OPERATION DATA SHEET

50kB Size 4 Downloads 6 Views

Sclero-foam. Angiogram only. PTA. Stent-incl covered. Stent graft. Other endolum . Regional hyperperf. Portosytemic shunt. RenalT/P-LRD. Renal T/P-cadaver ...
OPERATION DATA SHEET *Hospital …………………………………….………….. (*=Obligatory data entry) *Name of Consultant ………………………………….. *Surgeon (Cons / Fellow1 / 2 / Reg 1 / 2 / 3 / 4 / Radiologist / HMO)-If co- surgeons, circle both *Assistant (Cons / Fellow1 / 2 / Reg 1 /2 /3 /4 / Radiologist) *Date of Admission …………..………………………… *Date of Operation…………..……………………….… *Name of Operation…………..……………………….. Item No’s………………………………………………..

*Risk Factors: IHD / Diabetes / Hypertension / Smoking –Current(<2 weeks) / Ex / Non / Creat > 150 mMol/L

*Patient Type: Arterial / Venous / Renal failure / Other

*(If Arterial, type): Carotid / Chronic Limb / Acute Limb / Aneurysm / Trauma / Other



*Anaesthetic: General / Regional / Local / Sedation *ASA status: 1 / 2 / 3 / 4 / 5

*Indications for Operation: | | |Coarctation |Claudication |Primary VV | |Asymptomatic|Amaurosis |Dissection |Rest pain |Recurrent | |(Carotid / |TIA |Aneurysm-ele|Ulcer/gangrene(a|VV | |graft |Stroke |ctive |rterial) |Sup | |stenosis) |Steal |Aneurysm-rup|Acute Ischaemia |thromboph. | | |Retinal isch|t |Rejection |DVT | |MS | |Aneurysm-occ|Infection |Ulcer-non | | | |l |Wound closure |arterial | | | |Aneurysm-pai| |Aneurysm-ve| | | |n | |nous | | | |Aneurysm-myc| |Pelvic | | | |otic | |congestion | | | |Aortic | |Nutcracker | | | |ulcer(penetr| |synd | | | |) | |Claudic(ven| | | | | |ous) | | | |Transplant | |Portal | |Trauma |Trauma-non |T/P |Neoplasm-malig |hypert. | |iatrog: |iatro: |thrombosis |Neoplasm-benign |Varicocoele| |-Haemorrhage|-Haemorrhage|Venous |Graft/patch |Organ | |-Aneurysm-fa|-Aneurysm-fa|access/plas-|sepsis |harvest | |lse |lse |phoresis |Aortoenter. |React. Haem| |-Occlusion |-Occlusion |Dialysis |fist.-prim |Sec. Haem | |-AV Fistula |-AV Fistula |access |Aortoenter. |Renal a | | | |AVFistula |fist.-sec |stenosis | |Retrieval FB|Dehiscence |closure |Lymphocele |Mesent | |Exposure |Impotence |Arteritis/co|Compartment |ischemia | | |Graft |llagen d |syndr. Thoracic |Endoleak | | |occlusion |Entrapment |outlet |Pulm | | | |Advent. Cyst|May-Thurner |embolism | | | |Haematoma |SVC syndrome |Hyperhidros| | | | | |is | | | | | |GI bleed | | | | | | | | | | | | | | | | | | | |*Operation | | | | | |type: |Hybrid:CFA- |Explore only|VV |RenalT/P-LRD | |Bypass(+/-an|Endart/Endo |Excision |Venocuff |Renal | |gio) |Hybrid:IIB/E|graft/patch |Radiofreq |T/P-cadaver T/P | |Patch only |ndo |Local repair|ablation |nephrectomy | |Endart only | |Major amp |Endovenous |Tenckhoff in / | |Bypass + |Hickm/PermC |–1o |laser |out | |endart(+/-an|in |Major amp – |Non thermal |AV shunt | |gio) |R/O |2o |ablat. |Thoracic outlet | | |Hickm/PermC |Minor Amp |Thrombin |Fasciotomy | |Bypass + |Portacath |Excision |inject. |Sympathectomy | |thrombect(+/|Insert |Ligation |Sclero-foam |Exovasc collar | |- angio) |R/O |SSG |Angiogram |Exc aortic | | |Portacath |Debridement |only |graft/ELG + | |Endart + |Superficiali|Drainage |PTA |bypass (in situ)| |patch Endart|ze AVF |Retrieval |Stent-incl |Exc aortic graft| |+ resect. |DRIL |Release |covered |/ELG+ ax-bifem | |Embolectomy |AV | |Stent graft |L/Node | |Embolect & |Fistula-auto| |Other |dissection | |patch |g | |endolum. | | |Thrombectomy|AV | |Regional | | |(clot/ |Fistula-pros| |hyperperf | | |tumor) |th | |Portosytemic| | |Thrombect. &|AV F-banding| |shunt | | |patch |Transpositio| | | | | |n | | | | | |Interpositio| | | | | |n | | | | | |Re-implantat| | | | | |ion | | | |

*Side: Right / Left / Bilateral / Midline

*Patch/Conduit: GSV reversed / GSV in situ / GSV non reversed / SSV / SFA / SFV / Arm vein / Neck vein / ECA / Homograft / Composite / PTFE with cuff / PTFE / Dacron with cuff / Dacron / Stent / Stent graft / Polyurethane(Braun) / Flonova / Omniflow / Radial / Vein(other) / Prosthetic(other) / Pericardium

*If Carotid: Shunted – Y / N ; Eversion endarterectomy – Y / N ; Contralat status – Patent / Occluded ; % Stenosis - 0-15 / 16-49 / 50-59 / 60-69 / 50-69 / 70-79 / 80-99 / String sign / Thrombosed postop Time betw 1st symptom and surgery - < 48 hours / 3-7 days / 8-14 days / > 2 weeks / Asymptomatic

*If AAA: Suprarenal clamp-Y / N ; Suprarenal AAA – Y / N ; Blood loss(ml)- 0-999 / 1000 –1999 / 2000-2999 / 3000-3999 / >4000 ; Max diameter (cm) ……….

*ONLY If Infrainguinal bypass (ie. Not Fem-Fem x-over), site of proximal anastomosis: CFA / SFA / Profunda / Ext Iliac / AK Popliteal / BK Popliteal / Abdo Dacron / Aorta / Tibial / Vein graft Vein graft quality: Good / Suboptimal. Runoff status: Blind popliteal / 1 crural vessel / 2 vessel / 3 vessel runoff



|*Operative | | | | | |Site |R Atrium |SF ligation |Fem |Abdomen | | |Thor |SP ligation |fem(venous) |Abdo+leg(s) | | |aorta-an |Bil SF |GSV/SSV |Chest | |AK Pop bypass|Thor |Bil SP |Central vein|Neck | | |aorta-non an|Uni SF + SP |Jugular |Upper | |BK Pop bypass|Thoracoabd |Bil SF + SP |Axillosubcla|limb(s) | | |(open) |LSV ablation|vian v |Lower | |Bypass to TP |Thor-abd(end|SSV ablation|IVC |limb(s) | |trunk |olum) |LSV & SSV |SVC |Vertebral | |Bypass to ant| |ablat. |Portal v |Innominate | |Tib |Aorta(AAA |Perf |Mesenteric v|Subclavian | |Bypass to |rupture no |lig/coil/foa|Ovarian v |Axillary | |post Tib |bypass) |m |Testicular v|Brachial | |Bypass to |Aortic |Uni SF & |Iliac vein |Radial | |Peroneal |tube-Open |uni/bil perf|Femoral v |Aorta(not | |Bypass to DP |Aortic |Uni SF & |Popliteal v |AAA) | | |tube-endolum|bilat VV |Pulmonary a | | |Bypass PT |Aortoiliac-o|Uni SP & |Pulmonary v |Renal a | |pedal |pen(an) |uni/bil perf|Brachiocepha|Renal | |Ilio-pop |Aortoiliac-o|Uni SP & |lic |v(+/-IVC) | |bypass AK |pen-occl |bilat VV |Brachiobasil|Coeliac | |Ilio-pop |Aortoiliac-e|VV(avulsions|ic |SMA | |bypass BK |ndolum |/foam) |Radiocephali|IMA | | |Aortofem-ane|Venocuff +/-|c |Lumbar a | |Prosthetic |urysm |perf |Ulnobasilic |Iliac | |(or stent) |Aortofem- | |Ulnocephalic|CFA | |graft |occlusive |Lumbar-open |Brachiobrach|SFA | |Vein graft |Aorta + Ax |Lumbar-lap’s|ial |Profunda | |Anast. Repair|bifem |copic |Thigh loop |Popliteal | | |Iliofem byp-|Lumbar-chemi|Ax-ax AVF |TP trunk | |Carotid |an. |cal |Brachio-axil|Ant tib | |Carotid-stent|Iliofem |Thoracic |AVF |Post Tib | | |byp-occl. |VATS |Kidney |Peroneal | |In stent |Ilio fem x |First / | |DP | |stenosis(Caro|over |cervical rib| |Temporal | |tid only) |Iliofem(arte| | |>1 | | |rial) |Above elbow | |artery(Endo)| | |Ilio-SMA |Below elbow | |1 | | |bypass |AKA | |artery(Endo)| | |Ilio-Renal |BKA | | | | |Splenorenal(|Through knee| | | | |art) |Disarticulat| | | | |Aortorenal |ion | | | | |Ax uni fem |Hindquarter | | | | |Ax bi fem |(Fore)foot | | | | |Fem fem(art)|Toe(s) | | | | |Carotid-Subc|Finger(s) | | | | |l | | | | | |Subcl-Caroti| | | | | |d | | | | | |Vertebral-ca| | | | | |rotid | | | | | |Carotid-caro| | | | | |tid | | | | | |Axillo-axill| | | | | |ary | | | |

*Operation status: Elective / Emergency / Semiurgent ……… Primary op / Redo op

*Unplanned return to theatre : Y / N

Number of separate vascular procedures this operation ( & thus no of operation sheets ): 1 / 2 / 3 / 4 / 5

* If Endoluminal procedure: Proceed to separate data sheet AFTER completing this operation sheet.

COMMENT: 10/6/2015 -----------------------

Patient ID Label

Comments