OT notes · General Surgery

Wound debridement / fasciotomy

Usual anaesthesia
General or spinal, as decided by the anaesthetist; the patient is often septic
Position
Supine, limb supported and prepared circumferentially
Setting
emergency

Operative note template for surgical debridement of an infected or devitalised wound, or a decompression fasciotomy, with a filled example for emergency debridement of necrotising fasciitis of the leg.

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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 need for blood transfusion
  • further debridements under anaesthesia
  • spread of infection and sepsis despite surgery
  • amputation if the limb cannot be saved
  • large open wound needing skin grafting later
  • injury to veins and cutaneous nerves (saphenous, superficial peroneal) in fasciotomy
  • risk to life from sepsis
  • renal failure from muscle breakdown in compartment syndrome

Pre-operative details for this operation

  1. Diagnosis and extentnecrotising infection / crush / compartment syndrome / burn eschar; area marked on skin and time of marking
  2. Duration of symptoms or ischaemiahours since injury or onset
  3. Compartment pressure (if measured)pressure in mmHg and diastolic BP; difference
  4. Sepsis statuspulse, BP, urine output, lactate, blood sugar; ICU informed
  5. BloodHb, group and cross-match, units reserved
  6. Antibiotics already runningdrug, dose, time of last dose; cultures sent before starting
  7. Consent includes amputation / repeat surgeryYesNot applicable

Anaesthesia and position

  1. AnaesthesiaGeneralSpinalRegional block
  2. Positionsupine / lateral / prone; limb supported
  3. TourniquetNot usedUsed: pressure and time on / off
  4. Preparationwhole limb or area painted circumferentially

Operative findings

  1. Skinarea in cm, necrosis, bullae, crepitus
  2. Subcutaneous tissueliquefied fat, dishwater fluid, thrombosed perforators, pus
  3. Fasciagrey / necrotic / intact; extent in cm
  4. Musclecolour, contraction on stimulation, bleeding; which compartments
  5. Deep structurestendon, bone, joint, vessels exposed
  6. Margins at endhealthy bleeding tissue reached on all sides?

Procedure (steps)

  1. Painting and drapingantiseptic, extent
  2. Incisionsite, direction, length in cm
  3. DebridementExcision down to deep fasciaFascia excisedMuscle debridedTangential excisiontissue removed until healthy bleeding tissue seen
  4. FasciotomyNot doneLeg: two-incision four-compartmentForearm: volar with carpal tunnel releaseForearm: dorsalHandThighincision sites and lengths; each compartment named as released
  5. Structures protectede.g. great saphenous vein and saphenous nerve, superficial peroneal nerve, median nerve
  6. Muscle viability after releaseper compartment: colour, contraction, bleeding
  7. Samples takendeep tissue for culture, pus swab, tissue for HPE
  8. Irrigationfluid and volume
  9. HaemostasisElectrocauteryLigaturesPressure packs
  10. Size of final woundlength x breadth in cm; photograph taken (with consent)

Closure, drains and dressing

  1. WoundLeft openLoosely approximatedNegative pressure dressing
  2. Dressingtype (saline gauze, non-adherent), bulky dressing, splint
  3. Limb positionelevated / at heart level
  4. Plan for next lookday and reason

Specimens and implants

  1. Deep tissue for culture and sensitivityaerobic and anaerobic, sent in sterile container, not formalin
  2. Tissue for HPEif diagnosis uncertain or chronic wound
  3. ImplantsNone

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 sepsis monitoringpulse, BP, temperature, urine output hourly; ICU / HDU if unstable
  2. Antibioticscontinue therapeutic course; change as per culture report
  3. Wound inspectionlook at wound within 24 hours; mark any spreading edge
  4. Distal neurovascular checkpulses, capillary refill, sensation and movement, frequency
  5. Urine colour and renal functionafter fasciotomy or crush: watch for dark urine and rising creatinine
  6. Blood sugar controlif diabetic
  7. Limb elevationposition
  8. Nutritionearly oral or enteral feeding, protein
  9. Planre-look debridement; delayed closure or split skin graft when wound granulates

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.B., 56 years, known type 2 diabetic on irregular treatment, with 3 days of painful swelling of the left leg after a minor abrasion. Rapidly spreading redness, bullae and dusky skin over the medial calf, pain out of proportion, pulse 118/min, BP 96/60 mmHg, RBS 386 mg/dl. Clinical diagnosis: necrotising fasciitis of left leg.

Case details

Date: 14/10/2026. Emergency debridement of left leg. OT 5.

In OT 13:40. Induction 13:50. Skin incision 14:02. Dressing completed 15:05.

Surgeon: Dr A. (2nd-year resident, General Surgery). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: necrotising soft tissue infection of the left leg with sepsis. Edge of redness marked with skin marker at 11:30.

Blood culture sent at 11:15. Inj piperacillin-tazobactam 4.5 g IV 6-hourly and inj clindamycin 600 mg IV 8-hourly started at 11:30. IV fluids 2 L given. Insulin infusion started.

Hb 11.0 g/dl, TLC 22,400/cmm, creatinine 1.6 mg/dl. 2 units cross-matched.

Consent: general, high-risk, procedure-specific and anaesthesia consent taken in Hindi from patient and son. Explained need for repeat debridement, possible amputation and risk to life.

WHO checklist sign in and time out done.

Anaesthesia and position

General anaesthesia with endotracheal intubation. Supine. No tourniquet. Whole left lower limb from groin to toes painted with povidone-iodine and draped circumferentially.

Findings

Dusky non-blanching skin with bullae over medial calf, about 18 x 10 cm. Redness extending to 5 cm below the knee.

Subcutaneous fat liquefied with thin grey foul-smelling fluid. Thrombosed perforator vessels. Deep fascia grey and necrotic over medial and posterior calf, separating easily from muscle.

Gastrocnemius and soleus pink, bleeding when cut and contracting to cautery. No pus in deep posterior compartment.

No crepitus. Tibia not exposed. Ankle joint not involved.

Procedure

Longitudinal incision on medial side of leg from 4 cm below the knee to 8 cm above the medial malleolus, through the necrotic area.

Great saphenous vein thrombosed in the involved segment, ligated above and below and excised with the specimen.

All non-bleeding skin, liquefied fat and necrotic deep fascia excised until healthy bleeding tissue was reached on all sides. Skin flaps lifted to check the fascial plane; necrosis stopped 3 cm short of the marked redness at the upper end.

Deep tissue sent for aerobic and anaerobic culture. Pus swab sent. One piece of fascia sent for HPE.

Wound irrigated with 3 L warm normal saline.

Haemostasis with electrocautery and silk ligatures.

Final wound 24 x 12 cm, gastrocnemius and soleus exposed. Photograph taken for the case record.

Closure

Wound left open. Packed with saline-soaked gauze. Bulky cotton and crepe bandage. Limb elevated on a pillow.

Specimens and implants

Deep tissue in sterile container for culture and sensitivity. Pus swab for Gram stain and culture. Fascia in formalin for HPE. No implants.

End of procedure

Estimated blood loss 400 ml. One unit PRBC transfused intra-operatively.

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

No intra-operative complications.

Patient shifted to surgical ICU on ventilator for sepsis care as advised by the anaesthetist. Pulse 110/min, BP 104/66 mmHg on noradrenaline infusion.

Post-op orders

Hourly pulse, BP, urine output. Blood sugar 2-hourly on insulin infusion.

Continue piperacillin-tazobactam 4.5 g IV 6-hourly and clindamycin 600 mg IV 8-hourly. Review with culture report.

Dressing to be opened and wound inspected in 24 hours. Mark any new spreading edge.

Distal pulses, capillary refill and toe colour 2-hourly.

Creatinine and electrolytes tomorrow morning.

Ryle's tube feeds once extubated or as advised by ICU.

Re-look debridement under anaesthesia if the wound inspection shows further necrosis. Skin grafting later when the wound granulates.

Signature

Dr A., JR-2, General Surgery. Reg. no. ________. 14/10/2026, 15:30.

Must document for this operation

  • Extent of necrosis in each layer: skin, fat, fascia, muscle. The next surgeon uses this to judge whether the infection is spreading and how much more to remove.
  • That excision reached healthy bleeding tissue, or where it did not. Inadequate debridement leaves dead tissue that keeps the patient septic, and it is the first thing a review looks for.
  • For fasciotomy, each compartment released by name and the state of the muscle in it. A missed deep posterior compartment is a common error, and the note is proof that it was opened.
  • Final wound size and structures exposed. It is the baseline for later dressings and for planning skin grafting.
  • Samples sent, and in which medium. Antibiotics are changed on the culture report, and tissue in formalin cannot be cultured.
  • Consent discussion about repeat surgery, amputation and risk to life. These patients often die or lose the limb, and the family will ask what they were told.
  • Time of onset or injury and time of fasciotomy. Delay is judged against these times in audit and in medicolegal review.

Common mistakes in these notes

  • Writing 'debridement done' with no size or depth.
  • Not naming the compartments released in a fasciotomy.
  • No record of culture samples taken.
  • Leaving out the plan for re-look and its timing.
  • Not recording the consent discussion about amputation and death.

Indian practice and paperwork

  • For polymicrobial necrotising fasciitis, the ICMR antimicrobial guideline lists piperacillin-tazobactam 4.5 g IV 6-hourly plus clindamycin 600 mg IV 8-hourly, generally for 14 days if source control is adequate, with early surgical debridement and blood and intra-operative specimens sent for culture. (ICMR Treatment Guidelines for Antimicrobial Use in Common Syndromes 2019, Ch 6, Tables 6.1 and 6.5 (printed pp. 56, 59))

Sources

  • Scott-Conner CEH. Scott-Conner & Dawson: Essential Operative Techniques and Anatomy. 4th ed. Wolters Kluwer / Lippincott Williams & Wilkins; 2014, Ch 126 Debridement and split-thickness skin graft; Ch 134 Fasciotomy (Amin PB, Sharp WJ), pp. 679-681; 730-734.
  • Moran B, Mittal R, Lord A, eds. Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press; 2026, Ch 4A Surgery of the skin and subcutaneous tissue: necrotising infections; Ch 18 Vascular trauma: compartment syndrome, pp. 46; 391-392.
  • Sriram Bhat M. SRB's Surgical Operations: Text and Atlas. Jaypee; 2014, Ch 9 Principles of surgical treatment in infections: fasciotomy for compartment syndrome, pp. 234-235.
  • ICMR. Treatment Guidelines for Antimicrobial Use in Common Syndromes, 2nd ed., 2019. Ch 6 Skin and soft-tissue infections: Table 6.1 (necrotizing fasciitis, polymicrobial: piperacillin-tazobactam + clindamycin, generally 14 days) and Table 6.5 (piperacillin-tazobactam 4.5 g IV 6-hourly + clindamycin 600 mg IV TDS). 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.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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