OT notes · General Surgery

Laparotomy for intestinal obstruction (adhesiolysis / release of band)

Usual anaesthesia
General with rapid sequence induction
Position
Supine
Setting
emergency

Operative note template for laparotomy for small bowel obstruction with adhesiolysis or release of a band, with a filled example for a single adhesive band after a previous hysterectomy, bowel viable after release.

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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

  • injury to the bowel during adhesion release, needing repair
  • resection of non-viable bowel with anastomosis or stoma
  • anastomotic leak or faecal fistula if bowel is opened or resected
  • prolonged ileus and nasogastric tube for several days
  • recurrent obstruction from new adhesions
  • wound infection, burst abdomen and incisional hernia
  • chest infection, DVT and aspiration
  • second-look operation if bowel viability is doubtful

Pre-operative details for this operation

  1. Clinical pictureduration of pain, vomiting, distension, last flatus and stool; signs of strangulation (tachycardia, fever, tenderness, guarding)
  2. Previous abdominal surgeryoperation, year, incision
  3. Hernial orifices examinedNormalObstructed hernia found (site)
  4. ImagingX-ray (air-fluid levels), CT: transition point, closed loop, free fluid
  5. Conservative trialduration of nasogastric aspiration and IV fluids, and reason for surgery (failed trial / strangulation suspected)
  6. Resuscitationfluids given, urine output, electrolytes corrected, nasogastric tube and urinary catheter in place
  7. Stoma consent and site markingTaken and markedNot needed

Anaesthesia and position

  1. AnaesthesiaGeneral, rapid sequence induction
  2. PositionSupine
  3. Nasogastric tube aspirated before inductionYesvolume aspirated

Operative findings

  1. Peritoneal fluidvolume, character (straw, haemorrhagic, faeculent); sent for culture if turbid
  2. Cause of obstructionSingle bandMatted adhesionsInternal herniaVolvulusOther (state)
  3. Site of transition pointdistance in cm from the duodenojejunal flexure or ileocaecal junction
  4. Bowel proximal and distal to obstructionproximal dilated (diameter), distal collapsed
  5. Viability of constricted segmentViableDoubtful, viable after warm packsNon-viablecolour, sheen, peristalsis, mesenteric pulsation, bleeding on cut surface
  6. Rest of bowel run from duodenojejunal flexure to ileocaecal junctionany second point of obstruction, serosal tears

Procedure (steps)

  1. Skin preparation and draping
  2. IncisionMidline through old scar, peritoneum entered in fresh areaFresh midline incisionextent; where peritoneum was entered
  3. Adhesions to abdominal wall releasedsharp dissection close to the wall; parietal peritoneum left on bowel where densely stuck
  4. Transition point foundby tracing collapsed bowel back to the obstruction
  5. Band / adhesions dividedScissorsLigated and dividedBipolar cautery
  6. Interloop adhesions releasedAll releasedOnly obstructing adhesions released (rest left)reason if some left
  7. Viability assessmentwarm saline packs and oxygen for how many minutes; result
  8. Serosal tears / enterotomiesNoneSerosal tear repairedEnterotomy repairednumber, site, suture used
  9. Resection or bypassNot requiredResection and anastomosisResection and stomaBypass (enteroenterostomy)length resected; anastomosis type and suture
  10. Peritoneal lavagewarm saline, volume
  11. Bowel returned in natural position, omentum placed under the incision

Closure, drains and dressing

  1. DrainNonePelvic drainOthersize, site
  2. Sheath / linea albasuture material, size and technique (for example continuous mass closure)
  3. SkinInterrupted suturesStaplesLeft open / delayed closure
  4. Nasogastric tubeposition confirmed; left on free drainage

Specimens and implants

  1. SpecimenNoneResected bowel sent for HPEBand sent for HPE
  2. Peritoneal fluid cultureNot sentSent

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. Vitals and urine outputfrequency; urine output target
  2. Nasogastric tubefree drainage and aspiration frequency; chart output
  3. IV fluids and electrolytestype and rate; daily sodium and potassium
  4. Nil by mouth until bowel function returnsstart liquids when flatus passes and NG output falls
  5. Antibioticsdrug, dose, duration; stop after prophylaxis unless bowel was opened or gangrenous
  6. Analgesiadrug, dose, frequency
  7. DVT prophylaxis and mobilisationstockings / LMWH as per risk; sit up and walk from POD 1
  8. Chest physiotherapyincentive spirometry
  9. Wounddressing check day; watch for discharge or burst abdomen

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. L.K., 46 years, weight 62 kg, total abdominal hysterectomy through a lower midline incision 6 years ago, 2 days of colicky pain, bilious vomiting and no flatus for 36 hours; CT shows a single transition point in the distal ileum; pulse rose to 110/min with localised tenderness after 24 hours of nasogastric aspiration and IV fluids.

Case details

Date: 18/08/2026. Emergency. Emergency OT.

Decision 21:30. In OT 22:20. Induction 22:30. Skin incision 22:45. Closure completed 00:10.

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

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: adhesive small bowel obstruction with suspected strangulation (rising pulse, localised tenderness) after 24 hours of conservative treatment.

Hernial orifices normal. CT: dilated jejunum and proximal ileum, transition in distal ileum, small free fluid, no closed loop.

Resuscitation: 3 L RL over 12 hours, urine output 40 ml/h. Na 134, K 3.4 corrected with KCl. Ryle's tube draining 900 ml bilious fluid in 24 h. Foley catheter in place.

Consent: general, procedure-specific (including possible resection and stoma) and anaesthesia consent taken in Marathi from patient, husband present. Stoma site marked in right iliac fossa.

WHO checklist sign in and time out done. Inj cefazolin 2 g IV and inj metronidazole 500 mg IV at 22:32, before incision.

Anaesthesia and position

Ryle's tube aspirated before induction (150 ml). GA with rapid sequence induction. Supine.

Parts painted with povidone-iodine and draped.

Procedure

Midline incision from above the umbilicus down to the old scar. Peritoneum entered above the umbilicus in fresh tissue, then opened downwards under vision.

Findings: 200 ml straw-coloured fluid, sent for culture. Omentum and two ileal loops stuck to the old scar. A single band from the vaginal vault to the ileal mesentery trapped a loop of ileum 60 cm from the ileocaecal junction. Proximal bowel dilated to 4 cm, distal ileum and colon collapsed.

Adhesions to the abdominal wall released with scissors close to the wall, keeping a finger behind each loop.

Collapsed ileum traced back to the band. Band ligated with polyglactin 910 (Vicryl) 2-0 and divided.

Constricted 8 cm segment dusky with a ring mark, no perforation. Covered with warm saline packs and 100% oxygen for 10 minutes: colour turned pink, sheen returned, peristalsis seen crossing the segment, mesenteric pulsation present. Judged viable.

Entire small bowel run from duodenojejunal flexure to ileocaecal junction. No second point of obstruction. One 1 cm serosal tear on the jejunum repaired with interrupted silk 3-0 Lembert sutures. No enterotomy. No resection.

Peritoneal lavage with 3 L warm saline. Bowel returned in natural position. Omentum placed under the incision.

Closure

No drain.

Linea alba closed with continuous looped polypropylene (Prolene) No. 1 mass closure. Skin closed with interrupted polyamide (Ethilon) 2-0.

Ryle's tube in stomach, on free drainage.

Specimens

Peritoneal fluid for culture and sensitivity. No tissue specimen.

End of procedure

Estimated blood loss 100 ml. No transfusion. IV fluids in OT: 1.5 L RL.

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

No intra-operative complications apart from the serosal tear noted above.

Extubated, shifted to surgical ICU for overnight watch. Pulse 98/min, BP 118/74 mmHg, urine 50 ml in last hour.

Post-op orders

Pulse, BP, SpO2 hourly for 6 hours then 2-hourly. Urine output hourly, target more than 0.5 ml/kg/h (more than 31 ml/h for 62 kg).

Nil by mouth. Ryle's tube on free drainage with 4-hourly aspiration; chart output.

IV RL and DNS as per chart. Na, K on POD 1.

No further antibiotics after the pre-incision dose (no bowel opened, no gangrene).

Inj paracetamol 1 g IV 6-hourly.

Stockings and early mobilisation from POD 1; LMWH as per VTE risk score.

Incentive spirometry hourly while awake.

Start sips when flatus passes and Ryle's output is falling.

Signature

Dr A., JR-3, General Surgery. Reg. no. ________. 19/08/2026, 00:25.

Must document for this operation

  • The cause of obstruction and the exact site of the transition point. If obstruction recurs, the next surgeon plans the approach from this record.
  • How viability was judged and the signs seen. If the patient later leaks or develops gangrene, the note must show a proper viability check was done before the bowel was kept.
  • Every serosal tear or enterotomy and how it was repaired. A missed or poorly repaired tear can leak days later, and the ward team needs to know where to look.
  • Whether the whole small bowel was run, or why not. A second, missed point of obstruction is a known cause of failure after adhesiolysis.
  • Where the peritoneum was entered and whether adhesions were left. This helps the next surgeon choose a safer entry point if the abdomen is opened again.
  • Stoma consent and site marking, even if no stoma was made. If a stoma is needed during surgery, the consent record shows the patient agreed to it in advance.

Common mistakes in these notes

  • Writing 'adhesiolysis done' without naming the cause or site of obstruction.
  • Recording 'bowel viable' with no description of how this was decided.
  • Not noting serosal tears that were repaired.
  • Leaving out the fluid volumes and nasogastric output in the pre-op section.
  • Not writing why antibiotics were stopped or continued.

Indian practice and paperwork

  • NQAS expects post-operative notes to record vital signs, pain control, rate and type of IV fluids, urine and GI fluid output, other medicines and lab tests. Nasogastric output and electrolytes belong in the post-op orders. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, OT checklist ME E15.4)
  • NQAS expects that catgut is not used to close the fascia of abdominal wounds, and that braided biological sutures are not used in dirty wounds. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, OT checklist ME E15.3)
  • If a resection or stoma is done that was not in the written consent, the note must say why it could not wait. The Supreme Court allows an unconsented extra procedure only when it is needed to save life or preserve health. (Samira Kohli v. Dr Prabha Manchanda, (2008) 2 SCC 1)

Sources

  • Scott-Conner CEH, Dawson DL, eds. Scott-Conner & Dawson Essential Operative Techniques and Anatomy. 4th ed. Wolters Kluwer; 2015, Ch 88, Operations for Small Bowel Obstruction, pp. 463-468.
  • Bell RH Jr, Kaufman DB, eds. Northwestern Handbook of Surgical Procedures. Landes Bioscience; 2005, Ch 29, Enterolysis for Small Bowel Obstruction: Open (Caprini JA), pp. 82-83.
  • Bhat SM. SRB's Surgical Operations: Text and Atlas. Jaypee Brothers; 2014, Ch 21 Surgeries of Small Bowel and Appendix: viability of bowel; enterolysis/adhesiolysis, pp. 700, 704, 712-714.
  • Gvalani AK. Manual of Instruments and Operative Surgery. 2nd ed. CBS Publishers & Distributors, Ch 46 Small Intestine: exploratory laparotomy for intestinal obstruction, pp. 266-267.
  • Bratzler DW, et al. ASHP/IDSA/SIS/SHEA Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm 2013;70:195-283. Table 1: cefazolin 2 g, metronidazole 500 mg; Table 2: small intestine, obstructed: cefazolin + metronidazole; within 60 min before incision; less than 24 h. www.ashp.org/-/media/assets/policy-guidelines/docs/therapeutic-guidelines/therapeutic-guidelines-antimicrobial-prophylaxis-surgery.pdf
  • NHS. How and when to take paracetamol for adults (1 g per dose, at least 4 hours apart, not more than 4 g in 24 hours). www.nhs.uk/medicines/paracetamol-for-adults/how-and-when-to-take-paracetamol-for-adults/

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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