OT notes · General Surgery

Hemithyroidectomy

Usual anaesthesia
General with endotracheal intubation
Position
Supine, neck extended with sandbag or roll between the scapulae, head on a head ring, head end raised (reverse Trendelenburg)
Setting
elective

Operative note template for hemithyroidectomy (lobectomy with isthmus), with a filled example for a right solitary nodule with follicular cytology.

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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

  • change in voice or hoarseness (recurrent laryngeal nerve injury), temporary or permanent
  • loss of high pitch and voice fatigue (external laryngeal nerve injury)
  • bleeding and neck haematoma causing breathing difficulty, may need urgent reopening
  • low calcium (rare after one side, more if completion surgery later)
  • need for thyroxine later (hypothyroidism)
  • completion thyroidectomy if final histology shows cancer
  • scar: thick or keloid
  • wound infection and seroma

Pre-operative details for this operation

  1. Indicationnodule size and side on ultrasound, FNAC category / report, pressure symptoms
  2. SideRightLeft
  3. Thyroid functionT3, T4, TSH values and date; euthyroid or controlled
  4. Pre-op vocal cord checkIndirect laryngoscopy: both cords mobileFibreoptic laryngoscopy: both cords mobileCord palsy present: sidedate and by whom
  5. Serum calciumvalue and date
  6. Blood grouped and cross-matchedgroup, units reserved
  7. Consent for completion thyroidectomy discussedYesNo

Anaesthesia and position

  1. AnaesthesiaGeneral with endotracheal tubeGeneral with nerve-monitoring (EMG) tube
  2. PositionSupine, sandbag under shoulders, neck extended, head ring, reverse Trendelenburg
  3. Nerve monitoringNot usedIntermittent nerve stimulationEMG endotracheal tube

Operative findings

  1. Lobe operatedsize, nodule size and site (upper / mid / lower pole), consistency, capsule breach or not
  2. Opposite lobeNormal to palpationNodular
  3. Recurrent laryngeal nerveidentified or not, where, relation to inferior thyroid artery, branching, stimulated (if monitor)
  4. Parathyroidssuperior and inferior on operated side: seen and preserved / autotransplanted / not seen
  5. External laryngeal nerveSeen and preservedNot seen, superior pole vessels ligated close to gland
  6. Pyramidal lobe, lymph nodes, retrosternal extensionpresent / absent
  7. Strap muscle invasionNonePresent: straps excised en bloc

Procedure (steps)

  1. Skin incisiontransverse collar incision in a skin crease, about 1 cm below cricoid / 2 to 3 cm above sternal notch; length
  2. Subplatysmal flaps raisedup to thyroid cartilage, down to sternal notch; anterior jugular veins preserved or ligated
  3. Midline raphe opened, strap muscles retractedStraps retractedStraps divided high (reason)
  4. Middle thyroid vein(s) ligated and dividednumber of veins, ties used
  5. Superior pole vesselsligated individually close to the gland; ties / clips / energy device named
  6. Inferior pole vessels ligatedclose to gland, medial to lateral
  7. Recurrent laryngeal nerve identified and tracedto its entry into the larynx at ligament of Berry
  8. Parathyroid glands preservedon their blood supply; any autotransplant: site, marked with non-absorbable stitch / clip
  9. Inferior thyroid artery branchesdivided on the capsule, after the nerve is seen
  10. Ligament of Berry divided, lobe freed from trachea
  11. Isthmus divided at junction with opposite lobeclamp and suture ligate / oversew with absorbable / energy device
  12. Haemostasischecked again after removing the sandbag; bipolar / ties

Closure, drains and dressing

  1. DrainNoneSuction drain under straps, through separate stabsize
  2. Strap musclesabsorbable, interrupted or continuous
  3. Platysmainterrupted absorbable
  4. SkinSubcuticular absorbableSkin clipsInterrupted
  5. DressingLight dressingSkin strips / gluePressure dressing
  6. Vocal cords seen at extubationBoth movingNot checked

Specimens and implants

  1. Lobe with isthmus for HPEside, orientation stitch (e.g. on upper pole), weight if taken
  2. Frozen sectionSent: resultNot sent
  3. Parathyroid fragment for frozen section (if autotransplanted)SentNot applicable

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. Positionhead end up 30 degrees
  2. Watch for neck haematomaneck swelling, stridor, breathlessness, fall in SpO2; inform surgeon at once
  3. Stitch cutter / clip remover at bedsideto open the wound at the bedside if a tension haematoma forms
  4. Voicenote voice change and cough; ENT review if hoarse
  5. Drain (if placed)record output; usually removed in 24 to 48 h
  6. Oral intakeliquids when awake and swallowing well
  7. Analgesiadrug, dose, frequency
  8. Discharge and follow-upHPE review; completion thyroidectomy if malignant; TFT at follow-up

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: Mrs. S.K., 38 years, with a 3 cm solitary nodule in the right lobe of the thyroid, euthyroid, FNAC reported as follicular neoplasm, posted for right hemithyroidectomy.

Case details

Date: 15/05/2026. Elective. OT 3.

In OT 10:05. Induction 10:15. Skin incision 10:35. Closure completed 11:50.

Surgeon: Dr A. (3rd-year resident, General Surgery). Assistant: Dr B. (2nd-year resident). Consultant: Dr C., present and scrubbed for nerve dissection.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: solitary nodule right lobe, 3.1 x 2.4 cm on ultrasound, FNAC follicular neoplasm. No pressure symptoms.

T3, T4, TSH normal (TSH 2.1 mIU/l on 02/05/2026). Serum calcium 9.4 mg/dl.

Indirect laryngoscopy on 06/05/2026 by ENT: both vocal cords mobile.

Blood group O positive, 1 unit reserved.

Consent: general, procedure-specific and anaesthesia consent taken in Hindi from the patient, husband as witness. Voice change, haematoma, low calcium and possible completion thyroidectomy explained.

WHO checklist sign in and time out done. Side confirmed as right. No antibiotic prophylaxis (clean neck surgery, as per unit policy).

Anaesthesia and position

General anaesthesia with endotracheal tube. No nerve monitor.

Supine, sandbag under the shoulders, neck extended, head on a ring, 15 degrees head up. Parts painted with povidone-iodine and draped.

Findings

Right lobe enlarged with a 3 x 2.5 cm firm, well-capsulated nodule in the lower and mid pole. No capsular breach. No strap muscle involvement.

Left lobe normal to palpation. No pyramidal lobe. No enlarged central nodes.

Right recurrent laryngeal nerve found in the tracheo-oesophageal groove below the inferior thyroid artery, passing deep to the artery, single trunk, traced to its entry at the ligament of Berry. Preserved.

Right superior and inferior parathyroids seen, pink-brown, preserved on their pedicles. No autotransplant.

Procedure

Transverse collar incision of 6 cm in a skin crease, 1 cm below the cricoid.

Subplatysmal flaps raised up to the thyroid cartilage and down to the sternal notch. Anterior jugular veins preserved.

Midline raphe opened from the sternal notch to the thyroid cartilage. Right sternohyoid and sternothyroid retracted laterally. Straps not divided.

Right middle thyroid vein ligated with 4-0 absorbable ties and divided.

Superior pole vessels skeletonised and ligated individually close to the gland with fine ties, then divided. External laryngeal nerve not seen.

Inferior thyroid veins ligated close to the gland.

Right recurrent laryngeal nerve identified and traced up to the larynx as above.

Branches of the inferior thyroid artery ligated on the thyroid capsule, distal to the parathyroid branches.

Ligament of Berry divided sharply after seeing the nerve. Lobe lifted off the trachea.

Isthmus clamped at its junction with the left lobe and divided. Cut edge of the left side under-run with continuous polyglactin 910 (Vicryl) 3-0.

Sandbag removed and haemostasis checked again with bipolar cautery. Field dry.

Closure

No drain.

Strap muscles approximated in the midline with interrupted Vicryl 3-0. Platysma with interrupted Vicryl 3-0. Skin with subcuticular poliglecaprone 25 (Monocryl) 3-0.

Light gauze dressing.

Vocal cords seen by the anaesthetist at extubation: both moving.

Specimens and implants

Right lobe with isthmus, long stitch on the upper pole, sent for HPE.

No frozen section. No implants.

End of procedure

Estimated blood loss 50 ml. No transfusion.

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

No intra-operative complications.

Extubated, clear voice, no stridor. Shifted to recovery. Pulse 84/min, BP 126/80 mmHg, SpO2 98% on room air.

Post-op orders

Head end up 30 degrees.

Pulse, BP, SpO2 and neck check every 30 min for the first 6 hours, then 4-hourly. Look for neck swelling, stridor or breathlessness and call the surgeon at once.

Stitch cutter kept at the bedside.

Oral liquids once fully awake and swallowing well, then soft diet.

Tab paracetamol as per drug chart.

Note voice at each review.

Planned discharge on POD 1. Review with HPE report in the surgery OPD.

Signature

Dr A., JR-3, General Surgery. Reg. no. ________. 15/05/2026, 12:05.

Must document for this operation

  • Recurrent laryngeal nerve: seen or not, where, and whether it was intact at the end. If the voice changes, the note decides whether the injury is a known risk or a lapse, and the surgeon doing a completion operation needs to know the nerve course.
  • Parathyroids seen and preserved, or autotransplanted with the site. The surgeon planning a completion thyroidectomy on the other side must know how many glands remain alive on this side.
  • Pre-op and extubation vocal cord status. A palsy that existed before surgery must be on record, or it will be blamed on the operation.
  • Side operated and what was removed (lobe plus isthmus, pyramidal lobe). Completion surgery and radioiodine planning depend on what thyroid tissue was left behind.
  • Drain or no drain, and closure layers. Ward staff opening the wound for a tension haematoma need to know there are strap and platysma layers to open.
  • Orientation stitch on the specimen. The pathologist can report which pole the tumour and capsular invasion are in only if the specimen is oriented.

Common mistakes in these notes

  • Writing 'RLN preserved' when it was never actually seen.
  • Not recording the pre-op indirect laryngoscopy (IL) result.
  • Leaving out whether parathyroids were seen on the operated side.
  • Not writing that a stitch cutter is kept at the bedside in the post-op orders.
  • Sending the lobe with no orientation mark.

Indian practice and paperwork

  • 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)
  • In NQAS-assessed public hospitals, the OT checkpoint 'Operative Notes are Recorded' looks for the people present, pre- and post-op diagnosis, procedure, length of procedure, estimated blood loss, fluids given, specimen removed and complications. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, ME E8.4)

Sources

  • Moran B, Mittal R, Lord A, eds. Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press; 2026, Ch 23, Surgery of the neck: thyroid and parathyroid surgery, hemithyroidectomy, post-op complications, pp. 521-527.
  • Scott-Conner CEH, Dawson DL. Essential Operative Techniques and Anatomy. 4th ed. Wolters Kluwer; 2014, Ch 6, Thyroid lobectomy (Bhama AR, Lal G), pp. 34-44.
  • Sriram Bhat M. SRB's Surgical Operations: Text and Atlas. Jaypee; 2014, Ch 15, Surgery for thyroid and parathyroid, pp. 446-459.
  • Shifrin A, ed. Atlas of Thyroid Surgery. Springer; 2022, Ch 5, Total thyroidectomy (Shah US, Nicholson KJ, Carty SE): lobectomy steps and post-op monitoring, pp. 53-63.
  • Bratzler DW, et al. ASHP/IDSA/SIS/SHEA Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm 2013. Head and neck procedures: prophylaxis not recommended for clean procedures such as thyroidectomy. 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.

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