Colectomy Operative Note (Segmental)

Date: [Date] Start Time: [Start time] End Time: [End time] Facility/OR: [Facility/OR]

Primary Surgeon: [Name, credentials] Assistant(s): [Assistant(s) / none] Anesthesia: [general / specify] Urgency: [elective / urgent / emergent] Wound Classification: [clean-contaminated / specify] Prophylaxis: [Antibiotic and VTE prophylaxis per protocol / specify agents and timing]

Preoperative Diagnosis

[Preoperative diagnosis]

Indication

[Clinical scenario and rationale for surgery] (Summarize indication such as malignancy, diverticulitis, polyp not amenable to endoscopic resection, volvulus, bleeding, ischemia, or obstruction. Include failure of nonoperative management if relevant. Note planned contingencies such as possible ostomy, possible conversion, or splenic flexure mobilization. If ostomy planned or possible, state whether preoperative stoma marking was performed, by whom, or why not.)

Postoperative Diagnosis

[Final diagnosis after exploration] (If different from preoperative diagnosis, briefly explain. If pathology pending, state "Final pathology pending" with best intraoperative impression.)

Procedures Performed

• [Open / Laparoscopic / Robotic-assisted] [right / left / sigmoid] colectomy
• [Adjunct procedures] (List only clinically significant or separately billable procedures: splenic flexure mobilization, extensive lysis of adhesions, appendectomy, omentectomy, intraoperative endoscopy, ostomy creation with type, ureteral stent placement. Omit if none.)

Intraoperative Findings

[Narrative description of intraoperative findings] (3–6 sentences describing extent and location of disease, abdominal exploration findings, and findings guiding decisions. For malignancy, comment on peritoneal surfaces, liver, and adjacent organ involvement. Distinguish gross impression from confirmed pathology.)

Operative Description

Positioning, Prep, and Entry

[Patient position] [Arm positioning] [Skin prep and draping] [Entry method] (For open, specify incision type and location. For minimally invasive, describe trocar placement strategy including key ports and planned extraction site. Note clinically significant adhesiolysis if performed.)

Exploration and Localization

[Abdominal exploration findings] [Lesion localization method and result] (Document palpation, tattoo identification, colonoscopy localization, intraoperative imaging/ICG, or if unable to localize with subsequent decision-making.)

Mobilization

[Mobilization details tailored to segment] (For right colectomy: ileocolic/cecal mobilization, hepatic flexure mobilization, omentum management; identification/protection of duodenum, right ureter, gonadal vessels, SMV region. For left colectomy: lateral attachments, splenic flexure mobilization status; identification/protection of left ureter, gonadal vessels, spleen/pancreas tail. For sigmoid colectomy: sigmoid/mesosigmoid mobilization, extent of pelvic dissection; identification/protection of left ureter, hypogastric nerves if relevant. Note difficult mobilization with reason if applicable.)

Vascular Control

(List each pedicle addressed. Specify artery and vein, level of ligation, and rationale if non-standard. Do not document a vessel as ligated unless definitively identified. This section must be completed in detail.)

• [Pedicle name]: [Artery and vein] ligated [at origin/centrally / distally/at branch level]; [technique]; [rationale if non-standard]
• [Additional pedicles as applicable]: [Details as above]

Resection

[Proximal division site and technique] [Distal division site and technique] [Device used] [Specimen extraction route and wound protector use for minimally invasive] [En bloc resection details if applicable]

Perfusion Assessment

[Method: visual inspection / palpation / Doppler / ICG fluorescence angiography] [Result] (Note if assessment prompted change in transection site or corrective action for marginal perfusion.)

Anastomosis

[Anastomosis configuration: end-to-end / side-to-side / functional end-to-end] [Location: ileocolic / colocolic / colorectal] [Approach: intracorporeal / extracorporeal] [Method: stapled / hand-sewn] [Mesenteric defect: closed / left open with rationale] [Tension-free, correct orientation, no twist confirmed] (If no anastomosis performed, state "Restoration of continuity not performed" with reason and alternative procedure. This section must be completed in detail.)

Anastomotic Testing

[Testing method: air leak test / dye test / intraoperative endoscopy / donut inspection / visual inspection] [Result: negative / positive] [Corrective action if positive]

Ostomy Creation

(Include only if ostomy created.)

• Type: [end ileostomy / loop ileostomy / end colostomy / loop colostomy / mucus fistula]
• Indication: [Reason for diversion]
• Site: [Quadrant] [preoperatively marked / not marked with reason]
• Technique: [Maturation technique; for loop ostomy, proximal limb orientation and confirmation method]
• Fascial aperture: [Creation technique]
• Stoma appearance: [Color, viability at end of case]

Closure

[Irrigation performed] [Hemostasis confirmed] [Fascial closure: material and technique, especially extraction site] [Port-site fascial closure for ≥10 mm ports if applicable] [Skin closure method] [Dressings] [Ostomy appliance if applicable]

Specimens

• [Specimen and segment] oriented with [sutures / staples / clips / ink] [fresh / formalin]
• [Anastomotic donuts if applicable]
• [Additional specimens as needed]

Estimated Blood Loss and Transfusions

EBL: [mL] Transfusions: [units and products / none] (Reference anesthesia record for IV fluids and urine output.)

Drains and Tubes

[Drain type and location, e.g., JP drain in pelvis via RLQ / no drains placed] [NG tube if left in place] [Foley catheter if special considerations] (Omit items not applicable.)

Complications

[None / Yes: description] (If yes, describe what occurred, how recognized, how managed, and current status. For conversion from minimally invasive, document point in case and reason.)

Disposition

[stable / unstable] [extubated / intubated] to [PACU / ICU] [Key handoff items if unusual]

Oncologic Documentation

(Include only for confirmed or suspected colon malignancy.)

• Curative intent: [yes / no]
• Tumor location: [Segment]
• Vascular resection summary: [Pedicles managed as documented above]
• Rationale for deviation: [Explain if resection or vascular approach deviated from expected anatomic mapping] (Omit if no deviation.)