OT notes · Gynaecology

Vaginal hysterectomy with anterior colporrhaphy and posterior colpoperineorrhaphy

Usual anaesthesia
Spinal or epidural; general if preferred
Position
High dorsal lithotomy
Setting
elective

Operative note template for vaginal hysterectomy with anterior colporrhaphy and posterior colpoperineorrhaphy for uterovaginal prolapse, with a filled example for stage III prolapse 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, ureter or rectal injury
  • difficulty passing urine for some days, needing a catheter
  • urinary infection
  • recurrence of prolapse, or new prolapse in another part of the vagina
  • pain or difficulty with intercourse from narrowing or scarring
  • new leakage of urine on coughing (stress incontinence)
  • constipation after surgery
  • rare fistula between vagina and bladder or rectum

Pre-operative details for this operation

  1. Symptomsbulge, urinary, bowel (splinting), sexual
  2. Prolapse stagingPOP-Q points (Aa, Ba, C, D, Ap, Bp, gh, pb, tvl) and stage, or the grading used in your unit
  3. Stress incontinence check with prolapse reducedNegativePositive (occult SUI)
  4. Decubitus ulcer on cervix / vaginaNonePresent: treated before surgery
  5. Pap smear / cervical screening
  6. Ultrasounduterus, endometrial thickness, adnexa, hydronephrosis if procidentia
  7. Adnexa: decision and consentConserveRemove
  8. Sexual activity and wish to keep vaginal capacityaffects how much to narrow the introitus

Anaesthesia and position

  1. AnaesthesiaSpinalEpiduralGeneral
  2. PositionHigh dorsal lithotomylegs padded, neutral
  3. Vaginal prepPovidone-iodineChlorhexidine without alcohol
  4. Foley catheterInserted at start

Operative findings

  1. Degree of uterine descent under anaesthesia
  2. Uterussize, cervical elongation
  3. Anterior wall defectMidlineLateral (paravaginal)Both
  4. Posterior wall defect and perineal bodyrectocele size; perineal body deficient / intact; genital hiatus
  5. EnteroceleAbsentPresent
  6. Tubes and ovaries

Procedure (steps)

  1. Infiltrationdrug, dilution, volume (e.g. dilute vasopressin or lignocaine with adrenaline)
  2. Circumferential incision round cervix, anterior and posterior colpotomybladder pushed up; peritoneal entry confirmed
  3. Uterosacral, cardinal and uterine vessel pedicles clamped, cut, ligatedsuture; uterosacral sutures tagged
  4. Utero-ovarian pedicles clamped, cut, double-ligated; uterus removed
  5. Vault supportMcCall culdoplastyUterosacral sutures through vaultOther apical suspensionnumber of sutures, suture material
  6. Peritoneum and vault closedsuture
  7. Anterior colporrhaphy: midline incisionfrom vault to about 3-4 cm from the urethral meatus (bladder neck)
  8. Anterior wall flaps dissected laterally
  9. Fibromuscular (pubocervical) layer plicatedinterrupted / running, suture material and size, number of layers
  10. Excess anterior vaginal skin trimmed and closedamount trimmed; running locked / interrupted; suture
  11. Perineal triangle marked and excisedAllis clamps at 4 and 8 o'clock; check calibre before cutting
  12. Posterior wall dissected, rectovaginal fibromuscular layer plicatedsuture; rectal examination during plication
  13. Perineorrhaphybulbocavernosus and transverse perineal muscles approximated; suture
  14. Posterior vaginal skin and perineal skin closedsuture
  15. Final checksvaginal calibre (fingerbreadths), rectal examination, cystoscopy if done

Closure, drains and dressing

  1. Vaginal packNonePlaced: remove at (time)
  2. Foley catheterleft in; plan for removal
  3. Vaginal calibre at endnumber of fingers admitted
  4. Rectal examination at endNo sutures felt in rectum
  5. Urine at endclear / blood-stained

Specimens and implants

  1. Uterus with cervixweight, sent for HPE
  2. Trimmed vaginal skinDiscardedSent for HPE
  3. Graft / meshNone usedUsed: type, size, lot number, sticker

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; pad check
  2. Vaginal pack removaltime
  3. Catheterkeep while pack is in; then remove and check voiding
  4. Dietas tolerated
  5. Stool softener / bowel regimendrug, dose; avoid straining
  6. Analgesiadrug, dose, frequency
  7. Mobilisation and thromboprophylaxis
  8. Watch forretention of urine, urinary infection, constipation, perineal haematoma
  9. Advice at dischargeno intercourse or tampons for 6 weeks; avoid heavy lifting and straining
  10. 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. S.B., 58 years, P4L4 (all vaginal deliveries), postmenopausal for 8 years, something coming out per vaginam for 3 years, needs to push the bulge back to pass urine. Not sexually active. Stage III uterovaginal prolapse with cystocele and rectocele.

Case details

Date: 18/09/2026. Elective VH with anterior colporrhaphy and posterior colpoperineorrhaphy. OT 3.

In OT 09:00. Spinal 09:10. Incision 09:30. End 11:15.

Surgeon: Dr C. (consultant) did the hysterectomy. Dr A. (3rd-year resident) did the anterior colporrhaphy and posterior colpoperineorrhaphy under supervision. Assistant: Dr B.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

POP-Q: Aa +2, Ba +3, C +4, D +3, Ap +1, Bp +2, gh 5, pb 2, tvl 9. Stage III. Cervix healthy, no decubitus ulcer.

Cough stress test with prolapse reduced: negative. Pap smear negative. USG: uterus atrophic, endometrium 3 mm, ovaries atrophic, no hydronephrosis.

Consent: general, procedure-specific (including recurrence, voiding difficulty, bladder and rectal injury) and anaesthesia consent in Marathi. Tubes and ovaries to be conserved. Blood group O positive, 1 unit cross-matched.

WHO checklist done. Inj cefazolin 2 g IV at 09:18.

Anaesthesia and position

Spinal anaesthesia. High dorsal lithotomy, legs padded. Vulva and vagina painted with povidone-iodine and draped. Foley catheter inserted, urine clear.

Findings

Under anaesthesia, cervix comes 4 cm outside the introitus with traction. Uterus atrophic, cervix elongated. Midline anterior wall defect. Rectocele in the lower two-thirds with deficient perineal body. No enterocele. Both ovaries and tubes atrophic, normal.

Procedure

Cervicovaginal junction and anterior and posterior vaginal walls infiltrated with dilute vasopressin (20 units in 100 ml NS), total 40 ml.

Circumferential incision round the cervix. Bladder pushed up, anterior peritoneum opened, bowel seen. Posterior colpotomy done.

Uterosacral ligaments clamped, cut, transfixed with polyglactin 910 (Vicryl) 2-0 and tagged. Cardinal ligaments and uterine vessels clamped, cut and ligated with Vicryl 2-0.

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

Peritoneum closed with purse-string Vicryl 2-0. Tagged uterosacral pedicle sutures brought through the vault on each side, one arm anterior and one posterior, and tied. Vault closed with running Vicryl 2-0.

Anterior colporrhaphy: midline incision from vault to 4 cm from the urethral meatus. Vaginal flaps dissected off the fibromuscular layer out to the pubic rami. Fibromuscular layer plicated in the midline with interrupted Vicryl 2-0 (6 sutures). About 1 cm of excess skin trimmed each side. Anterior wall closed with running locked Vicryl 2-0.

Posterior colpoperineorrhaphy: Allis clamps at 4 and 8 o'clock at the hymen, approximated to check calibre. Triangle of perineal skin excised. Midline posterior incision up to the top of the rectocele. Fibromuscular layer dissected off the vaginal skin laterally to the sidewalls.

Rectovaginal fibromuscular layer plicated with interrupted polydioxanone (PDS) 2-0, with finger in rectum during plication.

Posterior vaginal skin closed with running locked Vicryl 2-0 to the hymen. Perineorrhaphy: bulbocavernosus and superficial transverse perineal muscles approximated with 3 interrupted PDS 2-0 sutures. Perineal skin closed with Vicryl 2-0.

Cystoscopy: bladder intact, both ureteric jets seen.

Closure

Vagina admits 2 fingers easily. Rectal examination: no sutures felt, rectal wall intact. Vaginal pack placed. Foley catheter left in, urine clear.

Specimens and implants

Uterus with cervix, 70 g, sent for HPE in formalin. Trimmed vaginal skin discarded. No mesh used.

End of procedure

Estimated blood loss 300 ml. No transfusion.

Mop, needle and instrument count correct.

No intra-operative complications.

Shifted to recovery, pulse 78/min, BP 130/80 mmHg.

Post-op orders

Pulse, BP and pad check every 30 min for 2 hours, then 4-hourly.

Vaginal pack to be removed after 6 hours. Foley catheter to remain till pack is out; then remove and check she voids well.

Oral fluids after 4 hours, then normal diet. Stool softener from POD 1; avoid straining.

Stockings and early mobilisation.

No intercourse or heavy lifting for 6 weeks. HPE at follow-up.

Signature

Dr A., JR-3, OBGY, for Dr C. Reg. no. ________. 18/09/2026, 11:30.

Must document for this operation

  • Prolapse stage before surgery, by a named system (POP-Q or unit grading). Without a baseline, recurrence or success cannot be judged at follow-up or in an audit.
  • The apical (vault) support procedure done. Hysterectomy alone does not treat prolapse, and a missing apical step is the first thing checked when prolapse recurs.
  • Suture material and technique for each plication. The surgeon doing a repeat repair needs to know what was used and where.
  • Vaginal calibre at the end and whether she is sexually active. Over-narrowing causes painful intercourse, and the note shows the calibre was checked and matched her wishes.
  • Rectal examination after posterior repair and cystoscopy or urine check after anterior repair. These show that rectal and bladder or ureteric injury were looked for before she left the OT.
  • Mesh or graft used, or 'no mesh used'. Mesh complications and recalls need a clear record of what was implanted.
  • Pack and catheter plan. The ward needs clear removal times, and the catheter must stay while the pack is in.

Common mistakes in these notes

  • Writing 'VH with PFR done' with no stage of prolapse and no description of each repair.
  • Not stating the vault support method.
  • Not recording the vaginal calibre at the end.
  • Forgetting to write the pack removal time.
  • No mention of rectal examination after posterior repair.
  • Not writing 'no mesh used' when native tissue repair was done.

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 32, Colporrhaphy and enterocele repair; Ch 22, Vaginal hysterectomy, e-book PDF pp. 1693-1724 (Ch 32); 1147-1204 (Ch 22).
  • Te Linde's Atlas of Gynecologic Surgery. Wolters Kluwer; 2014, Ch 3, Total vaginal hysterectomy; Ch 34, Cystocele repair using anterior fascial reinforcement; Ch 37, Rectocele repair using the defect-directed approach (Cundiff GW), pp. 25-33; 303-314; 337-344.
  • 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 32, PDF p. 1712: dilute vasopressin 20 units in 50 or 100 ml normal saline for hydrodissection.
  • 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.

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