OT notes · General Surgery

Open cholecystectomy

Usual anaesthesia
General anaesthesia (epidural is an alternative)
Position
Supine
Setting
elective

Operative note template for open cholecystectomy, with a filled example for an elective duct-first cholecystectomy through a right subcostal (Kocher) incision for chronic calculous cholecystitis.

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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

  • bile duct injury needing further major surgery
  • bile leak from the cystic duct or liver bed
  • bleeding from the cystic artery, liver bed or right hepatic artery
  • subtotal cholecystectomy if the anatomy is unsafe
  • common bile duct exploration and T-tube if stones are found
  • injury to duodenum or colon
  • wound infection and incisional hernia
  • numbness of skin below the incision
  • unexpected gallbladder cancer on histology

Pre-operative details for this operation

  1. IndicationSymptomatic cholelithiasisChronic calculous cholecystitisAcute cholecystitisEmpyemaMucoceleConversion from laparoscopy
  2. Reason for open approachlaparoscopy not available, unfit for pneumoperitoneum, previous surgery, conversion (state reason)
  3. USG and LFTstones, wall, CBD diameter, bilirubin, ALP; MRCP or ERCP if CBD stones suspected
  4. Coagulation and vitamin KPT/INR; vitamin K given if jaundiced
  5. Cholangiogram facilityC-arm availableNot available
  6. Consent for CBD exploration and subtotal cholecystectomyTaken

Anaesthesia and position

  1. AnaesthesiaGeneralEpiduralGeneral with epidural for analgesia
  2. Nasogastric tube and urinary catheterBoth placedNG onlyCatheter onlyNeither
  3. PositionSupineon a table that allows C-arm screening if cholangiogram is planned
  4. Surgeon positionsurgeon on the right, assistants on the left

Operative findings

  1. GallbladderChronic cholecystitisAcute cholecystitisEmpyemaMucoceleGangrenousContractedsize, wall thickness, stones palpable in neck
  2. Adhesionsomentum, duodenum, colon, and how dense
  3. Calot trianglefat, oedema, fibrosis; anatomy clear or not
  4. Cystic duct and arterylength and calibre of duct, stones in duct, number and course of arteries, any variant
  5. CBDdiameter, stones felt in supraduodenal and retroduodenal parts
  6. Liver and other organsliver texture, stomach, duodenum, pancreas, hiatus

Procedure (steps)

  1. IncisionRight subcostal (Kocher)Upper midlineRight paramedianKehr hockey stickMayo-RobsonRight upper transverselength, distance below costal margin
  2. Muscles and rectus divided, peritoneum openedligamentum teres divided between clamps or not
  3. Exploration of the abdomen
  4. Exposure and packingliver pulled down, colon packed down, stomach and duodenum packed medially, retractors used
  5. Gallbladder decompressionNot neededAspirated through a purse-stringbile sent for culture
  6. MethodDuct-first (Calot first)Fundus-first (top down)reason if fundus-first
  7. Calot triangle dissectedcystic duct, cystic artery and cystic duct-CBD junction identified
  8. Cystic arteryligated and divided close to gallbladder, suture used, number of ligatures
  9. Intraoperative cholangiogramNot doneDonecatheter, dye dilution, findings
  10. Cystic ductstones milked back; ligatures and transfixion, suture material; distance from CBD
  11. Gallbladder dissected off the liver bedplane close to gallbladder wall, accessory ducts ligated
  12. Liver bed haemostasiscautery, pack, haemostatic agent, under-running suture
  13. CBD palpated and checked at the endno stones, no bile leak
  14. Subtotal cholecystectomy (if done)how much of the wall left, cystic duct closed from inside, mucosa cauterised, drain

Closure, drains and dressing

  1. Mops removed and counted
  2. DrainNoneSubhepatic tube drainClosed suction drainreason and exit site
  3. Abdominal wallSingle layerTwo layerssuture material and size
  4. SkinInterrupted nylonStaplesSubcuticular

Specimens and implants

  1. Gallbladder opened in OTstones, mucosa, any mass
  2. Gallbladder sent for HPEYes
  3. Bile cultureSentNot sent
  4. Haemostatic material left in bedtype, if any

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 outputpulse, BP, SpO2, hourly urine while catheter is in
  2. Nasogastric tubefree drainage; remove when aspirate is low
  3. Oral intakesips then liquids when bowel sounds return and no vomiting
  4. Analgesiadrug, dose, frequency; epidural if placed
  5. Drainvolume and colour daily; bile in drain to be reported at once
  6. DVT prophylaxisearly mobilisation, stockings, heparin as charted
  7. Watch for jaundice, fever, distensionsigns of bile leak or retained stone
  8. Sutures and follow-upremoval day, HPE review

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. K.B., 48 years, recurrent right upper quadrant pain for 1 year. USG: multiple gallstones, wall 4 mm, CBD 6 mm. LFT normal. Admitted to a district hospital without laparoscopy facility.

Case details

Date: 22/01/2027. Elective open cholecystectomy. OT 1.

In OT 09:30. GA induced 09:40. Skin incision 09:55. Closure completed 11:25.

Surgeon: Dr A. (3rd-year resident, General Surgery). First assistant: Dr B. Second assistant: Dr F. Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: chronic calculous cholecystitis. Open approach because laparoscopy is not available at this centre.

No jaundice. PT/INR normal. No anticoagulants. CBD 6 mm with normal LFT, no MRCP needed.

Consent: general, procedure-specific (including bile duct injury, subtotal cholecystectomy and CBD exploration) and anaesthesia consent taken in Marathi from patient, son as witness.

WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 09:42, before incision.

Anaesthesia and position

General anaesthesia with endotracheal intubation. Ryle's tube and Foley catheter passed. Supine. Surgeon on the right.

Whole abdomen painted with povidone-iodine, draped around the right upper quadrant.

Findings

Gallbladder about 9 x 4 cm, wall thickened, chronic cholecystitis, multiple stones, one stone in Hartmann pouch. Omentum adherent to the fundus.

Calot triangle with moderate fat, anatomy clear after dissection.

Single cystic duct about 3 mm, 2 cm long. Single cystic artery above the duct.

CBD about 6 mm, no stones felt. Liver normal. Stomach, duodenum and pancreas normal to palpation.

Procedure

Right subcostal (Kocher) incision about 12 cm, 2 cm below and parallel to the costal margin. Anterior rectus sheath and rectus divided with cautery over a haemostat, lateral muscles divided. Peritoneum opened.

Abdomen explored. Liver pulled down to let air above it. Omentum freed from the fundus by sharp dissection. Colon packed down and stomach and duodenum packed medially with moist mops. Costal margin retracted.

Fundus held with sponge-holding forceps and pulled up, Hartmann pouch pulled down and out.

Duct-first method. Peritoneum over Calot triangle incised. Triangle dissected with pledget and right-angle forceps. Cystic duct, cystic artery and the cystic duct-CBD junction identified.

Cystic artery doubly ligated with silk 3-0 on the stay side and divided close to the gallbladder.

No cholangiogram (no C-arm, CBD normal on USG and LFT).

No stone felt in the cystic duct. Cystic duct transfixed with polyglactin 910 (Vicryl) 2-0 on the stump side with a second plain ligature, away from the CBD, and divided.

Gallbladder dissected off the liver bed with cautery, keeping close to the gallbladder wall. No accessory duct seen.

Liver bed ooze controlled with cautery and a warm mop for 5 minutes. Bed dry, no bile. CBD palpated again: no stone.

Closure

Mops removed, count correct. Subhepatic space washed with saline. No drain.

Abdominal wall closed in two layers with polyglactin 910 (Vicryl) No. 1. Skin closed with interrupted nylon.

Specimens and implants

Gallbladder opened in OT: about 15 mixed stones, mucosa uniform, no mass. Sent for HPE in formalin. No implants.

End of procedure

Estimated blood loss about 150 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 90/min, BP 128/80 mmHg.

Post-op orders

Pulse, BP, SpO2 hourly for 6 hours, then 4-hourly. Hourly urine output.

Ryle's tube on free drainage. Nil by mouth today, sips from tomorrow if aspirate is low.

IV fluids as charted.

No further antibiotic doses.

Analgesia as charted by the anaesthetist.

Mobilise from tomorrow morning. Catheter out once mobile.

Report any fever, jaundice or increasing distension. Review HPE report at follow-up.

Signature

Dr A., JR-3, General Surgery. Reg. no. ________. 22/01/2027, 11:40.

Must document for this operation

  • Why the open approach was used. An open operation when laparoscopy was available may be questioned, and conversion is an audited outcome.
  • That the cystic duct, cystic artery and the cystic duct-CBD junction were identified before anything was divided. In a bile duct injury claim, this is the record that the anatomy was confirmed.
  • Method used (duct-first or fundus-first) and the reason for fundus-first. Fundus-first carries its own risk of bile duct injury, so the choice must be explained.
  • How the cystic duct and artery were secured, with the suture material. A bile leak or bleed after surgery is managed with this information.
  • Cholangiogram done or not, and its findings. A retained CBD stone found later will be judged against what was checked in OT.
  • Any subtotal cholecystectomy, with how much wall was left and how the duct was closed. A later surgeon or endoscopist must know a remnant is present.
  • Gross appearance of the opened gallbladder and that it was sent for histopathological examination (HPE). An incidental cancer needs a second operation, and the gross description guides the pathologist.

Common mistakes in these notes

  • Writing 'Calot's triangle dissected, cystic artery and duct ligated' without saying the CBD junction was seen.
  • Not recording suture materials used on the cystic duct and artery.
  • Leaving out whether the CBD was palpated or a cholangiogram done.
  • Not writing the reason for the open approach or conversion.
  • Omitting the drain type and exit site.
  • Forgetting to note that the gallbladder was opened and sent for HPE.

Indian practice and paperwork

  • SRB, an Indian operative text, lists open cholecystectomy as the approach when laparoscopy is not possible, the patient is unfit for pneumoperitoneum or general anaesthesia, or laparoscopy fails. Farquharson also names resource-poor settings as a reason. State the reason in the note. (SRB's Surgical Operations 2014, Ch 22, printed p. 812 (PDF 819); Farquharson 11e, Ch 10, printed p. 176 (PDF 191))
  • The ICMR national antimicrobial guideline lists cefazolin, ampicillin-sulbactam or ceftriaxone for biliary operations (clean-contaminated), with the first dose within one hour before incision and no continuation beyond 24 hours. (ICMR. Treatment Guidelines for Antimicrobial Use in Common Syndromes, 2nd ed. 2019. Ch 10, Table 10.1, sections 10.3.8 and 10.3.10 (pp. 97-100). 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 SG039A (Cholecystectomy, without exploration of CBD, Open). 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 72, Cholecystectomy and common bile duct exploration, pp. 385-390.
  • Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press, Ch 10, Gallbladder and biliary surgery: open cholecystectomy, pp. 169-180; 186-187.
  • Bhat SM. SRB's Surgical Operations: Text and Atlas. Jaypee; 2014, Ch 22, Surgeries of liver and biliary system: technique of open cholecystectomy, pp. 811-820.
  • 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, within 60 min before incision) and Table 2 (biliary tract, open: cefazolin, cefoxitin, cefotetan, ceftriaxone or ampicillin-sulbactam). academic.oup.com/ajhp/article/70/3/195/5112717
  • ICMR. Treatment Guidelines for Antimicrobial Use in Common Syndromes. 2nd ed. 2019. Ch 10. 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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