Operative Note (Endoscopic Sinus Surgery)

Operative Note: Endoscopic Sinus Surgery (ESS)

(This template is designed for ESS cases, including adjunctive septoplasty, turbinate procedures, and optional image guidance. Do not infer laterality, procedures, extent of surgery, complications, specimens, or image guidance use. Explicitly document each item or use None as applicable. Omit sections that are not applicable per instructions.)

Case Information

• Procedure Date: [Date of surgery]
• Start Time / End Time: [Start time] / [End time]
• Location: [Facility name and setting]
• Primary Surgeon: [Attending surgeon name]
• Assistants: [Names and roles of assistants, or None]
• Anesthesia: [general / MAC / local] [Airway management if relevant]

Diagnoses

• Preoperative Diagnosis: [Diagnosis or diagnoses prompting surgery]
• Postoperative Diagnosis: [Confirmed diagnosis after surgical evaluation] (State same as preoperative only if truly unchanged)

Procedures Performed

(List each procedure on its own line with explicit laterality. Include adjunct procedures such as septoplasty, turbinate reduction, concha bullosa resection, balloon dilation, or CSF leak repair when performed. Do not list procedures not performed.)

[Procedures with laterality, e.g., Right maxillary antrostomy, Left total ethmoidectomy, Bilateral frontal sinusotomy Draf IIa, Septoplasty]

Indications

(Document the clinical indication and medical necessity. For CRS, include diagnosis category, objective evidence of disease, prior medical management, and rationale for surgery. For non-CRS indications such as mucocele or neoplasm, focus on imaging findings and clinical rationale.)

• Diagnosis Category: [CRS with nasal polyps / CRS without nasal polyps / recurrent acute rhinosinusitis / allergic fungal rhinosinusitis / mucocele / suspected neoplasm / complication of sinusitis / other]
• Objective Evidence of Disease:
  • Nasal endoscopy findings: [Findings with date] (If unavailable, prompt for endoscopy findings and date)
  • CT sinus findings: [Sinuses involved, key anatomic relationships, laterality, date] (If unavailable, prompt for CT report details and date)
• Prior Medical Management: [Topical intranasal corticosteroids, saline irrigation, systemic steroids, antibiotics for acute exacerbations, allergy management as applicable] (Include durations and that symptoms persisted despite appropriate therapy)
• Rationale for Surgery: [Persistent symptoms with objective disease / progressive polyp burden / need for tissue diagnosis / complications risk reduction / other]

Preoperative Preparation

• [Informed consent obtained, risks, benefits, and alternatives discussed]
• [Surgical time-out performed confirming correct patient, procedure, and site]
• [Topical decongestion used]
• [Local infiltration: agent, concentration, approximate volume] (Include only if performed)

Image Guidance

(Include this section only if image guidance was used; otherwise omit entirely.)

• Navigation system: [System name]
• Imaging dataset: [CT sinus dataset and date]
• Registration method: [Point merge / surface merge / automatic / other]
• Accuracy verification: [Landmarks verified]
• Clinical rationale for use: [Revision surgery / distorted anatomy / extensive polyposis / frontal disease / posterior ethmoid or sphenoid disease / proximity to skull base, orbit, optic nerve, or carotid / CSF leak / neoplasm / other]

Intraoperative Findings

(Organize by side. Do not document findings for sinuses not entered or evaluated. Specify anatomic variant source as preoperative imaging versus intraoperative observation.)

Right

• Global observations: [Polyp burden, purulence and location, mucosal edema, scarring or altered landmarks]
• Key landmarks visualized: [Middle turbinate, uncinate process, natural maxillary ostium, lamina papyracea, skull base, frontal recess, sphenoid ostium as applicable]
• Relevant anatomic variants: [Variants affecting approach or safety with source: preoperative imaging / intraoperative observation] (If none, state None)

Left

• Global observations: [Polyp burden, purulence and location, mucosal edema, scarring or altered landmarks]
• Key landmarks visualized: [Middle turbinate, uncinate process, natural maxillary ostium, lamina papyracea, skull base, frontal recess, sphenoid ostium as applicable]
• Relevant anatomic variants: [Variants affecting approach or safety with source: preoperative imaging / intraoperative observation] (If none, state None)

Procedure Details

(Provide a chronologic narrative organized by side. Describe only procedures actually performed. Omit any sinus or step not addressed.)

Positioning: [Patient position, head elevation, eye protection]

Right Side

• Uncinectomy and maxillary antrostomy: [Natural ostium identification, enlargement, tissue removed]
• Ethmoidectomy: [Partial / total, progression through ethmoid, attention to skull base and lamina papyracea]
• Sphenoidotomy: [Ostium identification, enlargement, contents] (Include only if performed)
• Frontal sinusotomy: [Approach and Draf classification, frontal drainage pathway confirmed] (Include only if performed)
• Polypectomy: [Instrument used, extent of removal] (Include only if performed)
• Hemostasis: [Methods used]
• Packing or spacers: [Type and location, or None]

Left Side

• Uncinectomy and maxillary antrostomy: [Natural ostium identification, enlargement, tissue removed]
• Ethmoidectomy: [Partial / total, progression through ethmoid, attention to skull base and lamina papyracea]
• Sphenoidotomy: [Ostium identification, enlargement, contents] (Include only if performed)
• Frontal sinusotomy: [Approach and Draf classification, frontal drainage pathway confirmed] (Include only if performed)
• Polypectomy: [Instrument used, extent of removal] (Include only if performed)
• Hemostasis: [Methods used]
• Packing or spacers: [Type and location, or None]

Special Circumstances

(Include only subsections that apply to this case.)

• Revision surgery: [Altered landmarks, adhesions, scarring, safety measures employed]
• CSF leak: [Location, estimated size, repair technique and materials, lumbar drain placed: yes / no]
• Orbital exposure: [Extent of lamina violation or periorbital exposure, management]
• Significant bleeding: [Source, control method, hemodynamic impact if any]

Final inspection: [Created openings patent, adequate hemostasis confirmed]

Specimens

[List all specimens with laterality and site, e.g., Right ethmoid polyps, Left maxillary sinus contents; cultures with site and specimen type if obtained; or None]

EBL, Implants, and Packing

• Estimated Blood Loss: [Volume in mL]
• Implants: [Steroid-eluting implant, frontal stent, or middle turbinate stabilization device with laterality and location, or None]
• Packing: [Absorbable / non-absorbable type, laterality, and location, or No packing placed]

Complications

[None / Description including what occurred, step where it occurred, recognition, management, outcome, and any postoperative monitoring or consultations required]

Disposition and Postoperative Plan

• Disposition: [PACU / observation / admission] [Patient stability at end of case]
• Condition: [Hemostasis status] [Vision check if orbital concern]
• Postoperative Debridement: [Planned timing for first endoscopic evaluation, whether debridement anticipated]
• Medications:
  • [Saline irrigation: start date and frequency]
  • [Topical intranasal corticosteroid or steroid irrigations]
  • [Antibiotics with indication, if prescribed]
  • [Systemic steroids with indication and regimen, if prescribed]
• Precautions: [Nose blowing restrictions, epistaxis precautions, red flags: vision changes, clear rhinorrhea, severe headache, uncontrolled bleeding]
• Follow-up: [Timing of postoperative appointment]