OT notes · General Surgery

Feeding gastrostomy (Stamm)

Usual anaesthesia
General; local infiltration in a cachectic or unfit patient
Position
Supine
Setting
elective

Operative note template for an open Stamm feeding gastrostomy, with a filled example for a patient with inoperable carcinoma of the oesophagus who cannot swallow.

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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 of gastric contents into the abdomen (peritonitis)
  • leak around the tube onto the skin and skin excoriation
  • tube blockage or falling out, needing replacement
  • wound infection
  • bleeding from the stomach wall
  • injury to the colon or placing the tube in the wrong organ
  • gastric outlet block if the tube balloon sits near the pylorus
  • chest infection after general anaesthesia in a weak patient

Pre-operative details for this operation

  1. Indicationreason oral feeding is not possible (for example inoperable oesophageal cancer, corrosive stricture) and why PEG was not done
  2. Nutritional statusweight, BMI, serum albumin
  3. Plan for later surgeryis future oesophagectomy or gastric pull-up planned? (affects the site on the stomach)
  4. Previous abdominal surgery / scars
  5. Tube availableMalecot catheterFoley catheterMushroom cathetersize in Fr

Anaesthesia and position

  1. AnaesthesiaGeneralLocal infiltration with sedationLocal infiltrationif LA, drug, strength and total volume
  2. PositionSupine

Operative findings

  1. Stomachsize (small and contracted / normal), wall, any tumour at the cardia
  2. Liver and peritoneummetastases, ascites, nodules (biopsy if taken)
  3. AdhesionsNonePresent, released

Procedure (steps)

  1. Skin preparation and draping
  2. IncisionShort upper midlineLeft upper paramedianRight paramedianLeft transverselength in cm
  3. Stomach identified with certaintythick wall, no taeniae or haustra, vessels on the curvatures; not transverse colon
  4. Site on stomachanterior wall, mid-body, well away from the pylorus, reaches the abdominal wall without tension
  5. Purse-string suturesTwo concentricThree concentricmaterial and size (for example silk 2-0 or polyglycolic acid 2-0), diameter
  6. Tube brought in through separate stab in left upper abdomenthrough middle of left rectus; site
  7. Gastrotomy and tube insertioncautery opening in centre of purse-strings; tube type and size; balloon volume if Foley; position confirmed by saline flush and aspiration
  8. Purse-strings tied, stomach inverted around tube
  9. Stomach fixed to the abdominal wall around the tubenumber of sutures (usually four), material
  10. Omentum placed around the gastrostomyYesNot available

Closure, drains and dressing

  1. Abdominal walllayers, suture material and technique
  2. Skinmaterial
  3. Tube fixation at skinsuture material; mark on tube at skin level (cm)
  4. Tube connected toFree drainage bagSpigotted

Specimens and implants

  1. SpecimensNonePeritoneal / liver nodule biopsy sent for HPE
  2. Feeding tubetype, size (Fr), make, batch number; sticker pasted

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 abdomenpulse, BP, temperature; look for peritonitis signs
  2. Gastrostomy tubefree drainage or spigot; chart output; check skin mark every shift
  3. Start of feedswhen, what (water then feeds), volume and rate, as decided by surgeon and dietician
  4. Flushingflush with water before and after feeds and medicines to prevent blockage
  5. Position during feedshead end raised
  6. Tube-site caredaily cleaning, look for leak and skin excoriation
  7. IV fluids and analgesiatype, rate; drug and dose
  8. Teach caregiverfeeding, flushing, what to do if the tube falls out

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., 61 years, inoperable squamous cell carcinoma of the mid-oesophagus, can swallow only sips of water, weight 42 kg, endoscopic PEG not possible because the scope could not pass the growth; referred for feeding access before chemoradiation.

Case details

Date: 22/07/2026. Elective. OT 1.

In OT 10:00. Induction 10:10. Skin incision 10:25. Closure completed 11:05.

Surgeon: Dr A. (2nd-year resident, General Surgery). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: feeding access. Inoperable mid-oesophageal carcinoma (CECT: T4 with aortic contact), grade IV dysphagia. PEG failed (scope could not cross growth).

Weight 42 kg, BMI 16. Serum albumin 2.8 g/dl. Hb 10.4 g/dl.

No previous abdominal surgery.

Consent: general, procedure-specific and anaesthesia consent taken in Hindi from patient, son present. Tube care, leak and tube falling out explained.

WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 10:12, before incision.

Anaesthesia and position

GA with endotracheal tube. Supine. Parts painted with povidone-iodine and draped.

Procedure

8 cm upper midline incision.

Findings: stomach small and contracted, wall normal. No tumour felt at the cardia. Liver smooth, no nodules. No ascites.

Stomach identified by its thick wall, no taeniae, and the vessels on both curvatures. Transverse colon seen separately below.

Site chosen on the anterior wall of the mid-body, nearer the greater curvature, well away from the pylorus.

Two concentric purse-string sutures of silk 2-0, inner about 1.5 cm across, placed with needles left on.

Separate stab made through the middle of the left rectus at the level of the purse-strings. 20 Fr Malecot catheter drawn into the abdomen through it.

Stomach opened with cautery in the centre of the purse-strings. Malecot tip stretched on a clamp and placed in the stomach. Saline flushed and aspirated freely.

Inner purse-string tied while the assistant pushed the edges in, then outer purse-string tied. Stomach inverted around the tube.

Stomach fixed to the underside of the abdominal wall around the tube exit with four silk 2-0 sutures, using the purse-string tails for two of them. Tube not visible once tied.

Omentum placed around the gastrostomy. Haemostasis checked.

Closure

Linea alba closed with continuous polypropylene (Prolene) No. 1. Skin closed with interrupted polyamide (Ethilon) 2-0.

Malecot fixed to skin with silk 1-0. Mark on tube at skin: 12 cm. Tube on free drainage.

Specimens and implants

No specimen.

20 Fr Malecot catheter, batch number and sticker pasted in the case sheet.

End of procedure

Estimated blood loss 30 ml. No transfusion.

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

No intra-operative complications.

Extubated, shifted to post-operative ward in stable condition. Pulse 92/min, BP 110/70 mmHg.

Post-op orders

Pulse, BP, temperature 2-hourly for 12 hours. Watch for abdominal pain, distension or fever.

Gastrostomy on free drainage for 24 hours. Chart output. Check 12 cm skin mark each shift.

IV RL and DNS as per chart till feeds are established.

Feeds to start on POD 1 after surgeon review, as per dietician plan. Flush tube with 30 ml water before and after each feed and medicine. Head end raised during feeds and for 1 hour after.

Inj paracetamol 600 mg (60 ml of 10 mg/ml) IV 8-hourly: 15 mg/kg for weight 42 kg.

Clean tube site daily. Teach son feeding, flushing and what to do if the tube comes out.

Signature

Dr A., JR-2, General Surgery. Reg. no. ________. 22/07/2026, 11:20.

Must document for this operation

  • Type of gastrostomy (Stamm, Janeway, other). A tube gastrostomy closes when the tube is removed, a mucosa-lined one does not, so the next doctor needs to know which was made.
  • Tube type, size, balloon volume if any, and the skin mark in cm. Nurses use the mark to spot a tube that has moved, and the size is needed for a replacement.
  • That the stomach was fixed to the abdominal wall, and with how many sutures. Without fixation, gastric contents can leak into the abdomen; the note shows this safety step was done.
  • How the stomach was identified and separated from the colon. Placing the tube in the colon is a known error, and the note should show the organ was confirmed.
  • Site on the stomach and distance from the pylorus. A Foley balloon too near the pylorus can block the outlet, and a surgeon planning later gastric surgery needs the site.
  • Findings in the liver and peritoneum. In cancer patients these findings change the stage and treatment plan.

Common mistakes in these notes

  • Writing 'gastrostomy done' with no tube type, size or skin mark.
  • Not writing when and how feeds may start.
  • Leaving out the fixation sutures between stomach and abdominal wall.
  • Not pasting the tube sticker or batch number.
  • No instruction for the ward on what to do if the tube falls out.

Indian practice and paperwork

  • NABH standard MOM.10(d) (5th edition) asks for the batch and serial number of implanted medical devices in the medical record, the master logbook and the discharge summary. Paste the tube sticker in the note. (NABH Hospital Accreditation Standards 5th ed. (April 2020), MOM.10 OE d)
  • 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 gastrostomy output and feed plan as part of this. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, OT checklist ME E15.4)
  • NABH standard COP.14(e) (5th edition) requires the operative note to be written before the patient is transferred out of recovery. (NABH Hospital Accreditation Standards 5th ed. (April 2020), COP.14 OE e)

Sources

  • Scott-Conner CEH, ed. Chassin's Operative Strategy in General Surgery: An Expositive Atlas. 4th ed. Springer; 2014, Ch 36, Gastrostomy (Scott-Conner CEH, Chassin JL), pp. 339-342.
  • Scott-Conner CEH, Dawson DL, eds. Scott-Conner & Dawson Essential Operative Techniques and Anatomy. 4th ed. Wolters Kluwer; 2015, Ch 57, Gastrostomy and Jejunostomy, pp. 314-322.
  • Gvalani AK. Manual of Instruments and Operative Surgery. 2nd ed. CBS Publishers & Distributors, Ch 33 Abdominal Operations, 6. Gastrostomy (Stamm's gastrostomy), pp. 209-211.
  • 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: 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. www.ashp.org/-/media/assets/policy-guidelines/docs/therapeutic-guidelines/therapeutic-guidelines-antimicrobial-prophylaxis-surgery.pdf
  • NHS. How and when to take paracetamol for adults (1 g per dose, at least 4 hours apart, not more than 4 g in 24 hours). www.nhs.uk/medicines/paracetamol-for-adults/how-and-when-to-take-paracetamol-for-adults/
  • Paracetamol 10 mg/ml solution for infusion, SmPC section 4.2 (electronic medicines compendium): adults over 33 kg up to 50 kg, 15 mg/kg per dose, at least 4 hours apart, maximum 60 mg/kg a day and not more than 3 g; over 50 kg with risk factors for liver toxicity (for example chronic malnutrition, dehydration), maximum 3 g a day. www.medicines.org.uk/emc/product/15148/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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