THEATRES

1
THEATRES OPERATION NOTES

• Presenter Praneil Patel
• Author Elizabeth Egbase
• Obstetrics and Gynaecology

2
SURGICAL OPERATION NOTES

• Objectives
• Theatre etiquette
• Format of the operation note
• Tips
• Common procedures for ST1 level

3
THEATRE ETTIQUETTE

• WHO check list
• Introduce yourself to the team
• Establishes risk
• Enables Preparation

4
WHO CHECK LIST - OBSTETRICS
5
WHO CHECK LIST Surgery
6
SURGICAL OPERATION NOTES

• Legal documentation
• No formal training
• Majority of operative notes are handwritten
• Important source for medical records legal and
  financial implications

7
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

8
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

9
THE FINDINGS

• 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

10
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

11
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

12
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

13
THE SIGN OFF

• Print your name Stamp
• Sign the notes
• Leave contact details

14
Thank you
15
Further Information

• Royal College of Surgeons of England - Guidelines
  for Clinicians on Medical Records and Notes
  (1994)

16
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
17
SURGICAL MANAGEMENT OF MISCARRIAGE

• The admin
• The surgery and the reason
• Gestation
• Rhesus status
• The findings
• VE size of uterus, anteverted/retroverted,
  active bleeding, os open/closed
• Size of suction curette used
• Products seen
• Haemostasis
• EBL

18
SURGICAL MANAGEMENT OF MISCARRIAGE

• The procedure
• 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)

19
SURGICAL MANAGEMENT OF MISCARRIAGE

• The Post Operative Plan
• Analgesia /-
• Medication antibiotics, Anti D
• Mobilize
• ED
• Products histology
• /- FBC
• Monitor PVB loss
• Debrief on the ward vs. nurse led discharge
• Discharge
• follow up
• The sign off

20
DIAGNOSTIC HYSTEROSCOPY

• The admin
• The surgery and the reason
• The findings
• VE
• Vagina and vulva
• Uterine size, position, masses, bleeding
• Hysteroscopy
• Cervical canal easy/difficult entry
• Utero-cervical length
• Uterus cavity/ endometrium/ fibroids/ polyps
  location and size
• Ostia
• EBL

21
DIAGNOSTIC HYSTEROSCOPY

• The Procedure
• 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
• ED
• Monitor PV loss
• Any biopsies/ tissue samples
• Follow up plans
• The sign off

22
CAESAREAN SECTION

• The admin
• The surgery and the reason
• Category for Emergency LSCS
• Indication for LSCS
• The findings
• Abdominal palpation
• VE
• Emergency LSCS dilation, presentation,
  position, station
• LSCS
• Difficult or unusual steps
• Adhesions
• Abdominal cavity findings (signs of obstruction/
  appearance of lower segment)
• Presentation and position
• Liquor

23
CAESAREAN SECTION

• The Procedure
• 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

24
CAESAREAN SECTION

• The Post Operative Plan
• 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