OT notes · Thoracic / Trauma

Exploration and repair of limb vascular injury (incl. temporary shunt)

Usual anaesthesia
General anaesthesia
Position
Supine; arm abducted 90 degrees on an arm board for brachial injury; hip and knee slightly flexed and externally rotated on a bolster for femoral and popliteal injury
Setting
emergency

Operative note template for exploration of a limb arterial (and venous) injury with primary repair, reversed vein interposition graft or temporary shunt, with a filled example for a stab wound of the brachial artery repaired with a vein graft.

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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 and blood transfusion
  • blockage of the repair and need for re-operation
  • loss of the limb (amputation)
  • compartment syndrome needing fasciotomy
  • nerve injury with weakness or numbness
  • wound or graft infection
  • leg wound where vein is taken for the graft
  • swelling of the limb if a vein is tied

Pre-operative details for this operation

  1. Mechanism and woundStabGunshotBlunt / fractureKnee dislocationCrushsite, side, time of injury
  2. Hard signsPulsatile bleedingExpanding / pulsatile haematomaThrillBruitAbsent distal pulseDistal ischaemia
  3. Distal limbpulses, Doppler signals, ankle-brachial or arterial pressure index, capillary refill, colour, sensation, movement
  4. Ischaemia timehours from injury to expected reperfusion
  5. ImagingCT angiography / angiography / none (hard signs)
  6. Associated injuriesfracture, dislocation, nerve, soft tissue loss
  7. Temporary bleeding controlPressureTourniquet (time applied)
  8. Tetanus and antibioticgiven, time

Anaesthesia and position

  1. AnaesthesiaGeneral
  2. PositionSupine, arm out 90 degrees palm upSupine, hip and knee slightly flexed and externally rotated
  3. Prepwhole injured limb with hand or foot in a sterile bag, area for proximal control (axilla and chest / groin and abdomen), opposite groin or leg for vein
  4. Equipmentvascular tray, Fogarty catheters 3 and 4 Fr, heparin saline, shunts, sterile Doppler, C-arm and contrast
  5. Sterile tourniquet on fieldYesNo

Operative findings

  1. Vessel injuredname, level
  2. Type of arterial injuryPartial lacerationComplete transectionSegmental lossIntimal injury / thrombosisContusionlength of damaged segment after debridement
  3. Accompanying veinintact / injured: type
  4. Nervesmedian / ulnar / radial / sciatic / tibial / peroneal: intact or injured
  5. Back-bleeding and forward flowafter Fogarty passage
  6. Musclecolour, contraction, devitalised tissue

Procedure (steps)

  1. Incisionbrachial: groove between biceps and triceps; femoral: vertical over artery midway between pubic tubercle and ASIS; popliteal: medial above and below knee
  2. Proximal and distal controlseparate incision if needed; vessel loops / bulldog clamps before opening haematoma
  3. Structures protectedbasilic / saphenous vein, median and ulnar nerves, profunda branches
  4. Damage control shunt (if used)when to shunt: patient in extremis / damage control, fracture needing fixation first (mangled limb), repair beyond a simple suture or end-to-end anastomosis, or help needed; no debridement before shunting; shunt type and size; secured with 0 silk ties tied together; Doppler flow confirmed; time in; checked at least every 30 min
  5. Debridement of vesselback to normal intima; length removed
  6. Fogarty thrombectomycatheter size, proximal and distal, clot retrieved, flow and back-bleed
  7. Regional heparin5000 units in 100 ml saline, 50 ml each end; systemic heparin given or not and why
  8. Arterial repairLateral sutureEnd-to-end anastomosisReversed saphenous vein interposition graftVein patchPTFE graftLigation (with reason)suture: running or interrupted monofilament polypropylene, needle from intima to adventitia on the artery side; write the size used (the popliteal chapter gives 5-0 or 6-0; the brachial chapters give no size); graft length and source; brachial artery is not tied (high limb loss)
  9. Venous injuryRepairedLigatedShuntedNot injured
  10. Flushing and releasevented before final stitches; order of clamp release
  11. Completion checkPalpable distal pulseDoppler signal onlyOn-table angiogram
  12. Compartmentsclinical and/or pressure; fasciotomy done or not and why. Triggers: severe ischaemia over 4-6 hours, shock before surgery, firm or hard compartment, reduced sensation or power, compartment pressure over 30 mmHg, pain out of proportion
  13. Fracture fixationdone after shunt, before definitive repair

Closure, drains and dressing

  1. Coverage of repairhealthy muscle or soft tissue over the graft
  2. Fascia and skinclosed / left open; suture
  3. Vein harvest siteclosure, drain
  4. DrainNoneClosed suction (site)
  5. Dressingnot tight; window to feel distal pulses

Specimens and implants

  1. Autologous graftvein used, side, length
  2. Synthetic graft or shunttype, size, make, batch number, sticker

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. Limb perfusion checkspulses, colour, warmth, capillary refill every 30 min for 6 hours; Doppler or pressure if pulse unclear
  2. Compartment checkspain on passive stretch, tense compartment, sensation, movement; call if any change
  3. CK levelsserial, e.g. 6-hourly on day 1
  4. Limb positionno tight bandage; avoid sharp flexion at the repair
  5. ThromboprophylaxisLMWH as per chart if bleeding risk allows
  6. Antibioticscontinue if wound contaminated
  7. Shunt in place (if damage control)time of planned return for definitive repair

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. M.S., 26 years, stab wound on the inner side of the right mid-arm, brought 1 hour after injury with pulsatile bleeding controlled by pressure, absent radial pulse, cool hand, normal sensation and movement.

Case details

Date: 07/07/2026. Emergency exploration of right brachial artery with reversed saphenous vein interposition graft. Emergency OT.

Injury 14:30. In OT 15:50. Incision 16:10. Flow restored 17:25. End 18:05.

Surgeon: Dr A. (3rd-year resident, General Surgery). Assistant: Dr B. (2nd-year resident). Consultant: Dr C. (Vascular Surgery), scrubbed.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Hard signs of brachial artery injury: pulsatile bleeding and absent radial and ulnar pulses. No imaging done.

Hand cool and pale, capillary refill 4 s. Median, ulnar and radial nerve function normal before surgery.

Pressure dressing only, no tourniquet. Hb 11.2 g/dl. 2 units cross-matched.

Consent: written consent from patient for exploration, repair with vein graft from the leg, fasciotomy, and the risk of loss of limb. Explained in Hindi.

Tetanus toxoid given in the emergency department. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 15:58.

Anaesthesia and position

General anaesthesia. Supine with right arm abducted to 90 degrees on an arm board, palm up.

Painted with povidone-iodine: whole right arm, axilla, shoulder, chest and both groins and left thigh. Hand in a sterile stockinette. Sterile tourniquet kept on the field, not used.

Findings

Brachial artery completely cut in the mid-arm, ends retracted, about 2.5 cm gap after trimming to normal intima. Both ends in spasm, short clot in the distal end.

Profunda brachii origin above the injury, intact. Brachial veins: one vena comitans cut. Basilic vein intact.

Median nerve seen crossing the artery, intact. Ulnar nerve intact.

Biceps and triceps healthy.

Procedure

Longitudinal incision of 12 cm in the groove between biceps and triceps, taking in the stab wound. Biceps retracted upwards, triceps with the ulnar nerve downwards. Basilic vein protected.

Proximal control of the brachial artery above the haematoma with a vessel loop, then distal control. Bulldog clamps applied.

Artery ends trimmed with Potts scissors back to normal intima.

3 Fr Fogarty catheter passed proximally and distally. Short clot removed from the distal end. Good forward flow and back-bleeding.

Regional heparin: 5000 units in 100 ml saline, 50 ml into each end. No systemic heparin.

Gap too long for tension-free end-to-end repair with the elbow in slight flexion.

Left great saphenous vein harvested from the groin downward through a separate 6 cm incision, reversed, 4 cm length taken with the arm in 15 degrees of flexion.

Distal anastomosis first, then proximal, end-to-end, with continuous monofilament polypropylene (Prolene), size ____ (as used), needle passed from inside to outside on the artery side. Graft vented before the last stitches.

Cut vena comitans tied with 3-0 silk.

Clamps released at 17:25. Radial pulse palpable at the wrist, hand pink, capillary refill 2 s. No on-table angiogram needed.

Forearm compartments soft. No fasciotomy: ischaemia time about 3 hours, no shock, compartments soft, no loss of sensation or power.

Closure

Graft covered with healthy muscle and soft tissue. Deep fascia and subcutaneous tissue with polyglactin 910 (Vicryl) 3-0. Skin with interrupted polyamide (Ethilon) 3-0. No drain.

Groin wound closed in layers with Vicryl 3-0 and skin with Ethilon 3-0.

Loose dressing with a gap at the wrist to check the pulse.

Specimens and implants

Graft: autologous left great saphenous vein, reversed, 4 cm. No synthetic implant. No specimen.

End of procedure

Estimated blood loss 300 ml. No transfusion.

Instrument, needle and mop count correct, confirmed by scrub nurse.

No intra-operative complications.

Pulse 84/min, BP 122/76 mmHg. Radial pulse palpable. Shifted to surgical HDU.

Post-op orders

Right radial pulse, hand colour, warmth and capillary refill every 30 min for 6 hours, then hourly. Inform Dr A. at once if the pulse is lost.

Check forearm compartments and median, ulnar and radial nerve function 2-hourly: pain on passive finger stretch, tense forearm.

Serum CK at 6 and 12 hours.

Arm on a pillow, elbow straight or slightly bent, no tight bandage, no BP cuff or IV line on the right arm.

LMWH as per chart from tomorrow if no bleeding.

Oral liquids from 4 hours.

Signature

Dr A., JR-3, General Surgery. Reg. no. ________. 07/07/2026, 18:20.

Must document for this operation

  • Distal circulation and nerve function before surgery. A nerve deficit after surgery will otherwise be blamed on the operation.
  • Time of injury and time flow was restored. Ischaemia time predicts limb loss and compartment syndrome, and decides whether fasciotomy is needed.
  • Type of arterial injury and repair, graft source, length and suture. Any re-operation for thrombosis or false aneurysm starts from these details.
  • How flow was confirmed at the end (palpable pulse, Doppler, angiogram). It is the baseline for post-op checks and shows the repair was working when the patient left theatre.
  • Compartments checked and the reason fasciotomy was or was not done. Missed compartment syndrome is a common cause of limb loss and litigation after vascular repair.
  • If a shunt was used: type, size, time in, and plan for definitive repair. A shunt is temporary and the next team must know when it must come out.
  • Veins ligated or repaired. A tied major vein increases limb swelling and changes post-op care.

Common mistakes in these notes

  • Writing 'artery repaired' without saying end-to-end, graft or patch.
  • Not recording nerve function before surgery.
  • No ischaemia time and no statement about compartments.
  • Leaving out the source and length of the vein graft.
  • Not writing the distal pulse status at the end of the operation.

Indian practice and paperwork

  • The district hospital OT checklist expects tetanus prophylaxis to be given when indicated. Record it. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, ME E15.2)
  • If a synthetic graft or commercial shunt is left in, record its batch and serial number in the case record, the OT implant register and the discharge summary. (NABH 5th ed., MOM.10(d))
  • Consent must explain the procedure, risks, benefits, alternatives and who will operate, in a language the patient understands. Include vein harvest from the leg and the risk of amputation. (NABH 5th ed., PRE.4(c))
  • NABH expects the operative note to be written before the patient leaves recovery, and post-op care to follow a written plan. (NABH 5th ed., COP.14(e) and (f))

Sources

  • Demetriades D, Inaba K, Velmahos G, eds. Atlas of Surgical Techniques in Trauma. Cambridge University Press; 2015, Ch 32, Brachial artery injury (Talving P, Benjamin ER); Ch 35, Femoral artery injuries (Velmahos G, Gelbard R); Ch 36, Popliteal artery (Talving P, Nash N), pp. 622-634, 671-693.
  • Wahlberg E, Olofsson P, Goldstone J. Emergency Vascular Surgery: A Practical Guide. Springer; 2007, Ch 9, Vascular Injuries in the Leg, pp. 101-117.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 2: vascular procedures, cefazolin; Table 1: cefazolin 2 g adult, within 60 min before incision. 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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