OT notes · General Surgery

Adrenalectomy (open / laparoscopic)

Usual anaesthesia
General anaesthesia with endotracheal intubation
Position
Laparoscopic: lateral decubitus on the kidney rest, operated side up. Open anterior: supine with a roll under the lower costal margin
Setting
elective

Operative note template for laparoscopic or open adrenalectomy, with a filled example for laparoscopic left adrenalectomy for a pheochromocytoma.

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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, including injury to the inferior vena cava (right) or renal vein (left)
  • conversion to open surgery
  • injury to spleen, pancreas, liver, colon or kidney
  • wide swings in blood pressure during and after surgery (pheochromocytoma)
  • low blood sugar or adrenal insufficiency after surgery
  • entry into the pleura (posterior approach)
  • incomplete removal or malignant histology needing further treatment
  • wound or port-site infection

Pre-operative details for this operation

  1. DiagnosisPheochromocytomaAldosterone-producing adenomaCortisol-producing adenomaSuspected adrenocortical carcinomaOther (state)biochemistry (metanephrines, aldosterone/renin, cortisol) and result
  2. Side and imagingCT / MRI: side, size, features, other adrenal, extra-adrenal lesions
  3. ApproachLaparoscopic lateral transabdominalOpen anterior transabdominalPosteriorFlank / thoracoabdominalreason (size over 6 to 10 cm or suspected cancer favours open)
  4. Pheochromocytoma preparationalpha-blockade: drug, start date (about 2 weeks), dose reached, BP and pulse on the day
  5. Potassium, sugar, steroid coverpotassium corrected (aldosteronoma), steroid cover planned (cortisol-secreting tumour)
  6. Blood cross-matchedunits
  7. Foley catheter, orogastric tube, compression stockingsPlaced

Anaesthesia and position

  1. AnaesthesiaGeneral with invasive monitoringGeneral
  2. PositionLateral decubitus on beanbag, kidney rest raised, table flexedSupine with roll under lower costal marginProne jackknife (posterior)
  3. Pneumoperitoneumentry method, pressure (e.g. 15 mmHg)

Operative findings

  1. Tumourside, size, colour (orange-yellow cortical, grey pheochromocytoma), capsule intact, invasion
  2. Adrenal veinlength, where it drained (renal vein / IVC), any variant
  3. Haemodynamic eventsBP peaks during handling, fall after vein division, drugs given by anaesthetist
  4. Upper pole of kidney after vein divisionPinkDusky / demarcated
  5. Accessory or residual adrenal tissue, other adrenal, retroperitoneumas seen or felt

Procedure (steps)

  1. Ports / incisionlaparoscopic: four ports two fingerbreadths below costal margin, 8 to 10 cm apart, sizes, open: bilateral subcostal or midline
  2. Abdomen explored
  3. Exposure (left)Splenic flexure mobilised, spleen and tail of pancreas rotated mediallyOpen: lesser sac entered, pancreas lifted, colon down
  4. Exposure (right)Right triangular ligament divided, liver retracted, hepatic flexure downOpen: hepatic flexure down, Kocher manoeuvre, IVC exposed
  5. Gerota fascia openedover the kidney, extended upwards
  6. Gland freed along lateral and superior bordersenergy device (harmonic / vessel sealer), clips, fat left on gland for grasping
  7. Adrenal vein dividedClips (number each side)Endoscopic stapler, vascular loadLigated in continuity (open)divided first or last, time
  8. Remaining attachments divided, gland freed
  9. Specimen retrievedin a retrieval bag, through which port, bag intact
  10. Haemostasis, irrigation, adrenal bed checked
  11. ConversionNot neededHand portConverted to open (reason, time)

Closure, drains and dressing

  1. Port fascia10 mm and larger ports closed with 0 absorbable suture
  2. Skinsubcuticular absorbable or staples
  3. DrainNoneSuction drain in adrenal bed (reason)
  4. Open woundsheath and skin closure, material

Specimens and implants

  1. Adrenal gland with tumour for HPEside, weight, size, capsule intact or breached
  2. Clips / staples lefttype and number (for later imaging)

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. BP and pulseICU or HDU monitoring for pheochromocytoma, limits and when to call
  2. Blood sugarin the immediate post-op period after pheochromocytoma removal, frequency as per ICU protocol
  3. Steroid coverfor cortisol-secreting tumours or bilateral adrenalectomy: hydrocortisone replacement if cortisol is low, dose and taper as advised by endocrinology, patient educated about adrenal insufficiency
  4. Potassiumafter aldosteronoma removal: check level, potassium supplement and spironolactone plan as advised by endocrinology
  5. IV fluids and urine outputtype, rate, hourly urine
  6. Analgesiadrug, dose, frequency
  7. Diet and mobilisationliquids from when, walk POD 1
  8. Follow-upHPE, repeat biochemistry as advised

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.R., 38 years, paroxysmal headache, sweating and palpitations with BP up to 210/120 mmHg, raised plasma metanephrines, CT shows a 4.5 cm left adrenal mass, alpha-blocked for 2 weeks with gradual dose increase.

Case details

Date: 26/11/2026. Elective. OT 1.

In OT 08:30. Induction 08:45. First port 09:25. Adrenal vein clipped 10:40. Specimen out 11:05. Closure completed 11:20.

Surgeon: Dr C. (Consultant, General Surgery). Assistant: Dr A. (3rd-year resident), camera and retraction, closed port sites. Dr B. (2nd-year resident) observing.

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

Indication and pre-op

Indication: left adrenal pheochromocytoma, 4.5 cm, biochemically confirmed. Right adrenal normal on CT. No extra-adrenal lesion.

Alpha-blocker started 2 weeks ago with gradual dose increase by endocrinology (drug and dose on drug chart). BP on the morning of surgery 124/80 mmHg, pulse 84/min.

Consent: laparoscopic left adrenalectomy, possible conversion to open. Risks of bleeding, BP swings, low sugar and injury to spleen, pancreas and kidney explained in Telugu to patient and wife.

2 units cross-matched. Foley catheter, orogastric tube and compression stockings placed. WHO checklist done. Inj cefazolin 2 g IV at 08:50, before incision, as per unit policy.

Anaesthesia and position

General anaesthesia with endotracheal intubation. Invasive BP monitoring by anaesthesia team (details in anaesthesia record).

Right lateral decubitus (left side up) on a beanbag, kidney rest between 11th rib and iliac crest raised, table flexed, tilted slightly back. Pressure points padded, axillary roll, pillows between legs, strapped at hip and shoulder.

Parts painted with povidone-iodine and draped.

Procedure

Open (Hasson) entry at port 2 in the midclavicular line, two fingerbreadths below the costal margin. CO2 pneumoperitoneum at 15 mmHg. 30 degree telescope. Ports 1 (midline) and 3 (anterior axillary line) under vision. Abdomen explored: no other abnormality.

Splenic flexure mobilised with harmonic scalpel. Port 4 placed under vision in the posterior axillary line between the 11th rib and the iliac crest.

Lateral attachments of spleen divided, spleen and tail of pancreas fall medially. Gerota fascia opened vertically over the kidney.

Findings: 4.5 cm grey, well encapsulated tumour in the left adrenal, above and medial to the upper pole of the kidney. Capsule intact. Left adrenal vein about 1.5 cm long, draining into the left renal vein.

Gland freed along lateral and superior borders with harmonic scalpel, leaving fat on the gland for grasping. Minimal handling of the tumour. BP rose to 190/110 mmHg twice during handling, controlled by anaesthetist.

Adrenal vein dissected last and divided between clips (2 on patient side, 1 on specimen side) at 10:40. BP fell to 88/52 mmHg, corrected by anaesthetist with fluids and vasopressor.

Remaining inferior attachments divided. Upper pole of kidney pink. Specimen placed in a retrieval bag and removed through port 2 with slight widening. Bag intact.

Adrenal bed dry. Irrigated. No accessory adrenal tissue seen. Spleen and pancreas not injured.

Closure

No drain. Pneumoperitoneum released under vision.

Fascia at 10 mm port sites closed with polyglactin 910 (Vicryl) No. 0. Skin with subcuticular poliglecaprone (Monocryl) 4-0. Sterile dressings.

Specimens and implants

Left adrenal gland with 4.5 cm tumour, capsule intact, sent for HPE in formalin. Three titanium clips on adrenal vein. No other implants.

End of procedure

Estimated blood loss 80 ml. No transfusion.

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

No surgical complications. Haemodynamic swings as above, managed by anaesthetist.

Extubated in OT. Shifted to surgical ICU. BP 112/70 mmHg on low-dose vasopressor, pulse 92/min.

Post-op orders

BP and pulse monitoring in surgical ICU. Vasopressor to be weaned by ICU team. Inform if BP is outside the limits written by the ICU team.

Capillary blood sugar monitoring as per ICU protocol.

IV RL as charted. Hourly urine output.

Inj paracetamol 1 g IV 8-hourly.

Sips after 6 hours, liquids on POD 1 if no nausea. Walk on POD 1.

Alpha-blocker stopped. Plasma metanephrines as advised by endocrinology at follow-up.

Signature

Dr A., JR-3, General Surgery, for Dr C. Reg. no. ________. 26/11/2026, 11:40.

Must document for this operation

  • Biochemical diagnosis and, for pheochromocytoma, the pre-operative blockade. Operating on a pheochromocytoma without blockade is a known cause of death, and the note shows it was done.
  • Time the adrenal vein was divided and the BP change that followed. The ICU team needs this to understand the vasopressor need after surgery.
  • Method of adrenal vein control (clips, stapler, ligature). Late bleeding and later imaging are interpreted against this.
  • Tumour capsule intact or breached, and whether the bag was intact. Capsule rupture changes the risk of recurrence, especially if histology shows cancer.
  • Colour of the upper pole of the kidney after vein control (left side). It shows the upper pole renal vessels were not injured.
  • Conversion to open and the reason, if it happened. Conversion is audited and must be explained to the patient.

Common mistakes in these notes

  • Not recording blood pressure swings and the time of adrenal vein division.
  • Writing 'adrenal removed' without side, size or capsule status.
  • No post-op blood sugar or steroid plan.
  • Naming only one anaesthetist when two were present.
  • Not stating why a drain was or was not placed.

Indian practice and paperwork

  • Name every anaesthetist in the note. A hospital was held negligent where the operation note did not name the anaesthetist though two gave anaesthesia. (Thomas J. Indian J Urol 2009;25(3):384-8)
  • If the laparoscopic operation is converted to open, the consent should have named conversion. An unconsented extra procedure is defensible only when needed to save life or health. (Samira Kohli v. Dr Prabha Manchanda, (2008) 2 SCC 1)
  • The operative note must be written before the patient leaves recovery, and post-op care must follow a written plan. (NABH 5th ed., COP.14(e) and (f))

Sources

  • Scott-Conner CEH, Dawson DL. Scott-Conner & Dawson: Essential Operative Techniques and Anatomy. 4th ed. Wolters Kluwer; 2014, Ch 105, Adrenalectomy; Ch 106, Laparoscopic Adrenalectomy (Carr JC, Howe JR), pp. 557-572.
  • Bratzler DW, et al. ASHP/IDSA/SIS/SHEA Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm 2013;70:195-283. No adrenalectomy row in Table 2. Common principles: for most procedures cefazolin is the drug of choice. Table 1: cefazolin 2 g. Table 2 footnote a: within 60 minutes before incision. www.ashp.org/-/media/assets/policy-guidelines/docs/therapeutic-guidelines/therapeutic-guidelines-antimicrobial-prophylaxis-surgery.pdf
  • OFIRMEV (acetaminophen injection) US prescribing information, 2010. Adults 50 kg and over: 1000 mg every 6 hours, maximum 4000 mg per day, minimum interval 4 hours. www.accessdata.fda.gov/drugsatfda_docs/label/2010/022450lbl.pdf
  • Lenders JWM, et al. Pheochromocytoma and paraganglioma: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2014;99:1915-42. Preoperative blockade for all functional tumours; recommendation 4.3: monitor blood pressure, heart rate and blood glucose in the immediate postoperative period. academic.oup.com/jcem/article/99/6/1915/2537399
  • Nieman LK, et al. Treatment of Cushing's syndrome: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2015;100:2807-31. Recommendation 5.1: hypocortisolaemic patients receive glucocorticoid replacement and education about adrenal insufficiency after surgical remission. pmc.ncbi.nlm.nih.gov/articles/PMC4525003/

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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