OT notes · Gynaecology

Operative hysteroscopy (polypectomy / septum resection / myomectomy)

Usual anaesthesia
General (LMA) or spinal; small polyps can be removed in the office without anaesthesia or with a cervical block
Position
Lithotomy, no head-down tilt
Setting
elective

Operative note template for operative hysteroscopy (polypectomy, septum resection, submucous myomectomy), with a filled example for bipolar resection of a type 1 submucous fibroid under general 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

  • uterine perforation, with possible laparoscopy to check bowel and bladder
  • fluid overload and low sodium from absorbed distension fluid
  • bleeding, possible balloon tamponade
  • incomplete removal and need for a second procedure
  • intrauterine adhesions
  • infection (endometritis)
  • cervical tear or false passage
  • gas or air embolism (rare)
  • for septum: weak area at fundus and rare uterine rupture in pregnancy

Pre-operative details for this operation

  1. Procedure plannedPolypectomySeptum resectionMyomectomyAdhesiolysis
  2. IndicationAUB / infertility / recurrent miscarriage / PMB, with duration
  3. Imaging / office hysteroscopyTVS / SIS / MRI: lesion size, site. For fibroid FIGO type (0, 1, 2) and myometrial free margin to serosa. For septum length and fundal contour
  4. LMP and pregnancy testday of cycle, UPT result
  5. Pre-op endometrial suppressionNoneOCP / progestogenGnRH analogue (dose, duration)
  6. Cervical primingNot givenGivendrug, dose, route, time before procedure
  7. Hb and anticoagulantsHb, anticoagulant stopped / continued with INR
  8. Concurrent laparoscopy / USG guidance plannedNoLaparoscopyTransabdominal USGconsider for septum, large fibroid, adhesions

Anaesthesia and position

  1. AnaesthesiaGeneral (LMA)General (ETT)SpinalCervical block / none (office)
  2. PositionLithotomy, no Trendelenburg
  3. Instrumentoperative hysteroscope with 5 / 7 Fr instruments, or resectoscope (outer sheath in mm, lens angle), or tissue removal system (make)
  4. EnergyCold (scissors / graspers)BipolarMonopolarMechanical tissue removal systemelectrode type and generator settings (cut / coag, W)
  5. Distension mediumNormal salineRinger lactateGlycine 1.5%Sorbitol 3%Mannitol 5%saline for bipolar and mechanical, non-electrolyte for monopolar
  6. Fluid system and pressureAutomated pump with deficit monitorPressure bagGravityset intrauterine pressure (mmHg) and the deficit limit agreed with the anaesthetist
  7. Cervical vasopressinif used: dilution, volume, sites. Anaesthetist informed

Operative findings

  1. EUAuterus size and position
  2. Cervical canal and cavityshape, both tubal ostia seen
  3. Lesionpolyp: number, size, site, base. Fibroid: size, wall, FIGO type. Septum: length, reaches internal os or cervix, thickness. Adhesions: extent
  4. Endometriumthin / thick / suspicious areas

Procedure (steps)

  1. Vaginal preparation, catheter, speculum, tenaculum on anterior lip
  2. Cervical dilatationdilator type and final size, or 'not needed'
  3. Entry under direct vision and orientationboth ostia and landmarks seen, air purged from sheath
  4. PolypectomyCut at base with scissors, removed with forcepsGrasped and twisted offBipolar electrode / snareTissue removal systemResectoscope loopbase checked afterwards
  5. Septum resectionInstrument. Cut in the midline, equidistant from front and back walls, from apex towards fundus. Stopped when both ostia seen together from the internal os or when vessels / bleeding appear. Residual septum length
  6. MyomectomyLoop / TRS. Electrode activated only when drawing back toward the scope. Resected to base / pseudocapsule. Complete or part left (size)
  7. Chips / tissue removedThrough sheathForceps / graspersSuction curetteCollected by TRS
  8. HaemostasisNot neededBall / bipolar coagulationRaised pressureIntrauterine balloon (catheter size, ml)
  9. Final inspection at low pressureno residual lesion, no bleeding, no perforation
  10. Fluid balanceinflow, outflow, deficit in ml, and time of each deficit check

Closure, drains and dressing

  1. Intrauterine device / balloon leftNonePaediatric Foley balloon (Fr, ml, how long)Other
  2. Tenaculum siteDryNeeded pressure / silver nitrate / suture
  3. Bleeding at endMinimalModerate (action taken)

Specimens and implants

  1. Polyp / fibroid chips / septal tissue for HPEall tissue removed goes for HPE; approximate weight or volume
  2. Tissue removal systemdevice make and lot number from sticker, if disposable

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 SpO2watch for breathlessness, confusion or low SpO2 (fluid overload)
  2. Serum sodiumurgent if deficit reached the limit, or if a hypotonic medium was used with a high deficit
  3. Vaginal bleedingpad check; spotting expected, heavy bleeding to be reported
  4. Intrauterine balloonif placed: when to deflate and remove, antibiotic cover while in place
  5. Oestrogen after septum / large fibroidif prescribed: drug, dose, duration
  6. Analgesia and dietdrug, dose, frequency; oral intake when awake
  7. Discharge and follow-upUsually same day. HPE review. For septum, second-look hysteroscopy or HSG after 1 to 3 cycles

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. A.R., 38 years, P1L1, with heavy menstrual bleeding for 1 year not controlled by tranexamic acid. TVS and office hysteroscopy show a 2.5 cm FIGO type 1 submucous fibroid on the posterior wall, myometrial free margin 12 mm. Hb 9.8 g/dl.

Case details

Date: 10/08/2026. Elective hysteroscopic myomectomy. OT 3.

In OT 10:00. GA 10:05. Scope in 10:18. Scope out 10:52.

Surgeon: Dr C. (Consultant, OBGY). Assistant: Dr A. (3rd-year resident). Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: heavy menstrual bleeding with anaemia due to a posterior wall type 1 submucous fibroid, 2.5 cm.

LMP 02/08/2026 (day 9). UPT negative. Not on anticoagulants. Oral iron for 6 weeks. No GnRH analogue. No cervical priming.

Consent: general, procedure-specific and anaesthesia consent taken in Hindi from the patient, husband as witness. Risks of perforation, fluid overload, incomplete removal and second procedure explained.

WHO checklist sign in and time out done, including pregnancy test check. Deficit limit of 2500 ml saline agreed with anaesthetist.

Anaesthesia and position

General anaesthesia with LMA. Lithotomy, no head-down tilt. Vulva and vagina painted with povidone-iodine and draped with under-buttock fluid collection drape. Bladder emptied with plain catheter.

Bipolar resectoscope, 9 mm outer sheath, 12 degree lens, bipolar loop electrode, generator in auto-bipolar mode (cut setting checked).

Distension medium normal saline via automated pump, pressure 75 mmHg, outflow open.

Procedure

EUA: uterus anteverted, about 8 weeks size, mobile.

Tenaculum on anterior lip. Dilute vasopressin (20 units in 50 ml saline), 10 ml injected into the cervical stroma at 4 and 8 o'clock. Anaesthetist informed.

Cervix dilated with Hegar dilators to 10. Resectoscope passed under vision.

Findings: cavity normal shape, both ostia seen. 2.5 x 2 cm sessile fibroid on the posterior wall, lower half, less than half intramural (type 1). Endometrium proliferative, no suspicious area.

Fibroid resected with the loop in serial passes, electrode activated only while drawing back toward the scope. Chips cleared through the sheath at intervals. Deeper part dissected from its pseudocapsule with the loop tip used as a blunt probe. Resected flush with the surrounding myometrium.

Final look at low pressure: no residual fibroid, one small oozing point coagulated. No perforation.

Fluid: inflow 3200 ml, outflow 2800 ml, deficit 400 ml. Running deficit read out by the scrub nurse through the case.

Closure

No intrauterine balloon needed. Tenaculum removed, site dry. Minimal bleeding from the os at end.

End of procedure

Estimated blood loss 50 ml. No transfusion.

Instrument count correct.

No intra-operative complications.

Specimen: fibroid chips, about 8 g, in formalin, for HPE.

Shifted to recovery in stable condition. Pulse 82/min, BP 120/74 mmHg, SpO2 99% on room air, chest clear.

Post-op orders

Pulse, BP, SpO2 every 15 min for 1 hour, then hourly. Inform if breathless or confused.

Serum sodium not needed (isotonic saline, deficit 400 ml).

Oral fluids after 2 hours, then normal diet. Oral analgesic as charted.

Pad check. Spotting expected for a few days, report heavy bleeding.

Discharge in the evening. Continue oral iron. Review with HPE in 2 weeks.

Signature

Dr A., JR-3, OBGY, for Dr C. Reg. no. ________. 10/08/2026, 11:10.

Must document for this operation

  • Distension medium, pump pressure, and the final inflow, outflow and deficit. Fluid overload is the main serious complication. The ward team needs the deficit to decide on a sodium check, and the note shows the agreed limit was respected.
  • Energy type, electrode and generator settings (or cold / mechanical instrument). A perforation with an energised electrode needs laparoscopy to exclude bowel injury, while a cold perforation may be observed.
  • Lesion details: size, wall, FIGO type for fibroids, septum length. These predict the chance of incomplete removal and are needed to plan any second stage.
  • Whether removal was complete, and the size of anything left behind. A part-resected type 1 or 2 fibroid may need a planned second procedure, and the patient must be told.
  • For septum: the end point reached and any residual septum. The next obstetrician needs to know how deep the fundus was cut when counselling about labour.
  • Any suspected perforation and what was done. Thermal bowel injury can show 2 to 3 days later, and the ward team must know to watch for it.
  • Balloon or device left in the cavity, with volume and removal plan. A forgotten intrauterine balloon causes infection, and the ward needs a removal time.

Common mistakes in these notes

  • No fluid deficit recorded, or only 'fluid balance satisfactory'.
  • Not stating whether monopolar or bipolar energy was used with which medium.
  • Writing 'fibroid removed' without saying if removal was complete.
  • No record of both tubal ostia being seen at the end of a septum resection.
  • Leaving out the vasopressin dose and the fact the anaesthetist was told.

Sources

  • Handa VL, Van Le L, eds. Te Linde's Operative Gynecology. 13th ed. Wolters Kluwer; 2024, Ch 15, Hysteroscopy (Christianson MS, Patzkowsky KE): distension media, operative hysteroscopy (Box 15.2), myomectomy, polyps, septate uterus, complications, e-book PDF pp. 762-768, 774-785, 805-810.
  • Cundiff GW, Azziz R, Bristow RE. Te Linde's Atlas of Gynecologic Surgery. Lippincott Williams & Wilkins; 2014, Ch 26, Hysteroscopic metroplasty (Solnik MJ); Ch 27, Hysteroscopic myomectomy (Solnik MJ, Azziz R), pp. 223-239.
  • Connor ME, Clark TJ, eds. Diagnostic and Operative Hysteroscopy. Cambridge University Press; 2020, Ch 10, Hysteroscopic endometrial polypectomy (Smith P, Clark TJ); Ch 12, Hysteroscopic management of fibroids (Istre O, Clark TJ), pp. 118-126, 144-149.

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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