Hysterectomy Operative Note

Patient Name: [Patient name]

MRN: [Medical record number]

Date of Birth: [DOB]

Date of Surgery: [Date]

Time In / Time Out: [Time in] / [Time out]

Facility: [Facility name]

Primary Surgeon: [Surgeon name and credentials]

Assistant(s): [Assistant name(s) and credentials / None]

Anesthesia Type: [General / Spinal / Epidural / MAC / Local with sedation]

Preoperative Diagnosis: [Preoperative diagnosis(es)]

Postoperative Diagnosis: [Postoperative diagnosis(es) / Same as preoperative]

Procedure(s) Performed: [Hysterectomy type and route]; [Adnexal procedures with laterality]; [Additional procedures] (Include conversion status if applicable. List all procedures performed with laterality where relevant.)

Indications

[Primary indication for hysterectomy, pertinent failed or declined prior treatments, and key supportive findings such as imaging or biopsy results] (Include rationale for non-standard approach or conversion if applicable.)

Consent and Verification

[Statement confirming informed consent obtained and time-out performed] (If morcellation was discussed preoperatively per institutional policy, document here.)

Preparation

• Antibiotic Prophylaxis: [Agent and timing / Per protocol]
• VTE Prophylaxis: [SCDs applied / Chemoprophylaxis agent and timing]
• Positioning: [Supine / Dorsal lithotomy / Trendelenburg]
• Surgical Prep: [Abdominal / Vaginal / Both]
• Foley Catheter: [Placed / Not placed]
• Uterine Manipulator: [Placed with type / Not used] (For minimally invasive cases.)

Intraoperative Findings

(Document only structures actually inspected. State explicitly if a structure was not visualized.)

• Uterus: [Size, contour, presence and location of fibroids, adenomyosis features]
• Adnexa: [Right and left tube and ovary appearance, adhesions, endometriosis] (State laterality for all findings.)
• Bladder and Cul-de-sacs: [Anterior and posterior cul-de-sac appearance, bladder, any obliteration or pathology]
• Ureters: [Visualization method and findings bilaterally]
• Other: [Unexpected pathology, adhesions to adjacent structures, other abnormal findings]

Procedure

Approach and Entry

[Surgical approach and entry description] (For laparoscopic/robotic: entry technique, insufflation, port placement by site and size, robotic docking if applicable. For abdominal: incision type and peritoneal entry. For vaginal: cul-de-sac entry and exposure. If conversion occurred, document timing, reason, and converted-to approach.)

Operative Steps

[Narrative of key steps in logical sequence] (Include identification and protection of ureters and bladder; adnexal pedicle management with laterality; uterine artery control method; colpotomy creation or cervical transection; specimen delivery route; vaginal cuff closure with suture type and technique; hemostasis verification and irrigation. Document any deviations, unexpected bleeding, or repairs at the point they occurred.)

Specimen Extraction

[Method of specimen removal] (If morcellation performed: specify type, location, containment system use and integrity, any spillage, and confirmation of complete retrieval.) (Omit this subsection if extraction was straightforward vaginal delivery without modification.)

Cystoscopy

[Indication, bladder mucosa findings, bilateral ureteral efflux status] (If efflux absent or abnormal, document actions taken.) (Omit this subsection if cystoscopy was not performed.)

Closure

[Closure details by approach] (Abdominal: fascial, subcutaneous, and skin closure. Laparoscopic/robotic: port-site closure for ports ≥10 mm, desufflation, local anesthetic if used. Vaginal: cuff closure confirmation, packing if placed.)

Counts

[Sponge, needle, and instrument counts: correct / discrepancy with resolution]

Specimens

• [Specimen with laterality as applicable]
• [Additional specimens]

[Orientation/marking if performed; frozen section results if obtained]

Intraoperative Data

Estimated Blood Loss: [EBL]

IV Fluids: [Volume and type]

Blood Products: [None / Product(s) and volume]

Urine Output: [Volume]

Drains: [None / Type and location]

Implants/Devices: [None / Device(s) listed]

Complications

[None / Description of each complication: what occurred, how recognized, interventions performed, and immediate outcome] (This section must always be present with explicit documentation.)

Disposition and Plan

[Patient condition, airway status, and destination] [Postoperative orders: diet, activity and pelvic rest, pain management, Foley plan, VTE prophylaxis, antibiotics, labs if indicated, pathology follow-up]