OT notes · Urology

No-scalpel vasectomy (NSV)

Usual anaesthesia
Local (bilateral perivasal block with 2% lignocaine without adrenaline)
Position
Supine
Setting
elective

Operative note template for no-scalpel vasectomy under the Indian family planning programme, with a filled example for a bilateral NSV under local anaesthesia at a district hospital camp.

Download printable PDFFree. Just log in with your Google (Gmail) account.

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

  • not effective until semen shows no sperm (usually about 3 months); condom or another method needed till then
  • pain, swelling and bruising of the scrotum
  • haematoma
  • infection of the wound, or orchitis
  • sperm granuloma
  • failure by recanalisation (rare), and repeat surgery
  • the operation is meant to be permanent; reversal is major surgery and success is not guaranteed
  • reaction to local anaesthetic

Pre-operative details for this operation

  1. Application cum consent form (Annexure 1)Signed by clientThumb impression with witness chosen by client
  2. Eligibility checklist (Annexure 2)ever married; age above 22 and below 60 years; at least one child above one year; neither partner sterilized before; sound mind
  3. Counselling donemethod-specific points explained, including back-up contraception until azoospermia
  4. Medical record and checklist (Annexure 2) filled by operating surgeon before surgeryYes
  5. Scrotal examinationboth vasa palpable; hernia, hydrocele, varicocele, infection, previous scrotal surgery
  6. PremedicationNoneOral anxiolytic: drug, dose, time

Anaesthesia and position

  1. AnaesthesiaLocal: 2% lignocaine without adrenaline, bilateral perivasal blocktotal volume in ml and mg; stay within 3 mg/kg and 200 mg
  2. PositionSupine
  3. Skin preparationantiseptic used; scrotum draped

Operative findings

  1. Right vasIdentified and deliveredCould not be identified
  2. Left vasIdentified and deliveredCould not be identified
  3. Scrotal contentsnormal / abnormality noted

Procedure (steps)

  1. Vas fixed in midlinethree-finger technique; ring (vas fixation) forceps at junction of upper one-third and lower two-thirds
  2. Skin punctureSingle midline punctureConverted to conventional incision (reason)sharp arm of vas dissector, spread
  3. Vas delivered and clearedsheath opened, bare vas lifted out
  4. Segment of vas excisedlength in cm (about 1 cm per programme standard), each side
  5. Occlusion of cut endsLigation 2-0 silkLigation 2-0 catgutCautery + ligationHemoclip
  6. Fascial interpositionDone both sidesNot done: reason
  7. Opposite vasfixed, delivered, excised and ligated through the same puncture
  8. Haemostasischecked before returning each vas

Closure, drains and dressing

  1. Puncture woundLeft to close, no suturePressure appliedSuture (type)
  2. Dressingantiseptic swab and sterile gauze held with scrotal support or tape, to stay 48 hours

Specimens and implants

  1. Vas segmentsSent for HPE (right and left in separate labelled containers)Not sent

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. Observationpulse, respiration, BP; discharge after at least 30 minutes if alert, walking, vitals stable and seen by the doctor
  2. Post Operative Instruction Card (Annexure 3)given with written and verbal instructions in the local language; date and place of follow-up filled
  3. Scrotal support and wound caretight underwear or scrotal support; dressing for 48 hours; no bathing for 24 hours
  4. Activitylimit activity for 24 hours; avoid heavy work for about a week
  5. Warning signsfever, blood or pus from the puncture, severe pain or swelling: come back
  6. Contraceptioncondom or another method until semen shows no sperm
  7. Semen examinationat 3 months; if sperm still present, repeat every month up to 6 months
  8. Sterilization Certificate (Annexure 4)issued only after semen examination shows no sperm

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: Mr. R.M., 34 years, married, two children (youngest 3 years), wife not sterilized, requesting permanent method; at a district hospital fixed-day NSV service.

Case details

Date: 10/09/2026. Elective NSV. Minor OT.

In OT 11:30. Local anaesthesia 11:35. Puncture 11:38. Procedure ended 11:52.

Surgeon: Dr A. (MS General Surgery, trained NSV provider). Assistant: Dr B. (2nd-year resident). Staff nurse: Sr C.

Indication and pre-op

Request for permanent male sterilization. Counselled on 03/09/2026 and again today, including that the method is not effective until semen shows no sperm and that condoms must be used till then.

Annexure 1 (Application cum consent form for Sterilization Operation) signed by client. Wife attended counselling.

Annexure 2 (Medical Record & Check List for Female and Male Sterilization) filled before surgery: ever married, age 34, two living children, youngest above one year, neither partner sterilized before, sound mind.

Examination: both vasa palpable and normal. No hernia, hydrocele or varicocele. Scrotal skin healthy.

No premedication. No antibiotic prophylaxis (clean procedure, no risk factors). WHO checklist done.

Anaesthesia and position

Supine. Scrotum painted with povidone-iodine and draped.

Local anaesthesia: 2% lignocaine without adrenaline, 4 ml total (80 mg): skin wheal in the midline and perivasal block on each side.

Procedure

Right vas brought to the midline by three-finger technique and fixed with the ring forceps at the junction of the upper one-third and lower two-thirds of the scrotum.

Single midline puncture with the sharp arm of the vas dissector, skin spread. Bare right vas lifted out of its sheath.

About 1 cm of right vas excised. Both cut ends ligated with 2-0 black silk. Fascial interposition done by closing the sheath over the testicular end.

Left vas fixed and delivered through the same puncture. About 1 cm excised, ends ligated with 2-0 black silk, fascial interposition done.

Both vasa identified with certainty. Haemostasis checked on each side before return.

Closure

Puncture not sutured; edges pressed together. Antiseptic swab and sterile gauze held with scrotal support, to stay for 48 hours.

Specimens and implants

Right and left vas segments (about 1 cm each) sent for HPE in separate labelled formalin containers. No implant.

End of procedure

Blood loss negligible. No complications. Instrument count correct.

Annexure 2 surgical section filled: technique NSV, single puncture, 2-0 silk, fascial interposition yes, length of vas resected 1 cm each side, no other surgery, no complications. Signed by operating surgeon and staff nurse.

Observed 30 minutes: pulse 78/min, BP 124/80 mmHg, walking, alert.

Post-op orders

Annexure 3 (Post Operative Instruction Card) given, instructions explained in Hindi.

Scrotal support for one week. No bath for 24 hours. Light work after 2 to 3 days, no heavy work for a week.

Tab paracetamol for pain if needed, dose as per protocol.

Use condoms until semen examination shows no sperm. Semen examination on 10/12/2026 (3 months). If sperm present, repeat monthly up to 6 months.

Sterilization Certificate (Annexure 4) to be issued only after semen shows no sperm.

Come back at once for fever, bleeding or pus from the puncture, or severe pain or swelling.

Signature

Dr A., Surgeon. Reg. no. ________. 10/09/2026, 12:05.

Must document for this operation

  • Each vas identified, excised and occluded, side by side, with length resected. If one vas was not found, the programme requires this to be written on the case sheet, countersigned by the client, and no certificate issued.
  • Occlusion material and whether fascial interposition was done (reason if not). Annexure 2 asks for these, and they matter in any failure review.
  • Local anaesthetic drug, strength and total dose. The total must stay within 3 mg/kg and 200 mg, and a reaction needs the exact dose on record.
  • Advice on back-up contraception and the date for semen examination. Pregnancy before azoospermia is the most common cause of so-called vasectomy failure; documented advice protects the client and surgeon.
  • Consent form (Annexure 1) signed, or thumb impression with a witness chosen by the client. This signature is the legal authority for sterilization and proof of cover under the Family Planning Indemnity Scheme (FPIS).
  • Instruction card (Annexure 3) given in the local language. The programme requires written and verbal instructions in the local language, and the card is proof of the operation for compensation.

Common mistakes in these notes

  • Writing 'bilateral vasectomy done' without saying each vas was clearly identified.
  • Not recording the length of vas removed and the occlusion material.
  • Telling the client he is sterile from the day of surgery instead of after a sperm-free semen test.
  • Issuing the sterilization certificate before the semen report.
  • Leaving Annexure 2 partly filled or unsigned.

Indian practice and paperwork

  • The current Government of India standard is 'Standards & Quality Assurance in Sterilization Services' (November 2014). NSV may be done by an MBBS doctor or above trained in no-scalpel vasectomy. (MoHFW Family Planning Division, SQAS 2014, section 1.1, https://nhm.gov.in/images/pdf/programmes/family-planing/guidelines/Standards_and_Quality_Assurance.pdf)
  • Forms named in SQAS 2014: Annexure 1 'Application cum consent form for Sterilization Operation'; Annexure 2 'Medical Record & Check List for Female and Male Sterilization' (filled by the operating surgeon before surgery); Annexure 3 'Post Operative Instruction Card'; Annexure 4 'Sterilization Certificate'. (SQAS 2014, contents and sections 1.5, 3.9, 3.10)
  • Eligibility for male clients: ever married, above 22 and below 60 years, at least one child above one year, neither partner sterilized before, and of sound mind. Consent of the partner is not required. (SQAS 2014, sections 1.3 and 1.4)
  • NSV technique in the standard: bilateral vasal block with 2% lignocaine without adrenaline; vas fixed in the midline at the junction of upper one-third and lower two-thirds; about 1 cm excised and ligated with 2-0 black silk; opposite vas through the same puncture; fascial interposition optional but recommended; dressing kept 48 hours. (SQAS 2014, section 3.7.2, pp 19-20)
  • Semen examination at 3 months; if sperm are present, test every month till 6 months; failure is not declared before 6 months. The Sterilization Certificate is issued only after semen shows no sperm. (SQAS 2014, sections 3.9 and 3.10)
  • If a vas cannot be identified on one side, the surgeon must write this on the case sheet, get it countersigned (or thumb impression) by the client, and not issue a certificate. (SQAS 2014, section 3.9)
  • Complications needing admission, deaths and failures are reported to the District Quality Assurance Committee; claims go on Annexure 20 (Claim form for Family Planning Indemnity Scheme). (SQAS 2014, section 1.4.3 and Annexure 20; FPIS Manual 2016)

Sources

  • Smith JA Jr, Howards SS, Preminger GM, Dmochowski RR, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2026, Ch 110, Vasectomy (Brugh), pp. 878-880.
  • Smith JA Jr, Howards SS, Preminger GM, eds. Glenn's Urologic Surgery. 8th ed. Wolters Kluwer; 2016, Ch 51, Vasectomy, e-book PDF pp. 770-784.
  • Ministry of Health and Family Welfare, Family Planning Division. Standards & Quality Assurance in Sterilization Services. November 2014. Sections 1.3 (eligibility), 1.5 (consent), 2.5 and 3.6 (local anaesthesia: lignocaine not more than 3 mg/kg, maximum 200 mg), 3.6-3.12 (vasectomy technique, follow-up, certificate), Annexures 1-4, 20. nhm.gov.in/images/pdf/programmes/family-planing/guidelines/Standards_and_Quality_Assurance.pdf
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Urologic recommendations: no antimicrobial prophylaxis for clean urologic procedures in patients without risk factors. academic.oup.com/ajhp/article/70/3/195/5112717

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.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

This page cannot be printed from the browser. Use the Download printable PDF button on the page.