Fothergill (Manchester) repair

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

• bleeding, primary or secondary
• bladder or rectal injury
• retention of urine or urinary infection
• infection
• narrowing of the cervical canal with blood collecting in the uterus
• reduced fertility, miscarriage from a weak cervix, or difficult labour
• pain during intercourse
• recurrence of prolapse, most often of the front wall
• difficulty taking Pap smears later

Pre-operative details for this operation

1. Reason for keeping the uterusWishes future pregnancyWishes to keep uterus
2. Prolapse stagingPOP-Q points and stage, or unit grading
3. Cervical elongationuterocervical length by sound, and cervical length
4. Cystocele / rectocele / enterocele / perineal deficiency
5. Stress incontinence check with prolapse reduced
6. Pap smear / cervical screeningresult and date; must be normal
7. Ultrasounduterus, endometrium, adnexa
8. Menstrual history and contraception / sterilisation wishvaginal tubal ligation to be added if family complete and consented

Anaesthesia and position

1. AnaesthesiaSpinalEpiduralGeneral
2. PositionDorsal lithotomy
3. BladderEmptied with catheterFoley in situ
4. Examination under anaesthesiadegree of descent, cervical length

Operative findings

1. Uterine sound lengthtotal uterocervical length in cm
2. Cervixlength, hypertrophy, decubitus ulcer
3. Curettingsamount and appearance
4. Anterior wall defect
5. EnteroceleAbsentPresent: repaired
6. Posterior wall and perineal body

Procedure (steps)

1. Dilatation and curettagesound length, dilated to (size), curettings sent
2. Infiltrationdrug, dilution, volume
3. Anterior vaginal wall incision and bladder dissected upincision shape; bladder pushed up to uterovesical peritoneum
4. Incision carried round the cervix, posterior and lateral vaginal walls separated from cervix
5. Cardinal (Mackenrodt's) ligaments with descending cervical vessels clamped, cut and ligatedlevel; suture; ends held long
6. Enterocele soughtNoneFound: sac closed with purse-string, uterosacrals approximated
7. Cervix amputatedlevel and length removed (cm)
8. Cervical stump coveredSturmdorf sutureBonney's methodsuture material
9. Cardinal ligaments fixed in front of the cervixFothergill stitchCut ends sutured to anterior cervix
10. Uterosacral ligaments plicated behind the cervix (if done)
11. Anterior colporrhaphypubocervical fascia plicated: suture, number; excess skin trimmed; skin closed
12. Cervical os patency checked at enddilator size passed
13. Posterior colpoperineorrhaphyfascial plication, levator / perineal muscle sutures, skin closure; suture
14. Vaginal tubal ligation (if consented)

Closure, drains and dressing

1. Vaginal calibre at endnumber of fingers
2. Rectal examinationNo sutures felt in rectum
3. Vaginal packNonePlaced: remove at (time)
4. Self-retaining catheterremoval plan

Specimens and implants

1. Amputated cervixlength, sent for HPE
2. Endometrial curettingssent for HPE in a separate labelled container

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. Vitals and vaginal bleedingfrequency; watch for primary and secondary haemorrhage
2. Vaginal pack removaltime
3. Catheterkeep while pack is in; then remove and check voiding
4. Dietas tolerated
5. Stool softener, avoid straining
6. Analgesiadrug, dose, frequency
7. Mobilisation and thromboprophylaxis
8. Advice at dischargeno intercourse for 6 weeks; report painful absent periods (stenosis)
9. Future pregnancy advicerisk of cervical weakness and of difficult labour; tell her obstetrician about this operation
10. HPE follow-upcervix and curettings

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