OT notes · Gynaecology

Laparoscopic myomectomy

Usual anaesthesia
General anaesthesia with endotracheal intubation
Position
Lithotomy on an anti-slip pad, arms tucked, Trendelenburg after primary entry
Setting
elective

Operative note template for laparoscopic myomectomy, with a filled example for removal of a single intramural fibroid with contained morcellation 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

  • bleeding and blood transfusion
  • conversion to open surgery (laparotomy)
  • hysterectomy if bleeding cannot be controlled
  • fibroids missed (cannot be felt at laparoscopy) or coming back
  • spread of an unsuspected cancer by morcellation
  • adhesions affecting the tubes and fertility
  • intrauterine adhesions if the cavity is entered
  • uterine rupture in a later pregnancy
  • bowel, bladder or blood vessel injury at port entry

Pre-operative details for this operation

  1. Indicationsymptoms, infertility; wish to keep the uterus
  2. Fibroid map from imagingnumber, size, FIGO type and site from USG / MRI; images reviewed in OT
  3. Suitability for laparoscopynumber of fibroids and largest size; note if above usual limits and why laparoscopy was still chosen
  4. Hb and blood reserved
  5. Consent for morcellation, conversion and hysterectomyTaken
  6. Misoprostol before surgeryNot givenGiven (dose, route, time)

Anaesthesia and position

  1. AnaesthesiaGeneral with ETT
  2. PositionLithotomy, anti-slip pad, arms tucked
  3. Foley catheterInserted
  4. EUA and uterine manipulatoruterine size; manipulator with channel for methylene blue

Operative findings

  1. Uterus size
  2. Each fibroidnumber them: site, type (subserosal / intramural / pedunculated / broad ligament), size in cm
  3. Right and left tube and ovary
  4. Pouch of Douglas, adhesions, endometriosis
  5. Upper abdomen

Procedure (steps)

  1. Primary entryVeress at umbilicusPalmer's point (left upper quadrant)Open (Hasson)insufflation pressure
  2. Portsnumber, size, site; height adjusted to uterine size; 10-12 mm port or suprapubic extraction site
  3. Uterine artery occlusionNot doneTemporary bulldog clamps on uterine arteries (time on / off)
  4. Vasopressindilution, volume injected, anaesthetist informed
  5. Uterine incisionsite, direction, length; energy device (ultrasonic / monopolar hook or scissors)
  6. Enucleationtenaculum or corkscrew traction; each fibroid numbered and parked in view
  7. Cavity enteredNo, confirmed with methylene blueYes: endometrium closed separately (suture)
  8. Myometrial closurenumber of layers, suture (barbed / polyglactin / PDS), size
  9. Serosal closuresuture and technique
  10. Tissue extractionContained morcellation in bagUncontained power morcellationMini-laparotomysite and length of extraction incision
  11. Fibroid and bag count, pelvis checked for fragments
  12. Haemostasis at low pressure, irrigation, adhesion barrierbarrier type if used

Closure, drains and dressing

  1. Fascia at ports 10 mm or more and extraction site
  2. Skin
  3. DrainNonePelvic drain (size, port)

Specimens and implants

  1. Fibroids / morcellated tissue sent for HPEnumber of fibroids, total weight

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. Vitalsevery 15 min in recovery, then hourly for 6 hours
  2. Watch for internal bleedingrising pulse, falling BP, abdominal distension, drain output
  3. Hbon post-op day 1
  4. Analgesiadrug, dose, frequency
  5. Catheterremove when walking
  6. Diet and mobilisationliquids when awake, walk the same evening or next morning
  7. Thromboprophylaxiscompression devices till walking
  8. Counselling before dischargewhat was removed, cavity entry, interval before trying to conceive, mode of delivery plan

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., 29 years, married 3 years, nulligravida, with dysmenorrhoea, heavy periods and infertility. MRI: single anterior intramural fibroid 6 cm (FIGO type 4), cavity not distorted. Tubes patent on HSG.

Case details

Date: 09/06/2026. Elective laparoscopic myomectomy. OT 3.

In OT 09:00. Induction 09:10. Veress entry 09:25. Last port closed 11:30.

Surgeon: Dr A. (Professor, OBGY). Assistant: Dr B. (3rd-year resident). Anaesthetist: Dr C. Scrub nurse: Sr D.

Indication and pre-op

Indication: symptomatic intramural fibroid with infertility. Hb 11.6 g/dl. Blood group B positive, 1 unit reserved.

Consent in English for laparoscopic myomectomy, contained morcellation, conversion to laparotomy, and hysterectomy only if bleeding cannot be controlled.

Tab misoprostol 400 microgram per vaginum at 08:35. WHO checklist sign in and time out done. Antibiotic prophylaxis not given: laparoscopic procedure without planned entry into bowel or vagina, as per unit protocol.

Anaesthesia and position

General anaesthesia with ETT. Lithotomy on anti-slip foam pad, arms tucked and padded.

Parts painted with povidone-iodine and draped. Foley catheter inserted. EUA: uterus 12 weeks, mobile. Uterine manipulator with dye channel placed.

Procedure

Veress needle at umbilicus, CO2 to 15 mm Hg. 10 mm umbilical camera port. Two 5 mm ports on the left and one 5 mm port on the right, lateral to the inferior epigastric vessels and above the anterior superior iliac spines, placed under vision.

Findings: uterus 12 weeks with a single anterior intramural fibroid of 6 cm. No other fibroid seen. Both tubes and ovaries normal. Pouch of Douglas free, no endometriosis. Liver and bowel normal.

Vasopressin 20 units in 200 ml NS, 30 ml injected into the myometrium over the fibroid after informing the anaesthetist. Blanching seen.

Transverse incision of 5 cm over the fibroid with ultrasonic shears, deepened to the pseudocapsule. Fibroid held with a 5 mm tenaculum and enucleated by traction and counter-traction. Bipolar used only on bleeding points.

Methylene blue pushed through the manipulator: no blue in the bed, cavity not entered.

Fibroid parked in the right paracolic gutter.

Myometrial bed closed in two layers with continuous 0 barbed delayed absorbable suture. Serosa closed with continuous 2-0 barbed suture.

Umbilical port incision extended to 3 cm. Fibroid placed in a containment bag, bag brought out, fibroid cut up with a scalpel inside the bag and removed completely. Bag removed intact.

Pressure lowered and the suture line checked: dry. Pelvis irrigated with NS and sucked dry. Oxidised regenerated cellulose barrier placed over the suture line.

Closure

Ports removed under vision. Gas let out. Umbilical fascia closed with polyglactin 910 (Vicryl) No. 1 interrupted. Skin closed with Ethilon 3-0. No drain.

Specimens

One fibroid, cut into pieces in bag, total 125 g, sent for HPE in formalin with requisition.

End of procedure

Estimated blood loss 200 ml. No transfusion.

Mop, needle and instrument count correct. Containment bag checked intact. Fibroid count 1 of 1.

No intra-operative complications. Urine clear.

Shifted to recovery in stable condition. Pulse 80/min, BP 118/70 mmHg, SpO2 99%.

Post-op orders

Pulse, BP, SpO2 every 15 min for 1 hour, then hourly for 6 hours. Report pulse over 110/min, fall in BP or abdominal distension.

Oral liquids after 4 hours, soft diet in the evening.

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

Catheter out in the evening once walking. Compression stockings till walking.

Hb on POD 1.

Before discharge: explain that one fibroid was removed and the cavity was not opened. Delivery plan to be decided by the treating obstetrician with this note.

Signature

Dr B., JR-3, OBGY, for Dr A. Reg. no. ________. 09/06/2026, 11:45.

Must document for this operation

  • Each fibroid by site, type and size, and the count removed against the pre-op map. Small fibroids cannot be felt at laparoscopy, so a later scan finding must be judged against what was actually removed.
  • Whether the cavity was entered, how it was checked (dye), and how it was closed. It decides the counselling on intrauterine adhesions and the delivery plan in pregnancy.
  • Number of myometrial layers and the suture used. Poor closure and heavy use of electrosurgery have been linked with uterine rupture in later pregnancy.
  • Method of tissue extraction: contained or uncontained morcellation, or mini-laparotomy. If HPE shows a sarcoma, the oncologist needs to know whether tissue was fragmented inside the abdomen.
  • Fibroid count and a check for retained fragments. Fibroids parked in the pelvis are easy to lose. A count, with each one tagged, prevents tissue being left behind.
  • Vasopressin dose and dilution, and any bulldog clamp times. Vasopressin can cause haemodynamic changes, and clamp times are needed if uterine blood supply is questioned later.

Common mistakes in these notes

  • Writing 'fibroid removed laparoscopically' with no site, type or size.
  • Not recording whether the cavity was entered.
  • Leaving out how the fibroid came out of the abdomen.
  • No fibroid count when several were parked in the pelvis.
  • Not recording the energy device used on the myometrium.

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)
  • Fibroid tissue not sent for HPE is 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: laparoscopic myomectomy, measures to decrease blood loss; Ch 2, Table 2.4 antimicrobial prophylaxis, e-book PDF pp. 1069-1071, 1094-1106; 164.
  • Te Linde's Atlas of Gynecologic Surgery. Wolters Kluwer; 2014, Ch 28, Abdominal myomectomy and uterine reconstruction: laparoscopic myomectomy section and postoperative considerations (Solnik MJ, Azziz R), pp. 250-252.
  • Te Linde's Operative Gynecology 13e, Ch 2, Table 2.4 (reprinted from ACOG Practice Bulletin 195, 2018): laparoscopic procedures without entry into bowel or vagina, antibiotic prophylaxis not recommended.
  • Te Linde's Operative Gynecology 13e, Ch 21: misoprostol 400 microgram single dose, any route, within 60 minutes before incision (pdf 1069); vasopressin 20 units in 200 ml normal saline (pdf 1099).

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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