THEATRES
&
OPERATION NOTES
Praneil Patel
Obstetrics and Gynaecology
SURGICAL OPERATION NOTES
Objectives
• Theatre etiquette
• Format of the operation note
• Tips
• Common procedures for ST1 level
THEATRE ETTIQUETTE
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WHO check list
Introduce yourself to the team
Establishes risk
Enables Preparation
WHO CHECK LIST - OBSTETRICS
WHO CHECK LIST Surgery
SURGICAL OPERATION NOTES
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Legal documentation
No formal training
Majority of operative notes are handwritten
Important source for medical records – legal
and financial implications
‘THE ADMIN’
Date of Procedure
Patient details
• Hospital sicker/hand write patient details
Staff details
• Operating Surgeon & grade
• Surgical assistant & grade
• Consultant overseeing care
• Anaesthetist and grade
THE SURGERY AND THE REASON
The full title of the operation carried out
• List from major to minor
• No abbreviations
Type of anaesthetic used.
Indication for the procedure – pre operative
diagnosis
i.e. 8/40 Missed Miscarriage with Vaginal Bleeding
‘THE FINDINGS’
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VE &abdominal palpation findings
What was seen during the operation
Post operative diagnosis
Pathological findings
Any relevant negative findings?
As much detail as possible – site, size, colour,
volume of structure involved
• Picture aids
• Any difficulties?
• Blood Loss
‘THE PROCEDURE’
Surgical steps
• Position
• Prepped and draped
• Incision (what instrument you used)
• Step by step description of surgical steps undertaken
• Sutures used and type of suturing (locking, continuous)
• Written justification of unusual steps
• Drains in situ / catheter – what is draining at end of
procedure
• Any samples obtained – how you took them
• Swabs, needles and instrument checked
POST OPERATIVE PLAN
Important guidance on managing the patient in the post operative period
Immediate
• Analgesia
• Medications
• VTE assessment
• Nutrition - fluids/ eating and drinking
• Catheter management
• Details of specific drains/dressing/packs/devices – when should they be removed
• Samples for the lab
• Routine post op care vs. close monitoring/ observations
• Anaesthetic concerns
THE POST OPERATIVE PLAN
Hospital Stay
• Suture / Staples care
• Blood tests
• Specific nursing/midwifery instructions
• Any specialist input needed e.g. physio
• Patient debrief – plan for future e.g. next
delivery/contraception
• Discharge – when and by whom
• Follow up
‘THE SIGN OFF’
• Print your name [Stamp]
• Sign the notes
• Leave contact details
Thank you
Further Information
Royal College of Surgeons of England Guidelines for Clinicians on Medical Records and
Notes (1994)
POSITION OF THE PATIENT
Important medical legal detail
• Appropriate position for access and to minimize complications e.g.. ulcers or nerve
damage
Common gynaecological patients’ positions
Position
Description
Procedure
Supine
flat on back
Caesarean section
Abdominal hysterectomy
Dorsal Lithotomy
flat on back, buttocks at edge of bed
Hips and knees fully flexed with legs
in stirrups
Perineal repair / Urogynae surgery
ERPC
Hysteroscopy
Vaginal Hysterectomy
Trandelenburg
Flat on back with feet higher then
head by 15-30 degrees
Laparoscopy
Abdominal hysterectomy
Lloyd- Davies
Trandelenburg position with hips
flexed 15 degrees
Laparoscopy
Sacrocolpoplexy
SURGICAL MANAGEMENT OF
MISCARRIAGE
‘The admin’
‘The surgery and the reason’
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Gestation
Rhesus status
‘The findings’
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VE – size of uterus, anteverted/retroverted, active bleeding, os open/closed
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Size of suction curette used
Products seen
Haemostasis
EBL
SURGICAL MANAGEMENT OF
MISCARRIAGE
‘The procedure’
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Lithotomy position
Prepped and draped
Intermittent catheterization
Cervix dilated – Hegar size
Easy vs. difficult dilatation
Size .... suction curettage used
Evacuation of products
Syntocinon given
Cavity checked – what with and by whom
EBL
Haemostasis achieved (contracted uterus)
SURGICAL MANAGEMENT OF
MISCARRIAGE
‘The Post Operative Plan’
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Analgesia +/Medication – antibiotics, Anti D
Mobilize
E+D
Products – histology
+/- FBC
Monitor PVB loss
Debrief on the ward vs. nurse led discharge
Discharge
follow up
‘The sign off’
DIAGNOSTIC HYSTEROSCOPY
‘The admin’
‘The surgery and the reason’
‘The findings’
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VE
Vagina and vulva
Uterine size, position, masses, bleeding
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Hysteroscopy
Cervical canal – easy/difficult entry
Utero-cervical length
Uterus – cavity/ endometrium/ fibroids/ polyps – location and size
Ostia
EBL
DIAGNOSTIC HYSTEROSCOPY
‘The Procedure’
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Dorsal Lithotomy position
Prepped and draped
Cervix dilated uterine
?size of cavity
Normal saline hysteroscopy – hysteroscope inserted under direct vision
Any additional steps – polypectomy, curetting, resection
Repeat hysteroscopy following intervention
‘The Post Operative Plan’
• Analgesia
• Mobilize
• E+D
• Monitor PV loss
• Any biopsies/ tissue samples
• Follow up plans
‘The sign off’
CAESAREAN SECTION
The admin’
‘The surgery and the reason’
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Category for Emergency LSCS
Indication for LSCS
‘The findings’
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Abdominal palpation
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VE
Emergency LSCS – dilation, presentation, position, station
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LSCS
Difficult or unusual steps
Adhesions
Abdominal cavity findings (signs of obstruction/ appearance of lower segment)
Presentation and position
Liquor
Placental delivery
EBL
Cord Gases
CAESAREAN SECTION
‘The Procedure’
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Supine position
Prepped and draped
Type of incision at skin
Entry into abdominal cavity
Bladder identified and reflected
Type of incision to lower segment
Delivery of baby – manual, forceps, any difficulty
Delivery of placenta
Uterine cavity check – empty
Uterine angles – any extension
Method of closure
Swabbing of vagina / uterus contracted
CAESAREAN SECTION
‘The Post Operative Plan’
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Analgesia – e.g. PR given
Medications – e.g. antibiotics, thromboprophylaxis, uterotonics
Catheter management
Details of specific drains/dressing/packs – when should they be removed
Suture care
Blood tests
Midwifery instructions
Patient debrief – plan for future e.g. next delivery/contraception
‘The sign off’