Total abdominal hysterectomy ± bilateral salpingo-oophorectomy

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
• injury to the ureter
• injury to the bladder
• bowel injury
• wound infection and fever
• pelvic collection or vault infection
• removal of ovaries means immediate menopause (if BSO)
• no periods and no future pregnancy
• vault or wound problems needing repeat surgery

Pre-operative details for this operation

1. Indicatione.g. fibroid uterus with heavy menstrual bleeding: size, number, Hb before and after correction
2. Cervical screeningPap / VIA result and date
3. Endometrial sampling (if abnormal bleeding)result, to rule out hyperplasia or cancer
4. Ultrasounduterine size, fibroid map, adnexa
5. Ovaries: decision and consentConserve bothBilateral salpingo-oophorectomyBilateral salpingectomy, ovaries conserved
6. Pregnancy test (reproductive age)
7. Blood grouped and cross-matchedunits reserved
8. Bowel preparationNoneGiven: agent

Anaesthesia and position

1. AnaesthesiaGeneralSpinalCombined spinal-epiduralEpidural
2. PositionSupineLow lithotomy
3. Examination under anaesthesiauterine size, mobility, adnexa
4. Abdomen and vagina painted, Foley catheter insertedTwo-wayThree-way

Operative findings

1. Uterussize in weeks, fibroids (number, site, largest size), adenomyosis
2. Right and left ovarysize, cysts, endometriosis
3. Right and left tube
4. Pouch of Douglas and adhesions
5. Upper abdomen (liver, omentum, appendix, bowel)normal / abnormal
6. Uretersseen on both sides, and where

Procedure (steps)

1. IncisionPfannenstielMidline verticalMaylardCherneylength
2. Exploration, bowel packed, retractor placedretractor used
3. Uterus held with clamps at the cornua
4. Round ligaments clamped, cut and ligatedsuture
5. Broad ligament opened, ureter identifiedside, site (pelvic brim / medial leaf)
6. Adnexal pedicleInfundibulopelvic ligament clamped, cut, ligated (BSO)Utero-ovarian ligament and tube clamped, cut, ligated (ovaries conserved)suture, double ligation
7. Uterovesical fold opened, bladder dissected downat least 1 cm below the cervicovaginal junction; sharp or cautery
8. Uterine vessels clamped, cut, ligatedlevel (isthmus), clamp used, suture
9. Cardinal and uterosacral ligaments clamped, cut, ligatednumber of bites each side, suture
10. Vagina entered and uterus removedClosed technique (clamps below cervix)Open technique (anterior colpotomy)
11. Vault angles and cuff closedangle stitches incorporating uterosacral ligaments, then figure-of-eight or running; suture
12. Haemostasis, irrigation, ureters checkedcourse and peristalsis; cystoscopy if injury suspected

Closure, drains and dressing

1. Packs and retractor removed, omentum placed down
2. PeritoneumNot closedClosed
3. Rectus sheath / fasciasuture material, size and technique
4. Subcutaneous tissueNot suturedSutured
5. SkinSubcuticularStaplesInterrupted
6. DrainNonePelvicSubcutaneous
7. Urine in catheterclear / haematuria

Specimens and implants

1. Uterus with cervixweight, cut section appearance, sent for HPE
2. Tubes and ovariesAttached to uterusSent separately (labelled right / left)Conserved

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 drain / vaginal bleedingfrequency
2. Urine outputhourly for the first few hours; report haematuria or low output
3. Catheter removalPOD 1 unless bladder or ureter repaired
4. IV fluidstype and rate
5. Dietadvance as tolerated
6. Analgesiadrug, dose, frequency
7. Mobilisation and thromboprophylaxis
8. HbPOD 1
9. Discharge criteriaafebrile, normal diet, bowel and bladder working, wound healing
10. Sexual intercourseavoid for 6 to 8 weeks; vault checked at follow-up
11. HPE follow-update to see report

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