OT notes · Urology

Arteriovenous fistula creation for haemodialysis

Usual anaesthesia
Local infiltration; brachial plexus block or general for upper-arm and transposition procedures
Position
Supine, arm abducted on an arm board
Setting
elective

Operative note template for creation of an arteriovenous fistula or graft for haemodialysis, with a filled example for a left radiocephalic fistula done under local anaesthesia.

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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

  • fistula may clot or fail to mature
  • bleeding and haematoma
  • steal syndrome: cold, painful or numb hand, rarely gangrene
  • swelling of the hand from venous hypertension
  • nerve injury (superficial radial, median, cutaneous nerves)
  • wound or graft infection
  • aneurysm or pseudoaneurysm later
  • need for a further access operation or continued use of a dialysis catheter

Pre-operative details for this operation

  1. Side and hand dominancenon-dominant arm first, unless the other arm has clearly better vessels
  2. Vein mapping (Doppler)target vein diameter in mm, continuity, stenosis or thrombosis; 2.5 to 3 mm or more preferred
  3. Artery assessmentpulse, diameter in mm, calcification on Doppler
  4. Allen test (for radial artery fistula)Normal ulnar fillingAbnormal
  5. Previous access and linesprevious fistulas, IV cannulas, central lines (side), current dialysis route
  6. Diabetes / peripheral vascular diseaserisk of calcified arteries and steal
  7. Last dialysis and potassiumdate, serum potassium, Hb
  8. Antiplatelets / anticoagulantsdrug and when last taken

Anaesthesia and position

  1. AnaesthesiaLocal infiltrationBrachial plexus blockGeneralfor local: drug, strength, volume
  2. PositionSupine, arm on arm board
  3. MagnificationLoupesNone

Operative findings

  1. Vein at surgeryname, diameter in mm, wall quality, flushes freely with heparinised saline
  2. Artery at surgeryname, diameter in mm, pulsation, calcification
  3. Thrill and bruit at endThrill palpable, bruit heardPulse only, no thrillAbsentwhere felt (at anastomosis / along the vein up to what level)
  4. Distal circulation at endradial / ulnar pulse, hand colour and capillary filling

Procedure (steps)

  1. Type of accessRadiocephalic (wrist)SnuffboxBrachiocephalicBrachiobasilic with transpositionForearm loop PTFE graftUpper arm PTFE graft
  2. IncisionLongitudinal between artery and veinTransversesite and length
  3. Vein mobilisedlength mobilised, tributaries ligated (suture), flushed with heparinised saline
  4. Artery exposed and controlledlength mobilised, silastic loops / bulldog clamps
  5. Systemic heparindose, time
  6. Arteriotomylength in mm
  7. Anastomosis typeEnd of vein to side of arterySide to sideGraft end to side of artery and vein
  8. Anastomosis suturee.g. polypropylene (Prolene) 6-0 or 7-0, continuous
  9. Clamp release orderproximal then distal; any extra stitches for leak
  10. Graft details (if used)material, diameter, length, tunnel shape and route
  11. Flow checkThrill palpatedDopplerOn-table imaging

Closure, drains and dressing

  1. Haemostasismethod
  2. Subcutaneous tissue and skinlayers, suture material
  3. Dressing

Specimens and implants

  1. PTFE graft (if used)make, diameter, length, lot / serial number, sticker pasted
  2. Diagram of the accessdrawn in the note: artery, vein, anastomosis site and direction of flow

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. Thrill and bruitcheck at regular intervals on the ward; inform surgeon at once if lost
  2. Hand circulationcolour, warmth, pain, numbness, capillary filling (steal)
  3. Woundbleeding or swelling at the site
  4. Protect the access armno IV cannula, blood sampling or injections in this arm
  5. Dialysiscontinue by the existing catheter; do not needle the new fistula until it matures
  6. Hand exerciseisometric hand exercise (ball squeezing) once the wound allows
  7. Patient teachingfeel the thrill daily, report loss of thrill, redness, swelling or a cold hand
  8. Maturation checkreview at about 6 weeks (2 weeks for a graft); Doppler if not maturing

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. R.M., 52 years, diabetic with CKD stage 5, on haemodialysis twice a week through a right internal jugular catheter. Right-handed. Doppler: left cephalic vein 3.1 mm at the wrist, left radial artery 2.4 mm, not calcified.

Case details

Date: 22/07/2026. Elective. Minor OT.

Start 11:05. End 12:10.

Surgeon: Dr A. (2nd-year resident, Urology). Assistant: Dr B. Consultant: Dr C., present. Scrub nurse: Sr D. Anaesthesia monitoring by Dr E. (anaesthetist).

Indication and pre-op

Indication: permanent vascular access for maintenance haemodialysis.

Left (non-dominant) arm. Allen test normal. No cannula in the left arm for 4 weeks.

Last dialysis 21/07/2026. Serum potassium 4.6 mEq/l. Hb 9.8 g/dl. Aspirin continued.

Consent: procedure-specific consent in Telugu, including failure to mature, steal and need for further access.

WHO checklist done. Inj cefazolin 2 g IV at 10:50.

Anaesthesia and position

Supine, left arm on arm board. Parts painted with chlorhexidine-alcohol and draped.

Local infiltration with 0.5% plain lignocaine 20 ml (100 mg; weight 58 kg). Loupes used.

Procedure

4 cm longitudinal incision at the left wrist, 1 cm lateral to the radial artery, proximal to the wrist crease.

Cephalic vein mobilised for 4 cm, 3 mm, good wall, one tributary ligated with silk 4-0. Flushed freely with heparinised saline.

Deep fascia divided. Radial artery exposed and mobilised for 2 cm, 2.5 mm, soft, good pulsation. Controlled with silastic loops and bulldog clamps.

Inj heparin 3000 IU IV at 11:30.

Cephalic vein divided distally, distal end ligated, proximal end spatulated. Arteriotomy 6 mm.

End of vein to side of radial artery anastomosis with continuous polypropylene (Prolene) 6-0. Vein laid without twist or kink.

Proximal clamp released first, then distal. No leak.

Findings at end: good thrill at the anastomosis and along the cephalic vein up to mid-forearm, continuous bruit heard. Radial pulse felt distal to the anastomosis. Hand pink, capillary filling under 2 seconds.

Closure

Haemostasis checked. Wound closed in layers. Dressing applied.

Diagram drawn in the notes: radial artery, cephalic vein, end-to-side anastomosis 2 cm above the wrist crease, flow towards the elbow.

End of procedure

Blood loss about 20 ml. No complications. No specimen. No implant.

Pulse 84/min, BP 146/88 mmHg. Shifted to ward.

Post-op orders

Check thrill and bruit at the wrist and look at the left hand at regular intervals. Inform surgeon at once if the thrill is lost, the hand turns cold or pale, or the wound swells.

No cannula, blood sampling or injection in the left arm.

Continue dialysis through the right IJV catheter as scheduled. Do not needle the fistula.

Isometric hand exercise with a soft ball from the next day.

Patient and wife taught to feel the thrill daily and to report loss of thrill, redness or swelling.

Review in OPD for wound and fistula check; maturation assessment at 6 weeks.

Signature

Dr A., JR-2, Urology. Reg. no. ________. 22/07/2026, 12:25.

Must document for this operation

  • Artery and vein used, their diameters, and the side. The next access surgeon needs to know which vessels are used up and their size, since access is planned from distal to proximal.
  • Anastomosis type and length, and suture used. If the fistula fails, the revision plan depends on whether it was end-to-side or side-to-side and where the anastomosis lies.
  • Thrill and bruit at the end, and how far the thrill is felt along the vein. This is the baseline against which early thrombosis is judged on the ward.
  • Distal pulse and hand circulation at the end. Steal can cause loss of fingers, so the state of the hand at the end of surgery must be on record.
  • A diagram of the access. The dialysis staff and later surgeons use it to know where to needle and where the anastomosis is.
  • Graft make, size and lot number, if a graft was used. Needed for infection audits and any device recall.

Common mistakes in these notes

  • Writing 'AVF done' without naming the artery, vein and side.
  • Not recording vessel diameters, so failure cannot be judged against vessel size.
  • Writing 'thrill present' without saying where, or not recording the bruit.
  • No record of the hand circulation and distal pulse at the end.
  • No heparin dose and time recorded.
  • No written instruction to protect the access arm from cannulas and blood sampling.

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., COP.14(e) and (f))
  • NABH asks that the batch and serial number of an implanted device be written in the record, the OT master logbook and the discharge summary. This applies to a PTFE graft. (NABH 5th ed., MOM.10(d))

Sources

  • Scott-Conner CEH, Dawson DL. Essential Operative Techniques and Anatomy. 4th ed. Wolters Kluwer; 2014, Ch 38, Vascular Access for Hemodialysis (Olmsted CL, Nicholson R), pp. 201-207.
  • Bhat SM. SRB's Surgical Operations: Text and Atlas. Jaypee; 2014, Ch 11, Surgeries in Arterial Diseases: Arteriovenous fistula for haemodialysis, pp. 332-337.
  • Moran B, Mittal R, Lord A, eds. Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press, Ch 4A, Surgery of the skin: local anaesthesia (lidocaine maximum dose); Ch 19, Operative management of vascular disease: arteriovenous access (complications), pp. 43, 396.
  • 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 IV adult (3 g if 120 kg or more), within 60 min before incision. Table 2, vascular: cefazolin. Text: upper-limb arterial procedures without prosthetic graft (e.g. brachial artery repair) do not appear to benefit from routine prophylaxis; prophylaxis is used where prosthetic material is implanted. 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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