Operative Report (Craniotomy for Tumor Resection)

Date of Procedure: [Procedure date]

Time of Incision: [Incision time] | Time Out of OR: [OR end time]

Facility/OR: [Facility and OR room]

Patient: [Patient full name] | MRN: [Medical record number] | DOB: [Date of birth]

Primary Surgeon: [Primary surgeon name]

Assistant(s): [Assistant names and roles / None]

Anesthesia: [Anesthesia provider name(s) and type]

Neurophysiology/IONM: [IONM provider and modalities used] (Omit line if IONM not used.)

Diagnoses and Procedures

Preoperative Diagnosis: [Diagnosis with laterality and location] (Use "tumor" or "mass" with "pathology pending" if histology not yet confirmed.)

Postoperative Diagnosis: [Diagnosis, noting if unchanged or different from preoperative]

Procedure(s) Performed:

• [Primary procedure with laterality — craniotomy for tumor resection listed first]
• [Additional procedures] (Include dural repair, cranioplasty, EVD placement, awake mapping, intraoperative imaging as applicable.)

Indication

[Brief statement linking clinical presentation, imaging findings, and surgical rationale; include surgical goals such as tissue diagnosis, cytoreduction, decompression, or seizure control] (1–3 sentences.)

Localization and Functional Preservation

• Neuronavigation: [System, registration method, and accuracy confirmation]
• Preoperative functional imaging: [fMRI/DTI used for planning] (Only include if applicable.)
• Awake mapping/Direct stimulation: [Cortical and/or subcortical mapping; tasks; how positive sites guided resection limits] (Only include if performed.)
• Intraoperative neuromonitoring: [Modalities used; baseline status; any alerts with surgical response] (Only include if used.)
• Intraoperative imaging: [Ultrasound/iMRI/iCT and purpose] (Only include if used.)

Approach and Position

Position: [Patient positioning and head fixation method with pin sites if relevant]

Approach: [Surgical approach with side, key anatomic landmarks, and planned corridor]

Extent of Resection

Intent: [Biopsy / Subtotal resection / Gross total resection]

Achieved: [Gross total / Near-total / Subtotal / Partial / Biopsy only] (If limited, document reason: adherence to vessels, proximity to eloquent cortex, mapping boundaries, or neurophysiologic changes.)

Final extent of resection to be confirmed on postoperative MRI.

Critical Structures

[Key neuroanatomy at risk based on lesion location] (E.g., motor/language cortex, corticospinal tract, major vessels and perforators, venous sinuses, cranial nerves.)

Operative Findings

• [Tumor location and gross appearance: color, consistency, vascularity, necrosis]
• [Tumor boundaries and relationship to dura, pial surface, vessels, and eloquent structures]
• [Ventricle entry status] (Only include if entered; note management.)
• [Unexpected findings] (Only include if present.)

Description of Procedure

Preparation and Positioning

[Time-out confirmation; antibiotic prophylaxis] (May reference anesthesia record.)

[Positioning details, head fixation with pin sites, and any special considerations]

Navigation and Mapping Setup

[Neuronavigation registration and accuracy confirmation]

[Awake mapping or direct stimulation: mapping sequence, tasks, positive sites, and influence on resection limits] (Only include if performed.)

[IONM baseline status and any significant alerts with surgical response] (Only include if used.)

Craniotomy and Exposure

[Skin incision and relation to anatomical landmarks]

[Bone flap creation relative to key landmarks or sinuses; bone hemostasis]

[Dural opening technique and dural flap orientation]

Tumor Resection

[Cortical entry approach and resection corridor]

[Resection technique: microsurgical dissection, ultrasonic aspirator, internal debulking vs en bloc]

[Endpoint of resection and stopping criteria: normal-appearing margins, mapping boundaries, vascular adherence, IONM thresholds]

[Ventricle entry management] (Only include if applicable.)

Hemostasis

[Tumor bed inspection, irrigation, hemostatic technique and adjuncts used]

[Valsalva maneuver and result] (Only include if performed.)

[Significant bleeding: source, control method, and resolution] (Only include if occurred.)

Closure

[Dural closure method and sealant if used]

[Bone flap replacement and fixation; cranioplasty material if used]

[Drain placement] (Document type and location, or state "None." Details also in Implants and Drains section.)

[Layered wound closure description]

Counts and Retained Items

[Sponge, sharps, and instrument counts: correct / discrepancy with actions taken]

[Intentional retained material: type, location, and handoff communication / None]

Specimens

• [Specimen: anatomic source with laterality; testing requested; special handling] (If frozen section performed, note preliminary result and label as preliminary. Add additional specimens as needed.)

(If no specimen obtained, document "No specimen sent" with explanation.)

Estimated Blood Loss and Fluids

EBL: [Volume in mL / see anesthesia record]

Blood Products: [Type and units transfused / None]

Fluids: [Crystalloid/colloid totals] (Optional; may reference anesthesia record.)

Implants and Drains

Implants: [Cranial fixation hardware, dural substitute, sealants, cranioplasty material / None]

Drains: [Type and location / None]

Complications

[Intraoperative complications / None]

Disposition

Condition: [Extubated in OR / Remained intubated]

Destination: [ICU / PACU]

Immediate Neuro Status: [Brief neurological assessment / See PACU/nursing assessment]

Postoperative Plan

• Imaging: [MRI brain with and without contrast within 24–48 hours including DWI] (Note if CT head planned first with rationale.)
• Steroids: [Dexamethasone dose and taper plan / No steroids with rationale] (Taper as rapidly as clinically tolerated.)
• Seizure prophylaxis: [Agent, dose, and duration] (Only include if ordered.)
• DVT prophylaxis: [Timing and modality]
• Antibiotics: [Surgeon-directed antibiotics beyond routine prophylaxis] (Only include if applicable.)
• Pathology follow-up: [Plan for final pathology review and tumor board discussion]

(For safety-critical items—complications, counts, drains, implants—default to explicit "None" or "Correct" rather than omitting. If exact values are unknown, state "see anesthesia record." Do not infer definitive histopathologic diagnosis before pathology confirmation.)