Gastrostomy Tube Placement Operative Note

Date of procedure: [Date]

Time of incision: [Time] (Include only if captured)

Location: [Facility and operating room]

Primary surgeon: [Name, credentials]

Assistants: [Names and roles] (Omit if none)

Anesthesia: [Type]

Preoperative diagnosis(es): [Diagnosis list]

Postoperative diagnosis(es): [Diagnosis list, or "same" if unchanged]

Procedure(s) performed: [Gastrostomy tube placement – open / laparoscopic / laparoscopic-assisted; additional procedures if applicable] (List in order performed with approach specified for each)

Indication

[Clinical rationale for gastrostomy and intended use: feeding, medication administration, venting/decompression, or combination. Include factors directly affecting intraoperative decision-making if relevant.] Informed consent was obtained.

Intraoperative Findings

• [Abdominal survey findings: adhesions, ascites, masses, or other relevant observations]
• [Stomach appearance at intended site]
• [Unexpected findings affecting technique or plan]

(If findings were unremarkable and clinically useful to document, state briefly. Omit items that do not apply.)

Operative Technique

Setup and access: [Patient position; prep and drape. Abdominal entry by open / laparoscopic / laparoscopic-assisted approach. For laparoscopic: entry technique and port placement. For open: incision location. Adhesiolysis if performed.] (Keep concise if routine; expand if access was challenging or required conversion.)

Site selection: [Skin exit site and gastric site selected] (Include rationale only if nonstandard location was selected.)

Gastrostomy creation and fixation: [Technique: Stamm / Seldinger-based laparoscopic / laparoscopic-assisted PEG / other. Fixation method with configuration; temporary vs permanent; number of fixation points.]

Tube placement: [Tube insertion steps. Confirmation of intragastric position with method and observed result: direct visualization of tip/balloon in stomach / aspiration of gastric contents / flush without resistance / air insufflation with gastric distention observed / endoscopic confirmation / fluoroscopic confirmation.]

Closure: [Hemostasis confirmation. Closure method for fascia and skin at port or incision sites. Local anesthetic infiltration if provided.]

Tube Details

Tube type: [Balloon-retained / Mushroom (bumper); Low-profile button / Standard tube]

Size: [French]

Length/measurement: [Button stem length in cm / External length or skin-to-bumper distance]

Balloon: [Volume and fill fluid] (Include only for balloon-retained devices)

External bolster position: [Distance from skin in cm]

Securement: [Sutures / securement device / dressing type]

(If any device detail is unavailable at dictation, note that it will be documented via addendum after verification.)

EBL and Complications

Estimated blood loss: [mL / minimal]

Complications: [None / Description of event, management, and status at case end]

Specimens: [Description and destination] (Include only if applicable)

Disposition and Postoperative Plan

• Disposition: [PACU / ICU / floor]
• Tube status: [To gravity drainage / capped / clamped; venting schedule if applicable]
• Feeding/medication timing: [When tube may be used for medications; when enteral feeds may begin; clinical conditions required before initiation]
• Flush regimen: [Volume and frequency]
• Site care: [Dressing management, timing of changes, external bolster position to maintain]
• Fixation device follow-up: [Removal timing for T-fasteners or temporary anchoring sutures] (Include only if applicable)

[Patient condition at case end and transfer destination]