Return to OR for Post-Transplant Complication Operative Note

(Use this template for return-to-OR procedures following solid-organ transplantation. Always document: [Procedure(s) Performed], [Key intraoperative findings], [Key interventions], and [Immediate postoperative plan]. Prefer specific, measurable statements over vague descriptors. Use explicit time anchors when clinically relevant. If data are missing, write "Unknown," "Not assessed," or "Not applicable." Omit optional subsections that do not apply rather than leaving them empty.)

Header Fields

Facility/Location: [Facility or OR location]

Date of Surgery: [Date]

Start Time: [Start time] / End Time: [End time]

Case Urgency: [elective / urgent / emergent]

Primary Service: [Transplant surgery service and organ type]

Surgeon(s): [Name(s) and credentials]

Assistant(s): [Name(s) and credentials]

Anesthesia Type: [general / regional / MAC / other]

Anesthesiologist/CRNA: [Name(s)]

Pre-operative Diagnosis: [Diagnosis prompting take-back]

Post-operative Diagnosis: [Diagnosis after surgical evaluation]

Procedure(s) Performed: [List all procedures including re-exploration, washout, thrombectomy, revision, repair, decompression, temporary closure as applicable]

Immediate Post-Procedure Summary

(For urgent ICU handoff; ensure consistency with detailed sections below.)

• Procedures Performed: [Concise procedure list]
• Key Intraoperative Findings: [Highest-priority findings impacting immediate care]
• Key Interventions: [Critical actions taken and confirmation of effect]
• Immediate Postoperative Plan: [Critical next steps, monitoring, medications, drain management, timing of re-evaluation]

Indication for Return to OR

[Narrative of indication] (Include: time since transplant as POD#, triggering clinical signs such as hemodynamics, drain output, abdominal distension, or oliguria; pertinent laboratory trends including Hgb, lactate, LFTs, creatinine, coagulation parameters; and imaging findings if available. Follow with concise summary of index transplant details relevant to current issue: organ transplanted, anastomosis configuration, existing drains or stents.)

Consent and Verification

Consent: [Consent obtained from patient/surrogate, or emergency exception invoked; include time]

Time-out: [Completed prior to incision; note any special considerations]

Antibiotic Prophylaxis: [Agent, dose, timing relative to incision; note deviations from standard]

VTE Prophylaxis: [Intraoperative and postoperative plan]

Operative Findings

(Problem-oriented format. Include relevant negative findings only when clinically meaningful.)

Entry and Exposure: [Incision reopened approach, adhesions encountered, hemoperitoneum or hematoma volume estimate, location of collections, condition of transplanted organ on inspection including color, turgor, edema, and capsule integrity]

Bleeding/Hemostasis Findings: (Include only if applicable.) [Source(s) identified with anatomic specificity, character of bleeding, coagulopathy indicators if present, confirmation of hemostasis at end of case with method]

Vascular Patency/Thrombosis Findings: (Include only if applicable.) [Arterial inflow patency by vessel, venous outflow patency by vessel, presence and extent of thrombus, anastomotic narrowing or kinking or intimal flap, method of assessment and results, graft perfusion status before and after intervention]

Biliary Findings: (Include only if applicable.) [Anastomosis status, leak site if present, T-tube or stent status, biloma or bile staining, peritonitis findings]

Ureteral/Urinary Findings: (Include only if applicable.) [Ureter perfusion and viability, anastomosis integrity, stent position, bladder integrity, urinoma presence and location]

Abdominal Compartment/Closure Findings: (Include only if applicable.) [Fascial tension, visceral or graft edema, intra-abdominal pressure measurement if obtained, evidence of organ dysfunction from compartment physiology]

Other Relevant Findings: (Include only if applicable.) [Bowel injury, lymphocele, abscess, contamination, other]

Interventions Performed

(For each intervention, document what was done, anatomic location, technique and key materials, and method of confirming success.)

Hemorrhage Control: (Include only if applicable.) [Specific bleeders addressed and location, technique used and suture type, anastomotic revision details, topical hemostatics used, packing placed with number and locations, damage-control rationale if utilized, method confirming hemostasis]

Thrombosis/Stenosis Management: (Include only if applicable.) [Thrombectomy details including approach and catheter type, anastomotic revision specifics, bypass or interposition graft with graft type and anastomosis sites, thrombolytics if used, intraoperative anticoagulation dose and timing, confirmation of restored flow with modality and objective findings]

Biliary Intervention: (Include only if applicable.) [Repair or revision performed, conversion to alternate reconstruction if performed, T-tube or stent placement with type and size, leak testing method and result, drain placement for bile leak with type, size, and location]

Ureteral/Urinary Intervention: (Include only if applicable.) [Revision of ureteroneocystostomy or reimplantation technique, ureteral stent placement with type, size, length, and laterality, bladder or ureter repair, urinoma drainage, leak testing method and result]

Abdominal Decompression/Closure: (Include only if applicable.) [Indication and rationale for decompressive laparotomy, temporary abdominal closure method and system type, fascial traction method if used, planned timing for re-exploration; if closed: fascial closure technique and whether tension-free]

Specimens and Cultures

[Specimens obtained with description, source, and destination as frozen versus permanent; cultures obtained with source and timing relative to antibiotics] (If none, state "None" or omit per local policy.)

Drains, Tubes, and Implants

Drains: [For each drain placed or removed: type, size in French, precise anatomic location, exit site quadrant]

Tubes and Stents: [Biliary T-tube or stent with type and size; ureteral stent with type, size, length, and laterality; Foley or urinary management plan]

Implants/Grafts: [Vascular graft type as autologous, cadaveric, or synthetic with size; other implants]

Packing/Intentional Retained Material: [Number and type of packs left, exact locations, plan for removal, confirmation that receiving team was notified]

Counts and Safety

[Sponge, needle, and instrument counts correct, or description of discrepancy and management] (If packing intentionally left, document that counts reflect intentional retention.)

Closure

[Fascial closure technique, skin closure method, temporary abdominal closure method if not closed, wound classification if captured locally, dressing applied]

Intraoperative Data

Estimated Blood Loss: [Volume in mL] (For significant hemoperitoneum, separately estimate pre-existing evacuated blood versus intraoperative loss.)

Transfusions: [PRBC, FFP, platelets, cryoprecipitate units; cell saver volume]

Fluids: [Crystalloid volume, colloid volume]

Urine Output: [Volume in mL]

Intraoperative Complications

[Unintentional injuries, repairs performed, and impact on operative plan; if none: "No intraoperative complications."]

Disposition, Condition, and Postoperative Plan

Disposition and Condition: [Extubated versus intubated, hemodynamic status, destination as PACU or ICU, immediate concerns for receiving team]

Postoperative Plan: (Organize by problem domain; include only applicable items with objective targets and timing.)

• Bleeding risk: [Transfusion thresholds, lab recheck timing, reversal strategy if applicable]
• Vascular revision: [Anticoagulation or antiplatelet plan with agent, dose, and start time; Doppler schedule; perfusion monitoring parameters]
• Bile leak/biliary: [Drain management, antibiotic plan, planned imaging or ERCP and timing]
• Ureteral/urinary: [Foley duration, stent plan and removal timing, imaging, creatinine and urine output monitoring]
• Open abdomen/packing: [VAC settings, DVT prophylaxis approach, planned re-exploration date and time]
• Infection: [Antibiotic plan, culture follow-up, source control status]
• Transplant coordination: [Immunosuppression adjustments, who is managing, therapeutic drug monitoring plan]

Communication

[Family or surrogate updated with time; primary transplant service notified with time; consulting services notified]

Signature

Surgeon Signature: [Name and credentials]

Date/Time Signed: [Date and time]