Liver Transplant Operative Note

Date: [procedure date (MM/DD/YYYY)]

Facility/OR: [hospital name and operating room]

Primary Service: Transplant Surgery

Surgeon of Record: [attending surgeon name]

Assistants: [fellows, residents, APPs, scrub staff as applicable]

Preoperative Diagnosis

[Primary indication for liver transplant] (State the main diagnosis prompting transplant; use concise standardized terminology.)

[Relevant co-diagnoses and anatomic/technical considerations] (Include portal vein thrombosis status, prior abdominal surgery, TIPS, prior transplant, hepatocellular carcinoma status within criteria, or other factors that alter complexity. Omit if none.)

Postoperative Diagnosis

[Same as preoperative diagnosis / Modified due to intraoperative findings: [brief modification]] (Typically unchanged; explicitly note modifications only if present.)

Indications

[Brief rationale for orthotopic liver transplant and timing] (1–3 sentences summarizing disease severity, failure of medical therapy, urgency, and transplant candidacy. Include key operative risk modifiers that materially influenced technique selection.)

Procedures Performed

• Orthotopic liver transplant, [deceased donor (DBD / DCD) / living donor], [whole / split] graft, [first transplant / retransplant]
• Recipient hepatectomy
• [Portal vein thrombectomy] (Only include if performed.)
• [Venovenous bypass / Temporary portocaval shunt with [cannulation sites]] (Only include if used.)
• Biliary reconstruction: [duct-to-duct anastomosis / Roux-en-Y hepaticojejunostomy]
• [Additional procedures: cholecystectomy, hernia repair, lysis of adhesions, diaphragmatic repair, others] (List only those performed.)

Anesthesia and Prophylaxis

[General endotracheal anesthesia] with [TEE / regional block / additional monitoring] (Include special modalities if used.)

[Antibiotic prophylaxis agents and timing] (Include if relevant to postoperative plan.)

Intraoperative Findings

Recipient Findings

• [Portal hypertension severity and collaterals/varices]
• [Ascites volume] (Include if notable.)
• [Native liver appearance]
• [Adhesions/previous surgery impact]
• [Portal vein status: patent / partial thrombosis / complete thrombosis; extent and chronicity if known]
• [Bile duct condition]

Graft Findings

• [Anatomic variants: arterial / portal / biliary] (State "standard anatomy" if none.)
• [Back-table reconstructions performed] (Describe arterial, portal, venous, or biliary reconstructions. Omit if none.)
• [Preservation details relevant to implantation] (Flushes, patches if applicable.)

Donor and Graft Details

• Donor type: [DBD / DCD / Living donor]
• Graft: [whole / split (segment details)]
• ABO compatibility: [identical / compatible / incompatible]
• Preservation solution: [solution name]
• Machine perfusion: [none / hypothermic / normothermic; device type if used]

(Avoid donor-identifying information beyond standard transplant identifiers. Reference procurement record for details not immediately available.)

Key Operative Times

• Incision: [HH:MM]
• Native liver out (start anhepatic phase): [HH:MM]
• Graft out of preservation: [HH:MM]
• Portal vein reperfusion: [HH:MM]
• Hepatic artery reperfusion: [HH:MM]
• Closure complete: [HH:MM]

• Cold ischemia time: [duration] (From donor cross-clamp to portal reperfusion.)
• Warm ischemia time: [duration] (From graft out of preservation to portal reperfusion; for DCD include functional warm ischemia.)
• Anhepatic time: [duration] (From native liver out to portal reperfusion.)

(If any required time is unavailable, indicate verification source and flag for addendum.)

Blood Loss, Fluids, and Transfusions

EBL: [mL]

Urine Output: [mL]

Cell Saver Returned: [mL] (Only include if used.)

Fluids/Transfusions: Crystalloid [mL]; Colloid/Albumin [mL]; PRBC [units]; FFP [units]; Platelets [units]; Cryoprecipitate [units]; [Hemostatic agents: PCC, fibrinogen concentrate, TXA with doses if clinically consequential]

Vasoactive Support at End of Case: [agents and infusion rates]; ongoing at handoff: [yes / no]

See anesthesia record for full hemodynamic and infusion timeline.

Drains and Devices

• [Drain type], [size (Fr)], [anatomic location], [to bulb suction / gravity / other]
• [Additional drains as placed]
• [Biliary stent / T-tube: size and configuration] (Only include if placed.)
• [Vascular grafts, patches, conduits, or hemostatic matrices left in situ] (Only include if applicable.)

Specimens

• Native liver explant to pathology
• [Donor gallbladder, thrombus, lymph nodes, bile duct margins, intraoperative cultures] (List only those sent.)

(Omit this section if no specimens were sent.)

Complications and Intraoperative Events

[No intraoperative complications.] (If complications occurred, describe type, timing, and management actions.)

Reperfusion events: [No postreperfusion syndrome / Describe: MAP change, hyperkalemia, dysrhythmias, treatments given, need for CPR or defibrillation]

Counts

[Sponge, needle, and instrument counts correct at case end / Discrepancy noted: actions taken and resolution]

Description of Procedure

(Provide chronological narrative using concise, standardized surgical terminology. Explicitly document technique choices. Omit subsections not applicable.)

Incision and Exposure

[Incision type and location]. [Entry findings: ascites volume, adhesions if notable]. [Retractor system used].

Mobilization and Recipient Hepatectomy

[Division of ligaments]. [Hilar dissection: hepatic artery, portal vein, bile duct handling]. [Caval management: piggyback / bicaval]. [Temporary portocaval shunt or venovenous bypass: cannulation sites if used]. [Portal vein thrombectomy: extent, technique, endpoint if performed].

Venous Outflow Reconstruction

[Outflow anastomosis: hepatic vein cuff / side-to-side cavo-cavostomy / bicaval]. [Suture material if nonstandard]. [Deairing and flush method].

Portal Vein Anastomosis and Reperfusion

[Anastomosis technique and configuration]. Portal reperfusion at [HH:MM]. [Immediate graft appearance and hemodynamic response]. [Interventions for portal inflow issues if any].

Hepatic Artery Reconstruction and Reperfusion

[Recipient artery used: proper hepatic / common hepatic / replaced / gastroduodenal]. [Conduit or patch if applicable]. Arterial reperfusion at [HH:MM]. [Flow verification: Doppler / palpation / intraoperative ultrasound; findings].

Biliary Reconstruction

[Duct-to-duct anastomosis / Roux-en-Y hepaticojejunostomy]. [Duct size management and technique]. [Stent or T-tube placement and configuration if used]. [Leak check method and result if performed].

Hemostasis and Closure

[Major bleeding sources and control]. [Topical hemostatics if clinically relevant]. [Coagulopathy management]. Drain placement confirmed. [Fascial closure technique]. [Skin closure method].

Disposition and Immediate Postoperative Plan

• Airway: [intubated / extubated]
• Hemodynamics: [stable / unstable]; pressors [yes / no]; ongoing transfusion [yes / no]
• Destination: [ICU / other]

Immediate postoperative orders:

• [Lab frequency and timing]
• [Doppler ultrasound timing]
• [Antibiotic plan]
• [Anticoagulation/antiplatelet plan or held due to bleeding risk]
• [Other critical instructions for receiving team]