OT notes · Gynaecology

Vaginoplasty (McIndoe) / vaginal reconstruction

Usual anaesthesia
General or spinal (graft donor site and perineum in one field)
Position
Dorsal lithotomy, with the graft donor thigh prepared
Setting
elective

Operative note template for creation of a neovagina for vaginal agenesis (McIndoe perineal approach, with the Davydov peritoneal option), with a filled example for a McIndoe vaginoplasty using a split-thickness skin graft in a woman with MRKH syndrome.

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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

  • the new vagina will narrow or close if dilators are not used regularly for months
  • no pregnancy is possible because there is no working uterus
  • injury to the rectum or bladder while making the space
  • part or all of the graft may not take
  • scar, slow healing and colour change at the skin graft donor site
  • bleeding
  • infection
  • change to an abdominal (peritoneal) approach if the perineal space cannot be made safely

Pre-operative details for this operation

  1. DiagnosisMRKH syndromeAndrogen insensitivityAcquired vaginal stenosisOther (state)karyotype if done; uterine rudiments and ovaries on imaging
  2. Associated anomalies checkedkidney and spine imaging results
  3. Depth of vaginal dimple before surgeryin cm; any previous dilator use
  4. Counsellingaim is sexual function, not pregnancy; lifelong need for dilatation unless regular intercourse; motivation to dilate recorded
  5. Graft plannedSplit-thickness skin graft (thigh)Amnion (at a caesarean in the same OT)Absorbable adhesion barrier (oxidised regenerated cellulose)Peritoneum (Davydov)plastic surgery help booked if skin graft
  6. Bowel preparationagent, time given, result
  7. Pre-op oral antibiotics (if unit protocol)drug, dose, days

Anaesthesia and position

  1. AnaesthesiaGeneralSpinalCombined spinal-epidural
  2. PositionDorsal lithotomydonor thigh prepared and draped in the field
  3. BladderFoley catheter size, inserted before dissection
  4. Rectal accessdraped so that rectal examination can be done without contaminating the field

Operative findings

  1. Vulvalabia, clitoris, urethral meatus, hymenal ring normal or not
  2. Vaginal dimpledepth in cm, site of the mucocutaneous junction
  3. Length and width of space createdin cm; admits how many fingers
  4. Rectal examination after dissectionRectum intactInjury (state repair)
  5. Uterine rudiments and ovaries (if abdomen entered)describe

Procedure (steps)

  1. ApproachMcIndoe (perineal, graft on mould)Davydov (combined perineal and abdominal, peritoneal lining)
  2. Incision at the mucocutaneous junctionTransverseEllipticalAllis forceps on either side
  3. Creation of the neovaginal spaceclosed scissors pushed in and spread in the midline then either side; then two index fingers sweeping medial to lateral, level by level, between bladder and rectum
  4. Depth reachedabout 10 cm, or down to the floor of the pouch of Douglas without opening it
  5. Haemostasis and washmethod; saline wash of the space
  6. Graft harvestdonor site, dermatome, graft size; donor dressing
  7. MouldCondom packed with gauzeCondom packed with spongeSilicone or other stentlength equal to the new space, diameter 3 to 4 cm
  8. Graft on the mouldraw surface outwards; side and top edges sutured (suture, size); lower edge left open
  9. Mould inserted, graft edge sutured to the introitussuture, size, interrupted all round
  10. Mould retainedT-bandageLabia majora sutured together over the mould
  11. Davydov only: peritoneal flapsaccess (laparoscopy / laparotomy), anterior and posterior flaps brought to the introitus, suture; vault closed by purse-string; ovaries placed over the vault

Closure, drains and dressing

  1. Introitusgraft or peritoneal edge to skin edge, suture and size
  2. Labial stitchesNonePlaced (must be removed before the mould)
  3. Donor site dressingparaffin gauze with antibiotic (framycetin), pad and bandage
  4. CatheterFoley size, left on free drainage
  5. Abdominal wound (Davydov)closure

Specimens and implants

  1. SpecimensNoneRudimentary uterine horn / tubes (Davydov), sent for HPE
  2. Mould / stenttype and size; this is temporary and must be removed; write the planned date

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. Mouldfirst condom mould kept in with T-bandage and removed on day 5 to 7 (remove labial stitches first). Skin graft (McIndoe): then a mould worn day and night for 3 to 6 months, taken out once a week for cleaning, and after that at least every other night if not having regular intercourse
  2. Catheterfree drainage; remove on day 5
  3. Donor sitekeep dressing dry; first dressing change as per plastic surgery
  4. Dilatation (peritoneal lining, Davydov)after the mould is out: dilator with water-based jelly, 10 minutes each time: 3 times a day for months 0 to 3, once a day for 3 to 6, alternate days for 6 to 9, once or twice a week for 9 to 12
  5. Dilator carewash with soap and water and dry after each use
  6. Intercoursemay start after 3 months; dilatation still needed when not having regular intercourse
  7. Analgesiadrug, dose, route
  8. Watch forfever, foul discharge, passage of stool or flatus per vagina, heavy bleeding

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: Ms. N.T., 22 years, MRKH syndrome (46,XX, absent uterus with small rudiments, normal ovaries, normal kidneys), 1 cm blind vaginal dimple, wants to become sexually active. For McIndoe vaginoplasty with a split-thickness skin graft.

Case details

Date: 03/09/2026. Elective. OT 2.

In OT 09:00. GA induced 09:10. Incision 09:30. Procedure completed 11:15.

Surgeon: Dr A. (Consultant, OBGY). Graft harvest: Dr E. (Plastic Surgery). Assistant: Dr B. (JR-3, OBGY).

Anaesthetist: Dr C. Scrub nurse: Sr D.

Indication and pre-op

Pre-op diagnosis: vaginal agenesis, MRKH syndrome. Karyotype 46,XX. MRI: uterine rudiments, both ovaries normal. Renal ultrasound and spine X-ray normal.

Counselled that the aim is sexual function and that pregnancy is not possible. Counselled and motivated for regular dilator use after surgery.

Bowel prepared with polyethylene glycol-electrolyte solution the evening before. Liquids only at dinner, then nil by mouth.

Tab ciprofloxacin 500 mg twice daily and tab metronidazole 400 mg three times daily for 5 days before surgery as per unit protocol.

Consent: general, procedure-specific (stenosis without dilatation, rectal or bladder injury, graft failure, donor site scar) and anaesthesia consent taken in Marathi from the patient herself, mother present.

WHO checklist sign in and time out done. Prophylactic IV antibiotic as per unit policy given at 09:15, before incision (drug and dose written in the anaesthesia record).

Anaesthesia and position

General anaesthesia. Dorsal lithotomy. Perineum, vulva and right thigh painted with povidone-iodine and draped, with the anus accessible for rectal examination.

16 Fr Foley catheter passed, urine clear.

Findings

Normal labia, clitoris and urethral meatus. Blind vaginal dimple 1 cm deep. Mucocutaneous junction seen below the meatus.

Space created: 10 cm long, admits two fingers. Rectal examination after dissection: rectum intact.

Procedure

Mucocutaneous junction held with Allis forceps on either side. Transverse incision of about 3 cm at the junction.

Closed scissors pushed in at the centre and opened, then on either side, between the bladder in front and the rectum behind.

Once two index fingers could enter, the space was widened by sweeping from medial to lateral and deepened level by level, by blunt and sharp dissection, to a depth of 10 cm. Pouch of Douglas not opened.

Rectal examination done: rectum intact. Bleeding points coagulated. Space washed with normal saline and packed with a moist mop.

Split-thickness skin graft about 15 x 10 cm taken from the right anterolateral thigh with a Humby knife by Dr E. Donor site dressed with framycetin paraffin gauze, pad and crepe bandage.

Mould made from a condom packed with gauze pieces and tied at the mouth, 10 cm long and about 3.5 cm wide.

Graft wrapped over the mould with the raw surface outwards. Overlap trimmed. Side edges and top edge sutured with polyglactin 910 (Vicryl) 4-0. Lower edge left open.

Mop removed. Mould with graft inserted into the new space. Lower edge of graft sutured to the skin edge of the introitus all round with interrupted polyglactin 910 (Vicryl) 4-0.

Closure

Mould held in place with a T-bandage. Labia not sutured.

Foley catheter on free drainage. Donor site dressing dry.

Specimens and implants

No specimen. No permanent implant.

Temporary condom-and-gauze mould left in the neovagina, to be removed on day 7, then replaced by a vaginal mould (see post-op orders).

End of procedure

Estimated blood loss 200 ml. No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse. Gauze pieces inside the mould counted and recorded as 6.

No intra-operative complications.

Extubated in OT. Shifted to post-operative ward in stable condition. Pulse 84/min, BP 110/70 mmHg.

Post-op orders

Pulse, BP and perineal pad checked 4-hourly.

T-bandage to stay. Foley catheter on free drainage, remove on day 5.

Remove the condom mould on day 7 in the ward procedure room, count the gauze pieces (6), and check graft take. Then fit a vaginal mould, to be worn day and night for 3 to 6 months and taken out once a week for cleaning. After that, mould or dilator at least every other night if not having regular intercourse. Teach mould care and use of water-based jelly.

Donor site dressing to be opened by plastic surgery team.

Analgesia as per anaesthetist's chart.

Inform if fever, foul discharge, stool or gas from the vagina, or bleeding.

Signature

Dr B., JR-3, OBGY, for Dr A. Reg. no. ________. 03/09/2026, 11:30.

Must document for this operation

  • Length and width of the space created. Later loss of depth can only be judged against the depth achieved in theatre.
  • Rectal examination after dissection and its result. A missed rectal injury leads to a rectovaginal fistula, and the note shows it was looked for.
  • Type of lining (skin graft, amnion, adhesion barrier or peritoneum) and the donor site. It explains the donor scar and guides the next surgeon if revision is needed.
  • Type and size of mould, anything packed inside it, and the date it must come out. A mould or a gauze piece left too long causes infection and pressure necrosis, and the ward team needs the date.
  • Counselling about pregnancy and dilatation, with the patient's own consent. Stenosis from poor dilatation is the usual failure, and the record must show she was told before surgery.
  • Labial stitches, if placed. They must be removed before the mould, and ward staff will not know unless it is written.

Common mistakes in these notes

  • Writing 'neovagina created' with no length or width.
  • Not recording that a rectal examination was done after the dissection.
  • Not writing the mould removal date or how the mould is held in place.
  • Leaving out the donor site and its dressing.
  • Not writing the dilatation schedule in the discharge instructions.
  • Not recording associated renal and spinal findings in the pre-op section.

Indian practice and paperwork

  • Consent must explain the procedure, risks, benefits, alternatives (including dilator treatment without surgery) and who will operate, in a language the patient understands. (NABH Hospital Accreditation Standards 5th ed. (2020), PRE.4(c))
  • The operative note must be written before the patient leaves recovery, and post-op care (mould, catheter, dilatation) must follow a written plan. (NABH 5th ed., COP.14(e) and (f))
  • Instruments, needles and sponges are counted before the case, before final closure and at the end. Write the number of gauze pieces left inside the mould so the count can be closed and the pieces accounted for at removal. (NQAS Assessor's Guidebook for District Hospitals 2020, ME E15.3)

Sources

  • Pal M, ed. Urogynecology and Pelvic Reconstructive Surgery. 2nd ed. Jaypee Brothers Medical Publishers; 2024, Ch 57, Vaginoplasty (Pal M): counselling, bowel preparation, McIndoe technique, Davydov peritoneal pull-through, post-op dilatation (Table 1), pp. 343-350.
  • Smith JA Jr, Dmochowski RR, Thomas JC, Preminger GM, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2026, Ch 78, Vaginoplasty and vulvoplasty (Lin JS, Douglass LM, Cohn JA, Bluebond-Langner R, Zhao LC): options for vaginal agenesis, graft tubularised over a stand, canal dissection with rectal examination, mould for 3 to 6 months after graft (McIndoe) vaginoplasty, pp. 644-646, 659.
  • Urogynecology and Pelvic Reconstructive Surgery 2e, Ch 57, printed p. 343-344: optional oral ciprofloxacin 500 mg twice daily and metronidazole 400 mg three times daily for 5 days; polyethylene glycol-electrolyte bowel preparation the evening before. Printed p. 349-350 (post-op paragraph after the Davydov section): catheter out after 5 days, condom mould out after 5-7 days, dilatation schedule (Table 1), intercourse after 3 months.
  • Hinman's Atlas 5e, Ch 78, printed p. 659 (PDF 704): after peritoneal or graft-based (McIndoe) vaginoplasty a vaginal mould is needed for 3 to 6 months, removed weekly for cleaning, then worn at least every other night or every third night if not having regular intercourse.

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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