OT notes · Gynaecology

Total laparoscopic hysterectomy (TLH) / LAVH

Usual anaesthesia
General anaesthesia with endotracheal intubation
Position
Low lithotomy with arms tucked, steep Trendelenburg after port placement
Setting
elective

Operative note template for total laparoscopic hysterectomy (and LAVH), with a filled example for a TLH with bilateral salpingectomy for a fibroid uterus with heavy menstrual bleeding.

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

  • bladder injury
  • ureteric injury, sometimes found only days later
  • bleeding from uterine or ovarian vessels and blood transfusion
  • bowel injury, including delayed thermal injury
  • conversion to open surgery (laparotomy)
  • vaginal cuff infection, haematoma or dehiscence
  • port-site bleeding, infection or hernia
  • spread of an unsuspected cancer if the uterus is morcellated
  • removal of ovaries and its effects, if planned

Pre-operative details for this operation

  1. Indicatione.g. fibroid uterus with heavy menstrual bleeding, adenomyosis, endometrial hyperplasia; state uterine size in weeks and USG findings
  2. Endometrial sampling / Pap smear resultdate and report, if done; matters when morcellation is planned
  3. Plan for ovaries and tubesOvaries conserved, bilateral salpingectomyOvaries and tubes conservedBilateral salpingo-oophorectomy (BSO)Unilateral salpingo-oophorectomyas consented
  4. Consent for conversion to laparotomy and for morcellationTakenMorcellation not planned
  5. Hb, blood group, units reserved
  6. Bowel preparationNot givenGiven (agent)
  7. Previous abdominal surgery (caesarean, laparotomy)number and type; relevant to bladder adhesions and entry site

Anaesthesia and position

  1. AnaesthesiaGeneral with ETT
  2. PositionLow lithotomy, arms tucked and paddedSteep Trendelenburg after ports placed
  3. Foley catheterInserted after painting
  4. Examination under anaesthesiauterine size, mobility, uterine sound length
  5. Uterine manipulatortype, colpotomy ring / cup size, pneumo-occluder used

Operative findings

  1. Uterussize in weeks, fibroids (number, site, largest size), adenomyosis
  2. Right and left ovarynormal / cyst (size, nature) / endometrioma
  3. Right and left tube
  4. Pouch of Douglas and pelvic peritoneumfree / adhesions / endometriosis / fluid
  5. Bladder adhesions to lower segmentNonePresent (from previous caesarean)
  6. Upper abdomenliver surface, bowel, omentum: normal or not
  7. Both ureters seenYes, transperitoneallyYes, after retroperitoneal dissectionNot clearly seen

Procedure (steps)

  1. Primary entry and pneumoperitoneumVeress needle at umbilicusOpen (Hasson)Palmer's pointOptical trocarinsufflation pressure (mm Hg)
  2. Portsnumber, size and site of each; accessory ports under vision, lateral to the inferior epigastric vessels
  3. AdhesiolysisNot neededDonesite and method
  4. Adnexa separated from uterusTube and utero-ovarian ligament sealed and cut (ovary conserved)Infundibulopelvic ligament sealed and cut (ovary removed)Mesosalpinx sealed and cut (salpingectomy)energy device used; side by side
  5. Round ligament divided, broad ligament opened
  6. Bladder flapvesicouterine fold incised, bladder pushed down sharply below the colpotomy ring
  7. Uterine vesselsskeletonised and sealed at the level of the colpotomy ring; device used (bipolar / vessel sealer / suture)
  8. Cardinal ligaments divided
  9. ColpotomyMonopolar hook on colpotomy ringHarmonic / other deviceDone vaginally (LAVH / LH)
  10. Specimen removalIntact per vaginumVaginal morcellation (contained / not)Mini-laparotomy
  11. Vaginal cuff closureLaparoscopicVaginalsuture (e.g. barbed / delayed absorbable 0 or 2-0), technique, uterosacral ligaments included
  12. Haemostasis check at low pressure, irrigation
  13. CystoscopyNot doneDone: both ureteric jets seen, bladder intact
  14. Ports removed under vision, gas let out

Closure, drains and dressing

  1. Fascia at ports 10 mm or moresuture used, technique or closure device
  2. Skinsuture / skin glue / staples
  3. DrainNonePelvic drain (size, port)
  4. Vaginal packNonePlaced (remove when)
  5. Urine at endcolour, haematuria?

Specimens and implants

  1. Uterus with cervix (with tubes / ovaries) sent for HPEweight or size, intact or morcellated; formalin
  2. Other tissue for HPEcyst wall, peritoneal biopsy

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 abdominal girthpulse, BP, SpO2 every 15 min in recovery, then hourly till stable
  2. Vaginal bleeding and drain outputcheck pad every hour for 6 hours
  3. Catheterremove on table or next morning unless bladder injury or wide bladder dissection
  4. Urine output and colourreport haematuria or less than 30 ml/h
  5. Oral intakeliquids once awake and not nauseated, then normal diet the same day
  6. Mobilisation and thromboprophylaxiswalk on the day of surgery; stockings or pneumatic compression, heparin if risk factors
  7. Analgesiadrug, dose, frequency
  8. Watch for delayed bowel or ureteric injuryfever, distension, pain out of proportion, leaking urine per vaginum in the first days
  9. Port dressingskeep covered for 24 to 48 hours
  10. Advice at dischargeno intercourse for at least 6 to 8 weeks; follow-up with HPE report

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. S.D., 46 years, P2L2, both by LSCS, with heavy menstrual bleeding not controlled on medical treatment. USG: bulky uterus with two intramural fibroids, largest 5 cm. Endometrial biopsy: secretory endometrium. Pap smear normal.

Case details

Date: 14/04/2026. Elective TLH with bilateral salpingectomy. OT 3.

In OT 09:05. Induction 09:15. Veress entry 09:32. Cuff closure completed 11:20. Ports closed 11:35.

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

Indication and pre-op

Indication: heavy menstrual bleeding with fibroid uterus, failed medical treatment, family complete. Hb 10.4 g/dl. Blood group O positive, 1 unit reserved.

Plan: TLH with bilateral salpingectomy, ovaries conserved. Consent in Marathi for the procedure, conversion to laparotomy and vaginal morcellation if needed. No bowel preparation.

WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 09:20, before skin incision. Pneumatic compression devices on both legs.

Anaesthesia and position

General anaesthesia with ETT. Low lithotomy, arms tucked and padded. Tilt test done before scrubbing.

Parts painted with povidone-iodine and draped. Foley catheter inserted, urine clear.

EUA: uterus 12 weeks, mobile. Uterus sounded to 9 cm. Uterine manipulator with colpotomy cup and vaginal occluder placed.

Procedure

Veress needle at umbilicus, CO2 insufflated to 15 mm Hg. 10 mm umbilical port and 10 mm telescope. Three 5 mm ports under vision: right and left lower quadrant lateral to the inferior epigastric vessels, and left upper quadrant.

Findings: uterus 12 weeks with two intramural fibroids, fundal 5 cm and anterior 3 cm. Filmy adhesions of bladder peritoneum to lower segment. Both ovaries and tubes normal. Pouch of Douglas free. Liver surface, omentum and bowel normal. Both ureters seen through the peritoneum at the pelvic brim.

Steep Trendelenburg. Bladder adhesions divided with scissors. Both tubes separated from the mesosalpinx with bipolar vessel sealer. Utero-ovarian ligaments and tubal isthmus sealed and cut close to the uterus. Ovaries left in place.

Round ligaments sealed and cut. Broad ligament leaves opened. Vesicouterine fold incised and bladder pushed down with sharp dissection to below the colpotomy cup.

Uterine vessels skeletonised and sealed with bipolar vessel sealer at the level of the cup on both sides, then cut. Cardinal ligaments divided along the cup.

Circumferential colpotomy with monopolar hook along the cup. Uterus with both tubes delivered intact per vaginum. Wet mop in a glove placed in the vagina to keep the pneumoperitoneum.

Vaginal cuff closed laparoscopically with continuous 2-0 barbed delayed absorbable suture, including both uterosacral ligaments at the angles.

Insufflation pressure lowered and pedicles rechecked: cuff and pedicles dry. Pelvis irrigated with NS. Both ureters seen intact. No bowel injury seen.

Closure

Ports removed under vision, no port-site bleeding. Gas let out. Umbilical 10 mm fascia closed with polyglactin 910 (Vicryl) 1-0 figure-of-eight. Skin closed with Ethilon 3-0. No drain. Vaginal mop removed.

Urine clear at end, 150 ml.

Specimens

Uterus with cervix and both tubes, 310 g, intact, sent for HPE in formalin with requisition.

End of procedure

Estimated blood loss 150 ml. No transfusion. Duration 2 hours 3 minutes from entry.

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

No intra-operative complications.

Shifted to recovery in stable condition. Pulse 84/min, BP 124/76 mmHg, SpO2 99% on room air.

Post-op orders

Pulse, BP, SpO2 every 15 min for 1 hour, then hourly for 6 hours. Pad check hourly.

Oral liquids after 4 hours if no nausea, normal diet in the evening.

Catheter out next morning.

Analgesia as charted by the anaesthetist: IV paracetamol, and an NSAID if no contraindication. Walk in the evening. Pneumatic compression till walking.

Report fever, abdominal distension, pain out of proportion or watery discharge per vaginum.

Port dressings for 48 hours. No intercourse for 8 weeks. Review with HPE report.

Signature

Dr B., JR-3, OBGY, for Dr A. Reg. no. ________. 14/04/2026, 11:50.

Must document for this operation

  • What was done with each ovary and tube, side by side. Ovarian conservation or removal changes her menopause and hormone care, and the pathologist must know what to expect in the jar.
  • That both ureters were seen, and how. Ureteric injury after laparoscopic hysterectomy often presents days later, and the note is the first thing checked when it does.
  • Energy device used for the uterine vessels and for colpotomy. Most ureteric injuries in TLH are thermal, and thermal spread at the cuff is linked to cuff dehiscence.
  • How the specimen came out: intact, morcellated (contained or not) or by mini-laparotomy. If HPE shows a sarcoma, the oncologist needs to know whether tissue was fragmented inside the abdomen.
  • Cuff closure: route, suture material and whether uterosacral ligaments were included. The next surgeon managing a dehiscence or vault prolapse needs this.
  • Port sizes and whether 10 mm or larger fascia was closed. Port-site hernia is a known late complication and is audited.
  • Any conversion to laparotomy, with the reason and the time. Conversion is audited, and the reason is needed for counselling and for the medicolegal record.

Common mistakes in these notes

  • Writing 'TLH done' without saying what happened to the ovaries and tubes.
  • Not recording whether the ureters were identified.
  • Leaving out the morcellation detail when the uterus was cut up to remove it.
  • Not recording a bladder adhesion or a small bladder nick that was repaired.
  • Calling the operation TLH when the cuff was closed vaginally (that is a laparoscopic hysterectomy, LH, or LAVH).
  • Copying port positions from a template instead of the ports actually used.

Indian practice and paperwork

  • NABH standard COP.14(e) (5th edition) requires the operative note to be written before the patient is transferred out of recovery. (NABH Hospital Accreditation Standards 5th ed. (April 2020), COP.14 OE e)
  • In NQAS-assessed public hospitals, the OT checkpoint 'Operative Notes are Recorded' looks for the people present, pre- and post-op diagnosis, procedure, length of procedure, estimated blood loss, fluids given, specimen removed and complications. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, ME E8.4)
  • The uterus and adnexa are Yellow category (a) human anatomical waste under the Bio-Medical Waste Management Rules 2016 if not sent for HPE; record where the specimen went. (CPCB/DGHS Guidelines under BMW Management Rules 2016)

Sources

  • Handa VL, Van Le L, eds. Te Linde's Operative Gynecology. 13th ed. Wolters Kluwer; 2024, Ch 24, Minimally invasive hysterectomy: laparoscopic and robotic-assisted hysterectomy, e-book PDF pp. 1283-1321.
  • Te Linde's Atlas of Gynecologic Surgery. Wolters Kluwer; 2014, Ch 4, Total laparoscopic hysterectomy (Bristow RE), pp. 35-41.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Hysterectomy (vaginal or abdominal, open or laparoscopic): single dose of cefazolin; Table 2 cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision; redose cefazolin after 4 hours, or if blood loss exceeds 1500 ml. 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.

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