Radical hysterectomy (Wertheim's)

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

• bladder dysfunction after surgery, which may need a catheter or self-catheterisation for weeks
• ureteric injury, ureteric fistula or stricture
• vesicovaginal fistula
• heavy bleeding and blood transfusion
• deep vein thrombosis and pulmonary embolism
• nerve injury, most often the obturator nerve (weak thigh adduction)
• leg lymphoedema after lymph node removal
• constipation and difficulty in passing stool
• shorter vagina (2 to 3 cm removed) and change in sexual function
• operation stopped if para-aortic nodes or spread outside the cervix is found, and radiotherapy advised instead

Pre-operative details for this operation

1. Histology and stagebiopsy report (squamous / adenocarcinoma), FIGO stage and year of the staging system, tumour size in cm
2. ImagingMRI pelvis / CT / PET findings: parametrium, nodes, hydronephrosis
3. Planned type of radical hysterectomyType B (modified radical)Type C1 (nerve-sparing)Type C2 (classical, non-nerve-sparing)Querleu-Morrow type; can differ on the two sides if the tumour is asymmetrical
4. Nodal planSentinel node mappingFull bilateral pelvic lymphadenectomySentinel node then lymphadenectomytracer used and injection sites if sentinel node mapping
5. Decision on ovaries, discussed before surgeryOvaries preserved, tubes removedBilateral salpingo-oophorectomyOvarian transposition if radiotherapy is likelyrecord that this was in the written consent
6. Blood grouped and cross-matchedgroup, units reserved
7. Bowel preparation / anticoagulants stoppedwhat was done and when
8. Frozen section bookedYesNo

Anaesthesia and position

1. AnaesthesiaGeneralGeneral with epidural catheter
2. PositionLow lithotomy, thighs 15 to 20 degrees, knees apart about 90 degreespressure points padded, calves free
3. Mechanical VTE prophylaxisPneumatic compression devices on both legs
4. Examination under anaesthesiarectovaginal-abdominal findings: tumour size, vaginal and parametrial extension
5. Skin and vaginal preparationrib margin to mid-thigh, perineum and vagina; antiseptic used
6. Foley cathetersize, inserted after draping

Operative findings

1. Upper abdomenliver surfaces, undersurface of diaphragm, omentum, bowel serosa and mesentery
2. Para-aortic nodesNot enlargedEnlarged, sent for frozen sectionfrozen section result
3. Pelvic nodesside, group and size of any enlarged node; frozen section result
4. Parametria and pelvic side wallfree / involved, after opening paravesical and pararectal spaces
5. Cervical tumoursize, barrel-shaped or not, vaginal extension
6. Uterus, tubes and ovariesnormal / abnormal
7. Ascites or peritoneal depositsNonePresent (describe)

Procedure (steps)

1. IncisionPfannenstielCherneyMaylardOther (state)length; self-retaining retractor used
2. Exploration and operabilityabdomen and pelvis checked; suspicious nodes to frozen section; decision to proceed or abandon
3. Round ligaments divided, broad ligaments openedsuture used for pedicles
4. Paravesical and pararectal spaces developedbase of broad ligament (cardinal ligament) palpated between the two spaces
5. AdnexaInfundibulopelvic ligaments ligated (BSO)Utero-ovarian ligaments divided, ovaries kept, salpingectomy
6. Pelvic node assessmentSentinel node biopsyBilateral pelvic lymphadenectomygroups removed on each side (common iliac, external iliac, internal iliac, obturator); obturator nerve seen and preserved
7. Ureter separated from the medial leaf of the broad ligamentboth sides
8. Uterine artery ligatedAt its origin from the internal iliac arteryAnterior division of internal iliac ligatedsuperficial uterine vein also ligated
9. Bladder reflected off the cervix and upper vaginasharp dissection
10. Ureteric tunnel unroofed and ventral parametrium (vesicouterine ligament) dividedC1: ureter freed from cervix, only the part of the ventral parametrium above the ureter removed; part below the ureter (bladder nerve branches) keptC2: ureter freed completely, ventral parametrium divided at the bladder wallroof of the tunnel clamped, cut and tied; ureter rolled laterally; ureteric sheath (adventitia) kept intact
11. Lateral parametrium (cardinal ligament) dividedC1: down to the deep uterine vein, splanchnic nerves below keptC2: along the internal iliac vein to the sacrum
12. Rectovaginal space opened, uterosacral ligaments dividedC1: at the level of the rectal attachment, hypogastric nerve branches keptC2: deep, below the rectal attachment
13. Paracolpos divided and vagina transectedWertheim clamp placed below the cervix before colpotomy; length of vaginal cuff removed in cm
14. Vaginal vault closeddelayed absorbable suture, size, running or interrupted
15. Ovarian transposition (if done)side, level fixed, permanent suture, metal clips placed as markers
16. Haemostasis and final checkpelvic side walls, vault, ureters seen along their course

Closure, drains and dressing

1. Pelvic peritoneumNot closedClosed
2. DrainNonePelvic drain (state type and side)if placed, reason
3. Rectus sheathrunning delayed absorbable suture, size; lateral extensions of Cherney or Maylard closed in external oblique fascia only
4. SkinSubcuticularInterruptedStaples
5. Urine at end of surgeryvolume and colour, any haematuria

Specimens and implants

1. Main specimenuterus, cervix, both parametria and vaginal cuff en bloc; tubes / ovaries; orientation marked
2. Lymph nodesseparate labelled containers by side and group; sentinel nodes labelled as such
3. Frozen sectionswhat was sent, result, time
4. Clips left in the bodyNoneOvarian marker clipsHaemostatic clips

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. Monitoringpulse, BP, urine output, drain output if any; HDU or ward as per unit
2. Urinary catheter and voiding trialafter nerve-sparing surgery, remove at 24 to 72 h and check post-void residual by bladder scan; discharge without catheter if residual below 50 to 75 ml and voided volume more than the residual
3. If residual stays highintermittent self-catheterisation or indwelling catheter for some weeks; do not let the bladder overfill
4. Thromboprophylaxispneumatic compression in OT and while in bed. Heparin 5000 U perioperatively, then LMWH until mobile (dose as per unit protocol)
5. Analgesiadrug, dose, route; epidural orders if catheter in place
6. Diet and mobilisationclear oral fluids once fully awake and able to swallow, solid food from POD 1, no need to wait for bowel sounds. Early mobilisation
7. Watch forfever, leak of urine from the vagina, flank pain, leg swelling, weak thigh adduction
8. Histopathology follow-update to review HPE; nodes, margins, parametria and LVSI decide the need for adjuvant radiation

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