OT notes · Thoracic / Trauma

Trauma laparotomy / damage-control laparotomy (packing, organ repair, temporary closure)

Usual anaesthesia
General anaesthesia with endotracheal intubation
Position
Supine with both arms abducted to 90 degrees; lithotomy if a rectal or anal injury is suspected
Setting
emergency

Operative note template for a trauma laparotomy with a damage-control option (bleeding control, contamination control, packing and temporary abdominal closure), with a filled example for blunt liver and splenic injury in a shocked patient.

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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

  • death despite surgery
  • massive blood transfusion
  • removal of spleen, kidney or bowel
  • stoma formation
  • abdomen left open with packs and planned return to theatre
  • intestinal fistula
  • abdominal compartment syndrome
  • later incisional (ventral) hernia needing repair

Pre-operative details for this operation

  1. Mechanism of injuryBlunt (RTA / fall / assault)StabGunshotOthertime of injury, time of arrival
  2. Indication for laparotomyhaemodynamic instability with positive FAST, peritonitis, evisceration, CT findings
  3. Physiology before incisionpulse, BP, temperature, pH / base deficit, lactate, INR or clotting test
  4. Resuscitation before OTIV lines (upper limb in penetrating abdominal injury), fluids, blood units given, massive transfusion protocol activated
  5. Blood arrangedPRBC, FFP, platelets: units reserved
  6. Other injurieshead, chest, pelvis, limbs; chest drain in situ
  7. ConsentWritten, patientWritten, relativeEmergency without consent: reason recordedinclude splenectomy, bowel resection, stoma, packing and re-look

Anaesthesia and position

  1. AnaesthesiaGeneral
  2. PositionSupine, arms out at 90 degreesLithotomy (rectal or anal injury)
  3. Skin preparationchin to knees, down to the table on both sides, groins included for vein graft
  4. Warmingwarm theatre, warm fluids, warming blanket
  5. Catheter and nasogastric tubeurine at insertion (clear / blood-stained)

Operative findings

  1. Haemoperitoneumestimated volume of blood and clot
  2. Liversegment, depth and length of laceration, active bleeding, retrohepatic haematoma
  3. Spleen
  4. Hollow viscusstomach, duodenum, small bowel from Treitz to ileocaecal junction, colon, rectum: site and size of each hole, mesenteric tears
  5. Retroperitoneal haematomaNoneZone IZone II (right / left)Zone IIIstable / expanding; explored or not, and why
  6. Diaphragmpalpated and seen both sides: intact / tear
  7. Kidneysboth palpated, present, normal size
  8. ContaminationNoneMinimalGross (bowel content / faeces)

Procedure (steps)

  1. IncisionMidline laparotomyXiphoid to pubisMidline with right subcostal extensionMidline with sternotomy
  2. Blood and clots evacuated, packingDirected packingFour-quadrant packingvolume removed
  3. Aortic control (if needed)Not neededManual compression below diaphragmClamp through left crusLeft thoracotomy clamptime applied and released
  4. Pringle manoeuvre (if used)vascular clamp across the hepatoduodenal ligament (foramen of Winslow); time on and time off (temporary control, up to 1 hour)
  5. Bleeding control, organ by organliver: packing / suture / resectional debridement; spleen: splenectomy; vessels: ligation / repair / shunt
  6. Contamination controlPrimary repairStapled or tied off, no anastomosisResection and anastomosisStoma
  7. Systematic explorationbowel Treitz to rectum both sides and mesentery, lesser sac, diaphragm, kidneys, pelvis
  8. Decision for damage controlreasons, written as values: temperature (below 35 C), base deficit (above 15 mmol/L) or pH, coagulopathy, blood given, bleeding hard to control; best taken early, before the patient is in extremis
  9. Packs left innumber and site (e.g. perihepatic, splenic bed, pelvis); radio-opaque pads only; folded plastic sheet on the liver under the packs; perihepatic packs kept off the IVC (BP watched while packing)
  10. Peritoneal washwarm saline, volume

Closure, drains and dressing

  1. Abdominal closureTemporary: vacuum pack (Barker)Temporary: commercial negative pressure systemTemporary: Bogota bagFascia closed (no damage control)after damage control the fascia and skin are never closed; suction pressure in mmHg (Barker 100 to 150 mmHg, lower if haemostasis incomplete)
  2. DrainsNoneClosed drain (site)
  3. SkinLeft openClosed
  4. Plan for return to theatresequence: ICU resuscitation (rewarm, correct acidosis and clotting), then re-look for pack removal and bowel reconstruction, usually 24 to 36 hours; earlier if bleeding into the canister

Specimens and implants

  1. Specimensspleen / bowel segment / liver fragments for HPE, or not sent
  2. Items left in the abdomennumber of packs, plastic sheet, absorbable mesh round liver
  3. Negative pressure systemmake, batch number

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. Shift to ICU on ventilatorcontinue resuscitation: warming, blood products, correct acidosis
  2. Vitals and urine outputhourly, with temperature
  3. Bladder pressuremeasure regularly from the first hours; report rising values
  4. Negative pressure canisterrecord output hourly; if fresh blood collects, stop suction and call the surgeon
  5. BloodsHb, platelets, clotting, ABG with lactate: repeat at set intervals
  6. Return to theatreplanned re-look, pack removal and reconstruction once warm, not acidotic and clotting normal
  7. Nil by mouth, nasogastric tube to drainage

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. V.K., 32 years, pillion rider in a road traffic accident, brought 50 minutes after injury with pulse 138/min, BP 72/40 mmHg after 2 units of blood, FAST positive in Morison's pouch and the left upper quadrant.

Case details

Date: 03/08/2026. Emergency trauma laparotomy, converted to damage-control laparotomy. Main OT.

In OT 01:05. Induction 01:08. Skin incision 01:14. Temporary closure completed 02:20. Out of OT 02:35.

Surgeon: Dr A. (3rd-year resident, General Surgery). Assistant: Dr B. (2nd-year resident). Consultant: Dr C., scrubbed from 01:20.

Anaesthetists: Dr D. and Dr E. Scrub nurse: Sr F.

Indication and pre-op

Blunt abdominal trauma with shock not responding to 2 units of blood. FAST positive in right and left upper quadrants.

Temperature 35.4 C, pH 7.18, base deficit 12 mmol/L, lactate 7.1 mmol/L at 00:50.

Massive transfusion protocol activated. Blood group O positive. 6 PRBC and 6 FFP issued.

Chest X-ray normal. Pelvis X-ray: no fracture. GCS 13.

Consent: written consent from wife for laparotomy, splenectomy, bowel resection, stoma, packing and planned re-operation. Explained in Hindi.

WHO checklist sign in and time out done. Inj cefazolin 2 g IV and metronidazole 500 mg IV at 01:10.

Anaesthesia and position

General anaesthesia, rapid sequence intubation. Supine, both arms out at 90 degrees. Warming blanket, warm fluids.

Foley catheter: clear urine. Nasogastric tube passed.

Painted with povidone-iodine from chin to knees and down to the table on both sides, groins included. Draped.

Findings

About 2.5 L of blood and clot in the peritoneal cavity.

Liver: deep laceration about 8 cm long across segments VI and VII, actively bleeding. No retrohepatic haematoma.

Spleen: shattered at the hilum, actively bleeding.

Small bowel: one full-thickness tear of 1.5 cm, about 60 cm from the ileocaecal junction, small spill of bowel content. Mesentery intact.

Stomach, duodenum, colon and rectum: no injury. Lesser sac: no injury.

Retroperitoneum: small stable Zone II haematoma around the right kidney, not expanding, not explored.

Diaphragm intact on both sides. Both kidneys palpable and normal in size.

Procedure

Midline laparotomy from xiphoid to below the umbilicus. Linea alba opened above the umbilicus and peritoneum entered with a finger.

Blood and clots scooped out. Packs placed around the liver and in the left upper quadrant. Anaesthetist allowed to catch up with transfusion.

Spleen mobilised and removed. Hilar vessels clamped, divided and tied. Tail of pancreas, stomach and colon seen to be safe.

Liver: bimanual compression by assistant. Falciform ligament divided. Pringle clamp applied 01:32, released 01:44 (12 minutes). Large bleeders in the depth of the laceration tied under vision.

Small bowel tear closed across with a linear stapler. Bowel not joined; no anastomosis at this stage.

Bowel run from ligament of Treitz to the rectum, both sides and mesentery. No other injury.

Decision for damage control at 01:50: temperature 35.0 C, pH 7.12, 8 units of blood given, ongoing ooze from raw surfaces.

Folded sterile plastic sheet placed on the liver. Six radio-opaque laparotomy pads packed above and below the right lobe, keeping clear of the IVC. BP stayed stable during packing. Two pads in the splenic bed.

Peritoneal wash with 2 L warm saline.

Closure

Fascia and skin not closed. Temporary closure by vacuum pack: fenestrated plastic sheet over the bowel under the peritoneum, moist towels, two silicone drains over the towels, adhesive drape to seal. Drains on continuous wall suction at 100 mmHg (low pressure because of the ooze).

Number of packs left in: 8 (6 perihepatic, 2 splenic bed). Written on the drape and in this note.

Specimens and implants

Spleen sent for HPE in formalin with requisition.

Left in the abdomen on purpose: 8 radio-opaque pads and one plastic sheet on the liver.

End of procedure

Estimated blood loss 3.5 L including haemoperitoneum. Transfused 8 PRBC, 6 FFP and 1 unit of single donor platelets in OT.

Instrument and needle count correct. Mop count: 8 pads left in the abdomen on purpose, all others accounted for. Confirmed by scrub nurse.

Cefazolin 2 g repeated at 02:05 because of heavy blood loss.

Pulse 112/min, BP 98/60 mmHg on noradrenaline, temperature 35.2 C. Shifted to surgical ICU on ventilator.

Post-op orders

ICU. Ventilate. Warm to 37 C with blanket and warm fluids.

Hourly pulse, BP, temperature, urine output and vacuum drain output. If fresh blood collects in the canister, stop suction and call Dr A.

Bladder pressure every 4 hours.

ABG, Hb, platelets, PT/INR at 04:00 and 08:00.

NPO. Nasogastric tube on free drainage.

Planned re-look laparotomy in 24 to 36 hours, once warm, not acidotic and clotting corrected: remove packs, join the bowel.

Signature

Dr A., JR-3, General Surgery. Reg. no. ________. 03/08/2026, 02:50.

Must document for this operation

  • The physiology that led to the damage-control decision (temperature, pH or base deficit, clotting, blood given). It shows why a definitive repair was not done and is reviewed in trauma audits and death reviews.
  • Number and site of every pack and sheet left in the abdomen. The surgeon at the re-look must remove every one, and a retained pack is a medicolegal disaster.
  • Each injury found, organ by organ, including those looked for and found normal. A missed injury is the commonest problem at re-look, and the note shows what was checked.
  • What was left unfinished (bowel not joined, vessel ligated, haematoma not explored) and why. The next operation is planned from this list.
  • Pringle and aortic clamp times. Clamp time explains later liver or bowel ischaemia and is asked about at review.
  • Type of temporary closure and suction pressure. The ICU team runs the dressing from this, and the pressure is kept low when there is ongoing ooze.
  • Blood products given in theatre. They go into the transfusion record and help the ICU judge ongoing bleeding.

Common mistakes in these notes

  • Writing 'abdomen packed' with no count or site of the packs.
  • Writing the mop count as 'correct' when packs were left in on purpose.
  • Not recording which bowel was stapled off and not joined.
  • Leaving out the reason a retroperitoneal haematoma was or was not explored.
  • No clear plan for the return to theatre.

Indian practice and paperwork

  • Extra procedures such as splenectomy, bowel resection or stoma should be named in the consent. An unconsented procedure is defensible only when needed to save life or health and it cannot wait; write that reason if it applies. (Samira Kohli v. Dr Prabha Manchanda, (2008) 2 SCC 1)
  • The district hospital OT checklist expects instruments, needles and sponges to be counted before the start, before final closure and at the end. When packs are left in on purpose, write the number counted out and the number left in. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, OT checklist ME E15.3)
  • Name every anaesthetist present. A hospital was held negligent when the op note left out 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 is moved out of recovery (or to ICU), and post-op care to follow a written plan. (NABH 5th ed., COP.14(e) and (f))
  • The spleen or bowel, if not sent for HPE, is human anatomical waste for the yellow bag. Discarded formalin is chemical waste in yellow (f). (Bio-Medical Waste Management Rules 2016, CPCB guidelines)

Sources

  • Demetriades D, Inaba K, Velmahos G, eds. Atlas of Surgical Techniques in Trauma. Cambridge University Press; 2015, Ch 20, General principles of abdominal operations for trauma (Frankel HL, Schlitzkus LL); Ch 21, Damage control surgery (Kaplan M, Demetriades D), pp. 366-393.
  • Scott-Conner CEH, ed. Chassin's Operative Strategy in General Surgery: An Expositive Atlas. 4th ed. Springer; 2014, Ch 8, Damage Control Laparotomy (Scott-Conner CEH), pp. 55-57.
  • 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 (redose 4 h), metronidazole 500 mg; Table 2 footnote a: start within 60 min before incision, redose may be warranted with excessive bleeding; colorectal and obstructed small bowel: cefazolin + metronidazole. 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.

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