How to write an inflammatory bowel disease surgical report.

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Authors: Abel Botelho Quaresma, Rafaela de Araújo Molteni, Paulo Gustavo Kotze
Cited by: 0

Abstract

The development of detailed surgical reports is essential for the effective management of inflammatory bowel disease, including Crohn's disease (CD) and ulcerative colitis. These reports facilitate postoperative care, multidisciplinary planning, and are critical for studies on surgical outcomes and complications. A well-structured report should include information before, during, and after surgery. Preoperative factors include team identification, surgical plan, anesthesia, patient positioning, estimated blood loss, and urinary output data. During surgery, documentation should cover unexpected findings, abnormal blood loss, and any anesthesia changes. Postoperatively, the patient's condition and transfer destination should be described. For perianal CD, reports should include details about fistulas, abscesses, and techniques such as fistulotomy and seton placement. In abdominal resections for CD, findings such as adhesions, associated complications, and disease characteristics must be outlined. For ulcerative colitis, reports should emphasize the extent of inflammation, colectomy techniques, details of anastomoses, and perfusion assessment. These structured reports are indispensable for improving care and long-term outcomes, reinforcing their importance in the evolving multidisciplinary management of inflammatory bowel disease.

Fields of Study & Subjects

Inflammatory Bowel Disease Colorectal Cancer Surgical Treatments Nursing Diagnosis and Documentation

Publication details

Journal / source
Europe PMC (PubMed Central)
Volume
8
Issue
1
Pages
otag003–otag003
Publication date
1 January 2026
Language
EN