OPERATION DATA SHEET



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( 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 VV |

|(Carotid / graft |TIA |Aneurysm-elective |Ulcer/gangrene(arterial) |Sup thromboph. |

|stenosis) |Stroke |Aneurysm-rupt |Acute Ischaemia |DVT |

| |Steal |Aneurysm-occl |Rejection |Ulcer-non arterial |

|MS |Retinal isch |Aneurysm-pain |Infection |Aneurysm-venous |

| | |Aneurysm-mycotic |Wound closure |Pelvic congestion |

| | |Aortic ulcer(penetr) | |Nutcracker synd |

| | | | |Claudic(venous) |

| | |Transplant | |Portal hypert. |

|Trauma iatrog: |Trauma-non iatro: |T/P thrombosis |Neoplasm-malig |Varicocoele |

|-Haemorrhage |-Haemorrhage |Venous |Neoplasm-benign |Organ harvest |

|-Aneurysm-false |-Aneurysm-false |access/plas-phoresis |Graft/patch sepsis |React. Haem |

|-Occlusion |-Occlusion |Dialysis access |Aortoenter. fist.-prim |Sec. Haem Renal a |

|-AV Fistula |-AV Fistula |AVFistula closure |Aortoenter. fist.-sec |stenosis |

| | |Arteritis/collagen d |Lymphocele |Mesent ischemia |

|Retrieval FB |Dehiscence |Entrapment |Compartment syndr. Thoracic |Endoleak |

|Exposure |Impotence |Advent. Cyst |outlet |Pulm embolism |

| |Graft occlusion |Haematoma |May-Thurner |Hyperhidrosis |

| | | |SVC syndrome |GI bleed |

| | | | | |

| | | | | |

| | | | | |

|*Operation type: | | | | |

|Bypass(+/-angio) |Hybrid:CFA- Endart/Endo |Explore only |VV |RenalT/P-LRD |

|Patch only |Hybrid:IIB/Endo |Excision graft/patch |Venocuff |Renal T/P-cadaver T/P |

|Endart only | |Local repair |Radiofreq ablation |nephrectomy |

|Bypass + |Hickm/PermC in |Major amp –1o |Endovenous laser |Tenckhoff in / out |

|endart(+/-angio) |R/O Hickm/PermC |Major amp – 2o |Non thermal ablat. |AV shunt |

| |Portacath Insert |Minor Amp |Thrombin inject. |Thoracic outlet |

|Bypass + thrombect(+/- |R/O Portacath |Excision |Sclero-foam |Fasciotomy |

|angio) |Superficialize AVF |Ligation |Angiogram only |Sympathectomy |

| |DRIL |SSG |PTA |Exovasc collar |

|Endart + patch Endart + |AV Fistula-autog |Debridement |Stent-incl covered |Exc aortic graft/ELG + bypass |

|resect. |AV Fistula-prosth |Drainage |Stent graft |(in situ) |

|Embolectomy |AV F-banding |Retrieval |Other endolum. |Exc aortic graft /ELG+ ax-bifem|

|Embolect & patch |Transposition |Release |Regional hyperperf | |

|Thrombectomy(clot/ |Interposition | |Portosytemic shunt |L/Node dissection |

|tumor) |Re-implantation | | | |

|Thrombect. & patch | | | | |

| | | | | |

*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 fem(venous) |Abdomen |

| |Thor aorta-an |SP ligation |GSV/SSV |Abdo+leg(s) |

|AK Pop bypass |Thor aorta-non an |Bil SF |Central vein |Chest |

|BK Pop bypass |Thoracoabd (open) |Bil SP |Jugular |Neck |

|Bypass to TP trunk |Thor-abd(endolum) |Uni SF + SP |Axillosubclavian v |Upper limb(s) |

|Bypass to ant Tib | |Bil SF + SP |IVC |Lower limb(s) |

|Bypass to post Tib |Aorta(AAA rupture no |LSV ablation |SVC |Vertebral |

|Bypass to Peroneal |bypass) |SSV ablation |Portal v |Innominate |

|Bypass to DP |Aortic tube-Open |LSV & SSV ablat. |Mesenteric v |Subclavian |

|Bypass PT pedal |Aortic tube-endolum |Perf lig/coil/foam |Ovarian v |Axillary |

|Ilio-pop bypass AK |Aortoiliac-open(an) |Uni SF & uni/bil perf |Testicular v |Brachial |

|Ilio-pop bypass BK |Aortoiliac-open-occl |Uni SF & bilat VV |Iliac vein |Radial |

| |Aortoiliac-endolum |Uni SP & uni/bil perf |Femoral v |Aorta(not AAA) |

|Prosthetic (or stent) |Aortofem-aneurysm |Uni SP & bilat VV |Popliteal v | |

|graft |Aortofem- occlusive |VV(avulsions/foam) |Pulmonary a |Renal a |

|Vein graft |Aorta + Ax bifem |Venocuff +/- perf |Pulmonary v |Renal v(+/-IVC) |

|Anast. Repair |Iliofem byp- an. | |Brachiocephalic |Coeliac |

| |Iliofem byp-occl. |Lumbar-open |Brachiobasilic |SMA |

|Carotid |Ilio fem x over |Lumbar-lap’scopic |Radiocephalic |IMA |

|Carotid-stent |Iliofem(arterial) |Lumbar-chemical |Ulnobasilic |Lumbar a |

| |Ilio-SMA bypass |Thoracic |Ulnocephalic |Iliac |

|In stent stenosis(Carotid |Ilio-Renal |VATS |Brachiobrachial |CFA |

|only) |Splenorenal(art) |First / cervical rib |Thigh loop |SFA |

| |Aortorenal | |Ax-ax AVF |Profunda |

| |Ax uni fem |Above elbow |Brachio-axil AVF |Popliteal |

| |Ax bi fem |Below elbow |Kidney |TP trunk |

| |Fem fem(art) |AKA | |Ant tib |

| |Carotid-Subcl |BKA | |Post Tib |

| |Subcl-Carotid |Through knee | |Peroneal |

| |Vertebral-carotid |Disarticulation | |DP |

| |Carotid-carotid |Hindquarter | |Temporal |

| |Axillo-axillary |(Fore)foot | |>1 artery(Endo) |

| | |Toe(s) | |1 artery(Endo) |

| | |Finger(s) | | |

*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

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Patient ID Label

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