DOI: 10.1093/bjs/znad241.442 ISSN:

131 Cholecystectomy operation notes - a review and core trainee survey

Jason Kho, Jen Yee Kuan, Vinutha Shetty, Ravindra Date, Ilayaraja Rajendra
  • Surgery



The “Good Surgical Practice” document by Royal College of Surgeons (RCS) England, in line with GMC’s “Good Medical Practice” emphasises the importance of “clear operative notes for every procedure”. The importance of clear documentation is well-established, facilitates effective handover and represents a legal document. A study was conducted to assess current documentation standards, including a survey amongst core surgical trainees on the use of a proforma for documenting cholecystectomies.


A retrospective review of cholecystectomy operation notes collected from hospital database was performed between February 2022 and July 2022. Operative documentation was compared to the guideline published by RCS England. Specific information relevant to cholecystectomy operation were reviewed; critical view of safety/Calot’s triangle, number and type of clips, gallbladder dissection difficulty and spillage of bile/stones. Compliance to RCS standards was considered satisfactory at ≥80%.


109 typed operation notes were reviewed. Majority of information including date and time (100%), procedure name (99%), name of surgeon and assistant (100%), operative findings (100%) and post-operative care instructions including VTE prophylaxis (92%) were clearly documented. Shortfalls in documentation included priority of operation (63%), intraoperative complications (66%), gallbladder dissection difficulty (53%), anaesthetist name (52%), removal of ports under vision (33%) and local anaesthetic details (70%). Survey of eight core surgical trainees found a consensus that a proforma would improve understanding and documentation of the procedure.


The use of an operation note proforma in cholecystectomies could improve patient care and compliance with RCS guideline, and act as a learning modality for surgical trainees.

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