Operative Note (Open Vascular Surgery)

Date of Surgery: [Date]

Patient Name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Location/OR Room: [Hospital and OR room]

Procedure Start Time: [Start time] (Omit if not reliably captured.)

Procedure End Time: [End time] (Omit if not reliably captured.)

Surgeon: [Primary surgeon]

Assistant(s): [Assistant names and roles]

Anesthesia Type: [general / regional / local with sedation / MAC]

Case Summary

Preoperative Diagnosis: [Diagnosis with laterality and anatomic level]

Postoperative Diagnosis: [Diagnosis] (State if different from preoperative and document the intraoperative basis for any change.)

Procedures Performed:

• [Primary procedure] — [Approach: retroperitoneal / transperitoneal / groin incision / other], [Laterality]
• [Additional procedure] — [Approach], [Laterality] (List additional procedures in chronological order.)

Indications: [Salient symptoms, relevant imaging or diagnostic findings, and rationale for open approach]

Findings:

• [Key anatomy encountered; variant anatomy if present]
• [Pathology: aneurysm extent or occlusion level; calcification; thrombus burden]
• [Target vessel quality: diameter, wall quality, distal runoff]
• [Unexpected findings that altered the operative plan]

EBL: [Estimated blood loss in mL] (Omit for truly minimal blood loss unless organizational policy requires explicit documentation.)

Fluids/Blood Products: [Crystalloid/colloid totals; blood products and units; cell saver volume if used]

Implants/Prosthetics:

• [Graft or conduit: type/material, configuration, size, anatomic location]
• [Patch: material, size, vessel/location]
• [Implantable hemostatic agents if applicable: type and location]

(Reference implant log for UDI/lot numbers. Omit section if no implants placed.)

Specimens:

• [Specimen name], [Laterality/location], [Destination: pathology / microbiology]

(Omit section if no specimens removed.)

Drains:

• [Drain type and size], [Anatomic location/target space], [Exit site]

(Omit section if no drains placed.)

Complications: [No apparent complications / Specific complications with brief description] (Document "No apparent complications" only if the case concluded without recognized adverse events.)

Counts: [Sponge, needle, and instrument counts correct / Discrepancy details, actions taken, imaging results, and resolution] (Only document counts as correct if confirmed.)

Disposition: [Destination: PACU / ICU / stepdown], [Airway status: extubated / remained intubated], [Hemodynamic stability], [Key vascular exam: named pulses/Doppler signals, limb or organ perfusion status]

Procedure in Detail

Positioning, Prep, and Prophylaxis

[Patient position and supports], [Pressure point precautions], [Antibiotic prophylaxis: agent, dose, timing, redosing], [VTE prophylaxis if relevant], [Skin prep and field].

Incision and Exposure

[Incision location and length], [Approach], [Redo considerations: prior scars/grafts/adhesions], [Structures exposed with specific vessel segments named], [Method of obtaining vascular control: vessel loops, Rumel tourniquets, clamp types].

Anticoagulation

[Heparin dose and timing relative to clamping], [ACT target and measurements if used], [Protamine dose, timing, and rationale if administered].

Vascular Control and Clamping

[Exact clamp sites and vessel segments], [Sequence of clamping], [Shunt use: type, indication, dwell time], [Distal ischemia management strategies].

Arteriotomy, Endarterectomy, or Thrombectomy

(Include this subsection when applicable.)

• [Vessel opened and arteriotomy length]
• [Endarterectomy plane and endpoints; tacking sutures if used]
• [Thrombectomy catheter type/size; number of passes; thrombus retrieved]
• [Backbleeding and forward flow assessment; intimal flap management]

Conduit or Graft Selection and Preparation

(Include this subsection when applicable.)

• [Conduit type: autologous vein reversed / autologous vein in situ / prosthetic / biologic]
• [Vein harvest details: segment, technique, side branch management, valve lysis method]
• [Graft configuration and size; preparation details]

Anastomoses and Reconstruction

(Document for each anastomosis.)

• [Proximal anastomosis]: [Exact vessel segment]; [Orientation: end-to-side / end-to-end]; [Technique: running / interrupted / parachute]; [Beveling or patch/cuff adjuncts]; [Suture type and size]; [Backbleeding/flush sequence].
• [Distal anastomosis]: [Details as above].
• [For bifurcated grafts: limb routing, tunneling path, measures to avoid kinks or compression].

Reperfusion and Completion Assessment

• [Unclamp sequence and de-airing steps]
• [Hemodynamic response if significant]
• [Completion assessment: Doppler signals at named sites; palpable pulses]
• [Completion duplex or angiography results if performed; revisions if any]
• [Final limb or organ perfusion status]

(Do not document completion assessment findings unless explicitly verified.)

Hemostasis and Closure

[Hemostasis strategy: additional sutures, topical agents], [Retroperitoneum or peritoneum management], [Layered closure technique], [Dressings or negative pressure therapy].

Clamp and Ischemia Times

• Cross-clamp time: [Start time] to [Stop time] — [Total duration]; [Clamp level: infrarenal / suprarenal / supraceliac]
• Organ ischemia times: [Organ]: [Start time] to [Stop time] — [Duration]
• Shunt dwell time: [Start time] to [Stop time] — [Duration]

(Use 24-hour format. Include organ ischemia times when clinically relevant. Include shunt dwell time only if shunt was used. If clamp time was not captured, document "Clamp time not recorded" with explanation and reference to anesthesia record. Do not estimate retrospectively.)

Postoperative Plan

• [Antiplatelet and/or anticoagulation plan: agents, dosing, timing, targets]
• [Blood pressure goals if graft- or anastomosis-dependent]
• [Neurovascular check frequency and parameters]
• [Antibiotic continuation plan: agent, duration]
• [Drain management and removal criteria]
• [Other immediate orders: activity, Foley, diet, imaging, dialysis considerations]

(Use case-specific details throughout; avoid copy-forward language. Omit sections or fields that do not apply rather than including placeholder text, except where organizational policy requires explicit "None" statements. If full dictation is delayed, enter a brief operative note with minimum required elements before patient transfer: surgeon, procedures performed, key findings, EBL, specimens, postoperative diagnosis.)