OT notes · General Surgery

Open abdominal aortic aneurysm repair

Usual anaesthesia
General anaesthesia with endotracheal intubation, arterial and central venous lines
Position
Supine, prepared from nipples to knees
Setting
elective

Operative note template for open infrarenal abdominal aortic aneurysm repair (elective or ruptured), with a filled example for an elective transperitoneal repair with a tube graft.

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

  • major bleeding and blood transfusion
  • heart attack
  • kidney failure
  • ischaemia of the legs from clot or debris
  • ischaemia of the colon
  • injury to the left renal vein, iliac veins or ureters
  • damage to pelvic nerves affecting ejaculation in men
  • graft infection or aorto-enteric fistula later
  • incisional hernia
  • death, much higher when the aneurysm has ruptured

Pre-operative details for this operation

  1. IndicationDiameter 5.5 cm or moreGrowth more than 5 mm in 6 monthsSymptomaticRupturedmaximum diameter and date of scan
  2. CT angiogram detailsneck length below renal arteries, iliac involvement, left renal vein (retro-aortic or not), accessory renal arteries, IMA patency, hypogastric arteries
  3. Reason for open rather than endovascular repairanatomy, patient choice, availability
  4. Cardiac, lung and kidney assessmentECG, echo, creatinine, physician / cardiology clearance
  5. Bowel preparationMild laxative day beforeNone (emergency)
  6. Blood reserved and cell saverunits cross-matched; cell saver set up
  7. Graft availabletube and bifurcated grafts of sizes needed

Anaesthesia and position

  1. AnaesthesiaGeneralGeneral with epiduralin rupture: induction only when the team is scrubbed and ready
  2. Linesarterial line, central line, urinary catheter, nasogastric tube
  3. Position and prepSupine, prep nipples to kneesRight lateral tilt for left retroperitoneal approachiodophor adhesive drape over skin
  4. ApproachTransperitoneal midlineLeft retroperitoneal

Operative findings

  1. Aneurysmsize, extent, intact or ruptured, retroperitoneal haematoma
  2. Necklength below renal arteries, level of proximal clamp (infrarenal / suprarenal / supracoeliac)
  3. Left renal veinNormal, retractedDivided (reason)Retro-aortic
  4. Iliac arteriesaneurysmal or not; distal clamp site
  5. Inferior mesenteric arteryOccludedBrisk back-bleeding: ligated from insidePoor back-bleeding: reimplanted
  6. Mural thrombus, lumbar arteriesnumber oversewn
  7. Colon and bowel at the endViable, well perfusedDoubtful: action taken
  8. Distal pulses at endfemoral and pedal pulses or Doppler, both sides

Procedure (steps)

  1. IncisionMidline xiphoid to pubisLeft flank from tip of 11th rib
  2. Exposuretransverse colon up, duodenum mobilised off aorta (ligament of Treitz divided), small bowel right, sigmoid left; self-retaining retractor
  3. Proximal control (neck)left renal vein identified and looped or divided; clamp site; supracoeliac control in rupture
  4. Distal controlcommon iliac arteries (or femoral) controlled; iliac veins and ureters protected
  5. Graft chosenTubeBifurcated aorto-bi-iliacBifurcated aorto-bifemoralmaterial, diameter, preclotted or not
  6. Systemic heparindose (units/kg), time; or not given in rupture with bleeding
  7. Clamps appliedproximal clamp time on; distal clamps
  8. Sac openedlongitudinal to the right of IMA, T-ed at both necks; thrombus removed
  9. Back-bleeding vesselslumbar arteries oversewn (suture); IMA handled
  10. Proximal anastomosissuture (polypropylene 3-0), continuous, parachute; flushed, clamp moved to graft, checked for leak
  11. Distal anastomosissite (bifurcation / iliac / femoral), suture, flushed before tying
  12. Clamp release and reperfusionsequence; proximal clamp time off; BP response
  13. IMA decision and haemostasisback-bleeding checked after flow; lumbars rechecked; femoral pulses palpated

Closure, drains and dressing

  1. Sac and retroperitoneum closed over graftsuture material (2-0 absorbable), graft fully covered from bowel
  2. Bowel inspected before closurecolour of sigmoid and left colon
  3. DrainNonePlaced (reason)
  4. Abdominal wallRunning nylon, knots buriedRetention suturesLeft open (compartment syndrome risk)
  5. Distal pulses / Doppler before leaving tableboth legs

Specimens and implants

  1. Aortic grafttype (woven / knitted Dacron, PTFE), configuration, diameter and length, make, lot and serial number, sticker pasted
  2. SpecimenNoneMural thrombus or wall for culture (if infection suspected)
  3. Cell savervolume returned

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. Direct transfer to ICUventilation, rewarming, arterial and central pressures
  2. Urine outputcharting frequency and the target below which to report, as written by the surgeon
  3. Leg perfusionfemoral and pedal pulses or Doppler, colour and warmth of both feet, at the frequency the surgeon writes
  4. Bleeding and coagulationHb, platelets, INR, APTT; correct abnormalities
  5. Heart and kidneysECG, troponin if indicated, creatinine and electrolytes
  6. Colon ischaemia watcha concern in the first days; write the signs the nurse must report
  7. Chest X-rayif central line inserted
  8. Analgesiaepidural or IV as per anaesthesia chart
  9. Follow upyearly clinical review; CT every 5 years for new aneurysm

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. J.S., 68 years, hypertensive, with an asymptomatic 6.2 cm infrarenal abdominal aortic aneurysm, 20 mm neck, normal iliac arteries, unsuitable for endovascular repair because of neck angulation.

Case details

Date: 10/09/2026. Elective open infrarenal AAA repair with tube graft. OT 1.

In OT 08:00. Incision 09:00. Proximal clamp on 10:05, off 10:52. Closure completed 12:30.

Surgeon: Dr A. (consultant, vascular surgery). Assistants: Dr B. (MCh resident), Dr C. (MS 3rd-year resident).

Anaesthetists: Dr D. and Dr E. Scrub nurse: Sr F. Perfusion / cell saver: Mr G.

Indication and pre-op

Asymptomatic AAA, 5.4 cm in 2025, 6.2 cm on CT angiogram 12/08/2026. Infrarenal neck 20 mm long, angulated. Normal left renal vein. No accessory renal artery. Iliac arteries normal. IMA patent.

Echo EF 50%, no inducible ischaemia. Creatinine 1.1 mg/dl. Cardiology clearance obtained.

Mild laxative given the day before. Blood group O positive, 2 units cross-matched. Cell saver set up.

Consent: general, procedure-specific and anaesthesia consent taken in Hindi from patient, wife and son present. Open and endovascular options explained.

WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 08:40.

Anaesthesia and position

General anaesthesia. Right radial arterial line, right IJV central line, Foley catheter, Ryle's tube.

Supine. Parts painted with povidone-iodine from nipples to knees and draped. Genitalia covered with a towel. Iodophor adhesive drape applied.

Findings

Intact infrarenal AAA about 6.5 cm, starting 2 cm below the left renal vein, ending above the aortic bifurcation. No retroperitoneal haematoma.

Left renal vein normal, retracted upward. Common iliac arteries normal.

Large laminated mural thrombus. Four pairs of lumbar arteries back-bleeding. IMA with brisk back-bleeding.

Sigmoid and left colon pink at the end of the procedure. Both femoral pulses and both DP Doppler signals present at end.

Procedure

Midline incision from xiphoid to pubis. Omni retractor.

Transverse colon lifted upward in moist pack. Ligament of Treitz divided and duodenum mobilised to the right off the aorta. Small bowel packed to the right, sigmoid retracted to the left.

Peritoneum over the aneurysm opened to the right of midline. Left renal vein identified and looped. Neck dissected on both sides by finger dissection. Test clamp done.

Both common iliac arteries controlled, iliac veins and ureters left undisturbed.

Woven Dacron tube graft 20 mm chosen (no preclotting needed).

Inj heparin 7000 units IV (100 units/kg, weight 70 kg) at 10:00.

Infrarenal aortic and both common iliac clamps applied gently at 10:05.

Sac opened longitudinally to the right of the IMA and T-ed at both ends through the anterior wall. Thrombus removed.

Lumbar arteries oversewn from inside with braided non-absorbable 2-0. IMA back-bleeding briskly: suture ligated from inside the sac.

Proximal anastomosis to the infrarenal neck with continuous polypropylene (Prolene) 3-0, parachute technique, posterior wall taken with full thickness. Graft flushed, clamp moved onto the graft. Suture line checked, no leak.

Graft cut to length. Distal anastomosis to the aortic bifurcation with continuous Prolene 3-0. Graft flushed before final tie.

Clamps released after warning the anaesthetist. Aortic clamp off at 10:52. Clamp time 47 min. BP maintained with fluids.

All suture lines dry. Lumbars rechecked after flow. Both femoral pulses felt.

Closure

Aneurysm sac and retroperitoneum closed over the graft in two layers with continuous polyglactin 910 (Vicryl) 2-0. Graft fully covered and away from the duodenum.

Sigmoid and left colon inspected: viable.

No drain.

Linea alba closed with running nylon No. 2, knots buried. Skin with staples.

Both femoral pulses and both DP Doppler signals present before leaving the table.

Specimens and implants

Implant: woven Dacron tube graft, 20 mm x ___ cm, make ________, lot ________, serial ________. Sticker pasted in case sheet, OT register and implant register.

Specimen: none. Mural thrombus not sent.

End of procedure

Estimated blood loss 1400 ml. Cell saver returned 600 ml. 1 unit PRBC transfused.

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

No intra-operative complications.

Shifted directly to surgical ICU, ventilated. Pulse 94/min, BP 118/68 mmHg, temperature 35.9 C, urine 60 ml in last hour.

Post-op orders

Active rewarming. Wean from ventilator when stable.

Urine output, arterial BP and CVP charted in ICU. Femoral pulses and DP Doppler both sides checked with each set of observations, frequency as written by the consultant.

Hb, platelets, INR, APTT, creatinine, electrolytes and ECG now and on POD 1. Chest X-ray for line position.

Analgesia as per anaesthesia chart. Ryle's tube on free drainage.

Signature

Dr B., MCh resident, for Dr A. Reg. no. ________. 10/09/2026, 12:50.

Must document for this operation

  • Level of the proximal clamp and clamp on and off times. Kidney and gut problems after surgery are judged against the clamp level and ischaemia time.
  • Graft type, size, configuration and sticker details. Graft infection, a later aneurysm or a recall all need exact graft details.
  • What was done with the inferior mesenteric artery and the state of the colon at the end. Colon ischaemia is a known complication, and the note must show the IMA and colon were assessed.
  • Left renal vein handling, especially if it was divided. It explains later kidney changes and warns the next surgeon about the anatomy.
  • Heparin dose and time, cell saver volume and transfusion. Bleeding and coagulation problems in ICU are managed against these figures.
  • Distal pulses or Doppler signals before leaving the table. They are the baseline for detecting limb ischaemia from debris or clot.
  • That the graft was covered with sac and retroperitoneum away from bowel. Aorto-enteric fistula years later is investigated with this note in hand.

Common mistakes in these notes

  • Not writing clamp level and clamp times.
  • Leaving out graft lot and serial number, or not pasting the sticker.
  • Not recording the inferior mesenteric artery decision.
  • No note of distal pulses at the end.
  • In a ruptured aneurysm, not recording blood pressure on arrival, time to clamp and total blood products.

Indian practice and paperwork

  • NABH asks that the batch and serial number of an implanted device be written in the patient record, the OT master logbook and the discharge summary. This applies to the aortic graft. (NABH 5th ed., MOM.10(d))
  • Under AB PM-JAY, daily case sheets and OT notes must be submitted for audit to qualify for payment when a patient dies on the table or leaves against advice after surgery. This matters for ruptured aneurysms. (NHA National Health Benefit Package 2.2 User Guidelines (Nov 2021))
  • Name every anaesthetist in the note. A National Commission case held a hospital negligent when the operation notes left out the name of one of two anaesthetists. (Thomas J. Indian J Urol 2009;25(3):384-8)
  • NABH expects the operative note to be written before the patient leaves recovery. When the patient goes straight to ICU, write it before transfer out of the OT. (NABH 5th ed., COP.14(e))

Sources

  • Scott-Conner CEH, ed. Scott-Conner & Dawson: Essential Operative Techniques and Anatomy. 4th ed. Lippincott Williams & Wilkins (Wolters Kluwer); 2014, Ch 111, Abdominal Aortic Aneurysm Repair and Aortofemoral Bypass (Bjornsdottir LT, Sharp WJ), pp. 586-595.
  • Bell RH Jr, Kaufman DB, eds. Northwestern Handbook of Surgical Procedures. Landes Bioscience; 2005, Ch 94, Repair Infrarenal Aortic Aneurysm: Elective; Ch 95, Repair Infrarenal Aortic Aneurysm: Emergent for Rupture (Matsumura JS), pp. 281-286.
  • 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 IV (3 g if 120 kg or more), redose at 4 h. Table 2: vascular procedures: cefazolin. Start within 60 min before incision; duration under 24 h. 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

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.