OT notes · Gynaecology

Laparoscopic tubal ligation (Falope ring)

Usual anaesthesia
Local anaesthesia (1% lignocaine) with sedation and analgesia; general only in selected cases
Position
Lithotomy, head-down (Trendelenburg) tilt of not more than 20 degrees after skin preparation
Setting
elective

Operative note template for interval laparoscopic tubal occlusion with Falope rings under the Indian family planning programme, with a filled example for a single-puncture procedure under local anaesthesia with 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

  • permanent method: reversal is major surgery and may not work
  • failure and pregnancy
  • bleeding from the tube or mesosalpinx
  • bowel, bladder or blood vessel injury at entry
  • conversion to minilaparotomy if the tubes cannot be reached
  • shoulder or chest pain from the gas
  • wound infection
  • sterilization may not be completed if a tube cannot be identified

Pre-operative details for this operation

  1. Application cum Consent Form for Sterilization Operation (Annexure 1) signedSignatureThumb impression with witness chosen by clientcounselled in her own language; partner consent not required
  2. Medical Record & Check List for Sterilization (Annexure 2) filled by operating surgeon before surgeryYes
  3. Eligibilityever married; age (22 to 49 years); number of living children and age of youngest (at least one child over 1 year); not sterilized before
  4. TimingInterval (42 days or more after delivery or abortion)With first-trimester abortion (under 12 weeks)
  5. LMP and pregnancy ruled outLMP date; urine pregnancy test if doubt
  6. Hb and urineHb (must be 7 g/dl or more), urine albumin and sugar
  7. Medical eligibility categoryAcceptCautionSpecialreason if not Accept
  8. Fasting and bladder emptiedhours fasting; passed urine just before OT

Anaesthesia and position

  1. Type of anaesthesiaLocal onlyLocal and analgesiaGeneral, no intubationGeneral, intubation
  2. Sedation / analgesiadrug, dose, route, time (as on the checklist)
  3. Local anaestheticlignocaine 1% without adrenaline, volume in ml (maximum 3 mg/kg)
  4. PositionLithotomy, Trendelenburg not more than 20 degrees
  5. Bimanual examination and uterine elevatoruterus size, position (AV / RV / mid), mobility; uterine elevator placed

Operative findings

  1. Uterussize, position, mobility, fibroids
  2. Right tube identified up to fimbriaYesNo: reason
  3. Left tube identified up to fimbriaYesNo: reason
  4. Ovaries
  5. Adhesions / hydrosalpinx / other pelvic findings
  6. Bowel and omentum at entry siteany injury seen on first look

Procedure (steps)

  1. Skin preparation and drapingantiseptic, applied twice
  2. Local infiltration at sub-umbilical siteskin, fascia; volume used; adequacy tested
  3. Incisionat lower margin of umbilicus, no bigger than the trocar
  4. PneumoperitoneumVeress needleDirect trocar entrygas (CO2 / air), insufflator used, volume in litres, pressure not above 15 mm Hg; entry confirmation test
  5. Trocar and laparoscopeSingle puncture (SPL)Double puncture (DPL)
  6. Falope rings loadedtwo rings on applicator
  7. Right tube: ring appliedsite from cornu (about 3 to 4 cm, isthmus), loop size, acute angle in mesosalpinx, bleeding
  8. Left tube: ring appliedsame details
  9. Extra ring or haemostasisNot neededExtra ring (reason)Cautery / pressure for bleeding
  10. Pelvis inspected for bleeding and injury
  11. Gas let out, laparoscope and trocar removed

Closure, drains and dressing

  1. Skinsingle stitch, absorbable or non-absorbable (material)
  2. DressingSmall dry dressing

Specimens and implants

  1. Falope ringsnumber used (normally 2, one each tube); lot / batch if recorded by the facility
  2. SpecimenNone

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 chart (section L of the checklist)pulse, BP, respiration and sedation score every 15 min for 1 hour, then hourly till 4 hours
  2. Check dressing and vaginal bleedingvaginal bleeding may mean a cervical tear from the vulsellum
  3. Oral fluidswater, tea, juice when comfortable
  4. Discharge criterianot before 4 hours; stable vitals, fully awake, passed urine, can talk, drink and walk; responsible adult with her
  5. Post Operative Instruction Card (Annexure 3)instructions given verbally and in writing in local language; client repeats them
  6. Follow-upcontact within 48 hours; visit on day 7 (stitch removal if non-absorbable); after 1 month or first period, whichever is earlier
  7. Warning signs explainedfainting, increasing pain, bleeding or pus from wound, fever, not passing urine or flatus, bloating
  8. Missed periodreport within 2 weeks of a missed period to rule out pregnancy
  9. Sterilization Certificate (Annexure 4)issued after 1 month or first period, whichever is earlier; not issued if a tube was not occluded

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. S.B., 28 years, P2L2, youngest child 3 years, weight 48 kg, requesting permanent sterilization at a district hospital fixed-day service. LMP 6 days ago. Hb 10.2 g/dl. Urine albumin and sugar nil.

Case details

Date: 15/07/2026. Interval laparoscopic tubal occlusion (Falope ring). OT 2.

Premedication 09:35. In OT 10:10. Local infiltration 10:14. Veress entry 10:18. Rings applied 10:24 and 10:26. Stitch 10:30.

Operating surgeon: Dr A. (empanelled laparoscopic sterilization surgeon, MS OBGY). Assistant: Dr B. (2nd-year resident). Staff nurse: Sr C.

Indication and pre-op

Indication: family complete, requests permanent method. Counselled in Marathi about all methods, permanence, failure and indemnity coverage.

Application cum Consent Form for Sterilization Operation (Annexure 1) signed by client. Medical Record & Check List for Sterilization (Annexure 2) filled and signed by operating surgeon before surgery: all eligibility items Yes. MEC category: Accept.

Timing: interval (youngest child 3 years). Pregnancy reasonably ruled out: within 7 days of start of period. Fasting 8 hours. Passed urine before entering OT.

WHO checklist sign in and time out done. Antibiotic prophylaxis not given: laparoscopic procedure without entry into bowel or vagina.

Anaesthesia and position

Type: local and analgesia. Inj pethidine 37.5 mg + inj promethazine 12.5 mg IM at 09:35.

Lithotomy. Bimanual examination: uterus normal size, anteverted, mobile, adnexa free. Uterine elevator placed with vulsellum on anterior lip of cervix.

Sub-umbilical area painted twice with povidone-iodine and draped. 1% lignocaine without adrenaline, 10 ml, infiltrated in skin and fascia at the lower umbilical margin. Anaesthesia checked before incision.

Procedure

Head-down tilt about 15 degrees. 1 cm incision at the lower margin of the umbilicus.

Veress needle passed at 45 degrees towards the pelvis, two gives felt, hanging-drop test positive. CO2 insufflated with insufflator at 1 L/min, 1.8 L given, pressure 12 mm Hg. Veress removed.

Two Falope rings loaded on the applicator of the operating laparoscope. Trocar and cannula passed towards the pouch of Douglas, laparoscope inserted under vision: single puncture (SPL).

Findings: no bowel or omental injury at entry. Uterus normal size. Both tubes normal, each traced from cornu to fimbria. Both ovaries normal. No adhesions.

Right tube held with the applicator tongs about 3 cm from the cornu at the isthmus, loop drawn in, first ring released. Loop of about 2 cm above the ring with acute angle in the mesosalpinx. No bleeding.

Left tube: same, second ring released, loop of about 2 cm, no bleeding.

Pelvis inspected: no bleeding, no injury. Table brought level. Laparoscope removed, gas let out slowly through the cannula, cannula removed.

Closure

Skin closed with one stitch of Ethilon 2-0. Small dry dressing. Uterine elevator and vulsellum removed, no bleeding from cervix.

Specimens and implants

No specimen. Falope rings: 2 used, one on each tube.

End of procedure

Blood loss negligible. No complications.

Instrument count correct. Intra-operative pulse, BP and respiration checked every 5 min, stable.

Shifted to recovery: pulse 82/min, BP 110/70 mmHg, RR 16/min, sedation score 1 (drowsy).

Post-op orders

Vitals and sedation score every 15 min for 1 hour, then hourly till 4 hours, on section L of the checklist.

Check dressing and PV bleeding. Oral fluids when fully awake.

Discharge not before 14:30 if vitals stable, fully awake, passed urine, able to walk, and accompanied by a responsible adult.

Post Operative Instruction Card (Annexure 3) given; instructions explained in Marathi and repeated by client.

Follow-up: contact with health worker within 48 hours, visit on day 7 for stitch removal, and after 1 month or first period, whichever is earlier. Report a missed period within 2 weeks.

Sterilization Certificate (Annexure 4) to be issued at the 1-month visit or after the first period.

Signature

Dr A., Operating surgeon, OBGY. Reg. no. ________. 15/07/2026, 10:40. Checklist sections K and N to be signed by operating and discharging doctor.

Must document for this operation

  • Each tube identified separately, traced to the fimbria, with a ring on each. The manual lists a ring on the round ligament, or on only part of the tube, as causes of failure, so the note must show each tube was confirmed.
  • If a tube could not be found or occluded, say so plainly, inform the client, and get her countersignature or thumb impression on the case sheet. The MoHFW standards require this, the Sterilization Certificate is then not issued, and the case is not eligible for failure compensation.
  • Consent form and checklist completed before surgery, with names of the empanelled surgeon. The consent form and checklist are the legal record of the operation and the proof of coverage under the Family Planning Indemnity Scheme.
  • Drugs given with dose, route and time, including lignocaine volume. The manual requires the name, dose, route and time of every drug to be recorded, and these are reviewed if the client has a reaction or dies.
  • Timing category: interval or with abortion (under 12 weeks). Laparoscopic occlusion is allowed only in these settings, and the checklist asks for it.
  • Gas used, insufflator used, and single or double puncture. They are fields in section K of the Annexure 2 checklist, which the operating surgeon signs.

Common mistakes in these notes

  • Writing 'B/L Falope rings applied' without confirming each tube was traced to the fimbria.
  • Signing the checklist after the operation instead of before it.
  • Leaving the sedation and lignocaine doses blank.
  • Not recording a one-sided failure on the case sheet with the client's countersignature.
  • Recording the wrong timing category, for example writing interval when done with an MTP.

Indian practice and paperwork

  • The client must sign the Application cum Consent Form for Sterilization Operation (Annexure 1) before surgery. Consent of the spouse is not required. If she gives a thumb impression, a witness chosen by her and not linked to the facility must sign. (MoHFW Reference Manual for Female Sterilization, Nov 2014, sections 3.2 and 3.2.1, printed p 22, Annexure 1 p 91-93: https://nhm.gov.in/images/pdf/programmes/family-planing/guidelines/Ref_Manual_for_Female_Sterilization.pdf)
  • The operating surgeon must fill in the medical record and checklist (Annexure-2, 'Medical Record & Check List for Female and Male Sterilization') before starting the surgery. Section J records the anaesthesia and drugs. Section K records timing, technique (laparoscopy SPL/DPL), method of occlusion (ring / clip), gas and insufflator, and complications. (MoHFW Standards & Quality Assurance in Sterilization Services, Nov 2014, printed p 10 and Annexure-2: https://nhm.gov.in/images/pdf/programmes/family-planing/guidelines/Standards_and_Quality_Assurance.pdf ; Reference Manual for Female Sterilization 2014, Annexure 2 p 94-99)
  • Eligibility: ever married, woman aged 22 to 49 years, at least one child over one year old (unless medically indicated), Hb 7 g/dl or more. Laparoscopic occlusion is only for interval cases or with first-trimester abortion. (MoHFW Reference Manual for Female Sterilization 2014, chapter 4 (printed p 23) and Table 2.1 (printed p 18): https://nhm.gov.in/images/pdf/programmes/family-planing/guidelines/Ref_Manual_for_Female_Sterilization.pdf)
  • If the surgeon cannot identify and occlude a tube on one side, it must be written on the case sheet, the client told the sterilization has not succeeded, and the note countersigned by her or her thumb impression taken. The Sterilization Certificate is then not issued, and the case is not eligible for failure compensation under FPIS. (MoHFW Standards & Quality Assurance in Sterilization Services 2014, section 2.10, printed p 15: https://nhm.gov.in/images/pdf/programmes/family-planing/guidelines/Standards_and_Quality_Assurance.pdf)
  • Discharge card: the Post Operative Instruction Card (Annexure 3) with follow-up at 48 hours, day 7 and one month or first period. The Sterilization Certificate (Annexure 4) is issued after one month or the first period, whichever is earlier, after ruling out pregnancy if no period. (MoHFW Standards & Quality Assurance in Sterilization Services 2014, sections 2.9-2.10, printed p 15; Reference Manual for Female Sterilization 2014, Annexures 3 and 4, p 100-102)
  • In a camp, one team with two laparoscopes should do no more than 30 laparoscopic occlusions in a day. (MoHFW Standards & Quality Assurance in Sterilization Services 2014, printed p 25: https://nhm.gov.in/images/pdf/programmes/family-planing/guidelines/Standards_and_Quality_Assurance.pdf)

Sources

  • Handa VL, Van Le L, eds. Te Linde's Operative Gynecology. 13th ed. Wolters Kluwer; 2024, Ch 18, Tubal sterilization: preoperative evaluation, laparoscopic procedures, silicone band (Falope ring), complications; Ch 2, Table 2.4 antimicrobial prophylaxis, e-book PDF pp. 918-920, 930-942; 164.
  • Ministry of Health and Family Welfare, Family Planning Division. Reference Manual for Female Sterilization. November 2014. Chapter 6 (local anaesthesia 1% lignocaine without adrenaline, maximum 3 mg/kg; Table 6.1 sedation doses by weight; monitoring every 5 min intra-op), chapter 9 (laparoscopic tubal occlusion steps: Trendelenburg not more than 20 degrees, CO2 at 1 L/min, pressure not above 15 mm Hg, 1.5 to 2 L, ring about 4 cm from cornu, 2 cm loop), chapter 10 (post-op monitoring, discharge after at least 4 hours, follow-up). nhm.gov.in/images/pdf/programmes/family-planing/guidelines/Ref_Manual_for_Female_Sterilization.pdf
  • Ministry of Health and Family Welfare, Family Planning Division. Standards & Quality Assurance in Sterilization Services. November 2014. Annexure-1 consent form, Annexure-2 medical record and checklist, Annexure-3 post-operative instruction card, section 2.10 certificate and one-sided failure documentation. nhm.gov.in/images/pdf/programmes/family-planing/guidelines/Standards_and_Quality_Assurance.pdf
  • 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.

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.

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