OT notes · Thoracic / Trauma

Decortication for empyema (open / VATS)

Usual anaesthesia
General anaesthesia with a double-lumen endotracheal tube
Position
Full lateral, operated side up, scapula pulled forward
Setting
elective

Operative note template for decortication of the lung for empyema or fibrothorax by VATS or thoracotomy, with a filled example for a chronic right post-pneumonic empyema with a trapped lung treated by open decortication.

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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

  • conversion from VATS to open thoracotomy
  • bleeding from the raw chest wall and blood transfusion
  • air leak from the lung surface
  • lung may not fully re-expand, leaving a space
  • recurrent empyema and further surgery
  • chest drains for several days
  • wound infection and chronic wound pain
  • prolonged hospital stay

Pre-operative details for this operation

  1. Cause of empyemaPost-pneumonicTuberculousPost-traumatic / clotted haemothoraxPost-operativeMalignant effusion with trapped lung
  2. StageExudativeFibropurulent with loculationsOrganising with thick peel
  3. ImagingCT and ultrasound: side, loculations, peel thickness, lung trapped, rib crowding
  4. Previous drainageintercostal drain / aspiration / fibrinolytic: dates, output, why failed
  5. Microbiologypleural fluid Gram stain, culture, AFB results; current antibiotic and days given
  6. Fitnesslung function, nutrition (albumin), diabetes, Hb
  7. Blood arranged

Anaesthesia and position

  1. Anaesthesiageneral, double-lumen tube, side isolated
  2. Positionfull lateral, operated side up, scapula pulled forward
  3. ApproachVATS (three ports)VATS converted to thoracotomyPosterolateral thoracotomyMuscle-sparing minithoracotomyRib resection and drainage onlyspace entered; reason for conversion

Operative findings

  1. Pleural contentsvolume and nature: thin pus, thick pus, fibrin, clot; smell
  2. Loculationsnumber, site
  3. Parietal peelthickness in mm, soft / firm / calcified
  4. Visceral peelthickness, plane with lung easy / difficult / absent
  5. Lungtrapped lobes, fissures, parenchymal disease, tears
  6. Diaphragm and ribsdiaphragm fixed / mobile, ribs crowded
  7. Re-expansion at endFullPartial (residual space)Poor

Procedure (steps)

  1. Port sites or incisionVATS: port positions; open: space entered, rib resected (which rib, length)
  2. Pus and debris evacuatedsponge holders and wide-bore suction; volume
  3. Samplespus and peel for culture and AFB; peel for HPE if TB or tumour suspected
  4. Parietal peel removedextent; full empyemectomy or cavity opened
  5. Visceral peel strippedblunt dissection with a peanut on a long artery forceps; fissures cleared; if no plane, peel cut crosshatched and lung reinflated firmly
  6. Diaphragm freed
  7. Re-expansion testedlung inflated by anaesthetist under saline; air leaks noted
  8. Air leaks and tearsNoneSmall surface leaks leftSutured (absorbable)Tissue glue
  9. Haemostasis of chest wallcautery, packs; time spent
  10. Irrigationsaline (with antibiotic if used), volume
  11. Residual spaceNoneMuscle flap usedLeft

Closure, drains and dressing

  1. Chest drainsnumber (two or more), sizes, positions (apical, basal), suction
  2. Thoracotomy / port closuremuscle layers with heavy absorbable sutures, skin
  3. Local anaesthetic / intercostal blockif given: drug, volume

Specimens and implants

  1. PusGram stain, culture, AFB smear and AFB culture
  2. PeelHPE and culture
  3. ImplantsNoneTissue glue / sealant (make, batch)

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. Chest drainsgentle suction; record output and air leak 4-hourly; do not clamp
  2. Chest X-rayin recovery and daily: lung expansion, residual space
  3. Physiotherapybreathing exercises and incentive spirometry from waking; sit out on day 1
  4. Antibioticscontinue at least the early post-op period; change as per culture
  5. Analgesiadrug, dose, frequency; adequate for coughing
  6. Bleeding watchdrain blood loss hourly for first 6 hours; Hb next morning
  7. Nutritionhigh-protein diet from the evening if tolerated
  8. Drain removalwhen lung expanded, no air leak and low output

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. H.R., 41 years, right post-pneumonic empyema 5 weeks old, treated with an intercostal drain and IV antibiotics; drain stopped working, persistent fever, CT shows a thick-walled loculated collection with a trapped right lower lobe.

Case details

Date: 14/09/2026. Elective (semi-urgent) right open decortication. CTVS OT.

In OT 09:00. Induction 09:10. Incision 09:40. End 12:30.

Surgeon: Dr A. (2nd-year resident, CTVS). Assistant: Dr B. (1st-year resident). Consultant: Dr C., scrubbed throughout.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Organising right empyema with trapped lower lobe, not drained by intercostal drain. Fever 38.2 C, TLC 14,600/mm3.

Pleural fluid: Gram-positive cocci, culture grew Streptococcus species. AFB smear negative. On IV antibiotics as per culture for 3 weeks.

CT: peel about 5 mm, two loculi posterobasal, right ribs crowded.

Hb 10.4 g/dl, albumin 3.1 g/dl, sugar normal. 2 units cross-matched.

Consent: written consent for VATS or open decortication, rib resection, and the risk of air leak and further surgery. Explained in Kannada.

WHO checklist sign in and time out done. Scheduled IV antibiotic dose given at 09:05.

Anaesthesia and position

General anaesthesia with left double-lumen tube. Left lateral position, right side up, scapula pulled forward. Painted with chlorhexidine-alcohol and draped.

Old drain removed after painting; site excluded from the incision.

Findings

About 450 ml of thick pus and fibrin in two posterobasal loculi.

Parietal peel 5-6 mm, firm. Visceral peel 3-4 mm over the lower and middle lobes, with a workable plane.

Right lower lobe trapped, oblique fissure filled with fibrin. Diaphragm fixed by peel.

No lung abscess, no bronchopleural fistula.

Procedure

Right posterolateral thoracotomy. Ribs crowded, so the posterior 6 cm of the 6th rib was resected and the chest entered through its bed.

Parietal peel lifted off the chest wall before placing the rib spreader.

Pus and fibrin removed with sponge holders and wide-bore suction. Pus sent for Gram stain, culture, AFB smear and AFB culture.

Parietal peel removed over the lateral and posterior chest wall. At the apex and over the diaphragm the cavity was opened and the visceral pleura approached directly.

Visceral peel stripped off the lower and middle lobes with a peanut on a long artery forceps. Oblique fissure cleared. Diaphragm freed.

Lung inflated by the anaesthetist under saline: full re-expansion to the chest wall. Small surface air leaks only; one 1 cm tear in the lower lobe closed with polyglactin 910 (Vicryl) 4-0.

Chest wall ooze controlled with cautery and hot packs for 15 minutes.

Pleura washed with 3 L warm saline. No residual space.

Closure

Three chest drains: 28 Fr apical, 28 Fr basal, 28 Fr along the posterior gutter, through separate stabs, to underwater seal with gentle suction.

Chest wall muscles closed in layers with heavy absorbable figure-of-eight sutures, polyglactin 910 (Vicryl) No. 1. Skin with interrupted polyamide (Ethilon) 2-0.

Specimens and implants

Pus: Gram stain, culture, AFB smear and AFB culture.

Peel: HPE and culture, in two labelled containers.

No implant.

End of procedure

Estimated blood loss 700 ml. 1 unit PRBC transfused in OT.

Instrument, needle and mop count correct, confirmed by scrub nurse.

No intra-operative complications.

Extubated in OT. Pulse 96/min, BP 126/80 mmHg, SpO2 96% on 4 L oxygen. Shifted to CTVS ICU.

Post-op orders

Drains on gentle suction. Hourly blood loss for 6 hours: inform Dr A. if the drains fill with fresh blood.

Record drain output and air leak 4-hourly. Do not clamp.

Chest X-ray in ICU and daily.

Physiotherapy and incentive spirometry from waking. Sit out tomorrow.

Continue IV antibiotics as per chart; review with culture of pus and peel.

Hb in the morning. Oral liquids from 4 hours, high-protein diet from tomorrow.

Signature

Dr A., JR-2, CTVS. Reg. no. ________. 14/09/2026, 12:45.

Must document for this operation

  • Stage of empyema and why drainage alone failed. It justifies a major operation over a tube or VATS clean-out.
  • Whether the lung fully re-expanded at the end. A residual space is the main cause of recurrent empyema and guides post-op imaging.
  • Air leaks and how they were handled. The ward team judges the drains against what was expected at the end of surgery.
  • Samples sent, including AFB tests. Tuberculous empyema changes treatment for months, and results must be chased.
  • Rib resected (which one and length) and drains placed. A later operation or window thoracostomy is planned from this.
  • Reason for conversion if VATS was converted to open. Conversion is a recognised step, and the note shows it was a planned decision, not a complication.

Common mistakes in these notes

  • Writing 'decortication done' without saying whether the lung re-expanded.
  • Not recording the thickness of the peel and the plane found.
  • Sending pus only for routine culture and not for AFB tests.
  • Leaving out drain sizes and positions.
  • Not writing the reason for converting from VATS to open.

Indian practice and paperwork

  • Consent must explain the procedure, risks, benefits, alternatives and who will operate, in a language the patient understands. Include conversion to open and possible rib resection. (NABH 5th ed., PRE.4(c))
  • Resected rib and pleural peel, if not sent for HPE, are human anatomical waste for the yellow bag. Discarded formalin from specimen jars is chemical waste in yellow (f). (Bio-Medical Waste Management Rules 2016, CPCB guidelines)
  • The district hospital checklist expects post-op notes to record vitals, pain control, IV fluid type and rate, drain output, other medicines and lab tests. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, OT checklist ME E15.4)
  • 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))

Sources

  • Kaiser LR, Jamieson GG, eds. Rob & Smith's Operative Surgery: Operative Thoracic Surgery. 5th ed. Hodder Arnold; 2006, Ch 22, Decortication of the lung (Clarke CP); Ch 21, Postpneumonectomy empyema (rib resection and drainage, cultures), pp. 243-248; 215-242.
  • Demetriades D, Inaba K, Velmahos G, eds. Atlas of Surgical Techniques in Trauma. Cambridge University Press; 2015, Ch 14, General principles of chest trauma operations (posterolateral thoracotomy and closure); Ch 3 (chest tube size), pp. 237, 240-241; 39.

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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