OT notes · Urology

Nephrectomy (simple and emergency / trauma)

Usual anaesthesia
General
Position
Flank (lateral decubitus) with table flexed for simple nephrectomy; supine for trauma laparotomy
Setting
emergency

Operative note template for open simple nephrectomy (flank or anterior) and emergency trauma nephrectomy, with a filled example for a trauma nephrectomy through a midline laparotomy in a haemodynamically unstable patient.

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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 needing blood transfusion
  • injury to bowel, spleen, liver, pancreas or duodenum
  • injury to the pleura (flank approach) and chest drain
  • injury to the large blood vessels (aorta, vena cava)
  • wound infection, hernia or flank bulge
  • numbness of the flank from nerve injury
  • reduced kidney function and need for long-term follow-up of blood pressure and creatinine
  • in trauma: the kidney may have to be removed even if repair was planned

Pre-operative details for this operation

  1. TypeElective simple nephrectomyEmergency trauma nephrectomy
  2. Indication (simple)Non-functioning kidney: obstructionNon-functioning kidney: infection / stonesReflux / dysplasia / polycysticPain, bleeding or renovascular hypertensionstate the function test result (split function) if done
  3. Indication (trauma)Haemodynamic instability not responding to resuscitationFailed or unavailable angioembolisationExpanding / pulsatile retroperitoneal haematoma at laparotomywrite the BP, pulse, fluids and blood given before OT
  4. ImagingCT / MRI findings, side, injury pattern, active extravasation, renal vessels
  5. Opposite kidneyFunctioning on CTFunctioning on one-shot IVP in OTPalpated at surgeryNot confirmed (state why)
  6. Hb, creatinine, blood grouped and cross-matchedunits reserved and units already given
  7. Consent for nephrectomyin trauma: whether consent was from patient or relative, or surgery done as life-saving without it

Anaesthesia and position

  1. AnaesthesiaGeneral endotracheal
  2. PositionFlank: 12th rib over kidney rest, table flexedSupine (anterior / trauma)axillary roll, pressure points padded
  3. Urinary cathetersize; urine colour at start
  4. Lines and bloodlarge-bore access, arterial line, blood in OT

Operative findings

  1. Retroperitoneal haematoma (trauma)NoneStableExpanding / pulsatile
  2. Kidneysize, appearance; injury: lacerations, poles, collecting system, hilum; or hydronephrotic / scarred / pyonephrotic
  3. Renal vesselsnumber of arteries and veins, any vessel injury
  4. Perinephric tissueNormal planesAdherent / inflamedPus
  5. Other organs (trauma survey)liver, spleen, bowel, pancreas, duodenum, diaphragm; injuries found and what was done
  6. Pleura (flank approach)IntactOpened, how managed

Procedure (steps)

  1. IncisionMidline xiphoid to pubis (trauma)Subcostal flankSupracostal (11th / 12th rib)Transcostal (11th rib)Anterior subcostal
  2. Abdominal survey and packing (trauma)injuries found, order of control
  3. Early hilar controlVia posterior peritoneum over aorta (medial approach)Lateral approach after colon mobilisedManual / clamp control of whole hilumvessel loops on artery and vein before opening the haematoma
  4. Colon mobilisedwhite line of Toldt incised; Kocher manoeuvre on the right
  5. Gerota's fascia opened / haematoma evacuatedor dissection outside Gerota's fascia
  6. Kidney mobilisedposterior, lower pole, upper pole; adrenal spared or removed; psoas fascia taken if adherent
  7. Hydronephrotic kidney decompressedNot neededPelvis aspirated
  8. Opposite kidney function confirmed before removal (trauma)how
  9. Renal artery ligated and dividednumber of arteries, ties and suture ligature (e.g. 0 silk tie + 3-0 polypropylene suture ligature), or pedicle clamp technique
  10. Renal vein ligated and dividedgonadal, adrenal and lumbar branches (left) ligated
  11. Ureter ligated and dividedlevel, tie used
  12. Kidney removed, haemostasis checkedrenal fossa, stumps, lumbar veins, adrenal bed

Closure, drains and dressing

  1. DrainTube drain in renal fossa through separate stabNonetype and size
  2. Muscle / fascialayers, suture material; table unflexed before tying (flank); intercostal bundle avoided
  3. Midline closure (trauma)Mass closure, single layerTemporary abdominal closure (damage control)suture used
  4. SkinStaplesInterruptedSubcuticular
  5. Chest drain (if pleura opened)Not neededPlaced, size

Specimens and implants

  1. Kidney for HPESent in formalinNot sent (reason)side labelled
  2. Pus / tissue for cultureNot applicableSent
  3. Haemostatic agents / clips left inNoneNamed

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. Monitoringpulse, BP and hourly urine output; ICU or HDU if trauma
  2. Hb and creatininewhen; the remaining kidney now does all the work
  3. Drainoutput each shift; check drain creatinine if output is high; remove when low
  4. Blood and fluidstransfusion trigger and fluids as ordered
  5. Chestlook for pleural effusion after a flank approach; chest drain care if placed
  6. Analgesiaepidural, block or IV drugs as ordered
  7. Oral intake and mobilisationas bowel function returns
  8. Avoid nephrotoxic drugsno long-term NSAIDs; the remaining kidney now does all the work
  9. Follow-upHPE report; blood pressure and renal function in the long term

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. V.R., 26 years, motorcycle crash with a blow to the left flank. CECT shows a shattered left kidney with active contrast leak and a large perirenal haematoma. Right kidney enhances and excretes normally. BP 78/50 mmHg despite 2 L crystalloid and 2 units of packed red cells. Angioembolisation not available at night.

Case details

Date: 03/06/2026. Emergency exploratory laparotomy and left nephrectomy. Emergency OT.

Decision 23:05. In OT 23:20. Induction 23:25. Skin incision 23:35. Closure completed 01:15.

Surgeon: Dr A. (3rd-year resident, General Surgery). Assistant: Dr B. Consultant urologist Dr C., scrubbed from 23:50.

Anaesthetists: Dr D. and Dr F. Scrub nurse: Sr E.

Indication and pre-op

Indication: ongoing bleeding from left renal injury with shock not responding to fluids and blood. Angioembolisation not available.

Hb 7.2 g/dl on arrival. Creatinine 1.0 mg/dl. Blood group O positive; 2 units given in casualty, 4 more units cross-matched, FFP 2 units ready.

Consent: written consent for laparotomy and possible nephrectomy taken from the patient's father in Telugu, as the patient was drowsy. Risk of losing the kidney explained.

Tetanus toxoid given in casualty. WHO checklist time out done. Inj cefazolin 2 g IV at 23:25.

Anaesthesia and position

General anaesthesia with rapid sequence induction. Two large-bore IV lines and arterial line. Supine. Foley 16 Fr in situ, urine blood-stained.

Parts painted with povidone-iodine from chest to mid-thigh and draped.

Procedure

Midline incision from xiphoid to pubis. About 300 ml of blood in the peritoneal cavity. Four-quadrant packing.

Survey: liver, spleen, stomach, small and large bowel, pancreas and diaphragm normal. Large expanding left retroperitoneal haematoma.

Small bowel moved to the right. Posterior peritoneum opened over the aorta, medial to the inferior mesenteric vein. Left renal vein found crossing the aorta. Left renal artery found behind it. Vessel loops passed around both.

White line of Toldt incised and descending colon mobilised medially. Gerota's fascia opened and about 800 ml of clot removed.

Findings: left kidney shattered into three pieces, lower pole detached, large tear of the renal vein at the hilum. Not repairable. Single renal artery and single renal vein.

Right kidney palpated: normal size and shape, in keeping with the CT.

Left renal artery ligated with 0 silk tie and 3-0 polypropylene (Prolene) suture ligature, and divided. Renal vein then ligated the same way and divided. Gonadal and adrenal veins ligated with 3-0 silk.

Ureter doubly ligated with 2-0 silk and divided at the level of the lower pole. Kidney removed with its fragments.

Renal fossa checked. Adrenal gland intact. Haemostasis secured. Packs removed and abdomen checked again: no other bleeding.

Closure

28 Fr tube drain placed in the left renal fossa through a separate stab in the left flank, fixed with silk 2-0.

Linea alba closed in a single layer with continuous looped No. 1 polydioxanone (PDS). Skin closed with staples.

Specimens and implants

Left kidney sent for HPE in formalin, labelled. No implants. No haemostatic agents left in.

End of procedure

Estimated blood loss 1800 ml (including haemoperitoneum and clot). Transfused 3 units packed red cells and 2 units FFP in OT. Inj cefazolin 2 g IV repeated at 00:40 as blood loss exceeded 1500 ml.

Mop, needle and instrument count correct, confirmed by scrub nurse. WHO sign out done.

No other intra-operative complications.

Shifted to surgical ICU intubated. Pulse 104/min, BP 108/64 mmHg on no vasopressor.

Post-op orders

ICU monitoring: pulse, BP, CVP and urine output hourly.

Hb, creatinine and electrolytes at 6 hours and on POD 1.

Drain output charted every shift.

Nil by mouth till bowel sounds return. IV fluids as per ICU chart.

Analgesia as on drug chart. Avoid NSAIDs (single kidney).

Follow-up: HPE report; blood pressure and creatinine at discharge and at follow-up.

Signature

Dr A., JR-3, General Surgery. Reg. no. ________. 04/06/2026, 01:30.

Must document for this operation

  • Why the kidney was removed rather than repaired or embolised. Many renal injuries are now managed without surgery, so the note must show the instability and the failed or unavailable alternatives.
  • How the function of the opposite kidney was confirmed before removal. Removing a kidney without a working partner leaves the patient with no kidney function, and any review will ask this first.
  • Number of renal arteries and veins, and how each was ligated. Silk ties can slip off a vessel stump and an accessory artery can be missed, so anyone treating bleeding later needs to know what was tied.
  • Other organs seen and injuries found (trauma). Most renal injuries come with other injuries, and anything not recorded as seen may be missed at the next review.
  • Blood loss, all blood products given and all anaesthetists present. These are needed for audit and transfusion records; an Indian consumer court case held an op note deficient for leaving out an anaesthetist's name.
  • Who gave consent and on what basis. In an emergency the patient may not be able to consent, so the note should say whether a relative consented or it was done to save life.
  • State of the pleura after a flank approach. Pleural injury is the main risk of supracostal and transcostal incisions, and the ward team must know whether to look for it.

Common mistakes in these notes

  • Writing 'nephrectomy done' with no side, approach or reason.
  • Leaving out how the opposite kidney was confirmed to work.
  • No record of the number of renal vessels or how they were tied.
  • Not documenting the survey of other organs in a trauma laparotomy.
  • Recording only one anaesthetist when two were present.

Indian practice and paperwork

  • NQAS assessors check that tetanus prophylaxis is given when indicated. Write it in the trauma note. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, ME E15.2)
  • An extra procedure without specific consent is defensible only when it was needed to save life or health and could not wait. Record the basis if nephrectomy was not in the written consent. (Samira Kohli v. Dr Prabha Manchanda, (2008) 2 SCC 1)
  • Name every anaesthetist in the note. A hospital was held negligent when the operation notes left out the anaesthetist's name although two had given anaesthesia. (Thomas J. Indian J Urol 2009;25(3):384-8)
  • NABH expects the operative note to be written before the patient is moved out of recovery or the OT, and post-op care to follow a written plan. (NABH 5th ed., COP.14(e) and (f))

Sources

  • Smith JA Jr, Dmochowski RR, Thomas JC, Preminger GM, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2026, Ch 18, Renal trauma (Johnsen NV), pp. 155-160.
  • Smith JA Jr, Dmochowski RR, Thomas JC, Preminger GM, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2026, Ch 8, Surgical approaches for open renal surgery, including open radical nephrectomy (Sanchez A, O'Neil B), pp. 66-82.
  • Dmochowski RR, Kavoussi LR, Peters CA, eds. Campbell-Walsh-Wein Urology. 13th ed. Vol 3. Elsevier; 2026, Ch 141, Contemporary open surgery of the kidney: approaches, simple nephrectomy, hilar ligation, pp. 2990-3001.
  • Smith JA Jr, Dmochowski RR, Thomas JC, Preminger GM, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2026, Ch 21, Laparoscopic and robotic living donor nephrectomy: postoperative advice to avoid chronic nephrotoxic medicines (NSAIDs) after removal of a kidney, pp. 188.
  • 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 adult (3 g if 120 kg or more), within 60 min before incision, redosing interval 4 h. Redosing also when blood loss exceeds 1500 ml. Table 2, urologic, clean with entry into urinary tract: cefazolin. 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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