Abdominoplasty Operative Note

Patient Name: [Patient full name]   MRN: [Medical record number]   Date of Birth: [DOB]

Date of Surgery: [Date]   Start Time: [Start time]   End Time: [End time]

Facility: [Facility name]   Operating Room: [OR number/name]

Primary Surgeon: [Surgeon full name, credentials]   Assistant(s): [Assistant name(s), credentials, role(s)]

Anesthesia Type: [general / regional / MAC / local with sedation]   Anesthesia Provider: [Provider name(s), credentials]

(Meta: Do not infer or auto-populate rectus plication, umbilical management, or drain placement; these must be explicitly documented from dictation. If a required value such as EBL or excision weight is not provided, insert a placeholder stating it was not provided. Ensure internal consistency between the narrative and the Drains, Specimens, and Implants/Mesh sections. Use past tense throughout Operative Details. Omit Implants/Mesh section if not applicable, but explicitly state when rectus plication was not performed and when no drains were placed.)

Preoperative Diagnosis

• [Preoperative diagnosis 1]
• [Preoperative diagnosis 2] (Add additional items as needed)

Postoperative Diagnosis

• [Postoperative diagnosis 1]
• [Postoperative diagnosis 2] (Include any intraoperative findings discovered, such as hernia)

Procedure(s) Performed

• [Abdominoplasty type: full / mini / extended / circumferential / fleur-de-lis / lipoabdominoplasty]
• [Rectus plication] (List as separate procedure if performed)
• [Concurrent procedure(s): hernia repair / monsplasty / scar revision / other] (Add additional items as needed)

Indications

[Brief indication for surgery in 2–4 sentences summarizing symptoms or functional issues such as symptomatic pannus, skin laxity, rectus diastasis, post-pregnancy changes, or massive weight loss. State that risks, benefits, and alternatives were discussed and informed consent was obtained.]

Findings

[Intraoperative findings relevant to technique and postoperative care: degree and location of rectus diastasis if assessed; presence or absence of umbilical or ventral hernia; scar tissue or adhesions; umbilical stalk characteristics; tissue quality. If findings were as expected, state that no unexpected pathology was encountered.]

Operative Details

The patient was positioned [supine] with [arm position]. The abdomen was prepared with [skin prep agent] and draped in a sterile fashion. A procedural timeout was performed confirming patient identity, procedure, site, and positioning per protocol. [Foley catheter was placed / Foley catheter was not placed].

The planned incision was [low transverse / extended / fleur-de-lis / circumferential] and marked for symmetry. The initial incision was made at [location], and dissection proceeded in the [suprafascial / preaponeurotic] plane.

The abdominal flap was elevated to [superior extent: costal margin / xiphoid / limited undermining to specified extent]. Hemostasis was achieved using [electrocautery / ligation / hemostatic agents] throughout the dissection.

Umbilical management: [Circumferential incision was made with stalk preservation and transposition to new site / Umbilical floating technique was performed / Umbilical excision with neo-umbilicoplasty was performed]. The new umbilical site was created at [location or measurement method], and the umbilicus was inset using [technique and suture material]. (Must explicitly document the approach taken.)

Rectus plication: [Rectus plication was performed / Rectus plication was not performed]. (If performed:) Indication was [indication]. Extent was [xiphoid to pubis / supraumbilical only / infraumbilical only]. Technique was [running / interrupted], [single-layer / double-layer], using [suture material and size]. (If not performed, explicitly state that rectus plication was not performed.)

The patient was flexed to [degree or description] to assist with tailoring. The flap was redraped and marked for symmetric excision. The redundant tissue was excised, weighing [weight in grams]. (If weight was not recorded, state: Excision weight was not recorded.)

[Progressive tension sutures / Quilting sutures] were placed for dead space management, approximately [number] sutures distributed [distribution pattern], using [suture material]. (Include only if performed.)

Closure was performed in layers [under flexion / in neutral position]: Scarpa's fascia with [technique and suture], deep dermal with [technique and suture], subcuticular with [technique and suture], and skin with [adhesive / strips / staples].

Sterile dressings consisting of [dressing type] were applied. Abdominal binder was [applied / not applied].

Specimens

• [Specimen description] — [sent to pathology / discarded per institutional policy]

(If no specimens were sent to pathology, state that specimens were discarded per institutional policy.)

Implants/Mesh

• [Implant or mesh name], [size], [manufacturer], [location and fixation method]

(Include this section only if implants or mesh were placed; otherwise omit entirely.)

Drains

[No drains were placed.] (Use if no drains; explicit statement required.)

[Drain type: JP / Blake], [size] Fr, [number placed], positioned in [anatomic location(s)], exiting [exit site location(s)], secured with suture, and placed to bulb suction. (Use if drains placed; provide details for each drain if multiple.)

Estimated Blood Loss

[EBL in mL]. (If not provided, state: EBL was not provided.)

[IV fluids: type and volume]   [Urine output: volume] (Include if tracked and clinically relevant.)

Counts

[All counts correct at completion of case / Count discrepancy noted and resolution described]

Complications

[None] (Or describe intraoperative complication, timing, management, and patient status at end of case.)

Disposition

The patient was transferred to [PACU / recovery / observation unit] in [stable / guarded] condition. [Relevant immediate postoperative plan elements if discussed.]