Operative Note (Exploratory Laparotomy/Damage Control Laparotomy)

Date of Operation: [Date of Operation]

Start Time: [Start Time]

End Time: [End Time]

Location: [Operating Room / Hybrid OR / Other]

Urgency: [emergent / urgent / elective]

(If any header values are unknown at the time of documentation, insert "Pending — to be reconciled" rather than omitting.)

Surgical Team

• Primary Surgeon: [Name, credentials]
• Assistants: [Names and roles] (Include only those present.)
• Anesthesia: [General / Regional / MAC] — [Anesthesiologist / CRNA name]

Preoperative Diagnosis

• [Problem-oriented diagnosis 1]
• [Problem-oriented diagnosis 2]
• [Additional diagnoses as applicable]

Postoperative Diagnosis

• [Intraoperative finding 1]
• [Intraoperative finding 2]
• [Suspected/possible finding with limitations stated]

(Reflect intraoperative findings; if uncertainty remains, label as suspected/possible and state why assessment is limited.)

Indication

[Mechanism of injury or acute abdominal process, key triggers for emergent operation, and damage control rationale when applicable] (Use 2–4 concise sentences. Do not duplicate full H&P.)

Consent

[Standard informed consent obtained from patient / surrogate with capacity noted] or [Emergent life-saving procedure; consent unobtainable due to clinical status; attempts to contact surrogate documented] (Use 1–2 sentences.)

Preoperative Physiology (Damage Control Snapshot)

(Include this section when a damage control approach was used or seriously considered; otherwise omit.)

• Hemodynamics: [SBP range] / [MAP range]; [Pressor(s) and dose(s) if applicable]
• Temperature: [Core temp and timing]; Warming measures: [Active warming measures]
• Acidosis: pH [value, time]; Base deficit [value, time]; Lactate [value, time]
• Coagulopathy: INR [value]; PTT [value]; Fibrinogen [value]; [TEG/ROTEM parameters if used]
• Transfusion to incision: PRBC [units]; FFP [units]; Platelets [units]; Cryo [units]; TXA [given/not given, timing]
• Preop Imaging: [FAST result]; [CT findings with timing]

(If any values are pending or unavailable, insert explicit placeholders rather than omitting.)

Procedures Performed

1. Exploratory laparotomy [approach and incision]
2. [Damage control action: packing / vascular shunt / bowel left in discontinuity / temporary abdominal closure]
3. [Additional procedures in operative sequence]

Operative Findings

(Document systematically by anatomic region. For each region examined, state findings, actions performed, and any deferred evaluation with rationale.)

• Entry/Initial Survey: [Hemoperitoneum amount/quality], [Enteric/feculent contents], [Immediate life threats] — [Immediate actions taken]
• Right Upper Quadrant: [Liver segments, bleeding character, gallbladder, right hemidiaphragm] — [Interventions]; [Deferred elements with rationale]
• Left Upper Quadrant: [Spleen injury grade/extent, stomach fundus, left hemidiaphragm] — [Interventions]; [Deferred elements with rationale]
• Foregut: [Stomach, duodenum, Kocher maneuver performed/not, pancreas assessment, lesser sac explored/not] — [Findings and actions]
• Small Bowel and Mesentery: [Number/location of enterotomies, mesenteric injuries, ischemia/viability assessment from ligament of Treitz to ileocecal valve] — [Repairs/resections/temporization]; [Segments not evaluated and plan to reassess]
• Colon: [Segment(s) injured, contamination degree, vascular injury] — [Interventions]; [Deferred elements with rationale]
• Pelvis/GU: [Bladder assessment approach, pelvic hematoma status] — [Interventions]; [Deferred elements]
• Retroperitoneum: [Hematomas by zone I/II/III, expanding/stable, explored vs not explored with rationale] — [Interventions]
• Diaphragm: [Right/Left injury present/absent, repair status] — [Thoracoabdominal considerations]

(For each injury, describe location, severity, physiologic consequence, and whether definitively repaired, temporized, or deferred. If exploration abbreviated, document what was not evaluated, why, and plan for reassessment.)

Hemorrhage Control

(Chronologic documentation; format as action followed by response/endpoint. Include durations for time-dependent maneuvers.)

1. [Packing: location(s) and count] → [Bleeding response]
2. [Direct pressure / clamp / suture ligation / organ-specific repair / resection] → [Response and hemostasis status]
3. [Vascular control maneuver and duration] → [Effect]
4. [Temporary vascular shunt: vessel, shunt type, patency check, distal perfusion assessment] → [Outcome]
5. [Topical hemostatic adjuncts] → [Effect]

Contamination Control

• Hollow viscus injuries: [Location and size]; Contamination: [serous / bilious / feculent]; Peritonitis: [localized / diffuse]
• Control measures: [Primary repair / stapled closure / resection with stapled ends / diversion / drain placement / lavage volume]
• GI continuity: [in continuity / left in discontinuity] (If discontinuity: document ends closed/stapled, ends marked for identification, plan for second look)

Definitive Repairs

(Include only repairs actually completed during this operation; otherwise omit section.)

• [Organ/segment]: [Technique]; Hemostasis verified: [yes / no]; Leak test: [performed with result / not performed]; Drain(s): [type, location]
• [Additional definitive repairs]

Temporary Abdominal Closure

(Include only if abdomen is not definitively closed; otherwise omit section.)

• Indication: [Physiologic exhaustion / ACS concern / planned second look / deferred anastomosis / persistent contamination]
• Technique: [Vacuum-pack / commercial NPWT / fascial traction system]; Layers: [details]; Suction: [setting]
• Fascial edges: [approximated / partially approximated / completely open]
• Packing beneath TAC: [Type and count], Location(s): [list], Removal plan: [at takeback]
• Planned re-exploration: [Target time window]

Abdominal Wall Closure

(Include only if definitive closure performed; otherwise omit section.)

• Fascial closure: [Suture type/size], [Technique], [Retention sutures if used]
• Skin closure: [Staples / Suture / NPWT / Open]
• Wound class: [Clean / Clean-contaminated / Contaminated / Dirty-infected]

Specimens, Cultures, and Implants

• Specimens to pathology: [List or None]
• Cultures obtained: [Site and type or None]
• Implants/devices placed: [List or None]

Estimated Blood Loss and Resuscitation

• EBL: [mL] or [Massive hemorrhage — EBL not reliably estimable]
• Crystalloid: [Type and volume]
• Blood products (intraoperative): PRBC [units]; FFP [units]; Platelets [units]; Cryo [units]; Other [agents with dose/timing]
• Urine output: [mL] (if tracked)

Counts and Retained Items

• Count status: [Correct / Incorrect with explanation and actions / Not performed with justification]
• Intentionally retained items: [Yes / No] (If yes: [Item type and count], Location(s): [list], Planned removal: [at next takeback])

(When packs are intentionally retained, explicitly state count is intentionally incorrect.)

Intraoperative Complications

[Complication(s) and corrective actions] or [No intraoperative complications.]

Disposition

[Destination: ICU / PACU / IR]; Airway: [intubated with settings / extubated]; Hemodynamics: [pressors/doses or stable off pressors]; Condition: [brief status at handoff]

Staged Return-to-OR Plan

(Include when damage control, temporary closure, packing, or deferred anastomosis occurred; otherwise omit.)

• Timing target: [within 24–48 hours / specific time window]
• Goals of next operation: [Pack removal / hemostasis reassessment / definitive vascular repair / bowel viability assessment / anastomosis vs ostomy decision / fascial closure attempt]
• Triggers for earlier takeback: [Rising pressor requirement / ongoing transfusion / increasing lactate / abdominal compartment concerns / worsening acidosis or coagulopathy]
• TAC care instructions: [Suction settings, pack count awareness, abdominal pressure monitoring, output monitoring]