OT notes · General Surgery

Open appendicectomy

Usual anaesthesia
General anaesthesia is preferred. Spinal anaesthesia is also used and is acceptable.
Position
Supine
Setting
emergency

Operative note template for open appendicectomy, with a filled example for an emergency appendicectomy through a gridiron incision for acute appendicitis with a retrocaecal appendix.

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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

  • wound infection and wound left open for delayed closure
  • intra-abdominal or pelvic abscess
  • bleeding from the appendicular artery needing re-operation
  • faecal fistula from the stump or caecum
  • injury to caecum, terminal ileum or ovary and tube
  • extension of the incision or a separate midline laparotomy
  • right hemicolectomy if a caecal or appendiceal tumour is found
  • removal of a normal-looking appendix
  • adhesions and bowel obstruction later
  • incisional hernia

Pre-operative details for this operation

  1. Diagnosis and basisduration of pain, RIF tenderness, WBC count, USG or CT findings (diameter, faecolith, collection)
  2. UrgencyEmergencyInterval (elective)
  3. Palpable massNo massMass felt before inductionMass felt only after induction
  4. Female patient: pregnancy test and ovarian pathology on USGresult of urine pregnancy test, adnexa on scan
  5. BladderVoided before shiftingCatheterised
  6. Nasogastric tubeNot neededPlaced (peritonitis / vomiting)
  7. Consent for extension of incision or laparotomyTakenNot taken

Anaesthesia and position

  1. AnaesthesiaGeneralSpinal
  2. Examination under anaesthesiaRIF palpated after induction: mass or no mass
  3. PositionSupine
  4. Paintingwhole abdomen prepared in case the incision must be extended

Operative findings

  1. Peritoneal fluidNoneSerousTurbidFrank pusBloodBile or bowel contentamount, sent for culture or not
  2. Position of appendixRetrocaecalPelvicPre-ilealPost-ilealSubcaecalSubhepatic
  3. State of appendixGrossly normalInflamedSuppurativeGangrenousPerforatedsite of perforation (tip / body / base), faecolith
  4. Base and caecumhealthy / oedematous / inflamed base, caecal wall
  5. Mass or abscessomentum or bowel wrapped around, abscess cavity and its size
  6. Other organs checkedterminal ileum and Meckel diverticulum, mesenteric nodes, right ovary and tube in females

Procedure (steps)

  1. Skin incisionGridiron (McBurney)Lanz (skin crease)Over the palpable massLower midlinelength in cm
  2. External oblique aponeurosis opened along its fibres
  3. Internal oblique and transversus abdominis split along their fibres
  4. Incision extendedNot neededRutherford Morison (muscle cutting, lateral)Fowler-Weir (rectus sheath opened, medial)reason for extension
  5. Peritoneum openedfluid sent for culture, pus sucked out
  6. Caecum identified and appendix deliveredtaeniae followed to the base, lateral peritoneal attachment divided if retrocaecal
  7. Direction of appendicectomyAntegrade (tip first)Retrograde (base first)
  8. Mesoappendix and appendicular arteryclamped, divided and ligated separately from the base, suture used
  9. Base of appendixLigated onceDouble ligatedTransfixed and ligatedcrushed or not, suture material and size
  10. Appendix dividedstump cleaned, mucosa of stump checked
  11. Stump burialNot buriedPurse-stringZ stitchLembert suturessuture used; do not attempt in oedematous caecum
  12. Search for other disease if appendix normallength of ileum run, Meckel diverticulum, nodes, ovary, tube, colon
  13. Peritoneal toiletsuction, saline wash, pelvis and paracolic gutter checked

Closure, drains and dressing

  1. Peritoneumsuture and technique
  2. Internal oblique and transversusa few loose interrupted sutures
  3. External oblique aponeurosiscontinuous absorbable suture
  4. SkinInterrupted non-absorbableSubcuticular absorbableLeft open for delayed closure (pus)
  5. DrainNoneTube drain into abscess cavityCorrugated drainSubcutaneous drainif abscess: brought out through a separate stab incision

Specimens and implants

  1. Appendix sent for HPEYesNoalways send; mention any mass or tumour seen at the tip or base
  2. Pus or peritoneal fluid for culture and sensitivitySentNot 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. Vitalspulse, BP, temperature; a rising pulse with falling Hb suggests a slipped appendicular artery ligature
  2. Oral intakesips and then liquids once awake and not vomiting; delay if peritonitis or ileus
  3. Nasogastric tubeif placed: free drainage, remove when aspirate is low and bowel sounds return
  4. Antibioticsstop within 24 h for simple appendicitis; full treatment course if gangrenous or perforated
  5. Analgesiadrug, dose, frequency
  6. Drainrecord output daily, colour, remove when output is minimal
  7. Mobilisationout of bed the same evening or next morning
  8. Woundinspect on day 2 to 3 for infection; skin sutures out on day 7
  9. HPE follow-upreview report at the first visit; tumour needs further plan

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. S.K., 22 years, 30 hours of periumbilical pain shifting to the right iliac fossa with fever and vomiting. RIF tenderness and guarding, WBC 14,800/cumm, USG shows a non-compressible appendix of 9 mm with periappendiceal fluid.

Case details

Date: 04/08/2026. Emergency open appendicectomy. OT 3.

In OT 21:40. GA induced 21:50. Skin incision 22:02. Closure completed 22:55.

Surgeon: Dr A. (2nd-year resident, General Surgery). Assistant: Dr B. (1st-year resident). Consultant: Dr C., informed and available.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Diagnosis: acute appendicitis, on clinical features, leucocytosis and USG.

Nil by mouth for 6 hours. Voided urine before shifting. No NG tube.

Consent: general, procedure-specific (including extension of incision, laparotomy and removal of a normal-looking appendix) and anaesthesia consent taken in Marathi from patient, father as witness.

WHO checklist sign in and time out done. Inj cefazolin 2 g IV and inj metronidazole 500 mg IV at 21:52, before skin incision.

Anaesthesia and position

General anaesthesia with endotracheal intubation. Supine. RIF palpated after induction: no mass felt.

Whole abdomen painted with povidone-iodine and draped.

Findings

About 20 ml serous fluid in RIF, sucked out, sample sent for culture.

Appendix retrocaecal, about 8 cm long, turgid and inflamed in the distal half, no pus, no gangrene, no perforation. Faecolith felt in the mid part.

Base healthy. Caecal wall normal.

Terminal ileum inspected near the ileocaecal junction: no enlarged nodes. Full small bowel run not done as the appendix explained the illness.

Procedure

Gridiron incision of 6 cm over McBurney point, perpendicular to the spino-umbilical line.

External oblique aponeurosis opened in the line of its fibres. Internal oblique and transversus abdominis split along their fibres. Peritoneum opened obliquely.

Caecum identified by its taeniae and delivered with a Babcock forceps. Tip bound down behind the caecum; lateral peritoneal attachment of the caecum divided and caecum rotated medially. Appendix then delivered.

Mesoappendix clamped and divided in three bites up to the base. Appendicular artery ligated separately with polyglactin 910 (Vicryl) 2-0.

Base not crushed. Base transfixed with Vicryl 2-0 and a second plain ligature of Vicryl 2-0 placed proximal to it. Appendix divided distal to the ligatures with a No. 15 blade. Stump cleaned with povidone-iodine. Stump not buried.

Stump and mesoappendix checked: no bleeding. RIF and pelvis sucked clean and washed with 500 ml warm normal saline.

Closure

Peritoneum closed with continuous Vicryl 2-0. Internal oblique and transversus apposed with two loose interrupted Vicryl sutures. External oblique aponeurosis closed with continuous Vicryl.

Skin closed with subcuticular Vicryl 3-0. No drain. Dry dressing.

Specimens and implants

Appendix sent for HPE in formalin. Peritoneal fluid sent for culture and sensitivity. No implants.

End of procedure

Estimated blood loss about 30 ml. No transfusion.

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

No intra-operative complications.

Extubated and shifted to post-operative ward in stable condition. Pulse 94/min, BP 124/78 mmHg.

Post-op orders

Pulse, BP, temperature 2-hourly for 12 hours.

Nil by mouth for 6 hours, then sips of water, then clear liquids if no vomiting.

IV fluids as charted till oral intake is adequate.

No further antibiotic doses after surgery, as the appendicitis was uncomplicated. Review the culture report.

Analgesia as charted by the anaesthetist.

Out of bed this evening with support.

Wound check on POD 2. Sutures out on POD 7. Review HPE report at follow-up.

Signature

Dr A., JR-2, General Surgery. Reg. no. ________. 04/08/2026, 23:10.

Must document for this operation

  • The position and state of the appendix, including perforation and its site. This decides how long antibiotics run and explains any later abscess or fistula.
  • How the base was secured: crushed or not, number of ligatures, transfixion, suture used, buried or not. If a faecal fistula or stump leak appears, the next surgeon needs to know what was done at the base.
  • That the appendicular artery was ligated separately from the base. A slipped artery ligature is the usual cause of reactionary bleeding, and the note shows how it was handled.
  • What else was examined when the appendix looked normal (ileum length run, Meckel diverticulum, ovary and tube). A normal appendix with no search for another cause is hard to defend if the real disease shows up later.
  • Any unexpected mass or tumour of the appendix or caecum, and its site. The pathologist and the follow-up surgeon need this to decide whether a right hemicolectomy is required.
  • Incision used and any extension, with the reason. A right iliac fossa scar is taken by later doctors to mean the appendix is out, so the note must say what was done.
  • Drain type and exit site, and whether the skin was closed or left open. Ward staff and the next shift need to know what to watch and when to remove it.

Common mistakes in these notes

  • Writing 'appendix removed' without its position, state or perforation.
  • Not recording how the stump was closed.
  • Not noting that pus or peritoneal fluid was sent for culture.
  • Leaving out the search for other disease when the appendix looked normal.
  • Writing the antibiotic plan as 'continue antibiotics' with no drug, dose or duration.
  • Forgetting to record that the appendix was sent for histopathological examination (HPE).

Indian practice and paperwork

  • The ICMR national antimicrobial guideline lists piperacillin-tazobactam or cefoperazone-sulbactam as the prophylactic choice before appendectomy, with the first dose within one hour before incision and prophylaxis not continued beyond 24 hours. Many Indian units use this; others use cefazolin with metronidazole. Write the drug actually given. (ICMR. Treatment Guidelines for Antimicrobial Use in Common Syndromes, 2nd ed. 2019. Ch 10, sections 10.3.8, 10.3.10 and Table 10.2 (pp. 99-101). https://www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/Treatment_Guidelines_2019_Final.pdf)
  • Under AB PM-JAY (HBP 2022) this operation is booked as SG017A (Appendicectomy - Open). NHA guidelines say package stratification depends on items such as type of anaesthesia and surgical technique, so the note must state the anaesthesia and approach that match the booked code; OT notes are also asked for in audits of on-table deaths and LAMA/DAMA cases. State rates vary. (AB PM-JAY HBP 2022 package master (Gujarat SHA SACHIS, https://www.sachis.in/assets/HBP-2022.pdf) and NHA HBP 2.2 User Guidelines (https://hem.nha.gov.in/HBP.pdf))

Sources

  • Scott-Conner CEH, Dawson DL, eds. Essential Operative Techniques and Anatomy. 4th ed. Wolters Kluwer; 2015, Ch 94, Appendectomy and resection of Meckel diverticulum, pp. 494-500.
  • Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press, Ch 13, Emergency small and large bowel surgery: Appendicectomy, pp. 245-250.
  • Bhat SM. SRB's Surgical Operations: Text and Atlas. Jaypee; 2014, Ch 21, Surgeries of small bowel and appendix: Open appendicectomy, pp. 734-746.
  • 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, 3 g if 120 kg or more; metronidazole 500 mg; start within 60 min before incision) and Table 2 (appendectomy: cefazolin plus metronidazole, cefoxitin or cefotetan). academic.oup.com/ajhp/article/70/3/195/5112717
  • ICMR. Treatment Guidelines for Antimicrobial Use in Common Syndromes. 2nd ed. 2019. Ch 10 (surgical prophylaxis timing, duration, Table 10.2). www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/Treatment_Guidelines_2019_Final.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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