OT notes · General Surgery

Cystogastrostomy for pancreatic pseudocyst

Usual anaesthesia
General anaesthesia with endotracheal intubation
Position
Supine
Setting
elective

Operative note template for open transgastric cystogastrostomy for a pancreatic pseudocyst, with a filled example for a symptomatic retrogastric pseudocyst after acute pancreatitis.

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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 from the cyst-gastric opening or into the cyst, possibly needing endoscopy, angiography or re-operation
  • leak from the gastrotomy closure
  • early closure of the opening and return of the cyst
  • infection of the cyst cavity
  • the cyst may prove to be a cystic tumour on histology, needing further surgery
  • a different drainage (cyst-jejunostomy) or external drainage if the stomach is not stuck to the cyst
  • wound infection and incisional hernia

Pre-operative details for this operation

  1. Cause and date of pancreatitis (or trauma)alcohol, gallstones, other; time since the attack in weeks
  2. Symptoms from the cystpain, early satiety, vomiting, obstruction; or enlarging on serial scans
  3. ImagingCT or MRI: size, site (retrogastric / head / tail), wall thickness, solid debris, relation to stomach; MRCP for duct
  4. Neoplasm excludedHistory and imaging typical of pseudocystEUS with cyst fluid analysis done
  5. Splenic / portal vein thrombosis or varicesNonePresent: details
  6. Nutrition, blood sugar, coagulationalbumin, weight loss, diabetes control, INR
  7. Plan for causee.g. cholecystectomy for gallstones: same sitting (consented) or later

Anaesthesia and position

  1. AnaesthesiaGeneral
  2. PositionSupine, arms outSupine, arms tucked
  3. Nasogastric tube and urinary catheterBoth placedNasogastric only
  4. ApproachOpen transgastricOpen extragastric (lesser sac)Laparoscopic transgastricLaparoscopic intragastric

Operative findings

  1. Site and size of the cystretrogastric bulge, estimated size
  2. Adherence of posterior gastric wall to cystFirmly adherentPartly adherentNot adherent: change of plan
  3. Needle aspirateClear / straw fluidTurbid or pusBlood: stop and reassess
  4. Cyst contentsvolume aspirated, necrotic debris present or not
  5. Loculations or second cystNonePresent: opened into main cavitySecond cyst: drained separately
  6. Retroperitoneum after drainageFlat, no residual massResidual mass felt
  7. Gallbladder, liver, other findings

Procedure (steps)

  1. IncisionUpper midlineChevronplaced over the palpable mass
  2. Exploration and confirmation of retrogastric cystPalpationIntra-operative ultrasound
  3. Stay sutures on anterior gastric wallmaterial (2-0 silk), over the cyst, midway between curvatures, away from pylorus
  4. Anterior gastrotomylongitudinal, length (5 to 6 cm), electrocautery, bleeding points secured
  5. Needle aspiration through posterior gastric wallneedle size (18 G), colour of fluid, blood or not; fluid sent for amylase, culture, cytology
  6. CystogramNot doneDone: contrast volume and findings
  7. Entry into cyst through posterior gastric wallcautery or clamp, contents sucked out, debris removed, loculations broken
  8. Opening enlargedfinal size in cm (aim 5 cm or more)
  9. Full-thickness biopsy of gastric wall and cyst wallfrozen section result: fibrous wall, no epithelial lining
  10. Haemostatic suture around the openingrunning locking 2-0 polyglactin 910 (Vicryl), full circumference
  11. Final haemostasis and NG tube positionNG tube lying in stomach
  12. Anterior gastrotomy closedTwo layers, suturedLinear staplersuture material; longitudinal or transverse closure

Closure, drains and dressing

  1. Omentum placed over gastrotomyYesNo
  2. Final checkretroperitoneum flat, haemostasis, no other collection
  3. DrainNoneNear gastrotomy (reason)
  4. Fascia and skinsuture material and technique

Specimens and implants

  1. Cyst wall with posterior gastric wall for HPEfrozen section sent; result
  2. Cyst fluidamylase, culture and sensitivity, cytology (CEA / mucin if neoplasm suspected)
  3. Gallbladder for HPENot applicableSent

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 bleeding watchhaematemesis, blood in NG tube, melaena, falling Hb: inform surgeon at once
  2. Nasogastric tubefree drainage, record output; remove when gastric emptying is adequate
  3. Oral intakewrite the day and what to start after NG removal
  4. Antibioticsprophylaxis only unless cyst was infected; change as per cyst fluid culture
  5. Blood sugarmonitor if diabetic or pancreatic insufficiency
  6. InvestigationsHb on POD 1; serum amylase if clinically indicated
  7. Drain (if placed)send drain fluid amylase and lipase; keep until output stops
  8. Follow upHPE of cyst wall; CT or MRI at 3 months, or earlier if symptoms persist

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.D., 38 years, 11 weeks after alcohol-related acute pancreatitis, with a 12 cm retrogastric pseudocyst causing epigastric pain and early satiety, thick wall and no solid debris on MRI.

Case details

Date: 03/08/2026. Elective open transgastric cystogastrostomy. OT 3.

In OT 09:30. Incision 10:05. Closure completed 11:45.

Surgeon: Dr A. (MS 3rd-year resident), under supervision of Dr B. (consultant, present). Assistant: Dr C. (MS 1st-year resident).

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Acute pancreatitis (alcohol) 11 weeks ago. Now epigastric pain and early satiety for 4 weeks. Cyst grew from 8 to 12 cm on serial CT.

MRI: 12 x 10 cm unilocular retrogastric collection with 5 mm wall, no solid debris, abutting posterior gastric wall. MRCP: no duct cut-off seen. No splenic vein thrombosis.

Hb 12.1 g/dl, INR 1.0, albumin 3.6 g/dl, FBS 102 mg/dl. Abstinent from alcohol for 11 weeks.

Consent: general, procedure-specific (including change to cyst-jejunostomy or external drainage) and anaesthesia consent taken in Hindi from patient, wife present.

Blood group B positive, 1 unit cross-matched. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 09:50.

Anaesthesia and position

General anaesthesia. Ryle's tube and Foley catheter placed.

Supine, arms out. Parts painted with povidone-iodine and draped.

Findings

Large retrogastric bulge in the lesser sac, posterior gastric wall firmly adherent to the cyst.

No ascites. Liver normal. Gallbladder normal, no stones felt.

Needle aspirate: straw-coloured fluid, no blood. About 650 ml of straw-coloured fluid with a small amount of soft debris sucked out of the cyst.

No second cyst. Retroperitoneum flat after drainage.

Procedure

Upper midline incision over the palpable mass. Abdomen explored.

Two stay sutures of silk 2-0 placed on the anterior gastric wall over the cyst, midway between the curvatures, well away from the pylorus.

Longitudinal anterior gastrotomy of 6 cm with cautery. Bleeding points secured.

18 G needle passed through the posterior gastric wall into the cyst. Straw fluid aspirated, no blood. Samples sent for amylase, culture and cytology. Cystogram not done (MRI adequate).

Posterior gastric wall opened into the cyst with cautery. Contents sucked out and soft debris removed. Cavity explored with finger: no loculations.

Opening enlarged to 6 cm.

Full-thickness piece of posterior gastric wall with cyst wall excised for biopsy. Frozen section: fibrous wall with granulation tissue, no epithelial lining.

Running locking polyglactin 910 (Vicryl) 2-0 placed around the full circumference of the opening. Haemostasis complete.

Ryle's tube confirmed lying in the stomach.

Anterior gastrotomy closed longitudinally in two layers: inner continuous Vicryl 3-0, outer interrupted seromuscular silk 3-0.

Closure

Omentum placed over the gastrotomy closure. Final check: retroperitoneum flat, no bleeding.

No drain.

Linea alba closed with running nylon No. 2, knots buried. Skin with staples.

Specimens and implants

Posterior gastric wall with cyst wall in formalin for HPE (frozen section done).

Cyst fluid for amylase, culture and sensitivity, and cytology.

No implant.

End of procedure

Estimated blood loss 150 ml. No transfusion.

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

No intra-operative complications.

Shifted to post-operative ward in stable condition. Pulse 84/min, BP 122/76 mmHg.

Post-op orders

Pulse and BP hourly for 6 hours, then 4-hourly. Watch for blood in Ryle's tube, haematemesis or melaena and inform surgeon at once.

Ryle's tube on free drainage, record output 6-hourly. Nil by mouth.

IV fluids and analgesia as per chart.

Hb on POD 1.

Follow up cyst fluid culture and HPE.

CT abdomen at 3 months, earlier if symptoms return. Counsel on continued abstinence from alcohol.

Signature

Dr A., JR-3, General Surgery. Reg. no. ________. 03/08/2026, 12:05.

Must document for this operation

  • Result of needle aspiration, especially whether blood was found. Blood in the cyst suggests a bleeding splenic artery pseudoaneurysm, which changes the whole plan, and the note must show this was checked.
  • That a full-thickness piece of cyst wall was sent, and the frozen section result. A cystic tumour can look like a pseudocyst, and only histology of the wall shows whether there is an epithelial lining.
  • Size of the cyst-gastric opening. A small opening closes early and the cyst returns, so the next surgeon or endoscopist needs this figure.
  • Haemostatic suture around the opening and the state of haemostasis at the end. Bleeding from the cystogastrostomy is the main early complication, and the note is checked first when it happens.
  • Debris, loculations or a second cyst, and how each was dealt with. Undrained loculations or a second cyst explain early recurrence and guide repeat imaging.
  • Any change from the planned drainage (cyst-jejunostomy, external drain) and the reason. The patient must be told, and the consent must cover it.

Common mistakes in these notes

  • Writing 'cystogastrostomy done' with no size of the opening.
  • Not stating whether the aspirate contained blood.
  • Not sending cyst wall for histopathology (HPE), or not recording the frozen section result.
  • Leaving out whether the posterior gastric wall was adherent to the cyst.
  • No follow-up imaging plan in the post-op orders.

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))
  • If a cholecystectomy or a different drainage is added, the written consent should cover it. A procedure outside the consent is defensible only if it was needed to save life or health and could not wait (Samira Kohli v. Dr Prabha Manchanda, Supreme Court, 2008). ((2008) 2 SCC 1)
  • Discarded formalin from specimen containers is chemical waste in the yellow (f) category. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)

Sources

  • Scott-Conner CEH, ed. Scott-Conner & Dawson: Essential Operative Techniques and Anatomy. 4th ed. Lippincott Williams & Wilkins (Wolters Kluwer); 2014, Ch 86, Internal Drainage of Pancreatic Pseudocysts, pp. 452-457.
  • Mulholland MW (editor-in-chief), Albo D, Dalman RL, Hawn MT, Hughes SJ, Sabel MS, eds. Operative Techniques in Surgery. Wolters Kluwer; 2015, Ch 48, Enteric Drainage of Pancreatic Pseudocysts: Pancreatic Cyst Gastrostomy and Cyst Jejunostomy (Lee KKW), pp. 856-866.
  • Bell RH Jr, Kaufman DB, eds. Northwestern Handbook of Surgical Procedures. Landes Bioscience; 2005, Ch 94, Repair Infrarenal Aortic Aneurysm: Elective (used only for midline fascial closure), pp. 282.
  • 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 (3 g if 120 kg or more). Table 2: gastroduodenal procedures entering the lumen: cefazolin. Start within 60 min before incision; duration under 24 h. www.ashp.org/-/media/assets/policy-guidelines/docs/therapeutic-guidelines/therapeutic-guidelines-antimicrobial-prophylaxis-surgery.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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