Living Donor Hepatectomy Operative Note

Patient Name: [Patient name]

MRN: [Medical record number]

DOB: [Date of birth]

Date of Surgery: [Date]

OR Location: [Operating room/location]

Start Time: [Incision time]

End Time: [Closure time]

Diagnosis and Procedures

Preoperative Diagnosis: Living liver donor

Postoperative Diagnosis: [Same as preoperative or updated diagnosis if intraoperative findings altered indication]

Procedures Performed:

• [Hepatectomy type with segments and approach] (e.g., Living donor right hepatectomy, segments V-VIII, open approach)
• [Additional procedures performed] (List chronologically; include cholecystectomy, intraoperative ultrasound, cholangiography/ICG cholangiography, bile leak test, back-table graft preparation as applicable)

Case Classification: Elective

Operative Team

Primary Surgeon: [Name, credentials]

Co-Surgeon(s): [Name(s), credentials] (Include if applicable)

Assistants: [Name(s), credentials, and role attribution for significant tasks] (e.g., hilar dissection, transection, graft harvest)

Anesthesiologist: [Name, credentials]

Anesthesia and Intraoperative Data

• Anesthesia Type: [General / general + epidural / general + TAP block]
• Estimated Blood Loss: [mL]
• Transfusions: [None / product type and units]
• IV Fluids: [Crystalloid and colloid amounts]
• Urine Output: [mL] (Include if tracked)

Indication and Consent

[Brief statement of living liver donation, planned segment(s), and high-level rationale including graft size matching and anatomic suitability. Confirm donor suitability without duplicating full evaluation. State that informed consent is documented in the chart. If new intraoperative risks required additional decision-making, document the event, discussion, and resolution.]

Time-Out Verification

[Pre-incision verification completed with full team participation. Donor identity confirmed. Planned hepatectomy type and segments verified.]

Operative Findings

• Liver and Abdominal Findings: [Gross liver appearance including steatosis, congestion, or lesions; adhesions; any findings that altered the plan]
• Hepatic Artery Anatomy: [Standard vs replaced/accessory; branches preserved vs divided]
• Portal Vein Anatomy: [Branching pattern encountered; notable variants]
• Hepatic Venous Anatomy: [RHV/LHV/MHV relationships; accessory inferior hepatic veins; significant segment V/VIII veins]
• Biliary Anatomy: [Confluence pattern as confirmed intraoperatively; method used: IOC / ICG / ultrasound / preoperative imaging only]

Operative Procedure

Positioning and Incision

[Position, padding, and prophylaxis; Foley and NG/orogastric placement. Prep and drape. Incision type, entry technique, and initial exploration findings.]

Mobilization and Exposure

[Division of falciform, triangular, and coronary ligaments. Mobilization off IVC as applicable. Cholecystectomy if performed with rationale.]

Intraoperative Mapping

• Ultrasound: [Transection plane, MHV location, major venous tributaries identified]
• Cholangiography: [IOC via cystic duct cannulation; biliary anatomy pattern identified; impact on division plan] (Include only if performed)
• ICG Cholangiography: [Biliary visualization and effect on plan] (Include only if performed)

Hilar Dissection

[Dissection strategy prioritizing preservation of biliary blood supply. Arterial and portal branches isolated; method of control. Anatomic variants encountered and management.]

Parenchymal Transection

[Determination of transection plane. Transection technique and tools. Hemostasis and biliostasis on cut surface. Management of major venous tributaries including segment V/VIII veins and MHV-related structures.]

Biliary Division

• Method of biliary identification: [IOC / ICG / ultrasound]
• Division point: [Description relative to confluence in anatomic terms]
• Number of bile duct orifices on graft: [Count]
• Donor stump closure: [Suture type and size, clips, reinforcement]
• Leak testing: [Method and results / not performed]

Vascular Division and Graft Retrieval

• Heparinization: [Dose and timing relative to clamping / not used]
• Order of clamping/division: [Sequence of artery, portal vein, hepatic vein(s), accessory veins]
• Division techniques: [Stapler / clamp-and-cut / suture ligation]
• Warm ischemia time: [Duration with start and end points per institutional definition]
• Remnant perfusion confirmation: [Method used prior to irreversible division]

Back-Table Handling and Graft Handoff

[Flush solution type and routes, volumes if tracked. Graft weight or pending. Packaging per institutional protocol. Chain-of-custody statement including handoff recipient and time.] (Minimize recipient identifiers in donor chart)

Donor Remnant Management and Closure

[Hemostasis and biliostasis confirmation; topical agents if used. Reconstitution or positioning measures. Drain placement with type and location. Fascial and skin closure techniques. Final wound status.]

Anatomy and Division Summary

• Graft Type and Segments: [Lobe and segment(s)]
• Arterial Division: [Variant pattern if any; branches divided; branches preserved to remnant]
• Portal Venous Division: [Branching pattern; division point; accessory branches]
• Hepatic Venous Division: [RHV/LHV/MHV handling; accessory veins divided or preserved]
• Biliary Division: [Confluence pattern; duct count; division point; stump closure]
• Graft Weight: [Weight / Pending]

(If any element is unknown at note completion, mark as "Pending" and finalize via addendum.)

Donor Safety Checkpoints

• Pre-incision: [Donor identity, procedure, and planned segments verified; team briefing completed]
• Pre-transection: [Transection plane confirmed by ultrasound or demarcation; remnant inflow and outflow preserved]
• Pre-biliary division: [Biliary mapping method confirmed; division point agreed upon by team]
• Pre-vascular division: [Donor hemodynamics acceptable; blood products available; remnant perfusion confirmed prior to irreversible division]
• Post-graft removal: [Remnant hemostasis and biliostasis confirmed; Doppler confirmation of remnant flow or not performed; counts correct; graft labeled and handed off; team communication of post-op concerns completed]

(If a component was not performed, state "not performed" rather than omitting.)

Specimens

• Tissues Removed: [Hepatic segments with specification; gallbladder if removed; additional tissue with rationale]
• Sent to Pathology: [Specimen name, segment/laterality, and destination for each]
• Implants: [None / list if applicable] (Document hemostatic products only if institutionally required)

Counts and Complications

• Counts: [Final status] (If discrepancy occurred, document discovery, imaging, resolution, and final status)
• Complications: [None apparent / description of each event, management, and current status]
• Deviations from Plan: [What changed, why, and consequence] (Include if applicable)

Disposition and Postoperative Plan

• Condition: [Stable / other; extubated / intubated]
• Disposition: [PACU / ICU]
• Drains and Lines: [Type and location of drains; relevant lines remaining]
• Postoperative Orders:
  • [Diet and timing]
  • [Activity and ambulation plan]
  • [Pain management pathway]
  • [Laboratory schedule]
  • [Planned imaging per protocol]
  • [VTE prophylaxis with timing]
  • [Antibiotic duration]
  • [Drain management criteria]

Signature

Surgeon Signature: [Name, credentials, date, and time] (Complete immediately postoperatively to support safe handoff)