Tubal reanastomosis / tuboplasty

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

• pregnancy is not guaranteed, and the chance falls with age
• ectopic pregnancy in a later pregnancy
• a tube may be too short or damaged to join, and the operation may be done on one side only or not at all
• blockage of the joined tube later
• bleeding and wound infection
• adhesions
• IVF may still be needed

Pre-operative details for this operation

1. Previous sterilisationLaparoscopic ring (Falope ring)Filshie clipModified Pomeroy (minilap / postpartum)CauteryNot knowndate, place; copy of the old sterilisation record if available
2. Reason for reversale.g. remarriage, loss of a child
3. Woman's age and ovarian reserveage in years; ovarian reserve test and result
4. Partner's semen analysisdate and result
5. HSGlength of patent proximal segment on each side, site of block
6. IVF discussed as an alternativeYes
7. Consent if a tube cannot be joinedLeave tube as foundSalpingectomy of that side allowedNot discussed

Anaesthesia and position

1. AnaesthesiaGeneralSpinalCombined spinal-epidural
2. PositionSupineLow lithotomy for cervical cannula, then supine
3. Uterine cannula for chromopertubationRubin cannulaLynch-Wilkinson cannulaUterine manipulator with dye channeldye used (methylene blue) and dilution
4. MagnificationOperating microscopeLoupeLaparoscope / robot
5. BladderCatheterisedEmptied before surgery

Operative findings

1. Uterus and ovariessize, fibroids, ovarian appearance
2. AdhesionsNoneFilmyDense (describe)
3. Right tubesite of occlusion, length of proximal and distal segments, fimbriae healthy or not
4. Left tubeas above
5. Pelvic endometriosis or infectionNonePresent (describe)

Procedure (steps)

1. AccessPfannenstiel minilaparotomyLaparoscopyRobot-assisted laparoscopyincision length or port sites
2. Adhesiolysisif any; technique
3. Mesosalpinx infiltrationDilute vasopressinNone
4. Distal segment assessedfine cannula (20 or 22 G intravenous catheter without stylet) passed from the fimbrial end to the block
5. Occluded segment excisedmesosalpinx under it tied for haemostasis; ring / clip removed with it
6. Proximal segment openedserial slices until methylene blue from the uterus is seen in the lumen
7. StentIntravenous catheterInfant feeding tube 4 FrInfant feeding tube 5 FrTubal stentNone
8. Mesosalpinx gap closed firstsuture and size; takes tension off the anastomosis and aligns the ends
9. Tubal anastomosisnumber of sutures and positions (6, then 3 and 9, then 12 o'clock), suture and size (Te Linde: 7-0 or finer, absorbable or permanent), mucosa included or not, one or two layers
10. Stent removed and chromopertubation repeatedFree spill from fimbrial endNo spill (state action)
11. Final tubal lengthin cm on each side
12. Other sidesame steps, or reason not done
13. Irrigationsaline irrigation through the procedure; mopping of tubes avoided

Closure, drains and dressing

1. Haemostasis and final pelvic washfluid used
2. Adhesion barrierNoneUsed (state product)
3. Rectus sheath / portssuture and technique
4. SkinSubcuticularInterruptedSkin glue
5. Uterine cannulaRemoved

Specimens and implants

1. Excised tubal segmentsSent for HPE, labelled right and leftNot sent (disposed as yellow category waste)include ring or clip if removed
2. ImplantsNone

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. Monitoringpulse, BP, wound, vaginal bleeding from the cannula site
2. Analgesiadrug, dose, route
3. Oral intake and mobilisationfrom when
4. Cathetertime of removal if placed
5. Stitchesremoval day if non-absorbable skin sutures
6. Counselling at dischargechance of pregnancy for her age; report a missed period early because of ectopic risk; plan if not pregnant (e.g. HSG or IVF referral)

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