OT notes · Gynaecology

Diagnostic hysteroscopy

Usual anaesthesia
None or paracervical block (office); IV sedation or short general anaesthesia in OT
Position
Lithotomy
Setting
elective

Operative note template for diagnostic hysteroscopy, with a filled example for a perimenopausal woman with abnormal uterine bleeding who had a directed endometrial biopsy under IV sedation.

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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

  • pain and cramping
  • uterine perforation
  • false passage or cervical tear
  • bleeding
  • infection
  • fluid overload from absorbed distension fluid
  • failed procedure or need to repeat
  • rarely injury to bowel, bladder or vessels after perforation

Pre-operative details for this operation

  1. IndicationAUB / postmenopausal bleeding / infertility / recurrent miscarriage / suspected polyp, fibroid, septum or adhesions / lost IUCD
  2. ImagingUSG findings: endometrial thickness, focal lesion, uterine size
  3. LMP and pregnancy testdate of LMP, day of cycle, contraception, UPT result
  4. Active pelvic infection excludedYes
  5. Anticoagulantsdrug, last dose, INR if on warfarin
  6. Cervical primingNot givenGivenif given: drug, dose, route, time before procedure
  7. SettingOffice / OPDDay-care OT

Anaesthesia and position

  1. AnaesthesiaNoneParacervical / intracervical blockIV sedationGeneral (LMA)Spinal
  2. PositionLithotomy
  3. BladderEmptiedVoided before
  4. Hysteroscoperigid or flexible, lens angle (0 / 30 degree), outer sheath diameter in mm, continuous flow or single flow
  5. Distension mediumNormal salineRinger lactateGlycine 1.5%CO2 (diagnostic only)
  6. Delivery and pressureSyringeGravity bag (height)Pressure bagFluid management pumpset intrauterine pressure in mmHg (and flow rate if CO2)

Operative findings

  1. EUAuterus size and position (anteverted / retroverted)
  2. Cervical canalnormal / stenosed / polyp / other
  3. Uterine cavity shapeNormalSeptate / arcuateDistorted
  4. Tubal ostiaBoth seenRight onlyLeft onlyNot seen
  5. Endometriumthin / proliferative / secretory / thick / irregular / atrophic, vascular pattern
  6. Focal lesionpolyp / submucous fibroid / adhesions / IUCD / growth: site (wall), size, base (broad / pedunculated)

Procedure (steps)

  1. Vulva and vagina prepared and drapedantiseptic; not needed for no-touch vaginoscopy
  2. Scope assembled and purgedlight cable attached, white balance and focus, sheath flushed with medium to expel air
  3. ApproachVaginoscopic (no speculum, no tenaculum)Speculum and tenaculum on anterior lip
  4. Cervical dilatationNot neededDilated (to Hegar / Pratt size)avoid over-dilating
  5. Scope passed under direct visioncanal and internal os seen on entry, cavity entered under vision
  6. Orientationpanoramic view from isthmus, both tubal ostia and fundus identified
  7. Systematic inspectionfundus, both cornua and ostia, anterior, lateral and posterior walls, canal again on withdrawal
  8. Endometrial samplingNot doneDirected biopsy with hysteroscopic forcepsPipelle / blind sampling after scopeCurettage
  9. Photographs / video savedYesNo
  10. Fluid balancetotal inflow, outflow and deficit in ml (or CO2 used)

Closure, drains and dressing

  1. Instruments removedtenaculum site bleeding checked
  2. Bleeding at endMinimalControlled with pressureOther (describe)

Specimens and implants

  1. Endometrial biopsy for HPESentNot takendirected / blind, site
  2. Otherpolyp removed, IUCD retrieved (type), culture

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. Vitalsuntil fully awake after sedation or GA
  2. Watch for fluid overloadbreathlessness, confusion, low SpO2; serum sodium if deficit was high or a hypotonic medium was used
  3. Oral intakewhen to start
  4. Analgesiadrug, dose, frequency
  5. Anticoagulant restartdrug and time
  6. Discharge advicelight bleeding and cramping for a day or two is expected. Return for heavy bleeding, fever, severe pain or foul discharge
  7. Follow-update to review HPE and plan further treatment

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. N.J., 46 years, P2L2, with heavy irregular menstrual bleeding for 6 months. TVS shows endometrial thickness 14 mm with a possible 1 cm echogenic focus. Hb 10.4 g/dl.

Case details

Date: 03/07/2026. Day-care diagnostic hysteroscopy with directed endometrial biopsy. Minor OT.

In OT 09:40. Sedation started 09:45. Scope in 09:50. Scope out 10:02.

Surgeon: Dr A. (2nd-year resident, OBGY). Supervising consultant: Dr C., present. Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: AUB (heavy, irregular) at 46 years with thick endometrium and possible polyp on TVS.

LMP 25/06/2026 (day 9 of cycle). Husband has had vasectomy. UPT negative today. No pelvic infection. Not on anticoagulants.

No cervical priming given.

Consent: general, procedure-specific and anaesthesia consent taken in Hindi from the patient. Risks of perforation, bleeding, infection and fluid overload explained.

WHO checklist sign in and time out done, including pregnancy test check.

Anaesthesia and position

IV sedation by anaesthetist. Lithotomy. Bladder emptied with plain catheter. Vulva and vagina painted with povidone-iodine and draped.

Rigid 30 degree telescope in a 5 mm continuous-flow sheath.

Distension medium normal saline, pressure bag set at 80 mmHg.

Procedure

EUA: uterus anteverted, bulky, about 8 weeks size, mobile.

Sheath flushed with saline to remove air. Cusco speculum placed, tenaculum on anterior lip. No dilatation needed.

Scope passed under direct vision through the canal and internal os into the cavity.

Panoramic view taken from the isthmus. Both tubal ostia and fundus seen.

Findings: cervical canal normal. Cavity normal shape. Endometrium thick, proliferative, uniform. A 1 x 0.8 cm pedunculated polyp arising from the left side of the posterior wall near the fundus. No other lesion. No suspicious vessels.

Directed biopsy of the polyp and posterior wall endometrium taken with 5 Fr hysteroscopic forceps. Scope removed with the forceps closed.

Canal inspected again on withdrawal. Photographs of both ostia and the polyp saved.

Fluid: inflow 600 ml, outflow 530 ml, deficit 70 ml.

End of procedure

Tenaculum removed, no bleeding from the site. Minimal bleeding from the os.

Blood loss negligible. Instrument count correct.

No intra-operative complications.

Specimen: endometrial biopsy (polyp tip and posterior wall), in formalin, for HPE.

Shifted to day-care recovery in stable condition. Pulse 76/min, BP 118/76 mmHg, SpO2 99% on room air.

Post-op orders

Vitals every 15 min until fully awake.

Oral fluids after 1 hour, then light diet.

Oral analgesic as charted.

Discharge today if comfortable. Mild spotting and cramps expected for 1 to 2 days. Return for heavy bleeding, fever or severe pain.

Plan: operative hysteroscopic polypectomy. Review with HPE in 1 week.

Signature

Dr A., JR-2, OBGY. Reg. no. ________. 03/07/2026, 10:15.

Must document for this operation

  • Type of hysteroscope (rigid or flexible, lens angle, sheath size) and the distension medium. RCOG standards quoted in the hysteroscopy text list scope type, distension medium, findings and complications as the minimum content of the note.
  • Distension pressure and the fluid inflow, outflow and deficit. Fluid overload is a recognised complication, and the deficit shows the ward team whether to check sodium or watch for pulmonary oedema.
  • Whether both tubal ostia were seen. Seeing both ostia proves the scope was in the cavity and that the whole cavity was examined.
  • Site, size and base of any lesion, by wall. The surgeon doing the operative hysteroscopy plans the approach and instruments from this description.
  • Pregnancy test result and LMP. The standard WHO checklist does not ask about pregnancy, so the hysteroscopy text advises adding it.
  • How the biopsy was taken (directed or blind) and from where. Blind sampling can miss focal lesions, and the pathologist and next clinician need to know what was sampled.

Common mistakes in these notes

  • Writing 'DH normal' without saying whether both ostia were seen.
  • No record of the distension medium, pressure or fluid deficit.
  • Describing a polyp without its wall, size or base.
  • Not recording the LMP, day of cycle and pregnancy test.
  • Writing 'no complications' without noting how cervical entry went (dilatation, false passage).

Sources

  • Handa VL, Van Le L, eds. Te Linde's Operative Gynecology. 13th ed. Wolters Kluwer; 2024, Ch 15, Hysteroscopy (Christianson MS, Patzkowsky KE): distension media and fluid management, preoperative considerations, office hysteroscopy, diagnostic hysteroscopy (Box 15.1), complications, e-book PDF pp. 739, 762-774, 805-810.
  • Connor ME, Clark TJ, eds. Diagnostic and Operative Hysteroscopy. Cambridge University Press; 2020, Ch 5, Hysteroscopy techniques and treatment settings (Chester JM, Clark TJ); Ch 17, Audit, data collection and clinical governance, pp. 57-71, 207-211.

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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