Appendectomy Operative Note (Laparoscopic/Open)

Date of Surgery: [Date]

Start Time / End Time: [Start time] / [End time]

Location: [Operating room / facility]

Urgency: [elective / urgent / emergent]

Preoperative Diagnosis: [Diagnosis]

Postoperative Diagnosis: [Diagnosis reflecting intraoperative findings]

Procedure(s) Performed: [List all procedures with approach in order performed]

Surgeon: [Name, credentials]

Assistant(s): [Name(s), credentials, and task attribution if applicable] (If assistants performed significant surgical tasks, specify who performed what)

Anesthesia: [Type of anesthesia]

Wound Classification: [Class I (clean) / Class II (clean-contaminated) / Class III (contaminated) / Class IV (dirty-infected)]

EBL: [Estimated blood loss in mL]

Complications: [None / List each intraoperative complication with management]

(If any header field cannot be determined from dictation, enter "Not documented" rather than omitting.)

Indication

[Chief indication for appendectomy]. [Preoperative impression of uncomplicated or complicated appendicitis with key supporting imaging findings including appendicolith, abscess, or phlegmon if present]. [Failed nonoperative management details if applicable]. [Pertinent risk modifiers affecting intraoperative decisions: pregnancy, obesity, prior abdominal surgery, anticoagulation]. Informed consent was obtained. Antibiotic prophylaxis was administered prior to incision [with agent if documented]. (Write 3–6 sentences. Include only items explicitly stated in the dictation.)

Intraoperative Findings

(Document only observed findings without inference. If preoperative imaging differed from intraoperative findings, document both.)

Overall classification: [uncomplicated (inflamed without perforation or abscess) / complicated (perforation and/or abscess/phlegmon and/or diffuse purulence)]

• Appendix: [inflamed / suppurative / gangrenous / perforated] [Additional descriptors if provided]
• Perforation: [present / absent / Not documented] (If present: location [tip / base / other], [contained / free], fecalith [present / absent])
• Contamination: [none / serous / purulent / feculent / Not documented]
• Abscess/phlegmon: [present / absent / Not documented] (If present: location and approximate size)
• Adjacent structures: [Cecum and terminal ileum status, adhesions, other intra-abdominal findings] (Include only explicitly observed findings)

Description of Procedure

(Use past tense, factual, chronological narration. Include only steps actually performed.)

Preparation and positioning: [Patient positioning, arm position, prep and drape details]. [Surgical time-out performed].

Abdominal entry and initial exploration: [Method of entry and initial survey findings including adhesions or anatomic variations if noted].

Laparoscopic Approach

(Include only if laparoscopy was performed.)

Access technique: [Veress needle / Hasson technique] at [site]. Pneumoperitoneum established to [pressure] mmHg.

Port placement: [Number, size, and locations of ports]. Camera placed via [location].

Exploration and mobilization: [Exploration findings]. The appendix was identified in the [location] and mobilized by [technique].

Mesoappendix control: [Energy device / clips / stapler] used to divide the mesoappendix with hemostasis confirmed.

Appendiceal stump management: [Endoloop / clips / stapler]. Stump integrity confirmed. [Base inspection findings if mentioned].

Specimen retrieval: Specimen placed in [retrieval bag: yes / no] and extracted via [extraction site]. Abdomen reinspected for hemostasis.

Irrigation and desufflation: [Irrigation: yes / no, with volume if documented]. Pneumoperitoneum released. Ports removed under direct vision.

Closure: Fascia closed at ports ≥10mm with [suture type]. Skin closed with [method]. [Dressing applied].

Open Approach

(Include only if open approach was performed.)

Incision and exposure: [Incision type and location] incision made and carried through layers to peritoneum. Wound protector [used / not used].

Appendectomy: Appendix delivered into wound. Mesoappendix divided using [method] with hemostasis achieved. Appendiceal base ligated with [method]. Stump [inverted / not inverted].

Irrigation and inspection: [Irrigation: yes / no, with volume if documented]. Hemostasis confirmed. Wound and peritoneal cavity inspected.

Closure: [Peritoneum closed / not closed]. Fascia closed with [suture type] in [layered / mass] fashion. Skin closed with [method]. [Dressing applied].

Conversion to Open

(Include only if conversion from laparoscopic to open occurred.)

Timing of conversion: [Before appendiceal division / after partial dissection / other].

Reason for conversion: [Dense adhesions / inability to identify anatomy safely / bleeding / extensive phlegmon / equipment failure / other].

Open incision: [Incision type and location].

Change in procedure scope: [None / Describe additional or modified procedures].

Source Control for Complicated Appendicitis

(Include only if complicated appendicitis or significant contamination was present.)

• Suction: [Yes / No] [Areas addressed]
• Irrigation/lavage: [Yes / No] [Volume and regions if extensive]
• Abscess drainage: [Yes / No / Not applicable] [Loculations broken down: yes / no]
• Intraoperative cultures: [Obtained / Not obtained] [Source: peritoneal fluid / abscess cavity / other]
• Appendicolith retrieval: [Retrieved / Not found / Spilled and retrieved]

Final hemostasis and inspection: Hemostasis confirmed. [Additional inspection findings if documented].

Specimens

• Appendix to pathology: [Yes / No] (If no, document reason)
• Additional specimens: [Peritoneal fluid to microbiology / abscess cultures / cecal margin / other / None]

Drains

[None] or [Drain placed: [Jackson-Pratt / Blake / other] drain in [pelvis / right lower quadrant / abscess cavity], exiting [location], secured with [suture], to [bulb suction / gravity]].

Counts

• Sponge count: [Correct / Incorrect / Not performed]
• Needle count: [Correct / Incorrect / Not performed]
• Instrument count: [Correct / Incorrect / Not performed]
• Discrepancy management: [Not applicable / Actions taken and resolution]
• Intentionally retained packing: [None / Type, quantity, location, and removal plan]

Disposition and Postoperative Plan

Patient [stable / other] at case end, [extubated / remained intubated], transported to [PACU / ICU / surgical floor].

• Diet: [NPO / clear liquids / advance as tolerated]
• Activity: [Early ambulation / restrictions including lifting limits]
• Pain management: [Multimodal analgesia plan]
• Antibiotics: [None / Agent with duration or stop criteria] (Specify duration for complicated appendicitis)
• VTE prophylaxis: [Mechanical / pharmacologic / both] [Agent and timing if applicable]
• Drain care: [Not applicable / Output monitoring and removal criteria]
• Wound care: [Dressing management and wound check instructions]
• Follow-up: [Clinic follow-up timing, wound check, suture/staple removal]
• Additional considerations: [Tailored instructions for complicated cases or additional procedures] (Include only if applicable)