OT notes · General Surgery

Circumcision

Usual anaesthesia
Local ring block (1% plain lignocaine) in adults; general anaesthesia with penile block in children
Position
Supine
Setting
elective

Operative note template for circumcision in adults and children, with a filled example for an adult circumcision for phimosis done under local ring block.

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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, mostly from the frenular vessels, and haematoma
  • wound infection
  • too much or too little skin removed
  • chordee (bend) if excess ventral skin is removed
  • meatal stenosis or narrowing near the meatus
  • injury to the glans or urethra
  • difficulty passing urine after surgery
  • change in appearance and sensation

Pre-operative details for this operation

  1. IndicationPhimosisRecurrent balanoposthitisParaphimosis (after reduction or dorsal slit)Balanitis xerotica obliteransRecurrent urinary tract infectionLesion of prepuce (diagnostic)Religious / cultural
  2. Meatus position and penile anomalies checkedNormalHypospadias / epispadias / chordee: circumcision deferredprepuce is needed for later repair in hypospadias
  3. Blood sugar (adults)diabetes is common with balanoposthitis
  4. Bleeding disorder / anticoagulants
  5. Consentfor a child, by parent or guardian; for religious circumcision, reason recorded

Anaesthesia and position

  1. AnaesthesiaLocal ring blockGeneral + penile blockSpinallocal anaesthetic drug, strength, volume; plain, without adrenaline
  2. PositionSupine

Operative findings

  1. PrepuceTight non-retractile ringThickened / inflamedWhite sclerotic scarring (suspected BXO)Lesion present
  2. Preputial adhesions to glansNonePresent, separated
  3. Glans and meatusnormal / inflamed / meatal narrowing / lesion
  4. Smegma or pusNonePresent

Procedure (steps)

  1. Skin preparation and drapingantiseptic
  2. Ring blockdrug, strength, volume, injected around the root of the penis
  3. Adhesions separated, glans cleanedif prepuce retracts
  4. TechniqueDorsal slit then circumferential excisionDouble incision (sleeve)Guillotine / clampDevice (Plastibell, Gomco, Mogen) in infants
  5. Dorsal slitin the dorsal midline up to near the corona
  6. Prepuce excisedouter and inner layers; less skin removed ventrally near the frenulum
  7. Frenular arterytransfixed and ligated; suture material and size
  8. HaemostasisLigaturesCautery
  9. Skin to mucosa approximationinterrupted absorbable sutures; material and size

Closure, drains and dressing

  1. Suturesabsorbable, interrupted; material and size
  2. DressingLight non-adherent dressing
  3. Bleeding at the endDryOozing, pressure applied

Specimens and implants

  1. Prepuce sent for HPEYesNosend if sclerosis (BXO), a lesion, or an adult with chronic balanoposthitis
  2. Device used (infant)type and ring size

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. Check for bleedinglook at the dressing before the patient leaves recovery
  2. Passing urinemust pass urine before discharge
  3. Analgesiadrug, dose, frequency
  4. Antibioticif prescribed: drug, dose, duration
  5. Blood sugarif diabetic
  6. Wound carewhen to remove the dressing, bathing, keep area clean
  7. Return ifbleeding soaking the dressing, swelling, inability to pass urine, fever
  8. Follow-upwound check; HPE report

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., 34 years, 68 kg, with a tight non-retractile prepuce and three episodes of balanoposthitis in the last year. Fasting blood sugar 96 mg/dl. Day-care surgery.

Case details

Date: 18/07/2026. Elective, day care. Minor OT.

In OT 11:00. Ring block 11:08. Incision 11:15. Dressing completed 11:50.

Surgeon: Dr A. (1st-year resident, General Surgery). Assistant: Dr B. (intern). Supervising: Dr C. (senior resident), present.

Scrub nurse: Sr E. No anaesthetist (local anaesthesia).

Indication and pre-op

Indication: phimosis with recurrent balanoposthitis. Meatus normal in position on examination under the prepuce opening. No hypospadias.

No bleeding disorder, not on antiplatelets or anticoagulants. FBS 96 mg/dl, HIV and HBsAg non-reactive.

Consent: general and procedure-specific consent (including bleeding, change in appearance, need for HPE) taken in Hindi from the patient.

WHO checklist sign in and time out done. No antibiotic prophylaxis (clean procedure).

Anaesthesia and position

Supine. Parts painted with povidone-iodine and draped.

Ring block with 1% plain lignocaine 10 ml (100 mg) injected around the root of the penis. No adrenaline.

Procedure

Findings: tight fibrous preputial ring, prepuce thickened. Flimsy adhesions to the glans, separated. Glans and meatus normal. No whitish sclerosis. Some smegma, cleaned.

Prepuce held with two artery forceps. Dorsal slit made in the midline up to near the corona.

Prepuce excised circumferentially along the corona, outer and inner layers together, keeping less skin excised on the ventral side.

Frenular artery transfixed and ligated with chromic catgut 3-0. Small bleeders ligated with chromic catgut 3-0.

Skin edge sutured to the mucosal cuff all round with interrupted chromic catgut 3-0.

Closure

Wound dry at the end. Light non-adherent dressing applied.

Specimens and implants

Prepuce sent for HPE in formalin, labelled (adult with chronic balanoposthitis). No implants.

End of procedure

Estimated blood loss 10 ml. No transfusion.

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

No intra-operative complications.

Patient walked to the day-care ward. Pulse 78/min, BP 122/78 mmHg.

Post-op orders

Check dressing for bleeding at 30 min and before discharge.

Discharge after passing urine and a dry dressing check.

Oral analgesic as charted.

Keep the area clean and dry. Dressing removal as advised at discharge.

Return at once if the dressing soaks with blood, swelling increases, or urine cannot be passed.

Review in surgery OPD on day 7 with the HPE report.

Signature

Dr A., JR-1, General Surgery. Reg. no. ________. 18/07/2026, 12:00.

Must document for this operation

  • Meatus position and absence of hypospadias checked before surgery. Circumcision in hypospadias uses up the skin needed for later repair, so the check must be on record.
  • Local anaesthetic drug, strength, volume and that it was plain. The total dose must stay within the safe limit for body weight (3 mg/kg for plain lidocaine), and the note shows a plain solution was used on an end organ.
  • How the frenular artery was controlled. Most bleeding after circumcision comes from the frenular vessels, and whoever re-explores needs to know what was done.
  • Appearance of the prepuce and whether it went for HPE. BXO and early penile cancer can hide under a phimotic prepuce, and a missed report can delay treatment.
  • Amount of skin removed ventrally. Excess ventral skin removal causes chordee, a common reason for complaints.

Common mistakes in these notes

  • Writing 'circumcision done' with no findings of the glans or meatus.
  • Not recording the local anaesthetic dose or whether it contained adrenaline.
  • Discarding the prepuce without noting why HPE was not sent.
  • No order about passing urine before discharge.
  • For a child, not recording who gave consent.

Sources

  • Bhat SM. SRB's Surgical Operations: Text and Atlas. Jaypee; 2014, Ch 7, Basic Surgical Procedures: Circumcision; Dorsal slit, pp. 144-146.
  • Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press, Ch 27, Paediatric surgery for the general surgeon: Circumcision, pp. 614.
  • Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press, Ch 4A, Surgery of the skin: local anaesthesia (lidocaine maximum dose), pp. 43.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Prophylaxis not routinely indicated for clean procedures without risk factors. 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.

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