Operative Report

Operative Report Components

Following are the key components to an operative report*:

Facility where study was performed
Patient identifying information (name + another identifier)
Procedure date
Preoperative diagnosis
Postoperative diagnosis
Procedure
Dictating physician
Surgeon(s)
Assistants
Anesthesiologist
Anesthetic
Patient history & clinical justification for procedure (indications)
Operations performed
Specimens removed (e.g., organs & tissue)
Pathological findings (e.g., intraoperative frozen section assessment of margins in pathology)
Complications
Estimated blood loss (EBL)
Fluids received
Findings
Chronological details of procedure including whether & what tissue was sent to pathology
Findings
Postoperative course
Disposition (discharge information & follow up instructions)

* Note that the order & presentation of these components may vary across hospitals

Common components in ovarian cancer staging operation reports

Evaluation of the undersurface of the diaphragm
Appearance of both ovaries
Whether the ovarian capsule was ruptured before or during the procedure
Extent of involvement of other abdominal organs (adnexa, pelvic wall, pelvic tissues)
Seeding & tumor implants
Encasement, nodularity of viscera
Frozen pelvis
Biopsies & intraoperative frozen section diagnoses of:
- Pelvic & abdominal peritoneum
- Pelvic & paraaortic lymph nodes
- Any suspicious nodules or masses
Tumor on or in the liver that is not biopsied
Nodules or evidence of tumor on the diaphragm that is not biopsied
Amount of tumor not resected (to estimate residual tumor bulk)
Areas where tumor was not removed
Peritoneal washings

Updated: June 8, 2018