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How to impress your surgeon by writing a good

OT NOTE
2.0

(HAND BOOK FOR INTERN DOCTORS)

Dr. Rajib Dey Sarker

Surgeon’s Musings

[email protected]
Rajib Dey Sarker

____rds_____insta
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Key points to remember Know your incision

1. Honour: Always use a completely separate

page to write an operation note. Do not write
the note in the same page where post-
operative order is already written or you are
intending to write on.

2. Genre: Don’t forget to mention whether it is an

elective surgery or an emergency surgery.

3. Corner: Always remember to write each and

every important particulars of the patient and
related to the surgery. Information of the
patient such as ward number, bed number,
hospital registration number, date of
admission, local address, tele-contact numbers,
name of legal/local guardian etc and particulars
regarding surgery e.g.- DM, HTN,
Hypothyroidism, Obesity, previous surgery (if
any), previous scar, previous incisions,
neo/adjuvant therapy status and antibiotic
prophylaxis has to be noted clearly on the OT
note.

Who will write the OT Note?

1. Medico-legally speaking, every person of the

surgical team is liable for what is written in OT
note.
2. Ideally, the junior most member of the team
does the writing part but under direct
supervision of chief surgeon.
3. If all team-mates are of same rank or
Figure: Langer’s lines. These depict the orientation of the
designation, the chief surgeon may nominate dermal collagen fibres. Courtesy: Bailey & Love’s Short
anyone to do the writing but under his/her Practice of Surgery, 27th edition, Chapter 7, Page 86

direct supervision.
4. It has to be written immediately after the
surgery.

This hand book is for informational purposes only. It is not intended to be a substitute for valuable guidance and instructions
given by your Registrars and Assistant Registrars. So please ignore each and every word of this handbook if needed.

How to impress your surgeon by writing a good OT NOTE

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What points to write on an OT Note? Know your incision

1. Brief particulars of the patient

a. Name of the patient
b. Age
c. Ward number
d. Bed number
e. Hospital registration number
f. Tele-contact number
2. Date of Surgery
3. Time of Surgery / Duration of Surgery
(mentioning the starting time and ending time)
4. Pre-operative working diagnosis
5. Name of Surgery
6. Name of Anaesthesia
7. Position of the patient
8. Name of incision /
Number and position of ports Figure: Natural crease lines on face [Courtesy:
9. Approach and Procedure FARQUHARSON Textbook of Operative General
Surgery, 10th edition, Chapter 02, Page 15]
10. Findings
11. Prosthesis, Mesh or implant information
12. Post-operative confirmatory diagnosis
13. Anticipated blood loss
14. Closure technique or closure fashion
15. Number and site of drain tubes (if placed)
16. Name of the resected/collected specimen
17. Advice for the specimen
18. Referral for the specimen
19. Name of chief surgeon
20. Name of anaesthesiologist
21. Name of assistant surgeons
22. Name of attending nurses
23. Antibiotics and DVT prophylaxis
24. Instructions for Post-operative ward staffs
25. Schedule for check dressing
26. Signature with Date
[References: RCS guideline for good surgical practice and BMJ]

Figure: Incision lines over the palmar aspect of right hand

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Model OT NOTE Format

Shaheed Suhrawardy Medical College Hospital

Sher-e-Bangla Nagar, Dhaka-1207. Emergency Contact: +880-1711-194851 Email: [email protected]

Name of Patient: ___________________________________________ Age: ________ Ward No: ______ Bed No: ______ Weight: _________
Hospital Reg. _____________ Address: _________________________________________________ Emergency contact: ________________

▪ Date of Surgery _______________________________ Time of Surgery ___________________________ Duration: ____________

▪ Pre-operative working diagnosis _______________________________________________________________________________
▪ Name of Surgery ____________________________________________________________________________________________
▪ Name of Anaesthesia  GA  SAB  Others ___________________ Position of the patient ____________________________
▪ Name of incision ___________________________ (For Laparoscopy) Number and position of ports  SILS  3  4  5  6
▪ Approach and Procedure:

▪ Findings:

▪ Post-operative confirmatory diagnosis _________________________________________________________________________

▪ Prosthesis, Mesh or implant information _______________________________________________________________________
▪ Anticipated blood loss ________________ Closure technique or closure fashion _______________________________________
▪ Number and site of drain tubes (if placed) (1) ________________________________ (2) ________________________________
▪ Name of the resected/collected specimen ______________________________________________________________________
▪ Advice for the specimen ____________________________________________________________________________________
▪ Referral for the specimen ___________________________________________________________________________________
▪ Name of chief surgeon
▪ Name of anaesthesiologist
▪ Name of assistant surgeons
▪ Name of attending OT nurses
▪ Antibiotics and DVT prophylaxis ______________________________________________________________________________
▪ Special instructions for Post-operative ward staffs ________________________________________________________________
▪ Schedule for check dressing __________________________________________________________________________________

Signature of Doctor :
Name and Designation :
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Laparoscopic cholecystectomy Appendicectomy (Open)

Diagnosis: Chronic calculus cholecystitis Diagnosis: Acute Appendicitis

With all aseptic precaution and after adequate With all aseptic precaution and after adequate

painting and surgical draping, a 10 mm umbilical port painting and surgical draping, a Grid iron incision was

was made and pneumoperitoneum done. made over the anterior abdominal wall and after

Laparoscope negotiated and the other three ports cutting and cauterization of the skin, subcutaneous

(epigastric, right hypochondriac and right iliac) were tissue & external oblique aponeurosis and splitting the

created. The gall bladder was discovered and after internal oblique, the peritoneum was accessed. The

cautious dissection the cystic duct, the cystic artery vermiform appendix was identified retrocaecally

and the common bile duct was identified. [The gall following the taenia coli and was found highly

bladder was found highly inflamed, oedematous and inflamed. The appendicular artery was identified and

grossly adherent to surrounding structures like the ligated within the meso-appendix by Vicryl 1-0 R-B

greater omentum and the duodenum] After achieving suture. The appendix was ligated as base with same

the critical view of safety, the cystic duct and the cystic suture material and crushed 0.5 cm distally.

artery was clipped with metallic clip and excised. [or, Appendicectomy was done in a very cautiously aseptic

the cystic duct was ligated intra-corporeally by Vicryl way. Proper haemostasis was ensured. [A 16 Fr drain

1-0 suture and the cystic artery was cauterized with tube was kept in the right iliac fossa or pelvis.] Wound

harmonic device/ bipolar device and both were was closed in layers by Vicryl & skin was closed by

excised] Cholecystectomy done by dissecting the GB Prolene 2-0 C/B. Resected specimen of the appendix

out of the liver bed by hook electrocautery and was sent for histopathology with proper labelling.

haemostasis achieved. [a 14 Fr drain tube was kept in

the hepatorenal pouch] Ports were closed in layers Diagnosis: Burst appendix
whereas the umbilical port was fashioned with Vicryl
Cautious dissection was done to release the vermiform
1-0 CB OS-6. Sterile surgin pads (size: 50, 5cm x 7cm)
appendix from the caecal wall, greater omentum and
were applied. Anaesthetic reversal was smooth.
other adherent structures. Profuse peritoneal toileting
Resected specimen of GB was sent for histopathology
was done with warm 0.9% normal saline irrigation and
with proper labelling.
suction.

Hand Book by DR. RAJIB DEY SARKER

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Open cholecystectomy

Diagnosis: Cholelithiasis

With all aseptic precaution and after adequate

painting and surgical draping, Kocher’s incision (right sub-costal incision) was given over the anterior
sub-costal incision) was given over the anterior abdominal wall and after careful cutting and
abdominal wall and after careful cutting and cauterization from skin to deeper layers, peritoneum
cauterization from skin to deeper layers, peritoneum accessed. The GB was identified and after cautious
accessed. The GB was identified and after cautious dissection at the Calot’s triangle, the cystic artery, the
dissection at the Calot’s triangle, the cystic atery, the cystic duct and the common bile duct was identified.
cystic duct and the common bile duct was identified. The cystic artery and the cystic duct were ligated with
The cystic artery and the cystic duct were ligated with Vicryl 1-0 R/B and transected. Then the GB was
Vicryl 1-0 R/B and transected. Then the GB was carefully separated from the liver bed and
carefully separated from the liver bed and cholecystectomy done. The cystic stamp was carefully
cholecystectomy done. The cystic stamp was carefully checked and haemostasis achieved. The CBD was
checked and haemostasis achieved. Wound was found dilated and after careful kocherisation of the
closed in layers and sterile dressing applied over the CBD, 2 stay-sutures of Vicryl 3-0 R/B were advocated
sutured incision line. Anaesthetic reversal was in longitudinal axis of the CBD. A longitudinal incision
smooth. Resected specimen of GB was sent for was made over the anterior wall of CBD and the lumen
histopathology with proper labelling. reached cautiously with suction and irrigation. Stones
were extracted with Desjardin’s forceps. Thorough
intra-luminal irrigation was done with normal saline
with 08 Fr drainage tube and 50 cc Toomey syringe.
Open Choledocholithotomy Primary closure of CBD was done Vicryl 3-0 R/B [Or, A
10/12/14 Fr silicone T-Tube was inserted within the
Diagnosis: Obstructive jaundice due to CBS and fixed with Vicryl 3-0 R/B around the cut-layer
Choledocholithiasis of CBD]. Again, haemostasis achieved and peritoneal
toileting was done with normal saline. Wound was
With all aseptic precaution and after adequate
closed in layers and sterile dressing applied over the
painting and surgical draping, Kocher’s incision (right
sutured incision line. Anaesthetic reversal was
smooth. Resected specimen of GB was sent for
histopathology with proper labelling.

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Repair of DU Perforation Laparoscopic choledocholithotomy

(Modified Graham’s Patch Technique)

Diagnosis: Acute abdomen due to perforation Diagnosis: Choledocholithiasis

of gas containing hollow viscus
With all aseptic precaution and after adequate
With all aseptic precaution and after adequate
painting and surgical draping, a 10 mm umbilical port
painting and surgical draping, an upper midline
was made and pneumoperitoneum done.
incision was given over the anterior abdominal wall
Laparoscope negotiated and the other three ports
and after careful cutting and cauterization from skin
(epigastric, right hypochondriac and right iliac) were
to deeper layers, peritoneum accessed. Huge created. The gall bladder was identified and after
collection of peritoneal fluid and some debris of cautious dissection the cystic duct, the cystic artery
gastric content was noticed and evacuated with and the common bile duct was identified. After
suction. Adhesion was noticed around the duodenum achieving the critical view of safety, the cystic duct and
with presence of slough and engulfing omentum in- the cystic artery was clipped with metallic clip [or, the
situ. After careful dissection, a perforation site was cystic duct was ligated intra-corporeally by Vicryl 1-0

noticed over the anterior wall of the 1st past of suture and the cystic artery was cauterized with

duodenum, mearing about 0.5 cm x 0.5 cm. After harmonic device/ bipolar device]. Careful dissection
for partial kocherisation of the CBD was done. With
identification, a small tissue from the perforation
the laparoscopic hook, a longitudinal orifice was
margin was taken with caution. Thorough peritoneal
created over the anterior wall of CBD. With the help of
toileting was done with 4 litres of warm normal saline.
plane grasper, the single large stone was milked out
Repair of the perforation was done with Vicryl 3-0 R/B,
from the lumen and extracted out. With the help of a
putting and fixing a viable part of healthy omentum
6 Fr / 8 Fr drain tube, thorough irrigation of the CBD
over the repaired site (Modified Graham’s Patch
was done with normal saline. Primary closure of the
technique). An 18 Fr drain tube was kept in the CBS was done by intracorporeal suturing with Vicryl 2-
hepatorenal pouch. Haemostasis achieved. Wound 0 R/B (Or, A 12 Fr / 14 Fr T-Tube was inserted along
was closed in layers and sterile dressing applied over the long axis of the CBD and fixed with Vicryl 3-0 R/B.
the sutured incision line. Anaesthetic reversal was Cholecystectomy done and haemostasis achieved. [a
smooth. 14 Fr drain tube was kept in the hepatorenal pouch]
Peritoneal fluid was sent for biochemical study and Ports were closed in layers whereas the umbilical port

culture sensitivity. Tissue from edge of the perforation was fashioned with Vicryl 1-0 CB OS-6. Sterile surgin

was sent for histopathology with proper labelling pads (size: 50, 5cm x 7cm) were applied. Anaesthetic
reversal was smooth. Resected specimen of GB was
sent for histopathology with proper labelling.

Hand Book by DR. RAJIB DEY SARKER

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TAPP Hernioplasty TEP Hernioplasty

(Transabdominal preperitoneal) (Total extraperitoneal)

Diagnosis: Right sided reducible incomplete Diagnosis: Right sided reducible incomplete
indirect inguinal hernia indirect inguinal hernia

With all aseptic precaution and after adequate With all aseptic precaution and after adequate
painting and surgical draping, a 10 mm umbilical port painting and surgical draping, a 10 mm umbilical port
was made and pneumoperitoneum done. was made and pneumoperitoneum done.
Laparoscope negotiated and the other two 05 mm Laparoscope negotiated. Another 5 mm port is
working ports (right and left pararectal ports, on each inserted 4 cm below the first port in the midline. Third
side and slightly below the level of umbilical port) were 5 mm port is inserted in the same line 4 cm below.
created to achieve adequate triangulation. Contents Dissection is carried out downwards carefully, then
of the hernia are reduced. Hernial sac is dissected in medially up to the pubic tubercle, iliopectineal
preperitoneal plane after making horizontal incision ligament, laterally to iliac vessels, and inferior
at the upper part of the sac opening. The Vas epigastric vessels. Once adequate space is dissected,
difference, gonadal vessels, pubic bone, inferior 15 x 15 cm mesh is placed and spread. Mesh was fixed
epigastric vessels are identified. Once sac is dissected to the iliopectineal ligament with 05 mm tacks. Ports
and excised, a Prolene mesh of 15 x 10 cm sized was were closed in layers whereas the umbilical port was
placed in pre peritoneal space. It is fixed to pubic bone fashioned with Vicryl 1-0 CB OS-6. Sterile surgin pads
using 5 mm non-absorbable tacks. Peritoneum is (size: 50, 5cm x 7cm) were applied. Anaesthetic
closed with continuous Prolene sutures or tacks. Ports reversal was smooth.
were closed in layers whereas the umbilical port was A pressure dressing is advocated over the original
fashioned with Vicryl 1-0 CB OS-6. Sterile surgin pads dressing using multi-layered sterile cotton pads to
(size: 50, 5cm x 7cm) were applied. reduce dead space and possible seroma formation.
Anaesthetic reversal was smooth.

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Herniorrhaphy
(Shouldice repair) breasting) in front of the cord. Wound is closed in
layers and sterile dressing applied.
(originated at Shouldice hernia clinic in Toronto by EE Shouldice 1930)

Diagnosis: Right sided reducible incomplete

indirect inguinal hernia
Herniorrhaphy
With all aseptic precaution and after adequate (Modified Bassini’s repair)
painting and surgical draping, a classical hernia
Diagnosis: Right sided reducible incomplete
incision was given and after careful cutting and
indirect inguinal hernia
cauterization from skin to deeper layers, hernial sac
was identified. After doing herniotomy, the With all aseptic precaution and after adequate
transversalis fascia is incised along the line of the painting and surgical draping, a classical hernia
wound from deep ring to pubic tubercle. Upper medial incision was given and after careful cutting and
flap is elevated without elevating lower lateral flap. cauterization from skin to deeper layers, hernial sac
First suture line-Lower latera l flap of fascia is sutured was identified. After identification and separation of
to posterior deep part of the elevated upper flap using the spermatic cord and its content from the hernial
continuous sutures from pubic tubercle to internal ring sac, the conjoined tendon and the lip of inguinal
which is tied at deep ring without cutting/ending. ligament are approximated with Prolene 2-0 R/B,
Second suture line - Using same suture which is not keeping space medially for the cord to reallocate.
cut, free margin of upper flap is sutured to the shelving Wound is closed in layers and sterile dressing applied.
edge of the inguinal ligament from deep ring towards
pubic tubercle. It causes double-breasting of the
transversalis fascia. Knot is placed at the end over the Hernioplasty
pubic tubercle. First and second line sutures are done (Lichtenstein’s Technique)
using a single suture material. Third suture line-The
conjoined tendon and anterior to the shelving part of Diagnosis: Right sided reducible incomplete
the inguinal ligament is sutured from internal ring to indirect inguinal hernia
pubic tubercle continuously and tied without cutting.
With all aseptic precaution and after adequate
Fourth suture line-Same uncut suture is again sutured
painting and surgical draping, a classical hernia
back continuously between conjoined tendon and
incision was given and after careful cutting and
anterior fibres of the inguinal ligament to reach
cauterization from skin to deeper layers, hernial sac
internal ring. External oblique aponeurosis is sutured
was identified. After identification and separation of
in two layers (5th and 6th suture lines; double-
the spermatic cord and its content from the hernial

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sac, herniotomy is done. After herniotomy 15 x 10 cm epididymis. A puncture was made on the sac and fluid
trimmed Prolene mesh is placed deep to the cord was allowed to escape. Turning of sac inside out
structures. It is sutured to the inguinal ligament, (eversion) so that it lies entirely behind the testis.
conjoined tendon and pubic tubercle using Prolene 3- Multiple interrupted knots were given by Vicryl 2-0
0 R/B. Mesh on its lateral part is slit onto two tails that R/B to retain it in position. Haemostasis achieved.
are approximated again with Prolene suture. Wound Return the testis in the right hemiscrotum, keeping a
is closed in layers and sterile dressing applied. drain in there. Scrotum was closed in layers and
Coconut bandage applied.

Circumcision
LIS
(Lateral Internal Sphincterotomy)
With all aseptic precaution, under GA, retraction of
prepuce was done to remove retained smegma by Diagnosis: Chronic anal fissure with sentinel
povidone soaked moist gauze. A narrow clamp was skin tag

placed distal to the glans and parallel to the corona.

With all aseptic precaution, under SAB, anal stretching
Divide the prepuce distal to the clamp. Release the
was done. Then a vertical incision was made in the left
clamp & hold the inner layer of the prepuce. Trimmed
edge anal verge and internal sphincter muscle fibres
this inner layer by fine scissors. Haemostasis was
were identified and separated from the mucosa and
secured by bipolar diathermy. Inner & outer layer of
the lateral wall. These it is cut in its middle with
the prepuce are closed with interrupted sutures by
diathermy. The small wound is sutured with Vicryl 2-0
Catgut (plain) 4-0 C/B. Slits of DuoDerm applied over
C/B. The skin tag is excised by diathermy and
suture line.
haemostasis achieved. A lubricant soaked anal-pack
was inserted and T-bandage was applied.

Hydrocelectomy (or Excision and

Eversion of Hydrocele)
Jaboulay’s Procedure LONGO Haemorrhoidopexy
Diagnosis: Right sided Hydrocele
Diagnosis: 2° Haemorrhoid
With all aseptic precaution, under SAB, a longitudinal
With all aseptic precaution, under SAB, the patient
incision was made in the right side of the scrotal wall.
was placed in lithotomy position and proctosocopy
Clean all the coverings of the sac by dissecting scissor
done. Then a circular anal dilator & obturator was
and diathermy until the sac become completely free.
inserted and fixed by stay suture with 2-0 silk in 3, 6, 9
Delivery of the sac done with right testis and right

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and 12 o’clock positions. A PPH anoscope in the closed, keeping two tails of RomoVac negative suction
obturator was inserted and placed a circumferential drain. Sterile dressing applied keeping gentle pressure
purse string suture by Prolene 2-0 R/B proximal to the over the operative site.
dentate line. Then the LONGO Haemorrhoidopexy Specimen of the resected right breast with right
stapler was introduced in to the anal canal and all the axillary tail was sent for histopathology and hormone
purse string suture was placed through stapler holes status study.
in the stapler. After closing the device and waiting for
2 minutes, the stapler was triggered and waited for 2
minutes. After maintaining proper haemostasis
stapler was taken out. A lubricant soaked anal-pack Dressing Note
was inserted and T-bandage was applied.
Date of Dressing:

Time of Dressing:
Serial of Dressing: 2nd check dressing.
Modified Radical Mastectomy Wound Report: Wound is unhealthy. Edges are
covered with slough. Granulation tissue is scanty or
Diagnosis: Carcinoma of Right breast T3N1M0 not seen.
Or, Wound is healthy with aberrant granulation
With all aseptic precaution and after adequate
tissue.
painting and surgical draping, an elliptical incision
Plan: Daily dressing Or, Secondary wound closure
was made over right breast from medial aspect of the
Advice: Wound swab for C/S, Transfusion, etc.
second and third intercostal space enclosing the
Dressing done by
nipple, areola and tumour extending laterally into the
Signature:
axilla along the anterior axillary fold. The Breast with
Name of Doctor:
tumour was raised from the medial aspect of the
Designation:
pectoralis major muscle. Dissection was proceeded
laterally with ligating pectoral vessels. Once dissection
reached axilla, lateral border of pectoralis major
muscle is cleared with level I nodes. Pectoralis minor is
divided from coracoid process to clear level II nodes.
Medial and lateral pectoral nerves were preserved.
Nerve to serratus anterior, nerve to latissimus dorsi,
intercostobrachial nerve, axillary vein, cephalic vein
and pectoralis major muscle were preserved. Toileting Figure: These 10% Lidocaine sprays are available
in Bangladesh which may be used 05 minutes
was done with Povisep and normal saline. Wound is prior to dressing to comfort patient from the
pain and distress of would handling.

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[*as carcinoma stomach is highly sensitive to

Radical Gastrectomy neoadjuvant therapy, no growth or lymph nodes may
be palpable during laparotomy.]
Diagnosis: GOO due to carcinoma stomach
(involving body and antrum)
Whipple’s Procedure
With all aseptic precaution and after adequate (Classical Pancreaticoduodenectomy)
painting and surgical draping, a long upper midline
incision was given over the anterior abdominal wall Diagnosis: GOO due to carcinoma stomach
(involving body and antrum)
and after careful cutting and cauterization from skin
to deeper layers, peritoneum accessed.
With all aseptic precaution and after adequate
The growth was palpated* along the body and antrum
painting and surgical draping, a roof top incision was
of the stomach and thorough staging evaluation was
given over the anterior abdominal wall and after
done. The transverse colon is completely separated
careful cutting and cauterization from skin to deeper
from the stomach. The sub-pyloric nodes are dissected
layers, peritoneum accessed. To aid exposure, costal
and the first part of the duodenum is identified and
margin retraction along with liver was given by
divided with linear cutting stapling device (80 mm).
Deaver’s retractor and the hard growth was palpated
Lymph node dissection continued to the origin of LEFT
at head of pancreas (or distal CBD). Lesser sac was
gastric artery and divided with Prolene 3/0 R-B (D2
approached through a port in the gastrocolic ligament
resection). The oesophagus is divided with the help of
and the gastroduodenal artery (GDA) was identified,
right angled non-crushing intestinal clamps, keeping a
dissected and ligated. After completing the
stay suture, 05 cm proximal to the pathology.
cholecystectomy, the duodenum and the CBD was
Then the stomach is removed en bloc, including tissue
Kocharised, carefully lifting the head of pancreas, off
of both greater and lesser omentum and resected part
the inferior vena cava. The SMV, common hepatic
of duodenum. Gastrointestinal continuity is
artery and the portal vein was cautiously identified
reconstituted by means of Roux-en-Y fashion in retro-
and carefully preserved.
colic position. Two 18 Fr drain tubes was kept in the
A tunnel is created behind the neck of pancreas,
hepatorenal pouch and the pelvis. Haemostasis
marking the pancreatic transection line and the
achieved. Wound was closed in layers and sterile
pancreas is transected by diathermy secured by
dressing applied over the sutured incision line.
putting stay sutures over superior and inferior border
Anaesthetic reversal was smooth. Resected specimen
of pancreas and haemostasis was achieved.
of Billroth-II gastrectomy was sent for histopathology
Antrectomy done at the level of incisura by linear
with proper labelling.
cutting stapling device and the small bowel is divided
in the proximal jejunum and passed through the

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transverse mesocolon into the supracolic

LPJ
compartment. The CHD also transected with fine (Lateral Pancreaticojejunostomy)
scissors.
‘Partington – Rochelle’ Procedure
To resume intestinal continuity, the Diagnosis: Pancreaticolithiasis or Chronic
pancreaticoenteric anastomosis, bilioenteric pancreatitis

anastomosis and gastrojejunostomy was fashioned

With all aseptic precaution and after adequate
with interrupted single layer suturing with Vicryl 3-0
painting and surgical draping, a roof top incision was
R/B. Two drains of 24 Fr calibre were placed covering
given over the anterior abdominal wall and after
all three anastomoses. Haemostasis was achieved.
careful cutting and cauterization from skin to deeper
Wound was closed in layers and sterile dressing
layers, peritoneum accessed.
applied over the sutured incision line. Anaesthetic
The full length of the pancreas is approached via the
reversal was smooth.
lesser sac after division of the gastrocolic omentum.
Resected specimen of Whipple’s Procedure was sent Syringing done to ensure the position of MPD. The
for histopathology with proper labelling. pancreatic duct is then incised using diathermy and
opened along its length into the head of the gland. A
Roux loop is fashioned and brought up into the lesser
sac through the transverse mesocolon to the right of
the middle colic vessels. The blind end of the Roux loop
is laid on the tail of the pancreas. A side-to- side
pancreas to small bowel anastomosis is fashioned.
using a single-layer technique with Vicryl 3/0 R-B.
Intestinal continuity is restored with an
enteroenterostomy 40 cm below the transverse
mesocolon.

Figure: Whipple’s Procedure Figure: ‘Partington – Rochelle’ Procedure

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Delorme’s Procedure
(Rectopexy: Perineal approach)

Diagnosis: Rectal prolapse

With all aseptic precaution, patient was draped in

lithotomy position and the rectal prolapse was
encouraged to lapse to its full extent by gentle
retraction of the rectal wall out through the anus. A
series of six to eight sutures was passed both through
the skin at the anal verge and through more distant
perineal skin to avert the anus (disposable self-
retaining anal retraction device used). A dilute
solution of Inj. Adrenaline was injected submucosally Figure: The mucosa forms a tube once the dissection reaches
the apex of the prolapse. The lateral plication sutures include
into the outer tube of the prolapse and the mucosa
several bites of prolapsed muscle wall. [Courtesy:
incised circumferentially with diathermy 1–2 cm FARQUHARSON Textbook of Operative General Surgery, 10th
edition, Chapter 22, Page 453
above the dentate line.
The mucosa from the whole prolapsed segment of
bowel was removed by cautious use of diathermy,
followed by reattachment of the proximal mucosal
‘Limberg’ Rhomboid Flap
edge, with the underlying muscle of the bowel wall, to
the initial circumferential incision just above the
Diagnosis: Pilonidal sinus in the natal cleft
dentate line.
As the dissection reached the apex of the prolapse, the With all aseptic precaution, patient was draped in
mucosa formed a sleeve, which was retracted to prone position and the buttocks are strapped apart. A
facilitate dissection on the inner surface of the rhombic area of skin and subcutaneous fat was
prolapse. 04 knots were given with Vicryl 2/0 R-B and excised, which includes sinus.
the muscle tube was reduced back to inside the anus. The line A–C was drawn and its length measured. C
Further 8–12 sutures completed the mucosal was adjacent to the perianal skin and A was placed so
apposition. The anal verge retraction sutures were cut that all diseased tissue can be included in the excision.
and the skin hooks detached, and so the suture line The line B–D transects the midpoint of A–C at right-
retracts within the anus. Soaked anal packed kept in- angles. The flap was planned so that D–E is a direct
situ. Sterile dressing applied. continuation of the line B–D and is of equal length to
the incision B–A, to which it was be sutured after

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rotation. E–F is parallel to D–C, and of equal length.

After rotation, it will be sutured to A–D. Closure of loop ileostomy
(Or, Restoration of gut continuity / ileostomy reversion)
The skin and subcutaneous fat was removed. The flap
is raised so that it includes skin, subcutaneous fat and Diagnosis: Post ileostomy status for repair of
the fascia overlying gluteus maximus. The flap was ileal perforation due to ileocaecal TB

then rotated to cover the midline rhomboid defect and

With all aseptic precaution and after adequate
the defect this creates can be closed in a linear fashion
painting and surgical draping, an elliptical incision
with Vicryl 2/0 R-B. A RomoVac negative vacuum drain
was given encircling the stoma and after careful
was inserted and then finally the skin was closed with
cutting, with adequate tractions and cauterization
interrupted sutures, keeping the scar in midline. Sterile
from skin to deeper layers, peritoneum accessed. The
dressing applied. Specimen of the sinus tract was sent
fascial defect was identified layer by layer and intra-
for histopathology with proper labelling.
peritoneal adhesionolysis done. The stoma was then
pulled out and eversion of proximal spouted part was
done. After trimming and alignment of the margins pf
both ends of tube, a bi-layer circumferential
interrupted suturing was done with Vicryl 3/0 R-B.
After closure of the bowel, the loop is dropped back
into the peritoneal cavity and haemostasis achieved.
A 18 Fr drain tube was kept in right iliac fossa and
wound was closed in layers. Sterile dressing was
applied.

Figure: Restoration of ileal continuity

with an elliptical incision

Figure: Limberg Rhomboid Flap

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Right hemicolectomy

Diagnosis: Carcinoma Caecum

Or, ileocaecal TB with failed medical treatment

With all aseptic precaution and after adequate

painting and surgical draping, a midline incision was
given over the anterior abdominal wall and after
careful cutting and cauterization from skin to deeper
layers, peritoneum accessed. There was a hard mass
in the caecum, involving the ascending colon and
terminal ileum, measuring about 6 cm x 4 cm, grossly
adherent with surrounding structures, with moderate
ascites, bur no peritoneal seedlings seedlings. Other
abdominal organs were quested for metastasis, and Splenectomy
nothing was reported. Mesocolic excision was
approached with associated lymph nodes and ileo-
Diagnosis: Beta-Thalassemia Major with huge
colic pedicle was identified and ligated at its origin splenomegaly with hypersplenism
from the superior mesenteric vessels. The right branch
With all aseptic precaution and after adequate
of the middle colic artery was also identified and
divided. The specimen was cut at terminal ileum 15 cm painting and surgical draping, a left subcostal incision

from the ileo-caecal junction and ascending colon 10 was given and after careful cutting and cauterization

cm away from the tumour margin. Ileo-colic from skin to deeper layers, peritoneum accessed. The

anastomosis was done linear cutting stapling devices lienorenal ligament, gastrosplenic ligament (with

and haemostasis achieved. A 24 Fr drain tube was kept short gastric and left gastroepiploic vessels within)

in the right iliac fossa and wound was closed in layers. and tail of the pancreas were carefully divided and
ligated. The splenic artery, then the splenic vein were
Sterile dressing was applied.
isolated and tightly ligated. After securing the hilar
vessels and releasing the adhesions, splenectomy was
done. Two 24 Fr drain tubes were placed in the
stomach bed and in the pelvis respectively and wound
was closed in layers. Sterile dressing was applied.

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Pre-operative Order Post-operative Order

Preoperative order on _______________ (date) Post-operative order on _______________ (date)

at ____________ (time) for Laparoscopic at ____________ (time)
Cholecystectomy under GA for Laparoscopic Cholecystectomy under GA

Diagnosis: Cholelithiasis Diagnosis: Cholelithiasis

1) Keep patient NPO from 10 pm tonight (date) 1) NPO-TFO
2) Inf. Hartsol (1000 ml) 2) Oxygen inhalation @ 60. L/min for next 30 min &
iv stat @ 10 drops/min from 7.00 am of __________
SOS
(Date of OT day)
3) Inj. Arixon (1 gm) (Ceftriaxone)
1 vial iv stat at 7.00 am of __________ 3) Inf. 5% Dexaqua / DA (1000 ml) +
4) Inj. Omenix (40mg) (Omeprazole) Inf. 5% Dexoride / DNS (1000 ml) +
1 vial iv stat at 7.00 am of __________
5) Cap. Lubistone (24 mcg) (Lubiprostone) Inf. Lactoride / Hartsol (1000 ml)
1 + 0 + 1 (today)
6) Tab. Alben-DS (400mg) IV stat @ 30 drops/min and Daily.
1 tab stat per orally (today)
7) Tab. Rivotril (0.5 mg) (Clonazepam) 4) Inj. Arixon (1 gm)
0 + 0 + 1 (tonight at 10.00 pm)
1 vial iv stat and 12 hourly
8) Please take written informed consent
9) Please clean and shave the operative area
5) Inj. Flamyd (500 mg/100 ml)
10) Please send the patient to OT in OT dress with patient 1 bottle iv stat and 8 hourly
record file and other essentials.
6) Inj. Sergel (40 mg) (Ceftriaxone)
Preoperative order on _______________ (date) 1 vial iv stat and 12 hourly
at ____________ (time) for Laparoscopic 7) Inj. Toradolin (30 mg)
Cholecystectomy under GA 1 amp iv stat and 8 hourly

Diagnosis: Cholelithiasis with DM with HTN 8) In. Anset (8 mg)

1 amp iv stat and 8 hourly
1) Keep patient NPO from 10 pm tonight (date) except
for medication with sips of water
9) Inj. Pethedine (100 mg)
2) Reflow RBS (with Glucometer) at 6.00 am on coming ¾ th amp (75 mg) IM stat and 8 hourly
morning and hourly
3) Tab. Osartil 50 Plus (50/12.5mg) 10) Suppo. Voltalin (50 mg)
1 + 0 + 0 at 7.00 am on OT day (Date) with sips 1 stick P/R stat and if patient complains of
4) Inf. 0.9% NS (1000 ml) pain
iv stat @ 10 drops/min from 7.00 am of __________
(Date of OT day) 11) Please record DT collection, BP, Pulse,
5) Inj. Arixon (1 gm) (Ceftriaxone) Temperature, Urine output/voiding status and
1 vial iv stat at 7.00 am of __________
dressing status routinely.
6) Inj. Omenix (40mg) (Omeprazole)
1 vial iv stat at 7.00 am of __________
7) Cap. Lubistone (24 mcg) (Lubiprostone)
1 + 0 + 1 (today) 12. Signature and Name of
8) Tab. Alben-DS (400mg) Doctor.
1 tab stat per orally (today)
9) Tab. Rivotril (0.5 mg) (Clonazepam)
0 + 0 + 1 (tonight at 10.00 pm)
10) Please take written informed consent.
11) Please clean and shave the operative area.
12) Please send the patient to OT in OT dress with
patient record file and other essentials.

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Post-operative Order Bowel Preparations

Post-operative order on _______________ (Date) Hemicolectomy

at ____________ (Time)
for Laparoscopic Cholecystectomy under GA
1. High protein diet 1 week prior to surgery
Diagnosis: Cholelithiasis with DM with HTN
2. Low residual diet 3 days prior to surgery.
1) NPO-TFO 3. Liquid diet on the day before surgery.
2) Reflow RBS – hourly in Post-operative ward and
record 4. Patient should be kept NPO 12 hours prior to
3) Maintain hourly BP chart surgery.
4) Oxygen inhalation @ 60. L/min for next 30 min &
SOS 5. 1000 ml of glucose and electrolyte rich
solution has to be infused @20 drops/min.
5) - Inf. 5% Dexoride / DNS (2000 ml) +
10 units of Inj. Actrapid HM 100IU (e.g. Inf. 5% DNS)
in each 1000 ml of DNS 6. Aqualax Powder (Polyethylene glycol)
- Inf. 0.9% NS (1000 ml)
IV stat @ 30 drops/min and Daily. 1 bottle to be mixed with 1.0 L of drinking
* (if RBS < 10 mmol/L, please stop the insulin drip water and taken on the evening before the
immediately and continue Inf. 5% DNS)
day of surgery.
6) Inj. Arixon (1 gm) 7. Cap. Lubistone (24 mcg)
1 vial iv stat and 12 hourly
7) Inj. Flamyd (500 mg/100 ml) 1 + 0 + 1 for 3 days (prior to surgery)
1 bottle iv stat and 8 hourly 8. Tab. Deflux (10 mg)

8) Inj. Sergel (40 mg) (Ceftriaxone) 1 + 1 + 1 for 3 days (prior to surgery)

1 vial iv stat and 12 hourly 9. Tab. Acifix (20 mg) / Rabeprazole
9) Inj. Napa (1 gm)
1 bottle iv running stat and 8 hourly 1 + 0 + 1 (b/m) for 7 days (prior to surgery)
10. Tab. Nightus (3 mg)
10) In. Anset (8 mg)
1 amp iv stat and 8 hourly 0 + 0 + 1 (at H/S) for 7 days
11) Inj. Pethedine (100 mg) 11. NG Suction should be started 6 hours before
¾ th amp (75 mg) IM stat and 8 hourly
surgery.
12) Suppo. Voltalin (50 mg) 12. Fleet enema
1 stick P/R stat and 12 hourly
1 bottle to be given per rectally on early
13) Please record DT collection, BP, Pulse, morning on the day of surgery.
Temperature, Urine output/voiding status and
dressing status routinely. Maintain RBS and BP
chart.

14) Signature and Name of Doctor.

[As we are supposed to give anti-HTN drugs on the early morning
of day of surgery, no need to write anti-HTN on post-operative
order. But if there is uncontrolled HTN in post-operative period,
we should add oral anti-HTN drugs with sips, preferably 4 hours
after surgery)

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NG Tube essentials

1. Silicone NG Tube (Size 16) – 1 pc

2. Jasocaine 2% Jelly – 1 pc
3. Toomey Syringe (70 cc) – 1 pc
4. Nichiban Micropore (1 inch) – 1 pc
5. Ansel Gloves (size: 6½ / 7 / 7½) – 1 pc

Catheterization essentials

1. Bardia Foley’s Catheter (Size:14/16) – 1 pc

2. Povicep Solution (30 ml) – 1 pc
3. Jasocaine 2% Gel – 1 pc
4. 10 cc Disposable Syringe – 1 pc
5. Nichiban Micropore (1 inch) – 1 pc
6. Ansel Gloves (size: 6½ / 7 / 7½) – 1 pc
7. Romo-30 Urobag (2000 ml) – 1 pc

If you discover any error, please don’t hesitate to inform me via email and I will gladly mention your credit on the next issue.

Hand Book by DR. RAJIB DEY SARKER

 P a g e | 20

If you believe, this small hand book was helpful for you, please PRAY for my
Mentors, who taught, governed, guided and inspired, to bring out the best from me.

Professor Dr. Pankaj Kumar Saha

Dr. S M Quamrul Akther Sanju Sir Dr. Akhter Ahmed Shuvo Sir Dr. Krishna Pada Saha Sir Dr. Sadia Imdad Madam Dr. Fayem Chowdhury Sony Sir and Myself

How to impress your surgeon by writing a good OT NOTE