OT notes · Gynaecology

Mid-urethral sling (TVT / TOT) for stress incontinence

Usual anaesthesia
Local with sedation, spinal or general (decided by patient, surgeon and anaesthetist)
Position
Low lithotomy in Allen-type stirrups, buttocks at the table edge
Setting
elective

Operative note template for a full-length retropubic (TVT) or transobturator (TOT) mid-urethral sling, with a filled example for an outside-in transobturator sling under spinal anaesthesia.

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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 synthetic mesh left in the body
  • difficulty in passing urine, needing a catheter for some days or cutting of the sling
  • mesh showing through the vaginal wall (about 2 in 100), needing trimming or removal
  • bladder or urethral injury (more with the retropubic route)
  • groin or thigh pain (more with the transobturator route)
  • new urgency or urge incontinence
  • bleeding or haematoma behind the pubic bone
  • leak not cured or coming back
  • pain during intercourse

Pre-operative details for this operation

  1. Stress urinary incontinence objectively confirmedCough stress test positiveUrodynamic stress incontinencePad test
  2. Retention excludedpost-void residual volume in ml
  3. Mixed symptoms / overactive bladderNonePresent, counselled
  4. Previous continence or prolapse surgerytype and date
  5. Concurrent procedure plannedNoneAnterior repairVaginal hysterectomyOther (state)if anterior repair, sling through a separate midurethral incision
  6. Mesh counsellingtold that permanent polypropylene mesh will be placed; alternatives (pubovaginal sling, Burch, bulking) discussed
  7. Sling kit availableroute (retropubic / transobturator), direction (bottom-up, outside-in, inside-out), make

Anaesthesia and position

  1. AnaesthesiaLocal with sedationSpinalGenerallocal agent, strength and volume if local
  2. PositionLow lithotomy in Allen stirrupsLithotomy with slight Trendelenburg (retropubic)legs high enough that the adductor longus is clear of the groin incisions (transobturator); peroneal area padded
  3. Preparationvagina, inner thighs and suprapubic area prepared and draped
  4. Bladdercatheterised and emptied, Foley size
  5. Mechanical VTE prophylaxisSequential compression devicesStockings

Operative findings

  1. Urethral mobilityHypermobileFixed
  2. Vaginal tissueatrophy, scarring from previous surgery
  3. Cystoscopy with bladder fullno trocar perforation, urethra intact, both ureteric jets seen
  4. Vaginal fornices after trocar passageIntactButtonhole (state action)

Procedure (steps)

  1. Route and directionRetropubic, bottom-up (TVT)Retropubic, top-downTransobturator, outside-in (TOT)Transobturator, inside-out (TVT-O)
  2. Skin marksretropubic: 2 cm either side of midline just above the pubic bone; transobturator: groin crease at the level of the clitoris, beside the adductor longus tendon
  3. Hydrodissection / localagent, strength, volume, sites (suburethral, paraurethral, retropubic)
  4. Suburethral incisionlength (1 to 1.5 cm), distance from the meatus; midurethra identified by Foley balloon at bladder neck
  5. Paraurethral tunnelsMetzenbaum scissors, about 2 cm, toward the inferior pubic ramus; stop on touching bone
  6. Bladder neck deviation (retropubic only)Rigid catheter guide usedNot used
  7. Trocar passage, righttip kept in contact with the back of the pubic bone (retropubic) or the back of the inferior pubic ramus (transobturator) throughout; exit point
  8. Trocar passage, leftas above
  9. Vaginal checkfornices palpated for perforation after each pass
  10. Cystourethroscopy70 degree scope, bladder completely filled (300 to 500 ml), perforation seen or not, ureteric jets (transobturator). Retropubic: done with the trocars still in place, before they are pulled through
  11. Sling tensioningKelly clamp spacerHegar dilator No. 9Mayo scissorsBabcock knucklesling lying flat against the urethra without tension
  12. Sheaths removed and arms trimmedexcess mesh cut below the skin

Closure, drains and dressing

  1. Vaginal incisiondelayed absorbable suture, size; sling not caught in the stitches
  2. Skin incisionsSkin glueSteri-StripsFine delayed absorbable suture
  3. Vaginal packNonePlaced (reason, time to remove)
  4. Catheter at endRemovedLeft for voiding trialLeft on drainage (reason)

Specimens and implants

  1. Sling implantmake, product name, route, lot / batch number, expiry; sticker pasted in the case sheet and OT implant register
  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. Voiding trial before dischargefill bladder with 300 ml sterile water, remove catheter, measure voided volume and post-void residual
  2. Pass criteriavoids two-thirds or more (200 ml or more) with residual 100 ml or less
  3. If voiding trial failsintermittent self-catheterisation or indwelling catheter and repeat trial; inform surgeon
  4. Analgesiadrug, dose, route; groin pain after transobturator route
  5. Watch forsuprapubic swelling or falling Hb (retropubic haematoma), inability to pass urine, fever
  6. Discharge cardsling make and lot number written; follow-up date
  7. Follow-upcheck for retention, urgency, vaginal mesh exposure, groin pain; retention lasting over 3 weeks is a reason to consider cutting the sling

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. P.M., 45 years, P2L2, 3 years of leakage on coughing and lifting, positive cough stress test with 300 ml in the bladder, post-void residual 30 ml, no urgency. For outside-in transobturator sling.

Case details

Date: 22/07/2026. Elective. OT 2.

In OT 10:00. Spinal given 10:10. Incision 10:25. Procedure completed 11:00.

Surgeon: Dr A. (Consultant, OBGY). Assistant: Dr B. (JR-3, OBGY).

Anaesthetist: Dr C. Scrub nurse: Sr D.

Indication and pre-op

Pre-op diagnosis: stress urinary incontinence, objectively confirmed by cough stress test. Post-void residual 30 ml. No prolapse beyond stage 1.

Counselled about permanent polypropylene mesh, the retropubic and transobturator routes, and alternatives. Chose transobturator route.

Consent: general, procedure-specific (mesh, retention, sling cut, mesh exposure, groin pain) and anaesthesia consent taken in Marathi from patient.

WHO checklist sign in and time out done. Sling kit checked before anaesthesia. Inj cefazolin 2 g IV at 10:15, before incision.

Anaesthesia and position

Spinal anaesthesia. Low lithotomy in Allen stirrups, legs raised so that the adductor longus tendons are clear of the groin. Peroneal areas padded. Sequential compression devices on both legs.

Vagina, inner thighs and suprapubic area painted with povidone-iodine and draped. 14 Fr Foley catheter passed, bladder emptied.

Findings

Hypermobile urethra. Vaginal tissues healthy, no atrophy.

Cystoscopy after trocar passage: no bladder or urethral injury, both ureteric jets seen.

Procedure

Route: transobturator, outside-in.

Groin stab incisions marked in the crease between the labia majora and the thigh, at the level of the clitoris, just beside the adductor longus tendon on each side.

Suburethral vaginal wall infiltrated with 10 ml normal saline. Allis clamps placed. 1.5 cm midline vaginal incision starting 1.5 cm from the external urethral meatus.

Paraurethral tunnels made with Metzenbaum scissors on both sides toward the ischiopubic ramus, widened enough for the index finger to reach the upper edge of the inferior pubic ramus.

Right side: helical trocar passed through the groin incision perpendicular to the skin, loss of resistance felt at the obturator membrane. Trocar then rotated medially with its tip kept against the back of the inferior pubic ramus, onto the left index finger placed under the ramus through the vaginal incision, and brought out through the vaginal incision. Left side done the same way.

Both lateral vaginal fornices palpated and inspected: no buttonhole.

Cystourethroscopy with 70 degree scope, bladder filled to 400 ml: no perforation, urethra intact, both ureteric jets seen. Bladder emptied.

Sling ends attached to the trocars and brought out through the groin incisions.

Kelly clamp placed between the sling and the urethra. Plastic sheaths removed. Clamp passed easily with no recoil on the sling.

Excess mesh cut below the skin on both sides.

Closure

Vaginal incision closed with polyglactin 910 (Vicryl) 2-0, sling not included in the stitches.

Groin stab incisions closed with skin glue. No vaginal pack. Foley catheter left in for the voiding trial.

Specimens and implants

Implant: transobturator polypropylene mid-urethral sling, make ________, lot no. ________, expiry ________. Sticker pasted in the case sheet and in the OT implant register.

No specimen.

End of procedure

Estimated blood loss 30 ml. No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Shifted to post-operative ward in stable condition. Pulse 76/min, BP 124/80 mmHg.

Post-op orders

Pulse and BP 4-hourly. Oral fluids once spinal wears off, then normal diet.

Voiding trial when sensation returns after spinal: fill bladder with 300 ml sterile water through the Foley catheter, remove it, record voided volume and bladder scan residual.

Pass if voided 200 ml or more and residual 100 ml or less. If not, intermittent catheterisation and inform the unit.

Analgesia as per anaesthetist's chart. Inform if suprapubic swelling, inability to void or severe groin pain.

Write the sling make and lot number in the discharge summary. Review at 6 weeks.

Signature

Dr B., JR-3, OBGY, for Dr A. Reg. no. ________. 22/07/2026, 11:15.

Must document for this operation

  • Route (retropubic or transobturator) and direction of trocar passage. Complications and any later removal differ by route, and the surgeon who removes or cuts the sling needs to know where the arms lie.
  • Sling make, product and lot number, with the sticker. Some vaginal mesh products have been withdrawn from the market, and the patient must be traceable to the exact product.
  • Cystoscopy findings after trocar passage, with the bladder filled. An unrecognised bladder or urethral perforation turns into a mesh erosion or fistula later.
  • How tension was set. Retention and failure are the two common problems, and the tensioning method is reviewed when either happens.
  • Vaginal fornices checked for perforation. A missed buttonhole is a known cause of later mesh exposure.
  • Voiding trial plan and result. Retention after a sling needs early action, and the ward needs clear pass and fail numbers.

Common mistakes in these notes

  • Writing 'TOT done' without the product, lot number or direction of passage.
  • Not recording that cystoscopy was done, or doing it with the bladder half full.
  • Leaving out how the sling was tensioned.
  • Discharging without a documented post-void residual.
  • Not writing that objective stress incontinence and a normal residual were confirmed before surgery.
  • Not noting a separate incision when a sling is placed with an anterior repair.

Indian practice and paperwork

  • The batch and serial number of an implanted device must be recorded in the patient's record, the master (OT implant) logbook and the discharge summary. A mesh sling is an implant. (NABH Hospital Accreditation Standards 5th ed. (2020), MOM.10(d))
  • Consent must explain the procedure, risks, benefits, alternatives and who will operate, in a language the patient understands. For a sling this includes telling her that permanent mesh will be placed. (NABH 5th ed., PRE.4(c))
  • The operative note must be written before the patient leaves recovery, and post-op care (here the voiding trial) must follow a written plan. (NABH 5th ed., COP.14(e) and (f))

Sources

  • Van Le L, Handa VL, eds. Te Linde's Operative Gynecology. 13th ed. Wolters Kluwer; 2024, Ch 33, Midurethral slings and surgery for stress urinary incontinence (retropubic and transobturator slings, Box 33.1 and 33.2, voiding trial, complications); Ch 2, Table 2.4, e-book PDF pp. 1749-1775; 162-164.
  • Smith JA Jr, Dmochowski RR, Thomas JC, Preminger GM, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2026, Ch 95, Transobturator midurethral slings (Gomelsky A), pp. 776-783.
  • Te Linde 13e Ch 2, Table 2.4, PDF p. 164: vaginal sling placement, cefazolin 2 g IV (3 g if over 120 kg), single dose within 1 hour before the procedure.
  • Te Linde 13e Ch 33, PDF p. 1763: voiding trial by retrograde fill of 300 ml; pass if 200 ml or more voided with residual 100 ml or less. PDF p. 1775: consider sling transection if retention lasts over 3 weeks. PDF p. 1775: vaginal mesh exposure 2.1% retropubic, 2.4% transobturator (2017 Cochrane review).

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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