OT notes · General Surgery

Exploratory laparotomy for perforation peritonitis (omental patch repair)

Usual anaesthesia
General anaesthesia with endotracheal intubation (rapid sequence), with or without epidural
Position
Supine
Setting
emergency

Operative note template for emergency exploratory laparotomy for perforation peritonitis with omental patch repair, with a filled example for a perforated duodenal ulcer.

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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

  • leak from the repair or re-perforation
  • collection or abscess in the abdomen (subphrenic, pelvic), needing drainage
  • wound infection and wound left open for delayed closure
  • burst abdomen and later incisional hernia
  • duodenal fistula or narrowing of the duodenum
  • need for a bigger operation (gastrectomy, drainage procedure) depending on findings
  • ventilator support and ICU stay
  • risk to life from sepsis

Pre-operative details for this operation

  1. Duration of symptoms before surgeryhours from onset of pain to incision
  2. Imagingerect chest / abdomen X-ray (free gas under diaphragm), USG, CT if done
  3. Resuscitation doneIV fluids given, NG tube, urinary catheter with urine output, CVP line if placed
  4. Blood resultsHb, TLC, urea, creatinine, sodium, potassium, lactate or ABG if done
  5. Risk factorsNSAID or steroid use, alcohol, smoking, previous ulcer disease, comorbidities, ASA grade
  6. Antibiotic starteddrug, dose, time
  7. High-risk consentTaken, including possible ICU stay and risk to lifeNot applicable

Anaesthesia and position

  1. AnaesthesiaGA with rapid sequence intubationGA with epidural
  2. PositionSupine
  3. Lines and tubesNG tube, Foley catheter, central line, arterial line

Operative findings

  1. Peritoneal fluidvolume in ml, type (bilious, purulent, faeculent, food particles), distribution (general / localised)
  2. Site of perforationFirst part of duodenum, anteriorPylorusStomach (site)Other (ileum, appendix, colon)
  3. Size of perforation and state of edgesin mm or cm; oedematous, friable, indurated
  4. Fibrin flakes, adhesions, sealed by omentum or liverdescribe
  5. Rest of the abdomenstomach, small bowel, colon, appendix, liver, gall bladder, pelvis: normal / abnormal
  6. Collectionssubphrenic, subhepatic, pelvic, interloop

Procedure (steps)

  1. IncisionUpper midlineMidline extended below umbilicusRight paramedianlength
  2. Peritoneal fluid sampleSent for culture and sensitivityNot sent (reason)
  3. Fluid sucked out, systematic explorationall four quadrants, subphrenic spaces, pelvis
  4. Perforation exposedliver lifted, stomach drawn down, omentum or liver seal gently separated
  5. Omental patch repairModified Graham: edges closed, then omental patch overTrue Graham: omental patch alone, edges not approximatedPrimary closure only
  6. Sutures for repairnumber, material and size, e.g. 3 interrupted silk 2-0 or polyglactin 910 (Vicryl) 3-0; bites along the long axis, not catching the back wall
  7. Omental pediclefree, well-vascularised tongue; ligated to gain length if needed
  8. Leak testAir through NG tube under saline: no bubblesNot done
  9. Gastric ulcer only: edge biopsy or excisionNot applicableBiopsies takenUlcer excised
  10. Peritoneal lavagewarm normal saline, volume in litres; subphrenic spaces and pelvis cleaned
  11. Feeding access (if severe peritonitis)NoneNasojejunal tubeFeeding jejunostomy
  12. Final checkhaemostasis, repair intact, no bile leak, mop and instrument count

Closure, drains and dressing

  1. DrainNoneTube drain in right subhepatic spacePelvic drainBothtype, size, exit site
  2. Omentum placed under the incisionYesNot available
  3. Fascia (linea alba)Small bites: continuous 2-0 polydioxanone (PDS), 5 mm apart, 5-9 mm from edgeMass closure: continuous looped No. 1 monofilament absorbable (PDS)Smead-JonesRetention sutures addedsuture-to-wound length ratio if measured
  4. SkinLeft open and packed for delayed closureVacuum dressingClosed with interrupted suturesSubcuticular

Specimens and implants

  1. Peritoneal fluid for cultureSentNot sent
  2. Ulcer edge biopsy for HPENot applicable (duodenal)Sent (gastric ulcer)

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. Place of careward / HDU / ICU, with vitals, urine output and monitoring frequency
  2. Nil by mouth and NG tubefree drainage and aspiration schedule; removal planned around day 5 or when output falls
  3. IV fluids and electrolytestype and rate; daily electrolytes
  4. Antibioticsdrug, dose, route; review with peritoneal fluid culture; usually 3 to 5 days if source control is adequate
  5. Acid suppressionIV PPI, then oral PPI for 6 to 12 weeks
  6. H. pylori eradicationtriple therapy for 14 days when taking orally
  7. Draindaily output and nature; removal in about 3 to 5 days
  8. Oral intakestart when bowel sounds return and flatus is passed
  9. Thromboprophylaxis and chest physiotherapystockings, LMWH, incentive spirometry, early mobilisation
  10. Woundpacking plan and date for delayed closure if skin left open
  11. Discharge advice and follow-upavoid NSAIDs and alcohol; upper GI endoscopy after 12 weeks

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.K., 42 years, smoker, taking over-the-counter painkillers for back pain, sudden severe epigastric pain 18 hours before admission, board-like rigidity, free gas under both domes of diaphragm on erect chest X-ray.

Case details

Date: 14/10/2026. Emergency. Emergency OT.

Admitted 01:30. Decision for surgery 03:15. In OT 04:40. Induction 04:50. Incision 05:05. Closure completed 06:25.

Surgeon: Dr A. (3rd-year resident, General Surgery). Assistant: Dr B. (1st-year resident). Consultant: Dr C., informed, present from 05:20.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: generalised peritonitis with pneumoperitoneum, probable perforated peptic ulcer. Pain duration about 21 hours at incision.

On arrival: pulse 118/min, BP 96/60 mmHg, temperature 38.2 degrees C. After 2 L RL: pulse 102/min, BP 112/70 mmHg.

Hb 14.2 g/dl, TLC 17,800/cumm, urea 58 mg/dl, creatinine 1.4 mg/dl, sodium 136, potassium 3.6 mmol/l.

NG tube 16 Fr: 400 ml bilious aspirate. Foley catheter: 30 ml/h urine after fluids.

Inj ceftriaxone 2 g IV and inj metronidazole 500 mg IV given at 02:10. Inj pantoprazole IV given.

Consent: general, procedure-specific, high-risk and anaesthesia consent taken in Hindi from patient, wife as witness. ICU stay, leak, wound left open and risk to life explained.

WHO checklist sign in and time out done.

Anaesthesia and position

GA with rapid sequence intubation. Supine. Parts painted with chlorhexidine-alcohol and draped.

Findings

About 1.5 L of bile-stained fluid with food particles in all four quadrants, subphrenic spaces and pelvis. Fibrin flakes over the stomach, liver and small bowel.

Perforation 6 mm on the anterior wall of the first part of the duodenum, 1 cm distal to the pylorus. Edges oedematous and friable. Partly sealed by the undersurface of the liver.

Stomach, rest of the duodenum, small bowel, appendix, colon, gall bladder and liver normal apart from fibrin. No other perforation.

Procedure

Upper midline incision of 15 cm. Peritoneum opened. Fluid sample taken for culture and sensitivity.

Fluid sucked out. Systematic exploration of all quadrants done.

Liver lifted with a retractor, stomach drawn down with a moist mop. Liver seal gently separated to expose the perforation.

Modified Graham patch repair: 3 interrupted silk 2-0 sutures placed along the long axis of the duodenum, full thickness, 5 mm from the edges, not catching the back wall. A free tongue of well-vascularised omentum placed over the perforation and the sutures tied over it, sides first, then the middle.

Leak test: saline in upper abdomen, air pushed through the NG tube, no bubbles.

Peritoneal lavage with 6 L warm normal saline, including both subphrenic spaces, paracolic gutters and pelvis. Fluid sucked dry.

Haemostasis checked. Repair intact, no bile leak.

Closure

Tube drain placed in the right subhepatic space, brought out through a separate stab in the right flank and fixed with silk.

Greater omentum laid under the incision.

Linea alba closed with continuous looped polydioxanone (PDS) No. 1, mass closure.

Subcutaneous tissue washed. Skin left open and loosely packed with saline gauze for delayed closure.

Specimens

Peritoneal fluid for culture and sensitivity sent. No tissue specimen (duodenal perforation).

End of procedure

Estimated blood loss 150 ml. No transfusion.

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

No intra-operative complications.

Extubated in OT. Shifted to surgical HDU. Pulse 98/min, BP 118/74 mmHg, SpO2 97% on 4 L oxygen by mask. Urine 40 ml in the last hour.

Post-op orders

HDU care. Pulse, BP, SpO2 and urine output hourly for 12 hours, then 2-hourly.

Nil by mouth. NG tube on free drainage with 4-hourly aspiration.

IV RL and NS alternating as per charted volumes. Electrolytes and creatinine daily.

Inj ceftriaxone 2 g IV once daily and inj metronidazole 500 mg IV 8-hourly. Review with culture report.

Inj pantoprazole IV. Inj paracetamol 1 g IV over 15 min 6-hourly.

Record drain output daily. Incentive spirometry. Stockings. Mobilise from POD 1.

Dressing change of open wound daily. Plan delayed skin closure when the wound is clean.

H. pylori eradication and oral PPI once taking orally.

Signature

Dr A., JR-3, General Surgery. Reg. no. ________. 14/10/2026, 06:40.

Must document for this operation

  • Time from onset of pain to surgery, and the vital signs at decision. Delayed presentation and shock predict death and leak, and the audit looks at delay to theatre.
  • Exact site, size and edge condition of the perforation. This decides whether a patch alone was the right repair and guides the next surgeon if it leaks.
  • Type of repair, suture material, number of sutures and whether a leak test was done. If the patient leaks, the note shows what was done and whether it was checked.
  • Volume and type of peritoneal contamination and the lavage volume. Explains later collections and wound infection and supports the antibiotic plan.
  • That the whole abdomen was explored. Missed pathology is a known cause of complaints and reoperation.
  • Biopsy of a gastric ulcer, or why it was not done. A perforated gastric ulcer can be a cancer, and the follow-up depends on the histology.
  • Fascial closure technique and whether the skin was left open. Needed to explain a burst abdomen or hernia later and to plan wound care.

Common mistakes in these notes

  • Writing 'Graham patch done' without the site and size of the perforation.
  • Not recording the hours from onset of pain to surgery.
  • Leaving out the volume and type of peritoneal fluid and the lavage volume.
  • Not writing that the rest of the bowel was examined.
  • Forgetting to record H. pylori treatment and endoscopy follow-up in the post-op orders.

Indian practice and paperwork

  • The NQAS district hospital OT checklist expects that braided biological sutures are not used in dirty wounds and that catgut is not used to close the fascia of abdominal wounds. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, OT checklist ME E15.3)
  • NQAS expects post-operative notes to record vital signs, pain control, rate and type of IV fluids, urine and GI fluid output, other medicines and lab tests. Write each of these in the post-op orders. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, OT checklist ME E15.4)

Sources

  • Moran B, Mittal R, Lord A, eds. Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press; 2026, Ch 8, Emergency surgery for peptic ulcer; Ch 6, Closing abdominal incisions; Ch 17, Emergency abdominal surgery (peritonitis, lavage), pp. 132-134, 80-81, 356-361.
  • Bhat SM. SRB's Surgical Operations: Text and Atlas. Jaypee; 2014, Ch 20, Surgery of stomach and duodenum: Surgery for duodenal ulcer perforation, pp. 638-642.
  • Scott-Conner CEH, ed. Scott-Conner and Dawson Essential Operative Techniques and Anatomy. 4th ed. Wolters Kluwer; 2014, Ch 44, Exploratory laparotomy; Ch 59, Plication of perforated duodenal ulcer, pp. 224-234, 323-325.
  • 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. Table 1 adult doses (ceftriaxone 2 g, metronidazole 500 mg); established infection is treatment, not prophylaxis. 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 as a 15-minute infusion, maximum 4000 mg per day. www.accessdata.fda.gov/drugsatfda_docs/label/2010/022450lbl.pdf
  • Sartelli M et al. The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines. World J Emerg Surg 2017;12:29. Simple closure with or without omental patch for perforations under 2 cm (1A); third-generation cephalosporin with metronidazole an option for mild infection; 3 to 5 days of antibiotics after adequate source control (1A). doi.org/10.1186/s13017-017-0141-6
  • Ceftriaxone 2 g powder for solution, SmPC section 4.2 (electronic medicines compendium): complicated intra-abdominal infection 1-2 g once daily. www.medicines.org.uk/emc/product/1362/smpc
  • Metronidazole 500 mg/100 ml IV infusion (Baxter), SmPC section 4.2: anaerobic infection 500 mg every 8 hours. www.medicines.org.uk/emc/product/1842/smpc

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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