. CBD not dilated on view.

Procedure

Open (Hasson) entry at the umbilicus, 10 mm port. CO2 pneumoperitoneum at 12 mmHg. 30 degree telescope.

10 mm epigastric port to the right of the falciform ligament, 5 mm right midclavicular and 5 mm right anterior axillary ports under vision.

Fundus retracted towards the right shoulder, Hartmann pouch retracted down and laterally. Omental and duodenal adhesions taken down with blunt dissection.

Posterior and then anterior peritoneum over the neck incised with the hook, staying above Rouviere sulcus. Hepatocystic triangle cleared of fat with blunt dissection and hook diathermy at low setting (below 30 W).

Critical view of safety achieved: triangle clear, lower third of the gallbladder off the cystic plate, only two structures entering the gallbladder. Time-out: anatomy confirmed by Dr C. Anterior and posterior views photographed.

No cholangiogram.

Cystic artery: two metal clips on the stay side, one on the gallbladder side, divided close to the gallbladder.

Cystic duct: no stones felt. Two medium-large metal clips on the stay side, one on the gallbladder side, divided leaving a cuff beyond the clips.

Gallbladder separated from the liver bed with the hook, keeping the cystic plate intact. No perforation, no spill.

Before final detachment: bed dry, no bile, clips checked in position.

Gallbladder placed in a retrieval bag and removed through the umbilical port.

Closure

Subhepatic space irrigated with saline and sucked dry. Ports removed under vision, gas let out.

Umbilical and epigastric 10 mm fascia closed with interrupted polyglactin 910 (Vicryl) 2-0. Skin closed with subcuticular absorbable suture. No drain.

Specimens and implants

Gallbladder opened in OT: multiple mixed stones, largest about 12 mm, mucosa uniform, no mass. Sent for HPE in formalin.

Four metal clips left in the patient: two on the cystic duct stump and two on the cystic artery stump.

End of procedure

Estimated blood loss about 30 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 82/min, BP 122/76 mmHg.

Post-op orders

Pulse, BP, SpO2 hourly for 4 hours, then 4-hourly.

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

No further antibiotic doses.

Analgesia and anti-emetic as charted by the anaesthetist.

Ambulate this evening. Report at once any fever, jaundice, increasing pain or distension.

Plan discharge when eating and comfortable. Review HPE report at follow-up.

Signature

Dr A., JR-3, General Surgery. Reg. no. ________. 07/11/2026, 10:55.

Must document for this operation

  • That the critical view of safety was achieved, with its three criteria, and that a time-out was done. In a bile duct injury case, this line is the main evidence that the duct was identified properly.
  • Photographs (anterior and posterior views) of the critical view of safety, if taken. A recorded image is stronger evidence than a written line in an audit or dispute.
  • What was done when the critical view could not be achieved, and why. Subtotal cholecystectomy or conversion is a safe choice, and the note must show it was chosen on purpose.
  • Method of securing the cystic duct and artery, and the number and type of clips. A later ERCP or re-operation for bile leak needs to know what is on the stump.
  • Any gallbladder perforation and whether spilled stones were retrieved. Lost stones can cause abscesses months later, and the note explains them.
  • Appearance of the opened gallbladder and that it was sent for histopathological examination (HPE). An unexpected cancer found on HPE needs further surgery, and the surgeon's gross description helps the pathologist.
  • Drain placed or not, and its site. Bile in a drain is the first sign of a leak, and the ward team must know a drain is there.

Common mistakes in these notes

  • Writing 'Calot's triangle dissected, cystic duct and artery clipped' without stating the critical view of safety.
  • Not recording clip numbers and type on the cystic duct.
  • Leaving out gallbladder perforation and stone spillage.
  • Not writing the reason for conversion or for a subtotal cholecystectomy.
  • Not noting that the gallbladder was opened and looked at before sending for HPE.
  • Omitting which port sites had fascial closure.

Indian practice and paperwork

  • The ICMR national antimicrobial guideline treats biliary operations as clean-contaminated and limits prophylaxis for laparoscopic cholecystectomy to higher-risk patients (for example emergency surgery, diabetes, age over 70, colic within 30 days, acute cholecystitis, bile spill, jaundice). Write which risk factor justified the antibiotic. (ICMR. Treatment Guidelines for Antimicrobial Use in Common Syndromes, 2nd ed. 2019. Ch 10, Table 10.1 (pp. 97-98). https://www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/Treatment_Guidelines_2019_Final.pdf)
  • Under AB PM-JAY (HBP 2022) this operation is booked as SG039C (Cholecystectomy, without exploration of CBD, 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

  • Safe Laparoscopic Cholecystectomy. CRC Press (Taylor and Francis), Ch 4, Steps of laparoscopic cholecystectomy and the critical view of safety; Ch 5, Cystic artery; Ch 6, Cystic duct; Ch 7, Gallbladder bed, pp. 25-37; 39-53.
  • Scott-Conner CEH, Dawson DL, eds. Essential Operative Techniques and Anatomy. 4th ed. Wolters Kluwer; 2015, Ch 73, Laparoscopic cholecystectomy and common bile duct exploration, pp. 396-406.
  • Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press, Ch 10, Gallbladder and biliary surgery, pp. 169-180; 186-187.
  • Bhat SM. SRB's Surgical Operations: Text and Atlas. Jaypee; 2014, Ch 18, Basic principles in laparoscopy (insufflation pressure), pp. 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, 3 g if 120 kg or more, within 60 min before incision) and Table 2 (laparoscopic cholecystectomy: none if elective low-risk; cefazolin if high-risk). academic.oup.com/ajhp/article/70/3/195/5112717
  • ICMR. Treatment Guidelines for Antimicrobial Use in Common Syndromes. 2nd ed. 2019. Ch 10, Tables 10.1 and 10.2. 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.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

This page cannot be printed from the browser. Use the Download printable PDF button on the page.