OT notes · Thoracic / Trauma

Neck exploration for penetrating trauma

Usual anaesthesia
General anaesthesia with endotracheal intubation (surgical airway ready)
Position
Supine, shoulder roll, head turned to the opposite side (neutral if cervical spine not cleared)
Setting
emergency

Operative note template for exploration of a penetrating neck injury (vascular and aerodigestive structures), with a filled example for a zone II stab wound with an expanding haematoma from an internal jugular vein tear.

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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

  • bleeding and blood transfusion
  • stroke if the carotid artery is injured, repaired or tied
  • air embolism from a torn neck vein
  • hoarseness from recurrent laryngeal or vagus nerve injury
  • leak from a repaired oesophagus or trachea
  • need for tracheostomy
  • extension into the chest (sternotomy or thoracotomy)
  • wound infection, drooping of lower lip (marginal mandibular nerve)

Pre-operative details for this operation

  1. Woundside, zone (I / II / III), length, whether it crosses the platysma, weapon or missile
  2. Hard signsPulsatile bleedingExpanding / large haematomaBruit or thrillShockHaemoptysisHaematemesisAir bubbling from woundNone
  3. Soft signs and neurologyhoarseness, stridor, subcutaneous emphysema, dysphagia, limb weakness, GCS
  4. Imaging and endoscopy doneCT angiography, chest X-ray, contrast swallow, endoscopy, bronchoscopy; or none (unstable)
  5. AirwayIntubated in EDIntubated in OTSurgical airway
  6. IV linesarm opposite the injury
  7. Temporary bleeding controlFinger pressureFoley catheter balloon in woundNone needed

Anaesthesia and position

  1. AnaesthesiaGeneral
  2. Positionsupine, shoulder roll, head turned away; Trendelenburg if major venous injury
  3. Prepneck ear to ear with chin, whole chest, both groins (vein graft)
  4. Endoscope availableRigidFlexibleNot available

Operative findings

  1. Track of wounddepth, direction, platysma breached
  2. Haematomasite, size, carotid sheath involved
  3. Carotid arteries (common / internal / external)intact / injury type and size
  4. Internal jugular veinintact / laceration length / transected
  5. Vertebral artery
  6. Trachea and larynxfront and back wall
  7. Pharynx and oesophagusfront and back wall
  8. Nervesvagus, recurrent laryngeal, hypoglossal: seen and intact
  9. Thyroid

Procedure (steps)

  1. IncisionAnterior border of sternocleidomastoidCollarClavicularAdded sternotomy / thoracotomycurved back near the angle of the mandible; stab wound included or not
  2. Platysma divided, sternocleidomastoid retracted laterally
  3. Proximal and distal controlobtained before opening the haematoma; loops / clamps on which vessels
  4. Carotid sheath exploredfacial vein divided if needed
  5. Venous injuryLateral venorrhaphyLigationNot injuredrunning monofilament; ligation for larger injuries; avoid tying both internal jugular veins; head-down tilt against air embolism
  6. Arterial injuryPrimary repairVein patchInterposition saphenous vein graftShuntLigation (external carotid)Not injuredpermanent monofilament suture, size; external carotid may be tied safely; common or internal carotid tied only if the patient is comatose or bleeding cannot be controlled and a shunt is not possible (write the reason)
  7. Midline structures exposedmiddle thyroid vein (and inferior thyroid artery) divided, thyroid rotated medially, carotid sheath lateral
  8. Oesophagus and pharynxinspected front and back; on-table endoscopy; repair in two layers over bougie (40-46 Fr) if injured
  9. Trachea / larynxrepair with interrupted absorbable, knots outside; muscle flap between trachea and oesophagus repairs
  10. Haemostasisthyroid bleeders suture-ligated; small muscle bleeders controlled

Closure, drains and dressing

  1. DrainClosed suction drainPenroseNonealways if oesophagus or pharynx repaired or contamination; separate stab
  2. Sternocleidomastoid to cervical fasciaabsorbable suture
  3. Platysma
  4. Skin

Specimens and implants

  1. SpecimensNoneForeign body retained / handed to police (record chain of custody)
  2. Grafts or patchesvein graft site, or synthetic patch: type, size, batch

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. Airway watchstridor, neck swelling; keep suture cutter and intubation kit at bedside
  2. Neurological checkGCS, limb power, speech: hourly if carotid repaired or tied
  3. Drainoutput and nature (blood / saliva)
  4. Oral intakenil by mouth until swallow checked if oesophagus or pharynx repaired
  5. Voicenote hoarseness; ENT review if present
  6. Anticoagulationconsider after venous repair if no bleeding risk (decision by surgeon)
  7. Tetanus prophylaxisif not already given

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. P.T., 22 years, stab wound 2 cm long on the left side of the neck at the level of the thyroid cartilage (zone II), brought 40 minutes after assault with an expanding haematoma, no stridor, no haemoptysis, BP 100/68 mmHg.

Case details

Date: 26/10/2026. Emergency left neck exploration. Emergency OT.

In OT 20:05. Intubation 20:12. Incision 20:25. End 21:30.

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

Anaesthetist: Dr D. Scrub nurse: Sr E. Medico-legal case registered in emergency department.

Indication and pre-op

Zone II penetrating neck wound through the platysma with an expanding haematoma (hard sign). No CT: taken straight to OT.

Voice normal. No subcutaneous emphysema. Limb power normal. GCS 15.

IV lines in the right arm. Pressure over the wound by Dr B. during transfer.

Consent: written consent from patient for neck exploration, vessel repair or ligation, vein graft from the leg, possible sternotomy and tracheostomy. Explained in Tamil.

Tetanus toxoid given in the emergency department. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 20:15.

Anaesthesia and position

General anaesthesia. Intubated by Dr D. with surgical airway set open on the trolley.

Supine, shoulder roll, head turned to the right. Painted with povidone-iodine from ear to ear, chin, whole chest and both groins. Clear drape over the face.

Findings

Wound track running backwards and inwards through the platysma and the front edge of the sternocleidomastoid into the carotid sheath.

Haematoma about 150 ml in the carotid sheath.

Internal jugular vein: 1 cm laceration on its front wall, bleeding darkly. No other venous injury.

Common, internal and external carotid arteries: intact, good pulse.

Vagus nerve seen, intact.

Oesophagus and trachea: no injury seen on inspection front and back; on-table oesophagoscopy normal. Thyroid lobe not injured.

Procedure

Incision along the anterior border of the left sternocleidomastoid, about 10 cm, taking in the stab wound, curved back at the upper end away from the angle of the mandible.

Platysma divided. Sternocleidomastoid retracted laterally.

Internal jugular vein controlled above and below the haematoma with vessel loops before the haematoma was opened. Head-down tilt during venous repair.

Clot removed. Vein laceration closed by lateral venorrhaphy with running polypropylene (Prolene) 5-0. Vein lumen not narrowed much, flow seen.

Carotid sheath explored along its length. Arteries intact.

Middle thyroid vein tied and divided. Thyroid rotated medially. Oesophagus and trachea inspected on both sides and the back wall. Flexible oesophagoscopy on the table by Dr C.: no mucosal tear.

Small muscle bleeders cauterised.

Closure

12 Fr closed suction drain along the carotid sheath, through a separate stab.

Sternocleidomastoid front edge to cervical fascia with polyglactin 910 (Vicryl) 3-0. Platysma with Vicryl 3-0. Skin with interrupted polyamide (Ethilon) 4-0.

End of procedure

Estimated blood loss 350 ml including haematoma. No transfusion.

Instrument, needle and mop count correct, confirmed by scrub nurse.

No intra-operative complications. No foreign body found.

Specimens: none. Implants: none.

Extubated in OT. Voice normal. Moving all four limbs. Pulse 90/min, BP 118/72 mmHg. Shifted to surgical HDU.

Post-op orders

Watch for neck swelling and noisy breathing. Suture cutter and intubation tray at the bedside.

Pulse, BP, SpO2 hourly for 6 hours. GCS and limb power 2-hourly for 12 hours.

Drain: record output 4-hourly. Inform Dr A. if the drain fills with fresh blood or the neck swells.

Oral liquids from 6 hours if no swelling.

Voice to be checked in the morning.

Signature

Dr A., JR-3, General Surgery. Reg. no. ________. 26/10/2026, 21:45.

Must document for this operation

  • Zone, side and depth of the wound, and the hard or soft signs that decided exploration. The zone and signs justify operating without imaging and are used when comparing with any later scans.
  • Every structure examined, each marked injured or intact (carotids, jugular, vertebral, trachea, oesophagus, nerves). A missed oesophageal or back-wall injury is the main cause of death after neck exploration.
  • How the oesophagus was checked (inspection, on-table endoscopy, contrast study). If a leak shows later, the note shows what was done to exclude it.
  • Type of vessel repair or ligation and the suture used. Carotid ligation carries a stroke risk and must be justified; the next surgeon needs the repair details.
  • Neurological state before and after surgery. A new deficit after carotid surgery must be compared with the state before.
  • Any foreign body or weapon fragment removed and to whom it was handed. This is evidence in a medico-legal case.

Common mistakes in these notes

  • Writing 'neck explored, no injury' without naming the structures checked.
  • Not recording the neurological state before a carotid repair.
  • Leaving out the zone of injury.
  • No mention of how the oesophagus was examined.
  • Not noting the side of IV access and the drain position.

Indian practice and paperwork

  • The district hospital OT checklist expects tetanus prophylaxis to be given when indicated. Record it. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, ME E15.2)
  • Consent must explain the procedure, risks, benefits, alternatives and who will operate, in a language the patient understands. Include vessel ligation, vein graft, sternotomy and tracheostomy. (NABH 5th ed., PRE.4(c))
  • Records written after the patient's discharge or death have no legal value; entries must not be erased. Write the note promptly, especially in an assault case. (Thomas J. Indian J Urol 2009;25(3):384-8)
  • 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))

Sources

  • Scott-Conner CEH, ed. Scott-Conner & Dawson: Essential Operative Techniques and Anatomy. 4th ed. Wolters Kluwer; 2014, Ch 13, Neck Exploration for Trauma (Helling KD, Pelaez CA), pp. 98-104.
  • Demetriades D, Inaba K, Velmahos G, eds. Atlas of Surgical Techniques in Trauma. Cambridge University Press; 2015, Ch 7, Neck operations for trauma: general principles (Joos E, Inaba K), pp. 110-120.
  • 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 adult; Table 2 footnote a: within 60 min before incision. 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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