OT notes · Orthopaedics

Wide local excision of soft-tissue tumour / sarcoma

Usual anaesthesia
General (the Northwestern handbook prefers GA without muscle relaxant so that nerve function can be checked; an epidural catheter may interfere with this)
Position
Depends on site. Anterior thigh: supine, limb slightly abducted and externally rotated, bump under the knee, lateral malleolus padded
Setting
elective

Operative note template for wide (en bloc) excision of an extremity soft-tissue tumour or sarcoma with the biopsy tract, with a filled example for a deep high-grade sarcoma of the anterior thigh.

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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

  • positive or close margin needing re-excision or radiotherapy
  • local recurrence
  • injury to or planned sacrifice of a nerve, with weakness or numbness
  • injury to a major vessel, possible vascular reconstruction
  • wound infection and wound breakdown, higher after pre-operative radiotherapy
  • seroma or haematoma, drain in place for some days
  • need for flap cover or skin graft
  • loss of muscle with weakness of the limb
  • amputation if the tumour cannot be removed with a safe margin

Pre-operative details for this operation

  1. Diagnosis and how it was madeCore needle biopsyOpen incisional biopsyFNACPrevious unplanned excision (re-excision of tumour bed)histological type and grade as reported, biopsy date and who did it
  2. Site, side, size and depthcompartment, superficial or deep to fascia, greatest dimension in cm on MRI
  3. StagingMRI of the part; CT chest (for large or high-grade tumours); stage (Enneking or AJCC)
  4. Neoadjuvant treatmentNonePre-operative radiotherapyPre-operative chemotherapydose and date completed
  5. Relation to nerves, vessels and bone on MRIstructures that may need to be sacrificed or reconstructed
  6. Planned marginWideMarginal (state why)Radical
  7. Biopsy scar marked for excisionYesNo previous open biopsy
  8. Vascular / plastic surgery team informedif vessel reconstruction or flap cover may be needed

Anaesthesia and position

  1. AnaesthesiaGeneral, without muscle relaxantGeneralSpinal / epiduralif relaxant avoided, say so, for nerve stimulation
  2. Positionposition and padding; for the thigh, supine, limb slightly abducted and externally rotated, bump under knee
  3. Preparationcircumferential painting so the limb can be moved; extent of the prepared area
  4. TourniquetNot usedUsed: limb elevated, not exsanguinated by compressionpressure, inflation and deflation times

Operative findings

  1. Tumoursize, depth, compartment, muscles involved, consistency, any breach of the pseudocapsule
  2. Relation to neurovascular bundlefree / adherent / encased; structure sacrificed if any
  3. Relation to bone and periosteum
  4. Margin achieved by the surgeon's assessmentWide: normal tissue all roundMarginal: plane through pseudocapsule at (site)Intralesional: tumour entered at (site)name the closest point and the tissue there, e.g. fascia or periosteum

Procedure (steps)

  1. Skin incisionlongitudinal, along the long axis of the limb; ellipse around the biopsy scar with 1-2 cm skin margin, extended over the length of the tumour
  2. Flaps raisedmedial and lateral flaps, thickness, how far
  3. Neurovascular structures exposed above and below the tumourwhich vessels and nerves, looped with vessel loops before tumour dissection
  4. Plane of dissectionthrough normal tissue outside the pseudocapsule; muscles taken en bloc (name them); cautery / knife / scissors
  5. Deep margindone last; tissue taken with the deep surface (fascia, periosteum, muscle cuff)
  6. Biopsy tractExcised en bloc in continuity with the tumourNo previous biopsy tract
  7. Vessel or nerve handlingAll preservedNerve sacrificed (name, reason)Vessel resected and reconstructed (reversed saphenous vein / PTFE)
  8. Radiopaque clips in resection bedtitanium clips to mark the bed for radiotherapy: number and where
  9. Brachytherapy cathetersNot placedPlaced (number) because margin is close at bone / nerve
  10. Wash and haemostasiswarm saline; tourniquet released before closure if used

Closure, drains and dressing

  1. Drainflat closed-suction drain in the bed, brought out through a stab in line with the incision and at its lower end
  2. Deep dermisabsorbable 3-0, airtight
  3. SkinInterrupted nylon (simple)Interrupted nylon (vertical mattress)Flap / graft cover (separate note)
  4. Dressing
  5. Distal pulses and nerve function at endif the patient is awake enough, or as checked in recovery

Specimens and implants

  1. Tumour specimen for HPEone piece en bloc with skin ellipse and biopsy tract; labelled with site and side; state which surface is deep and any orientation marks used
  2. Separate margin samplesextra tissue from a doubtful margin, labelled by site
  3. Clips / catheters left innumber of titanium clips; brachytherapy catheters if any
  4. Vascular graftif used: type, size, make, lot, sticker

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. Limb elevationon pillows
  2. Distal circulation and nerve functionpulses, capillary refill, movement and sensation; more often after vessel reconstruction
  3. Drainrecord output each day; remove when under 30 ml in 24 h on two days in a row
  4. Mobilisationphysiotherapy from POD 1, crutch walking; weight bearing as allowed
  5. Analgesiadrug, dose, frequency
  6. Woundcheck for infection and breakdown, especially after pre-operative radiotherapy
  7. Suturesremoval at 2 weeks
  8. HPE follow-up and tumour boardmargin status and grade; plan for radiotherapy or re-excision decided on final report
  9. Surveillanceclinical check, chest imaging and local imaging every 4-6 months for the first 2-3 years

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. S.K., 56 years, painless swelling of the right anterior thigh for 5 months. MRI: 9 cm mass deep to fascia in the vastus intermedius and rectus femoris, clear of the femoral vessels and the femur. Core needle biopsy: high-grade undifferentiated pleomorphic sarcoma. CT chest clear. Tumour board plan: wide excision followed by post-operative radiotherapy.

Case details

Date: 07/10/2026. Elective list. OT 4.

In OT 09:05. GA 09:15. Skin incision 09:48. Closure completed 12:20.

Surgeon: Dr A. (consultant, orthopaedic oncology). Assistant: Dr B. (3rd-year resident, Orthopaedics), who opened and closed.

Anaesthetist: Dr C. Scrub nurse: Sr D.

Indication and pre-op

High-grade undifferentiated pleomorphic sarcoma, right anterior thigh, 9 cm, deep, AJCC stage III, no metastases on CT chest.

Core biopsy entry point on the anterolateral thigh, marked for excision with the tumour.

Distal pulses (dorsalis pedis, posterior tibial) palpable. Knee extension power 4/5.

Consent in Marathi: wide excision, possible sacrifice of femoral nerve branches, weakness of knee extension, drain, flap if skin cannot be closed, amputation if margin not possible (not expected). Right thigh marked.

WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 09:30, before incision.

Anaesthesia and position

General anaesthesia, no muscle relaxant after intubation (to allow nerve stimulation).

Supine. Right limb slightly abducted and externally rotated, towel bump under knee, lateral malleolus padded.

Limb painted circumferentially from knee to above anterior superior iliac spine with povidone-iodine and draped free. No tourniquet.

Procedure

Longitudinal anterior thigh incision, 24 cm, with a skin ellipse 2 cm around the biopsy site.

Medial and lateral flaps raised above the fascia.

Femoral vessels and nerve identified in the femoral triangle above the tumour and looped. Superficial femoral vessels identified distally in the adductor canal region and looped.

Dissection in normal muscle outside the pseudocapsule with cautery and knife. Rectus femoris and a cuff of vastus lateralis and vastus medialis taken en bloc. Nerve to vastus intermedius passing into the tumour divided.

Deep margin taken last: vastus intermedius taken with the femoral periosteum over 6 cm, bone not involved.

Biopsy tract and skin ellipse removed in continuity with the tumour. Pseudocapsule not seen or breached at any point.

Findings: 10 x 7 x 6 cm firm mass. Femoral vessels and main nerve free. Closest point is at the periosteum (deep). Surgeon's assessment: wide margin.

Six titanium clips placed at the proximal, distal, medial, lateral and deep edges of the resection bed for the radiotherapist.

Wound washed with warm saline. Haemostasis checked.

Closure

Flat closed-suction drain in the resection bed, brought out distally through a stab in line with the incision.

Deep dermis closed with interrupted polyglactin 910 (Vicryl) 3-0. Skin closed with interrupted polyamide (Ethilon) 2-0 vertical mattress sutures. No tension. Dressing applied.

Pulses palpable at the ankle at end.

Specimens and implants

Specimen: single en bloc piece with skin ellipse and biopsy tract, in formalin, labelled right anterior thigh. Long stitch on proximal end, short stitch on lateral side, deep surface is the periosteal surface. Sent for HPE with margin assessment.

Left in: 6 titanium haemostatic clips.

End of procedure

Estimated blood loss 450 ml. No transfusion.

Mop, needle and instrument count correct. No intra-operative complications.

Shifted to recovery, stable. Pulse 86/min, BP 124/78 mmHg.

Post-op orders

Right leg elevated on pillows. Distal pulses, toe movement and sensation 2-hourly for 24 h.

Drain output charted daily. Remove when under 30 ml in 24 h on two days in a row.

Analgesia as per anaesthesia chart.

Physiotherapy from POD 1: quadriceps and hip exercises, crutch walking, weight bearing as tolerated.

Sutures out at 2 weeks. HPE to tumour board; radiotherapy referral after wound heals.

Signature

Dr B., JR-3, Orthopaedics, for Dr A. Reg. no. ________. 07/10/2026, 12:45.

Must document for this operation

  • The margin, named as intralesional, marginal, wide or radical, and the closest point. An oncological resection means little without the margin; the pathologist, radiotherapist and tumour board plan further treatment on it.
  • That the biopsy tract and scar were excised en bloc with the tumour. The biopsy tract is treated as contaminated with tumour; leaving it behind is a known cause of local recurrence.
  • Any breach of the pseudocapsule or entry into the tumour. A breach changes the margin to marginal or intralesional and may change adjuvant treatment.
  • Structures sacrificed (nerve, vessel, muscle) and any reconstruction. Explains a post-operative deficit and is needed for rehabilitation and for any medicolegal question.
  • Number and position of clips (and any brachytherapy catheters) left in the bed. The radiotherapist uses them to plan the field.
  • How the specimen was oriented and labelled. Without orientation the pathologist cannot say which margin is close.

Common mistakes in these notes

  • Writing 'tumour excised' with no margin named.
  • Not stating whether the biopsy tract was removed.
  • No mention of the closest margin and the tissue there (fascia, periosteum, nerve sheath).
  • Specimen sent without orientation marks being described in the note.
  • Drain exit site not recorded, although it becomes part of the field for any re-excision or radiotherapy.

Indian practice and paperwork

  • 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. (2020), COP.14(e) and (f))
  • Tissue not sent for HPE is human anatomical waste (yellow category). Discarded formalin from specimen jars is chemical waste, yellow (f). (Bio-Medical Waste Management Rules 2016, DGHS/CPCB guidelines)
  • If a structure not covered by the consent (for example a major nerve) has to be sacrificed, record why it could not wait. An added procedure without consent is defensible only when needed to save life or health. (Samira Kohli v. Dr Prabha Manchanda, (2008) 2 SCC 1)

Sources

  • Bell RH Jr, Kaufman DB, eds. Northwestern Handbook of Surgical Procedures. Landes Bioscience; 2005, Ch 68, Radical excision of soft tissue tumor (sarcoma) (Wayne JD), pp. 190-192.
  • Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; 2027, Ch 30, Soft-tissue tumors (treatment considerations, undifferentiated pleomorphic sarcoma); Ch 26, General principles of tumors (biopsy, margins), pp. 1004-1005, 1021-1022; 875, 881-882.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision, redose at 4 h. academic.oup.com/ajhp/article/70/3/195/5112717

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.

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