Split-thickness skin grafting

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

• partial or complete graft loss needing regrafting
• infection of recipient or donor site
• haematoma or seroma under the graft
• pain at donor site, often more than at the graft
• slow healing or ulcer at donor site
• colour change, pigmentation and hypertrophic scar at donor site
• meshed pattern and contracture at graft site
• need for immobilisation of the grafted part

Pre-operative details for this operation

1. Recipient woundcause, site, size in cm, age of wound, previous debridements
2. Granulation tissueHealthy red, flat, bleeds on touchPale / oedematousSlough present
3. Latest wound culturedate and result; Streptococcus pyogenes (beta-haemolytic group A) must be absent
4. Hb and serum albuminvalues; graft take is poor if Hb < 10 g/dl or albumin < 3 g/dl
5. Blood sugar controlif diabetic
6. Donor site chosen and markedIpsilateral thighContralateral thighArmOtheruse the opposite limb if the defect follows excision of a malignancy

Anaesthesia and position

1. AnaesthesiaSpinalGeneralLocal infiltration
2. Positionsupine / prone / lateral; donor and recipient both prepared
3. TourniquetNot usedUsed: pressure and time

Operative findings

1. Recipient bed after preparationsize in cm, bleeding base, exposed structures (tendon, bone, periosteum, paratenon)
2. Donor site after harvestpattern of bleeding: fine and dense (thin) or larger and sparse (thicker); fat exposed?
3. Graftsize, translucency, uniform thickness

Procedure (steps)

1. Painting and draping of recipient and donor sites
2. Recipient bed preparedexcess granulation and slough scraped or excised to a bleeding base; haemostasis by pressure / cautery
3. Donor site lubricated and stabilisedliquid paraffin / saline; assistant makes the surface flat and firm; boards used
4. Harvest instrument and settingHumby knifeWatson knifePower dermatomeSilver knifeblade, thickness setting (thin / intermediate / thick or dermatome setting), width
5. Graft harvestedsize in cm, number of strips
6. Graft handledkept in saline on gauze, orientation (raw side) maintained
7. Graft expandedNot meshedFenestrated by hand with bladeMeshed with mesher: ratio
8. Graft applied raw side down, slightly overlapping edges
9. Graft fixedStaplesInterrupted suturesAdhesive stripsQuilting suturessuture material and size
10. Graft immobilisedTie-over (bolus) dressingPressure / crepe dressingNegative pressure dressingSplint
11. Donor site dressinglayers used; not to be opened till the planned day
12. Excess graft storedNoneStored in refrigerator at 4 degrees C, labelled with name and date

Closure, drains and dressing

1. Recipient dressingcontact layer (paraffin gauze), absorbent layer (cotton / gauze), binding layer (crepe)
2. Donor dressingparaffin gauze, gauze, roller cotton, crepe
3. Immobilisationsplint / slab if graft crosses a joint

Specimens and implants

1. SpecimensNoneExcised granulation tissue for HPE (chronic ulcer)
2. ImplantsNone

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 elevation and restgrafted part elevated and immobilised
2. Recipient dressingfirst inspection on POD 5 for clean wounds; earlier (48 to 72 hours) if infected or soaked
3. Donor dressingdo not remove for about 10 days; add outer layers if soaked
4. Pain controldonor site pain is common in the first week
5. Signs to reportfever, foul smell, soakage, increasing pain
6. Nutrition and sugar controlprotein intake, blood sugar charting if diabetic
7. Mobilisationwhen and how much, protecting the graft
8. After healingemollient to donor site, scar care, follow-up for contracture

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