Pediatric Surgery Operative Report (Full)

Operative Report (Full) – Pediatric Surgery

Patient Name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Sex: [Sex]

Weight (kg): [Weight in kg] (Use most recent preoperative weight for all weight-based calculations.)

Date of Procedure: [Date]

Procedure Start Time: [HH:MM]

Procedure End Time: [HH:MM]

Urgency: [elective / urgent / emergent]

Primary Surgeon: [Name, credentials]

Assistant(s): [Name(s), credentials] (Include trainees and APPs if applicable.)

Anesthesia Type: [Type of anesthesia]

Anesthesia Clinician: [Name, credentials]

Patient Position: [Position] (Include padding and positioning devices if relevant.)

Preoperative Diagnosis: [Preoperative diagnosis(es)]

Postoperative Diagnosis: [Postoperative diagnosis(es)] (State "same" if unchanged.)

Procedure(s) Performed

(List each procedure in chronological order. Include laterality/site and approach. Note unplanned procedures with brief rationale.)

• [Procedure name; laterality/site; approach]
• [Additional procedure if performed]

Procedure Summary

• Key Intraoperative Findings:
  • [Most clinically important normal and abnormal findings]
• Wound Classification: [clean / clean-contaminated / contaminated / dirty-infected]
• Counts: [correct / discrepancy with resolution]
• Estimated Blood Loss (EBL): [mL] ([mL/kg])
• Fluids and Blood Products: [Crystalloid type and mL; blood products with volumes as applicable]
• Drains/Tubes/Lines Placed: [Type; size (Fr); location; drainage mode] (Omit if none.)
• Specimens: [Label; source; destination] (Omit if none.)
• Implants: [Device; size; location] (Omit if none.)
• Complications: [none apparent / description with management]
• Disposition: [Destination; condition; airway status; hemodynamic support if any]

Indications

[Clinical indication for surgery including symptom duration, acuity, failed conservative measures, or emergent findings. Reference pertinent imaging and labs. Note relevant prior operations affecting anatomy. Document consent obtained from parent/guardian/emancipated minor; for emergencies with implied consent, document circumstances.]

Operative Findings

[Narrative description of intraoperative findings including relevant normal and abnormal anatomy with severity, measurements, and locations. Note congenital variants and anatomic relationships. Include size constraints or tissue fragility in neonates/infants that affected approach.]

Operative Technique

Preparation and Positioning: [Skin check, positioning, padding, time-out, antibiotics, skin preparation, draping]

Access and Exposure: [Incision location and length OR port number/size/positions; for minimally invasive cases include entry technique, insufflation gas, and pressure in mmHg]

Operative Steps: [Stepwise chronological description of dissection planes, identification and protection of critical structures, vascular control, hemostasis, and specific resection/repair/reconstruction performed; include anastomosis configuration and suture type/size when clinically meaningful]

Adjuncts: [Intraoperative adjuncts such as endoscopy, ultrasound, fluoroscopy, cholangiography, nerve monitoring with purpose and findings] (Omit if none used.)

Specimen Handling: [Specimens collected with labels and handling; frozen section or margin assessment if performed] (Omit if no specimens.)

Implants/Grafts: [Device or graft placed with location and fixation method] (Omit if none.)

Hemostasis, Irrigation, and Testing: [Irrigation performed; hemostasis confirmation; integrity or leak testing with results]

Closure: [Layered closure technique including fascial closure method/material, skin closure, dressings, local anesthetic infiltration if performed]

Conversion: [If converted from minimally invasive to open, document timing and reason] (Omit if not applicable.)

Key Decisions/Deviations: [Decision points and rationale for deviations from planned approach] (Omit if none.)

Specimens

(Include only if specimens obtained; otherwise state "Specimens: None" or omit per local preference.)

• Label: [Exact label]; Source: [Anatomic source with laterality]; Destination: [Pathology / Microbiology / Cytology / Research]; Special Handling: [Frozen section / margin evaluation / culture / other]

Implants and Prosthetics

(Include only if implants placed; otherwise state "Implants: None" or omit.)

• Device: [Name and type]; Manufacturer/Model: [Details]; Size: [Size]; Location: [Anatomic site]; Fixation: [Method]; Notes: [MRI compatibility, temporary with removal plan, or other relevant details]

Drains and Tubes

(Include only if placed by surgical team; otherwise omit.)

• Type: [Drain/tube type]; Size: [French]; Location: [Anatomic site]; Mode: [Suction / water seal / gravity]; Removal Criteria: [Criteria if established]

Complications

Complications: [None apparent / Detailed description including what happened, clinical impact, corrective actions, and effect on operative plan or disposition]

Disposition and Postoperative Plan

[Patient condition at case completion (stable/guarded/critical); airway status (extubated/intubated); hemodynamic support if any; destination (PACU/PICU/NICU/ward/transfer)]

• Diet: [NPO / clear liquids / advance as tolerated; timing]
• Activity: [Restrictions and duration]
• Analgesia: [Multimodal plan with weight-based guidance if applicable]
• Antibiotics: [Agent(s), indication, duration; pending cultures if applicable]
• Imaging/Labs: [Planned studies and timing]
• Drain/Catheter Care: [Management instructions]
• Follow-up: [Clinic timing; wound check; pathology review; referrals]

Authentication

Surgeon Signature: [Name, credentials, signature]

Date/Time: [Date and time of authentication]

Attestation: [Statement documenting attending surgeon presence during key and critical portions] (Include only if trainee performed portions of procedure.)