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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. WHO check list Introduce yourself to the team Establishes risk
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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 • WHO check list • Introduce yourself to the team • Establishes risk • Enables Preparation
SURGICAL OPERATION NOTES • 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’ • 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
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
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
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)
SURGICAL MANAGEMENT OF MISCARRIAGE ‘The Post Operative Plan’ • 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’ • 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
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 • E+D • Monitor PV loss • Any biopsies/ tissue samples • Follow up plans ‘The sign off’
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 • Placental delivery • EBL • Cord Gases
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
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’