Kidney Transplant Operative Note

Procedure Date: [Date]

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

Surgeon: [Attending of record]

Assistants: [Names and roles]

Anesthesia: [Provider and type]

Pre-operative Diagnosis: [ESRD due to etiology]

Post-operative Diagnosis: [Diagnosis] (If same as pre-op, state "same as pre-operative diagnosis".)

Procedure(s) Performed: [List each procedure: kidney transplant with laterality and donor type, back-table preparation, vascular anastomoses, ureteroneocystostomy ± stent, additional procedures]

Donor and Organ Identification

Donor Type: [living / deceased DBD / deceased DCD]

UNOS Donor ID: [ID]

Graft Laterality: [left kidney / right kidney]

Preservation: [Static cold storage on ice with solution / machine perfusion with pump system and solution]

(If any element is unavailable in the OR record, explicitly state "not available at time of dictation" rather than omitting or inferring.)

Indications

[ESRD etiology; primary vs re-transplant status; recipient factors influencing operative approach such as prior surgery, vascular disease, or body habitus. Statement confirming informed consent verification and surgical time-out performed.]

Operative Findings

• [Recipient iliac vessel quality: calcification, caliber, suitability] (Include meaningful negatives such as "without significant calcification".)
• [Adhesions or prior transplant bed findings] (Include only if relevant.)
• [Allograft appearance on receipt: capsule integrity, perfusion concerns]
• [Allograft vascular anatomy: number of arteries/veins, early branching, anatomic variants]

Prophylaxis

• Antibiotic Prophylaxis: [Agent(s) and timing relative to incision]
• Induction Immunosuppression: [Agent(s) and dose(s) administered in OR]
• Heparin: [Dose and timing; reversal agent if given] (Include only if used.)

Operative Description

Positioning and Incision: [Patient position; skin prep; incision type and side; extraperitoneal vs peritoneal approach]

Recipient Vessel Exposure: [Selected vessels; extent of dissection; lymphatic management; clamp placement]

Back-Table Preparation: [Graft laterality confirmation; perinephric fat removal; flush solution and effluent quality; vascular reconstruction if performed] (If a separate bench note exists, summarize key points and reference it.)

Venous Anastomosis: [Recipient vein; configuration; suture material; use of venous extension or reconstruction if applicable]

Arterial Anastomosis: [Recipient artery; configuration; Carrel patch use; handling of multiple arteries; intraoperative flow concerns and management if any]

Reperfusion: [Clamp release sequence; immediate graft appearance including color and turgor; arterial pulse assessment; management of capsular bleeding]

Ureteroneocystostomy: [Technique: extravesical/intravesical, refluxing/nonrefluxing; ureter spatulation; periureteral tissue preservation; stent placement with type and size; bladder closure method; leak test and result if performed]

Closure: [Drain type/size/location; fascial closure technique; skin closure method; confirmation of correct sponge/needle/instrument counts]

Additional Procedures: [Description of each additional procedure with indication and key steps] (Include only if performed: peritoneal window, native nephrectomy, prior graft explant, allograft biopsy with timing.)

Ischemia Times and Metrics

Organ Out of Cold Storage: [Time]

Start of First Anastomosis: [Time]

Reperfusion Time: [Time]

Recipient Warm Ischemia Time: [Minutes] (Do not back-calculate if anchor times are uncertain.)

Cold Ischemia Time: [Hours] (Label source: OPO-provided vs institutional timestamp.)

Estimated Blood Loss: [mL]

Urine Output: [Total mL; urine production post-reperfusion: yes / no]

Immediate Graft Assessment

[Visual perfusion status at case completion; arterial pulse or Doppler findings; urine production after reperfusion; any concern for delayed graft function and immediate actions taken] (Qualify assessments rather than stating "good function" based solely on appearance.)

Implants

• Ureteral Stent: [Type, size/length, UDI or lot number]
• [Other implants: vascular grafts, patches with device type and identifiers] (Include only if applicable.)

Complications

[None / List each complication with specific description and intraoperative management]

Specimens and Disposition

Specimens: [Each specimen with source, type, and destination] (Include only if specimens obtained.)

Disposition: [PACU / ICU]; [extubated in OR / remained intubated]; [hemodynamic status]; [drains in place with type]; [Foley catheter in place]

Postoperative Plan

• Immunosuppression: [Continuation plan: calcineurin inhibitor, antimetabolite, steroid taper]
• Antibiotics: [Perioperative continuation or discontinuation timing]
• VTE Prophylaxis: [Agent and start time relative to surgery]
• Foley Catheter: [Duration and removal criteria]
• Drain Management: [Monitoring and removal criteria] (Include only if drain placed.)
• Ureteral Stent: [Planned removal timeframe and responsible service]
• Postoperative Studies: [Timing for ultrasound, labs, urine output targets]

(For required transplant data—UNOS Donor ID, graft laterality, ischemia times, implant identifiers—if unknown at dictation, explicitly document as "not available at time of dictation" and reconcile via addendum. Do not infer or copy-forward transplant-specific data from prior notes.)