Bowel Resection and Anastomosis Operative Note (Pediatric)

Patient Name: [Patient full name]

MRN: [Medical record number]

Date of Birth: [DOB]

Date of Surgery: [Date]

Start/Stop Time: [Start time – Stop time] (Reference anesthesia record if unavailable.)

Location: [Operating room / facility]

Case Status: [Elective / Urgent / Emergent]

Procedure(s) Performed

[Procedure list including segment(s) resected, anastomosis configuration, and stoma if created]

Surgical Team

Primary Surgeon: [Name, credentials]

Assistant(s): [Name(s), credentials, and role if significant]

Anesthesiologist: [Name, credentials]

Trainee Participation: [Description of trainee roles in significant portions] (Only include if applicable.)

Anesthesia

[Type of anesthesia and regional adjuncts relevant to postoperative plan]

Diagnoses

Preoperative Diagnosis: [Clinical diagnosis prompting surgery]

Postoperative Diagnosis: [Intraoperative confirmation and any additional findings]

Indications

[Clinical course leading to surgery including symptoms, imaging, deterioration, failed non-operative management. Include pediatric context: gestational age/prematurity, congenital anomalies, NEC concern, volvulus, or trauma. Document why resection was required and rationale for anastomosis versus diversion.] (Format as 3–6 sentence narrative paragraph focused on operative justification.)

Operative Findings

• Segments involved: [Jejunum / ileum / colon with subsegments]
• Pathology: [Ischemia/necrosis distribution, perforation location and spillage, obstruction/atresia/stricture/adhesions/volvulus]
• Contamination: [Purulent / feculent / enteric spillage / none]
• Viability assessment: [Visual perfusion / bleeding edge / peristalsis / Doppler / fluorescence]
• Ileocecal valve status: [Present / removed / not assessed]
• Length of bowel resected: [cm]
• Estimated remaining small bowel length: [cm, with landmarks] (State "not assessed" if not measured.)
• Colon continuity: [In continuity / diverted / not assessed]

Procedure Details

Approach and Exposure: [Laparoscopic / open / converted with reason. Incision type and location. Abdominal entry technique if reoperative. Brief exploration summary.]

Resection: [Proximal and distal landmarks. Method for determining healthy margins. Mesenteric vessel control. Management of contamination.]

Anastomosis: [Configuration, technique, management of lumen disparity, tension-free status, leak test method and result, perfusion confirmation. Rationale for no diversion if contaminated field.] (Only include if anastomosis performed.)

No Anastomosis: [Rationale and how contamination was controlled.] (Only include if no anastomosis performed.)

Ostomy: [Type, site, limb orientation, maturation technique, distal segment management, rationale for diversion.] (Only include if ostomy created.)

Closure: [Fascial closure technique and material. Skin closure. Dressing. If temporary closure, specify device and re-exploration plan.]

EBL and Fluids

Estimated Blood Loss: [mL] (For neonates/infants, include percentage of estimated blood volume if significant.)

IV Fluids: [Type(s) and volume(s)]

Blood Products: [Product and amount / None]

Urine Output: [mL / Not tracked] (Reference anesthesia record if unavailable.)

Drains, Tubes, and Lines

• [NG/OG tube: size and settings]
• [Foley catheter: size]
• [Intraabdominal drain(s): type, location]
• [Rectal tube] (If placed.)
• [Central line(s) placed intraoperatively: type, site]

(If none, state "None.")

Specimens

• [Specimen name/segment, orientation markers, destination]

(If none, state "None.")

Implants and Materials

• [Staple loads: type, size, count]
• [Mesh / adhesion barrier / hemostatic agents with identifying details]

(If none, state "None.")

Counts

[Instrument, sponge, and sharps count status] (If discrepancy occurred, document actions taken and final status.)

Complications

[None / Description of complication(s), timing, clinical impact, and corrective actions]

Postoperative Plan

• Disposition: [PACU then ward / PICU / NICU; intubation status; hemodynamic status]
• GI management: [NPO status, NG decompression settings, TPN timing if SBS risk or prolonged ileus expected]
• Ostomy management: [Output replacement plan and thresholds] (Only include if stoma created.)
• Antibiotics: [Agent(s) and duration based on contamination]
• Analgesia: [Multimodal plan with monitoring considerations]
• Drain/stoma monitoring: [Expected output, concern thresholds]
• Labs: [Tests and timing]
• Surveillance triggers: [Signs of anastomotic leak or ischemia to monitor]
• Second-look/reoperation: [Timing and criteria] (Only include if applicable.)
• Pathology questions: [Specific questions for pathologist] (Only include if applicable.)

Surgeon Signature

Attending Surgeon: [Name, credentials, date, time]

[Attestation statement per institutional policy] (Only include if trainee participated.)

(Do not auto-populate findings unless explicitly confirmed. Reference anesthesia or nursing records for unavailable perioperative values. Remaining small bowel length, ileocecal valve status, and stoma rationale must be explicitly addressed; state "not assessed" rather than omitting.)