THEATRES &

OPERATION NOTESPraneil Patel

Obstetrics and Gynaecology

SURGICAL OPERATION NOTES

Objectives• Theatre etiquette • Format of the operation note• Tips • Common procedures for ST1 level

THEATRE ETTIQUETTE

• WHO check list • Introduce yourself to the team• Establishes risk• Enables Preparation

WHO CHECK LIST - OBSTETRICS

WHO CHECK LIST Surgery

SURGICAL OPERATION NOTES

• Legal documentation• No formal training • Majority of operative notes are handwritten• Important source for medical records – legal

and financial implications

‘THE ADMIN’

Date of ProcedurePatient details • Hospital sicker/hand write patient detailsStaff details • Operating Surgeon & grade• Surgical assistant & grade• Consultant overseeing care• Anaesthetist and grade

THE SURGERY AND THE REASON

The full title of the operation carried out • List from major to minor• No abbreviations

Type of anaesthetic used.

Indication for the procedure – pre operative diagnosis

i.e. 8/40 Missed Miscarriage with Vaginal Bleeding

‘THE FINDINGS’

• VE &abdominal palpation findings• What was seen during the operation• Post operative diagnosis• Pathological findings • Any relevant negative findings?• As much detail as possible – site, size, colour,

volume of structure involved • Picture aids • Any difficulties?• Blood Loss

‘THE PROCEDURE’Surgical steps• Position • Prepped and draped • Incision (what instrument you used)• Step by step description of surgical steps undertaken• Sutures used and type of suturing (locking, continuous)• Written justification of unusual steps• Drains in situ / catheter – what is draining at end of

procedure• Any samples obtained – how you took them • Swabs, needles and instrument checked

POST OPERATIVE PLAN

Important guidance on managing the patient in the post operative period

Immediate• Analgesia• Medications • VTE assessment• Nutrition - fluids/ eating and drinking• Catheter management• Details of specific drains/dressing/packs/devices – when should they be removed • Samples for the lab • Routine post op care vs. close monitoring/ observations• Anaesthetic concerns

THE POST OPERATIVE PLAN

Hospital Stay• Suture / Staples care• Blood tests• Specific nursing/midwifery instructions• Any specialist input needed e.g. physio• Patient debrief – plan for future e.g. next

delivery/contraception• Discharge – when and by whom• Follow up

‘THE SIGN OFF’

• Print your name [Stamp]• Sign the notes• Leave contact details

Thank you

Further Information

Royal College of Surgeons of England - Guidelines for Clinicians on Medical Records and Notes (1994)

POSITION OF THE PATIENTImportant medical legal detail• Appropriate position for access and to minimize complications e.g.. ulcers or nerve

damageCommon gynaecological patients’ positions

Position Description Procedure

Supine flat on back Caesarean section

Abdominal hysterectomy

Dorsal Lithotomy flat on back, buttocks at edge of bed Hips and knees fully flexed with legs in stirrups

Perineal repair / Urogynae surgery

ERPC

Hysteroscopy

Vaginal Hysterectomy

Trandelenburg Flat on back with feet higher then head by 15-30 degrees

Laparoscopy

Abdominal hysterectomy

Lloyd- Davies Trandelenburg position with hips flexed 15 degrees

Laparoscopy

Sacrocolpoplexy

SURGICAL MANAGEMENT OF MISCARRIAGE

‘The admin’‘The surgery and the reason’

• Gestation• Rhesus status

‘The findings’ • VE – size of uterus, anteverted/retroverted, active bleeding, os open/closed

• Size of suction curette used• Products seen • Haemostasis• EBL

SURGICAL MANAGEMENT OF MISCARRIAGE

‘The procedure’

• Lithotomy position• Prepped and draped• Intermittent catheterization • Cervix dilated – Hegar size • Easy vs. difficult dilatation • Size .... suction curettage used• Evacuation of products • Syntocinon given• Cavity checked – what with and by whom• EBL• Haemostasis achieved (contracted uterus)

SURGICAL MANAGEMENT OF MISCARRIAGE

‘The Post Operative Plan’

• Analgesia +/- • Medication – antibiotics, Anti D• Mobilize• E+D• Products – histology• +/- FBC• Monitor PVB loss• Debrief on the ward vs. nurse led discharge • Discharge• follow up

‘The sign off’

DIAGNOSTIC HYSTEROSCOPY‘The admin’‘The surgery and the reason’

‘The findings’

• VE• Vagina and vulva• Uterine size, position, masses, bleeding

• Hysteroscopy• Cervical canal – easy/difficult entry• Utero-cervical length • Uterus – cavity/ endometrium/ fibroids/ polyps – location and size• Ostia• EBL

DIAGNOSTIC HYSTEROSCOPY

‘The Procedure’

• Dorsal Lithotomy position• Prepped and draped• Cervix dilated uterine • ?size of cavity• Normal saline hysteroscopy – hysteroscope inserted under direct vision • Any additional steps – polypectomy, curetting, resection• Repeat hysteroscopy following intervention

‘The Post Operative Plan’• Analgesia• Mobilize• E+D• Monitor PV loss• Any biopsies/ tissue samples• Follow up plans

‘The sign off’

CAESAREAN SECTION The admin’‘The surgery and the reason’

• Category for Emergency LSCS• Indication for LSCS

‘The findings’

• Abdominal palpation

• VE • Emergency LSCS – dilation, presentation, position, station

• LSCS• Difficult or unusual steps• Adhesions• Abdominal cavity findings (signs of obstruction/ appearance of lower segment)• Presentation and position• Liquor • Placental delivery• EBL• Cord Gases

CAESAREAN SECTION

‘The Procedure’

• Supine position• Prepped and draped• Type of incision at skin• Entry into abdominal cavity• Bladder identified and reflected• Type of incision to lower segment• Delivery of baby – manual, forceps, any difficulty• Delivery of placenta • Uterine cavity check – empty• Uterine angles – any extension• Method of closure• Swabbing of vagina / uterus contracted

CAESAREAN SECTION

‘The Post Operative Plan’

• Analgesia – e.g. PR given • Medications – e.g. antibiotics, thromboprophylaxis, uterotonics• Catheter management• Details of specific drains/dressing/packs – when should they be removed • Suture care• Blood tests• Midwifery instructions• Patient debrief – plan for future e.g. next delivery/contraception

‘The sign off’