OT notes · Thoracic / Trauma

Repair of oesophageal injury / perforation

Usual anaesthesia
General anaesthesia with a double-lumen endotracheal tube for thoracic repair (single-lumen tube first if endoscopy is done after induction)
Position
Lateral decubitus with the operated side up: right lateral (left side up) for a left 7th-space thoracotomy for the distal oesophagus; left lateral (right side up) for a right 5th-space thoracotomy for the high and mid thoracic oesophagus; supine with head turned for the neck
Setting
emergency

Operative note template for operative management of an oesophageal perforation (primary layered repair with buttress, drainage, or exclusion), with a filled example for a distal oesophageal rupture after vomiting repaired through a left thoracotomy.

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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 and a fistula
  • infection of the chest and mediastinum
  • prolonged ventilation and ICU stay
  • need for feeding jejunostomy or gastrostomy
  • removal of the oesophagus (oesophagectomy) or a neck oesophagostomy
  • further operations or drains
  • lung collapse and pneumonia
  • death

Pre-operative details for this operation

  1. CauseAfter vomiting (Boerhaave)Instrumental (endoscopy / dilatation)Penetrating traumaForeign bodyOther
  2. Time since perforationhours from event to surgery; treatment within 12 h is best, repair after 36-48 h is harder
  3. Imagingchest X-ray, CT, water-soluble contrast swallow: site, side of leak, free or contained, pleural spill, distal stricture
  4. TypeFreeContained
  5. Underlying oesophageal diseaseNoneStrictureAchalasiaCancer
  6. ResuscitationIV / central line, fluids, chest drain before surgery (side, output), broad-spectrum antibiotic and antifungal start time
  7. Nasogastric tubenot passed blindly; to be placed under vision

Anaesthesia and position

  1. Anaesthesiageneral; no forceful mask ventilation before intubation; single-lumen tube for endoscopy then double-lumen tube
  2. On-table endoscopyDoneNot donesite, size, underlying disease
  3. ApproachLeft posterolateral thoracotomy, 7th spaceRight posterolateral thoracotomy, 5th spaceLeft neck incisionLaparotomy / transhiataldistal third: left posterolateral 7th space, even if the leak is into the abdomen; high and mid thoracic: right posterolateral 5th space; neck: incision on the side of the leak or on the left
  4. PositionRight lateral (left side up)Left lateral (right side up)Supine, head turned

Operative findings

  1. Pleural cavityvolume and nature of fluid (food, bile, pus), fibrin on lung, lung trapped or expanding
  2. Mediastinuminflammation, necrotic fat, abscess
  3. Perforationlevel (cm above GE junction or in relation to inferior pulmonary vein), side, length of muscle tear and of mucosal tear
  4. Oesophageal wallHealthyOedematousFriable / necrotic
  5. Distal oesophagus and stomachstricture, achalasia, tumour

Procedure (steps)

  1. Intercostal muscle flapHarvested before entering chestNot harvestedpedicle kept intact, wrapped in warm wet sponge
  2. Chest entered, lung collapsed, inferior pulmonary ligament divided
  3. Mediastinal pleura opened, oesophagus mobilisedtaped with Penrose drains above and below the hole; plane on the longitudinal muscle
  4. Perforation identifieddirect view / saline and air test / on-table endoscope
  5. Nasogastric tube passed under vision into stomach
  6. Edges trimmed, muscle split to show full mucosal tearlength of mucosal tear after exposure
  7. RepairTwo layersSingle layer (oedematous tissue)mucosa interrupted absorbable 3-0 / 4-0 (polyglyconate); muscle interrupted non-absorbable 3-0 (silk); single layer interrupted non-absorbable 2-0
  8. ButtressIntercostal muscle flapPleural flapStomach (fundoplication)OmentumNonesutures used
  9. Alternative if repair not possibleNot neededT-tube controlled fistulaCervical oesophagostomy with exclusionResectionnever close a perforation above a stricture on its own (resect, or repair plus myotomy for achalasia); friable tissue or late presentation: drainage with diversion, or a T-tube controlled fistula; one book advises wide drainage with diversion for most Boerhaave cases with heavy contamination and delay
  10. Debridement and decorticationnecrotic tissue and fibrin removed; lung re-expanded
  11. Pleural irrigationvolume
  12. Feeding accessFeeding jejunostomyGastrostomyBothNonein a critically ill patient both gastrostomy and feeding jejunostomy are advised; write tube type, size and site

Closure, drains and dressing

  1. Chest drainsnumber and size; straight tube to apex; right-angled tube on diaphragm near (not touching) the repair
  2. Thoracotomy closuremuscles in layers with heavy absorbable suture; skin
  3. Neck wound (cervical)left open / drain (closed suction or Penrose)

Specimens and implants

  1. Pleural fluidsent for Gram stain, culture and fungal culture
  2. TissueNoneDebrided tissue / resected oesophagus for HPE
  3. Tubes left infeeding jejunostomy / gastrostomy / T-tube: type and size

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. ICU, ventilatedusually 12-24 hours; no forceful mask ventilation if reintubation is needed
  2. Nasogastric tubedo not remove or reposition; flush regularly and keep draining
  3. Nil by mouthuntil contrast study
  4. Feedingjejunostomy feeds from 48 h, or parenteral nutrition if no feeding tube
  5. Antibiotics and antifungalcontinue 7-10 days (14 days if blood culture positive); drugs and doses as per drug chart
  6. Acid suppressionH2-receptor antagonist
  7. Chest drainshourly output; apical drain out when lung expanded and no air leak (about day 2); drain near repair stays till contrast study
  8. Contrast swallowday 8-9 (water-soluble if a leak is suspected); if no leak, remove the angled drain near the repair and start a soft diet

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. N.J., 46 years, sudden severe chest and back pain after forceful vomiting following a heavy meal and alcohol, seen 9 hours later with a left hydropneumothorax; water-soluble contrast swallow shows a free leak from the left side of the distal oesophagus into the left pleura.

Case details

Date: 18/06/2026. Emergency left thoracotomy and primary repair of distal oesophageal perforation with intercostal muscle flap. Main OT.

In OT 21:00. Induction 21:10. Incision 21:45. End 00:20.

Surgeon: Dr A. (3rd-year resident, CVTS). Assistant: Dr B. (1st-year resident). Consultant: Dr C., scrubbed throughout.

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

Indication and pre-op

Free distal oesophageal perforation (Boerhaave), about 11 hours old at incision. No known oesophageal disease.

Pulse 118/min, BP 104/64 mmHg, temperature 38.4 C. TLC 17,800/mm3.

Left 28 Fr chest drain in emergency department at 19:00: 600 ml turbid fluid with food particles.

Broad-spectrum IV antibiotics and IV antifungal started at 19:15 (drug chart). Central line and urinary catheter in place.

Consent: written consent from patient and wife for thoracotomy, repair, feeding jejunostomy, and oesophagostomy or oesophagectomy if repair is not possible. Explained in Hindi.

WHO checklist sign in and time out done.

Anaesthesia and position

General anaesthesia. Rapid sequence induction without mask ventilation. Single-lumen tube first.

On-table endoscopy by Dr C.: 2.5 cm longitudinal tear on the left wall, 3 cm above the GE junction. No stricture, no tumour. Tube changed to left double-lumen tube.

Right lateral position, left side up. Painted with chlorhexidine-alcohol and draped. Existing chest drain site included in the field.

Findings

Left pleura: about 800 ml turbid fluid with food particles. Thick fibrin over the lower lobe and diaphragm. Lung trapped at the base.

Mediastinal pleura over the distal oesophagus torn and inflamed.

Perforation on the left wall of the distal oesophagus, muscle tear 3 cm; mucosal tear 4 cm after exposure. Wall mildly oedematous but holding sutures.

Procedure

Left posterolateral thoracotomy through the 7th intercostal space. Latissimus dorsi divided. Serratus anterior divided as low as possible.

7th intercostal muscle flap raised on its pedicle before entering the chest, wrapped in a warm wet sponge.

Pleura entered. Left lung collapsed. Inferior pulmonary ligament divided and lung packed upwards.

Fluid suctioned and sent for Gram stain, culture and fungal culture.

Mediastinal pleura opened along the oesophagus above and below the hole. Oesophagus mobilised on its muscle coat and taped with Penrose drains above and below.

Nasogastric tube passed by anaesthetist and guided into the stomach under vision.

Muscle layer split upwards and downwards until both ends of the mucosal tear were seen. Edges trimmed.

Mucosa closed with interrupted polyglyconate (Maxon) 3-0. Muscle closed with interrupted silk 3-0.

Intercostal muscle flap laid over the repair and sutured to healthy oesophageal muscle with interrupted silk 3-0.

Fibrin and necrotic tissue removed from the pleura and mediastinum. Lower lobe decorticated and seen to re-expand with ventilation.

Chest irrigated with 3 L warm saline.

After chest closure, patient turned supine. Feeding jejunostomy placed through a 6 cm upper midline incision, 14 Fr tube, about 30 cm from the duodenojejunal flexure, fixed to the abdominal wall.

Closure

Two 36 Fr drains: straight tube to the apex, right-angled tube on the diaphragm with its tip near, but not touching, the repair. Old emergency drain removed.

Chest wall closed in layers with polyglactin 910 (Vicryl) No. 1. Skin with interrupted polyamide (Ethilon) 2-0.

Specimens and implants

Pleural fluid for Gram stain, culture and fungal culture. Debrided fibrin sent for culture.

Tubes: nasogastric tube 16 Fr at 60 cm at the nostril. Feeding jejunostomy 14 Fr.

End of procedure

Estimated blood loss 400 ml. No transfusion.

Instrument, needle and mop count correct at chest closure and again at abdominal closure, confirmed by scrub nurse.

No intra-operative complications.

Pulse 104/min, BP 112/70 mmHg on low-dose noradrenaline. Tube changed to single-lumen. Shifted to CTVS ICU on ventilator.

Post-op orders

Ventilate overnight. If reintubation is needed, no forceful mask ventilation.

Nasogastric tube: do not remove or move. Flush 4-hourly. Free drainage.

Nil by mouth. Jejunostomy feeds from 48 hours.

Continue antibiotics and antifungal as per drug chart for 7 to 10 days, adjust to culture.

H2-receptor antagonist IV.

Chest drains to underwater seal. Hourly output. Chest X-ray in the morning.

Water-soluble contrast swallow on day 8 or 9 before any oral intake.

Signature

Dr A., JR-3, CTVS. Reg. no. ________. 19/06/2026, 00:40.

Must document for this operation

  • Time from perforation to operation. Outcome and the choice of repair depend on it, and it is the first question at any morbidity meeting.
  • Length of the mucosal tear after the muscle was opened, not only the muscle tear. The mucosal tear is often longer, and an incomplete closure is the main cause of leak.
  • Layers, sutures and buttress used. A surgeon dealing with a leak needs to know what was done and what tissue is already used.
  • Underlying disease (stricture, achalasia, cancer) found or excluded. A perforation above a stricture must not be closed on its own, and the note shows this was checked.
  • Position and size of each chest drain, especially the one near the repair. That drain controls any leak and must not be removed before the contrast study.
  • Nasogastric tube size and length at the nostril. It was placed under vision past the repair; a blind re-passage can reopen the hole.

Common mistakes in these notes

  • Writing 'perforation repaired' without its level, side and length.
  • No record of the time from vomiting or instrumentation to surgery.
  • Not stating that the nasogastric tube was placed under vision and must not be moved.
  • Leaving out the pleural decortication and washout.
  • No plan for feeding and for the contrast study.

Indian practice and paperwork

  • Consent must explain the procedure, risks, benefits, alternatives and who will operate, in a language the patient understands. Include oesophagostomy or resection as possible steps. (NABH 5th ed., PRE.4(c))
  • If a further procedure is done without consent, it is defensible only when needed to save life or health and it could not wait. Record the reason. (Samira Kohli v. Dr Prabha Manchanda, (2008) 2 SCC 1)
  • Name every anaesthetist present. A hospital was held negligent when the op note left out an anaesthetist's name. (Thomas J. Indian J Urol 2009;25(3):384-8)
  • The district hospital checklist expects post-op notes to record vitals, pain control, IV fluid type and rate, urine and GI output (nasogastric and drain), other medicines and lab tests. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, OT checklist ME E15.4)

Sources

  • Kaiser LR, Jamieson GG, eds. Rob & Smith's Operative Surgery: Operative Thoracic Surgery. 5th ed. Hodder Arnold; 2006, Ch 41, Perforation of the esophagus (Krishnadasan B, Huber O, Pellegrini C), pp. 425-436.
  • Scott-Conner CEH, ed. Scott-Conner & Dawson: Essential Operative Techniques and Anatomy. 4th ed. Wolters Kluwer; 2014, Ch 56, Management of Esophageal Perforation, pp. 310-313.
  • 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.

Videos of this operation

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