OT notes · Gynaecology

Non-descent vaginal hysterectomy (NDVH)

Usual anaesthesia
Spinal or general
Position
Dorsal lithotomy, hips just over the table edge
Setting
elective

Operative note template for vaginal hysterectomy on a uterus without prolapse, with a filled example for NDVH with bivalving of a 12-week fibroid uterus 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

  • bleeding and blood transfusion
  • bladder injury
  • ureteric injury
  • bowel injury
  • conversion to abdominal (open) operation
  • vault haematoma or infection
  • difficulty passing urine after surgery, needing a catheter
  • vault prolapse later
  • removal of tubes / ovaries if planned, or if found diseased

Pre-operative details for this operation

  1. Indicatione.g. AUB with fibroid / adenomyosis: size, Hb
  2. Uterine size and mobility on examinationweeks size; mobile; lateral extension of fibroids
  3. Vaginal accessparity and mode of delivery, vaginal calibre, pubic arch, previous caesarean
  4. Cervical screening result
  5. Endometrial sampling (if abnormal bleeding)result
  6. Ultrasounduterine size, fibroid position, adnexa
  7. Adnexa: decision and consentConserveSalpingectomySalpingo-oophorectomy
  8. Consent for laparotomy if vaginal route failsTaken
  9. Blood grouped and cross-matched

Anaesthesia and position

  1. AnaesthesiaSpinalCombined spinal-epiduralGeneral
  2. PositionDorsal lithotomyavoid hip hyperflexion; legs padded
  3. Examination under anaesthesiauterine size, mobility, descent with traction, adnexa
  4. BladderEmptied with straight catheterFoley catheter left in

Operative findings

  1. Uterussize, fibroids (site and size), adenomyosis
  2. Pouch of DouglasFreeAdhesions
  3. Uterovesical foldEasy entryScarred (previous caesarean)
  4. Tubes and ovariesseen / palpated; normal or abnormal

Procedure (steps)

  1. Cervix heldTwo vulsella / tenacula on both lipsLahey clamp
  2. Infiltration at cervicovaginal junctionSalineDilute vasopressinLignocaine with adrenalineNonedrug, dilution, volume
  3. Circumferential incision at cervicovaginal junction
  4. Posterior colpotomyentry into pouch of Douglas; posterior cuff haemostasis
  5. Anterior colpotomybladder pushed up, peritoneum opened, entry confirmed by seeing bowel
  6. Uterosacral ligaments clamped, cut, transfixed and taggedsuture
  7. Cardinal ligaments clamped, cut, ligatednumber of bites, suture
  8. Uterine vessels clamped, cut, ligatedsingle or double clamp; suture; ureter position
  9. Debulking (if needed)NoneBivalvingIntramyometrial coringMyomectomyonly after uterine vessels are secured
  10. Fundus deliveredPosteriorlyAnteriorly
  11. Utero-ovarian ligament, round ligament and tube clamped, cut, double-ligatedor infundibulopelvic ligament if adnexa removed
  12. Haemostasis of all pedicles checked
  13. Vault supportUterosacral sutures brought through the vaultMcCall culdoplastyNone
  14. CystoscopyDone: both ureteric jets seenNot done

Closure, drains and dressing

  1. PeritoneumPurse-string closureNot closed separately
  2. Vaginal vaultRunningRunning lockedInterruptedsuture material and size
  3. Vaginal packNonePlaced: remove at (time)
  4. CatheterRemoved at endFoley left in: remove at (time)

Specimens and implants

  1. Uterus with cervixintact or bivalved / morcellated (pieces in one container), weight, sent for HPE
  2. Tubes / ovariesNot removedSent with uterusSent separately

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 vaginal bleedingfrequency; report fresh bleeding
  2. Catheter and voidingtime of removal; check she passes urine well (voiding trial) before discharge
  3. Vaginal pack removal (if placed)time
  4. Dietas tolerated, early feeding
  5. Analgesiadrug, dose, frequency
  6. Mobilisation and thromboprophylaxiscompression devices or stockings until walking; heparin if risk factors
  7. HbPOD 1 if blood loss was large
  8. Advice at dischargeno intercourse or tampons for 6 weeks; avoid heavy work
  9. HPE follow-update

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. N.J., 44 years, P2L2 (both vaginal deliveries), heavy menstrual bleeding for 2 years from a 12-week fibroid uterus, no uterine descent. Endometrial biopsy benign. Wants ovaries conserved.

Case details

Date: 05/08/2026. Elective NDVH. OT 3.

In OT 09:10. Spinal 09:20. Incision 09:40. End 11:05.

Surgeon: Dr C. (consultant). Assistant: Dr A. (3rd-year resident, did posterior colpotomy, uterosacral and cardinal pedicles and vault closure under supervision). Second assistant: Dr B.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: AUB-L. USG: uterus 11 x 7 x 7 cm, two intramural fibroids 4 cm (fundal) and 3 cm (posterior wall). Both ovaries normal. Hb 10.8 g/dl.

Endometrial biopsy: secretory endometrium. Pap smear negative. No previous caesarean.

Consent: general, procedure-specific (including conversion to laparotomy), anaesthesia. Tubes and ovaries to be conserved. Blood group B positive, 1 unit cross-matched.

WHO checklist done. Inj cefazolin 2 g IV at 09:28.

Anaesthesia and position

Spinal anaesthesia. Dorsal lithotomy with hips at table edge, legs padded. Parts painted with povidone-iodine including vagina and draped.

EUA: uterus 12 weeks, mobile, cervix descends 1 cm with traction. Fornices free. Bladder emptied with straight catheter.

Procedure

Weighted speculum placed. Cervix held with two vulsella on anterior and posterior lips.

Cervicovaginal junction infiltrated with 30 ml of 0.5% lignocaine with 1:200000 adrenaline.

Circumferential incision at cervicovaginal junction. Posterior colpotomy done, pouch of Douglas free. Posterior cuff bleeding controlled with cautery.

Bladder dissected up with scissors. Anterior peritoneum opened, bowel seen. Deaver retractor placed to hold bladder up.

Uterosacral ligaments clamped, cut and transfixed with polyglactin 910 (Vicryl) 2-0, tagged on both sides.

Cardinal ligaments clamped in 1 bite each side close to the cervix, cut and ligated with Vicryl 2-0.

Uterine vessels clamped with single Heaney clamp each side at the level of the internal os, cut and ligated with Vicryl 2-0.

Uterus bivalved in the midline under vision, fibroids enucleated, lateral and upper margins kept intact. Fundus delivered posteriorly.

Utero-ovarian ligament, round ligament and tube clamped together each side, cut, free-tied and transfixed with Vicryl 2-0. Uterus removed.

Both ovaries and tubes seen: normal. All pedicles checked from uterosacral to utero-ovarian: dry.

Uterosacral pedicle sutures brought through the vault, one arm anterior and one posterior, on each side, and tied.

Closure

Vault closed with running polyglactin 910 (Vicryl) 2-0, full thickness. No vaginal pack.

Foley catheter inserted at end, urine clear 100 ml.

Specimens and implants

Uterus with cervix, bivalved, with two fibroids in the same container, total weight 280 g. Sent for HPE in formalin.

End of procedure

Estimated blood loss 250 ml. No transfusion.

Mop, needle and instrument count correct.

No bladder or bowel injury.

Shifted to recovery, pulse 80/min, BP 118/74 mmHg.

Post-op orders

Pulse, BP and PV bleeding every 30 min for 2 hours, then 2-hourly.

Oral fluids after 4 hours, then normal diet as tolerated.

Foley catheter to be removed next morning; watch for voiding.

Stockings, early mobilisation.

No intercourse or tampons for 6 weeks. HPE report at follow-up.

Signature

Dr A., JR-3, OBGY, for Dr C. Reg. no. ________. 05/08/2026, 11:20.

Must document for this operation

  • Uterine size and mobility on examination under anaesthesia. This justifies choosing the vaginal route for a non-prolapsed uterus and is questioned if conversion or injury occurs.
  • Any debulking (bivalving, coring, myomectomy) and that it was done after the uterine vessels were secured. The pathologist must know the specimen was cut on purpose, and the timing shows the step was done safely.
  • Bladder dissection and entry into both pouches, with any bladder injury and repair. A bladder injury changes the catheter plan, and a missed one can present later as urine leaking per vaginam.
  • Adnexa seen and what was done with them. It must match the consent, and an unexpected ovarian finding needs a plan.
  • How the vault was supported and closed. The next surgeon needs this if she presents with vault prolapse or enterocele.
  • Catheter plan and voiding check. Voiding difficulty is common after vaginal hysterectomy and the nurse needs a clear order.

Common mistakes in these notes

  • Writing 'NDVH done' with no uterine size or reason the vaginal route was suitable.
  • Not writing that the uterus was morcellated or bivalved, so the pathologist thinks the specimen was damaged.
  • Leaving out how the adnexa were handled.
  • Not recording the vasoconstrictor drug and volume injected.
  • No mention of vault support.
  • No catheter removal time.

Indian practice and paperwork

  • Under AB PM-JAY, all obstetrics and gynaecology packages need pre-authorisation, and hysterectomy packages are recommended to be reserved for public hospitals (open to private hospitals on referral by government doctors). (NHA, National Health Benefit Package 2.2 User Guidelines (Nov 2021), section 3.13 and FAQ 36: https://hem.nha.gov.in/HBP.pdf)

Sources

  • Te Linde's Operative Gynecology. 13th ed. Wolters Kluwer; 2024, Ch 22, Vaginal hysterectomy, e-book PDF pp. 1147-1204.
  • Te Linde's Atlas of Gynecologic Surgery. Wolters Kluwer; 2014, Ch 3, Total vaginal hysterectomy (Geoffrion R), including example operative note, pp. 25-33.
  • Te Linde 13e Ch 2, PDF p. 162-165: cefazolin 2 g IV within 60 minutes before surgery (3 g if over 120 kg).
  • Te Linde 13e Ch 22, PDF p. 1153: vasopressin 10-20 units in 50 ml saline, or 20-30 ml of 0.5% lignocaine with 1:200000 adrenaline, at the incision site.
  • National Health Authority. National Health Benefit Package 2.2 User Guidelines. November 2021. hem.nha.gov.in/HBP.pdf

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.

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