DATE AND TIME: [Date and time]
URGENCY: Elective / Non-elective
SURGEON: [Name]
ASSISTANT: [Name / None]
ANAESTHETIST: [Name]
OPERATION: Laparoscopic Heller Myotomy and Dor Fundoplication
ANAESTHETIC: General endotracheal anaesthesia
ANTIBIOTICS: [Drug and dose / Not indicated]
DVT PROPHYLAXIS: [Agent / mechanical / Not indicated]
POSITION: Supine in stirrups, legs abducted, surgeon between legs. Beanbag support. Pneumatic compression stockings. Orogastric tube inserted and removed prior to myotomy.
INDICATION:
Esophageal achalasia. Preoperative assessment: barium swallow [bird beak appearance / sigmoid oesophagus / dilated oesophagus], upper endoscopy [mechanical obstruction excluded], oesophageal manometry [absent peristalsis, incomplete LOS relaxation confirmed]. [Previous pneumatic dilatation / botulinum toxin injection — noted].