Evaluation of Operative Notes for Splenic Flexure Mobilization: Are the Key Aspects Being Reported?

Area of Science:

• Surgical Documentation
• Colorectal Surgery

Background:

• Accurate operative documentation is crucial for surgical quality and patient safety.
• Splenic flexure mobilization (SFM) is a key step in various colorectal surgeries.

Purpose of the Study:

• To evaluate the accuracy and completeness of operative notes for surgeries involving splenic flexure mobilization (SFM).

Main Methods:

• A retrospective review of 51 operative notes for complete SFMs was conducted.
• Data were collected for surgeries performed at a single institution between January 2015 and June 2020.

Main Results:

• None of the operative notes provided a rationale for SFM.
• Preoperative imaging use, reasoning for the chosen method, and safety steps were not documented.
• Most reports lacked technical details, with one-third simply stating "the splenic flexure was mobilized."

Conclusions:

• Operative documentation for SFM is critically lacking in essential details.
• Increased awareness can drive initiatives to standardize SFM techniques and enhance operative note quality.