OT notes · Gynaecology

Abdominal myomectomy

Usual anaesthesia
Regional (spinal or combined spinal-epidural) or general
Position
Supine (lithotomy if a uterine manipulator or dye injection through the cervix is planned)
Setting
elective

Operative note template for abdominal (open) myomectomy, with a filled example for removal of three intramural and subserosal fibroids in a woman who wants to conceive.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • heavy bleeding and blood transfusion
  • hysterectomy if bleeding cannot be controlled
  • adhesions that may block the tubes and affect fertility
  • intrauterine adhesions if the cavity is opened
  • uterine rupture in a later pregnancy, and advice about caesarean delivery
  • fibroids coming back, or small fibroids left behind
  • unexpected cancer (sarcoma) on histopathology
  • infection, fever after surgery
  • bladder, bowel or ureteric injury

Pre-operative details for this operation

  1. Indicationheavy bleeding / pressure symptoms / infertility / recurrent miscarriage; wish to keep the uterus
  2. Fibroid map from imagingnumber, size, site (FIGO type) from USG or MRI; images available in OT
  3. Hb and blood reservedHb, group, units cross-matched; cell saver if available
  4. Pre-op GnRH analogue / ironNoneGiven (drug, duration)
  5. Urine pregnancy testNegative
  6. Consent for possible hysterectomyTakenRefused (record)
  7. Measures to reduce blood loss plannedmisoprostol, tranexamic acid, vasopressin, tourniquet: drug, dose, route, time

Anaesthesia and position

  1. AnaesthesiaSpinalCombined spinal-epiduralGeneral
  2. PositionSupineLow lithotomy
  3. Foley catheterInserted
  4. Dye in uterine cavityNot usedMethylene blue via paediatric Foley / cannula

Operative findings

  1. Uterus sizein weeks
  2. Each fibroidnumber them: site (anterior / posterior / fundal / cornual / cervical / broad ligament), type (subserosal / intramural / submucosal / pedunculated), size in cm
  3. Right and left tube and ovary
  4. Pouch of Douglas, adhesions, endometriosis
  5. Appearance of fibroids on cut sectionwhorled / soft / degenerated / suspicious

Procedure (steps)

  1. IncisionPfannenstielMaylardCherneyMidline verticallength
  2. Uterus delivered out of the woundYesNo
  3. Tourniquet / vascular clampsNot usedRubber catheter around lower segment through broad ligament windowsClamps on ovarian vesselstime applied and removed
  4. Vasopressindilution, total volume injected, anaesthetist informed
  5. Uterine incision(s)number, site, direction (transverse / vertical), length
  6. Enucleationplane inside the pseudocapsule; each fibroid numbered and size; morcellated with scalpel or intact
  7. Cavity enteredNoYes: endometrium closed separatelysuture used
  8. Myometrial closurenumber of layers, suture material and size, interrupted / continuous
  9. Serosal closurefine suture, technique
  10. Tourniquet released, haemostasis checked
  11. Adhesion barrierNot usedUsed (type)
  12. Fibroid countnumber removed matches the list; any left behind and why

Closure, drains and dressing

  1. PeritoneumClosedNot closed
  2. Rectus sheathsuture material and technique
  3. Subcutaneous tissue
  4. SkinSubcuticularInterruptedStaples
  5. DrainNonePelvic drain (size)

Specimens and implants

  1. Fibroids sent for HPEnumber of fibroids / pieces, total weight
  2. Uterine manipulator or intrauterine catheter left inNonePaediatric Foley in cavity (remove when)

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Vitalspulse, BP every 15 min for 1 hour, then hourly; watch for concealed bleeding
  2. Drain and vaginal bleedingoutput hourly for 6 hours if drain placed
  3. Hbon post-op day 1
  4. Analgesiadrug, dose, frequency
  5. Catheterremove next morning if walking
  6. Mobilisation and thromboprophylaxiscompression devices till walking; walk on post-op day 1
  7. Feverlow-grade fever is common, but examine for a source if it persists
  8. Counselling before dischargewhat was removed, whether cavity was opened, when to try for pregnancy, and planned caesarean if the wall was deeply breached

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mrs. P.K., 31 years, married 4 years, nulligravida, with heavy menstrual bleeding and primary infertility. USG: three fibroids, anterior intramural 7 cm, fundal subserosal 4 cm, posterior intramural 3 cm; cavity not distorted. Husband's semen analysis normal.

Case details

Date: 20/05/2026. Elective abdominal myomectomy. OT 1.

In OT 08:50. Spinal given 09:00. Skin incision 09:18. Skin closure completed 11:05.

Surgeon: Dr A. (Associate Professor, OBGY). Assistant: Dr B. (2nd-year resident). Anaesthetist: Dr C. Scrub nurse: Sr D.

Indication and pre-op

Indication: symptomatic fibroids (heavy menstrual bleeding) with infertility, wishes to keep the uterus. Hb 10.8 g/dl after 6 weeks of oral iron. Blood group A positive, 2 units cross-matched. Urine pregnancy test negative.

Consent in Hindi for myomectomy and for hysterectomy only if bleeding cannot be controlled. Explained adhesions, recurrence and possible caesarean in a future pregnancy.

Tab misoprostol 400 microgram per vaginum at 08:20. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 09:05, before skin incision.

Anaesthesia and position

Spinal anaesthesia. Supine. Foley catheter inserted. Parts painted with chlorhexidine-alcohol and draped.

Procedure

Pfannenstiel incision of 12 cm. Rectus sheath opened transversely, peritoneum opened vertically. Uterus delivered out of the wound.

Findings: uterus 16 weeks. Fibroid 1: anterior intramural, 7 x 6 cm. Fibroid 2: fundal subserosal, 4 cm, broad base. Fibroid 3: posterior intramural, 3 cm. Both tubes and ovaries normal. Pouch of Douglas free, no endometriosis.

Bladder peritoneum pushed down. Red rubber catheter passed through windows in both broad ligaments close to the uterine vessels and tied around the lower segment as a tourniquet at 09:32, held with an artery forceps.

Vasopressin 20 units diluted in 50 ml NS, 10 ml (4 units) injected into the myometrium over fibroids 1 and 2 after informing the anaesthetist. Blanching seen.

Single 5 cm transverse incision on the anterior wall, carried into fibroid 1. Fibroid 1 enucleated in the plane inside the pseudocapsule with traction on a towel clip. Fibroid 3 reached through the same bed by a lateral tunnel and removed. Cavity not entered.

Fibroid 2 removed through a separate 3 cm transverse fundal incision, away from both cornua.

Anterior bed closed in three layers: two deep layers of interrupted polyglactin 910 (Vicryl) 0, then a running horizontal mattress layer of Vicryl 2-0. Fundal bed closed in two layers of interrupted Vicryl 0. Serosa closed with continuous subserosal Vicryl 4-0.

Tourniquet released at 10:20 (48 minutes). Two bleeding points on the anterior suture line controlled with figure-of-eight Vicryl 2-0. Uterus dry.

Three fibroids removed, matching the pre-op USG. Pelvis irrigated with warm NS. No adhesion barrier used.

Closure

Peritoneum not closed. Rectus sheath closed with continuous Vicryl No. 1. Subcutaneous fat 1.5 cm, not sutured. Skin closed with subcuticular Monocryl 3-0. No drain.

Specimens

Three fibroids, total weight 260 g, sent for HPE in formalin with requisition. Cut surface whorled and firm in all three.

End of procedure

Estimated blood loss 450 ml (suction 250 ml + mops). No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications. Urine clear, 200 ml.

Shifted to recovery in stable condition. Pulse 92/min, BP 116/74 mmHg.

Post-op orders

Pulse and BP every 15 min for 1 hour, then hourly for 6 hours. Watch for abdominal distension and fall in BP.

IV RL 1 L over 8 hours. Oral liquids after 6 hours.

Analgesia as charted by the anaesthetist: IV paracetamol, and an NSAID if no contraindication.

Compression stockings till walking. Walk on POD 1. Catheter out on POD 1 morning.

Hb on POD 1.

Before discharge: explain that the cavity was not opened. Advise waiting before conception as per consultant and delivery plan to be decided by the treating obstetrician with this note.

Signature

Dr B., JR-2, OBGY, for Dr A. Reg. no. ________. 20/05/2026, 11:20.

Must document for this operation

  • Every fibroid: site, type, size, and whether it was removed. The next scan and any repeat surgery are judged against this list, and a fibroid left behind looks like recurrence if not recorded.
  • Whether the uterine cavity was entered and how it was repaired. It changes the counselling on intrauterine adhesions, and the obstetrician uses it to plan the mode of delivery.
  • Depth and site of each uterine incision and the number of layers closed. A deep breach of the myometrium is a risk for uterine rupture in a later pregnancy.
  • Vasopressin dose and dilution, and tourniquet times. Vasopressin can cause sudden hypertension or bradycardia, and a long tourniquet time must be explainable.
  • Incisions near the cornua or tubes. Tubal damage at the cornua can cause infertility, and the fertility specialist will ask.
  • Consent status for hysterectomy. If bleeding forces a hysterectomy, the note must show that she agreed to it beforehand, or why it was life-saving.

Common mistakes in these notes

  • Writing 'multiple fibroids removed' without numbers, sites and sizes.
  • Not stating whether the cavity was opened.
  • Leaving out the vasopressin dose and dilution.
  • No record of tourniquet application and release times.
  • Not counselling or recording advice about delivery in a future pregnancy.

Indian practice and paperwork

  • NABH standard COP.14(e) (5th edition) requires the operative note to be written before the patient is transferred out of recovery. (NABH Hospital Accreditation Standards 5th ed. (April 2020), COP.14 OE e)
  • In NQAS-assessed public hospitals, the OT checkpoint 'Operative Notes are Recorded' looks for the people present, pre- and post-op diagnosis, procedure, length of procedure, estimated blood loss, fluids given, specimen removed and complications. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, ME E8.4)
  • Fibroids not sent for HPE are Yellow category (a) human anatomical waste under the Bio-Medical Waste Management Rules 2016; record where the specimen went. (CPCB/DGHS Guidelines under BMW Management Rules 2016)

Sources

  • Handa VL, Van Le L, eds. Te Linde's Operative Gynecology. 13th ed. Wolters Kluwer; 2024, Ch 21, Myomectomy: indications, preoperative optimisation, measures to decrease blood loss, myomectomy by laparotomy; Ch 2, Table 2.4 antimicrobial prophylaxis, e-book PDF pp. 1066-1071, 1113-1126; 162-165.
  • Te Linde's Atlas of Gynecologic Surgery. Wolters Kluwer; 2014, Ch 28, Abdominal myomectomy and uterine reconstruction for intramural myomas (Solnik MJ, Azziz R), pp. 241-253.
  • Te Linde's Operative Gynecology 13e, Ch 2, Table 2.4 (reprinted from ACOG Practice Bulletin 195, 2018): laparotomy without entry into bowel or vagina, consider cefazolin 2 g IV (3 g if over 120 kg), single dose within 1 hour before the procedure.
  • Te Linde's Operative Gynecology 13e, Ch 21, p. (pdf) 1069: misoprostol 400 microgram single dose, any route, within 60 minutes before incision; Te Linde's Atlas Ch 28, printed p. 244: vasopressin 20 units in 50 ml normal saline.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 2: cefazolin 2 g IV (3 g if 120 kg or more), started within 60 min before incision, redose interval 4 hours. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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