Staging laparotomy for ovarian cancer

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
• injury to bowel, bladder, ureter or major vessels
• splenic injury during omentectomy, possible splenectomy
• removal of both ovaries and uterus (loss of fertility, surgical menopause)
• second operation if frozen section and final report differ
• ileus, wound infection, chest and urinary infection
• thromboembolism
• lymphocele or leg swelling after lymphadenectomy
• incisional hernia

Pre-operative details for this operation

1. IndicationUSG / CT description of the mass, side, size, solid or cystic, ascites
2. Tumour markers (baseline)CA-125, and CEA / CA 19-9 if a GI primary is possible, AFP / beta-hCG / LDH in young women, inhibin if granulosa cell tumour suspected
3. CT abdomen and pelvis (and chest)nodes, omentum, peritoneum, liver, pleural effusion
4. Other primary excludedcolonoscopy / upper GI endoscopy / mammography where indicated
5. Fertility wishFamily completeWants fertility preservedif fertility-sparing surgery is an option, record what was discussed for each possible finding
6. Frozen section bookedYesNot available
7. Bowel preparationNoneMechanical
8. Blood arrangedgroup and units cross-matched

Anaesthesia and position

1. AnaesthesiaGeneralGeneral + epidural
2. PositionSupineLow lithotomy
3. CatheterFoley catheter
4. Retractorself-retaining type

Operative findings

1. Ascitesvolume in ml, colour. Or 'no ascites'
2. Primary tumourside, size, solid / cystic, capsule intact or ruptured (before or during surgery), surface excrescences, adhesions to other organs
3. Opposite ovary and uterusnormal / involved
4. Upper abdomenboth hemidiaphragms, liver surface, gallbladder, stomach, spleen, omentum, pancreas via lesser sac: site and size of any deposit
5. Bowel and mesenterysmall bowel run from ileocaecal junction to DJ flexure, colon, appendix
6. Peritoneumpelvic peritoneum, paracolic gutters, bladder peritoneum, pouch of Douglas
7. Retroperitoneal nodespelvic and para-aortic up to renal vessels: palpable or not, size
8. Frozen section resulttime reported and exact wording
9. Provisional surgical stageFIGO stage, to be confirmed on final HPE

Procedure (steps)

1. IncisionVertical midline (pubis to umbilicus, extended above)Transverse (with reason)
2. Ascitic fluid or peritoneal washings for cytologyascites volume sent, or saline instilled (about 100 ml) and aspirated from pelvis, gutters and upper quadrants
3. Systematic explorationorder followed, findings recorded above
4. Removal of the ovarian massUnilateral salpingo-oophorectomyBilateral salpingo-oophorectomyureter identified before dividing the infundibulopelvic ligament. Removed intact or ruptured / spilled
5. Frozen section senttime sent, time reported
6. Hysterectomy and removal of opposite adnexaTotal abdominal hysterectomy + BSOUterus and opposite ovary preserved (fertility-sparing)
7. Infracolic omentectomyplane between omentum and transverse colon, lesser sac entered, from hepatic to splenic flexure. Pedicles ligated (suture) or vessel-sealing device. Gastroepiploic arcade kept
8. Peritoneal biopsiespouch of Douglas, bladder peritoneum, both pelvic side walls, both paracolic gutters, both hemidiaphragms (biopsy or scraping), plus any adhesion or suspicious area
9. Pelvic lymphadenectomyBilateralNot done (reason)limits: mid common iliac to circumflex iliac vein, obturator fossa above the obturator nerve
10. Para-aortic lymphadenectomyBilateral, up to renal veinsUp to IMANot done (reason)
11. AppendicectomyDone (mucinous tumour / abnormal appendix)Not done, appendix normal
12. Residual disease at endNo gross residualResidual (site and largest size)
13. Haemostasis, ureters and bowel checked, peritoneal wash

Closure, drains and dressing

1. DrainNoneClosed suction drain (site)
2. Fascia (sheath)suture material and size, continuous mass closure, small bites 5 to 8 mm apart
3. Subcutaneous tissueNot suturedSutured
4. SkinStaplesInterruptedSubcuticular
5. Dressing

Specimens and implants

1. Ascitic fluid / peritoneal washings for cytologyvolume, sent fresh
2. Ovarian mass for frozen section and HPEside labelled, capsule intact / ruptured noted on form
3. Uterus with cervix and other adnexa
4. Omentum
5. Peritoneal biopsieseach site in a separate labelled container
6. Lymph nodesright pelvic, left pelvic, right para-aortic (paracaval), left para-aortic: separate containers
7. AppendixSentNot removed

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, SpO2, urine output hourly for the first 24 hours
2. Drainrecord output. Remove when under 50 ml in 24 hours
3. Cathetertime of removal
4. Oral intakeadvance when bowel sounds return. No need to wait for flatus
5. Analgesiaepidural or other: drug, dose, frequency
6. Thromboprophylaxisearly mobilisation, stockings / pneumatic compression, LMWH. Consider extended prophylaxis for 28 to 35 days
7. InvestigationsHb and electrolytes on POD 1
8. Discharge criteriaafebrile, eating normal diet, bowel and bladder working, wound healthy
9. HPE and tumour boardfinal stage and need for chemotherapy decided on histology, grade and stage

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