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Surgeons generally initial their incision site pre op; one of the general docs I worked with had the initials "HA", and would do laparoscopic surgeries with 3 port sites... so our patients would roll in with "HA HA HA" written across their abdomen. Always got a kick out of it! ^_^
Yeah they do it with a marker when the patient is awake. Like "this is the surgery I'm doing on you, you cool with that? Ok I'm initialing that we are doing the right thing here"
Like for an amputation they'll mark the leg while the patient is awake "yes I want this one removed"