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Per op note for Toatal abdominal hysterectomy

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operative note template total abdominal hysterectomy TAH surgical dictation

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total abdominal hysterectomy operative note dictation template

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I now have enough detail from Schwartz's Principles of Surgery (lines 3282–3299) plus the MTSamples dictation to construct a complete, accurate operative note template. Here it is:

Operative Note: Total Abdominal Hysterectomy (TAH)

Date of Procedure: _______________ Surgeon: _______________ Assistant(s): _______________ Anesthesiologist: _______________ Anesthesia: General endotracheal / Spinal / Epidural

Preoperative Diagnosis

_______________ (e.g., Symptomatic uterine leiomyomata / Endometrial hyperplasia / Abnormal uterine bleeding / Pelvic organ prolapse)

Postoperative Diagnosis

Same as above / (state if different)

Procedure Performed

Total Abdominal Hysterectomy ± Bilateral Salpingo-Oophorectomy (TAH ± BSO)

Estimated Blood Loss

_______________ mL

Fluids Administered

_______________ mL crystalloid / blood products

Urine Output

_______________ mL

Specimens Sent

  • Uterus (weight: ___ g), cervix
  • Right/Left fallopian tube and ovary (if BSO performed)
  • (Other: endometrium, lymph nodes, etc.)

Complications

None / (describe if any)

Description of Procedure

The patient was identified, taken to the operating room, and placed in the supine position. After the administration of [general/spinal/epidural] anesthesia, the abdomen was prepped and draped in the usual sterile fashion. A Foley catheter was inserted for continuous bladder drainage.
Abdominal Entry: A [Pfannenstiel / low midline / midline] incision was made through the skin and subcutaneous tissue. The fascia was incised transversely/vertically, and the rectus muscles were separated in the midline. The peritoneum was entered sharply. A self-retaining retractor (Bookwalter / Balfour) was placed for exposure.
Exploration: The upper abdomen was examined and found to be without evidence of extrapelvic disease. The uterus was noted to be [describe size, shape, consistency, any fibroids]. The adnexa were inspected bilaterally and noted to be [describe].
Bowel Packing: The small bowel was packed superiorly with moistened laparotomy sponges to expose the operative field.
Round Ligaments: The round ligaments were identified bilaterally, doubly clamped, divided, and ligated with 0-Vicryl suture.
Broad Ligament / Adnexa:
  • If BSO: The peritoneal incision was extended from the round ligament laterally toward the infundibulopelvic (IP) ligament. The retroperitoneal space was bluntly developed. The ureter was identified and swept medially. The IP ligament was isolated, doubly clamped, cut, and suture-ligated with 0-Vicryl on both sides.
  • If ovaries preserved: An opening was created below the utero-ovarian ligament and fallopian tube. The fallopian tube and utero-ovarian ligament were clamped, divided, and ligated bilaterally.
Bladder Flap: The vesicouterine peritoneum was incised transversely, and the bladder was mobilized by sharp dissection off the anterior surface of the lower uterine segment and cervix, taking care to avoid bladder injury.
Uterine Vessels: Heaney clamps were placed bilaterally on the uterine vessels at the cervicouterine junction. The vessels were cut and suture-ligated with 0-Vicryl. Hemostasis was confirmed.
Cardinal and Uterosacral Ligaments: The cardinal ligaments were serially clamped, divided, and ligated bilaterally in a stepwise fashion until the vaginal angles were reached.
Colpotomy / Cervical Amputation: The uterus was elevated and the vaginal angles were clamped. The cervix was amputated from the vaginal vault using Mayo scissors / knife. The uterus and cervix were passed off as specimen.
Vaginal Cuff Closure: Sutures were placed at each lateral vaginal angle incorporating the cardinal and uterosacral ligament pedicles. The vaginal cuff was closed with a running or interrupted 0-Vicryl suture. The cuff was inspected and found to be intact and hemostatic.
Hemostasis and Irrigation: The pelvis was irrigated with warm normal saline. All pedicles were inspected and hemostasis was confirmed throughout.
Reperitonization: The pelvic peritoneum was reapproximated / left open (per surgeon preference).
Fascial Closure: The fascia was closed with running [#1 PDS / Looped PDS] suture. The subcutaneous layer was irrigated and hemostasis confirmed. The skin was closed with [staples / 4-0 Monocryl subcuticular / interrupted Nylon].
Sponge, Instrument, and Needle Counts: Correct × [number of counts].
Condition of Patient: Stable. Transferred to the PACU in stable condition.

Postoperative Plan

  • IV fluids until tolerating oral intake
  • Foley catheter to remain for [24 hours / per protocol]
  • DVT prophylaxis: SCDs in place / anticoagulation per protocol
  • Analgesics: [multimodal per ERAS protocol]
  • Ambulation: [POD #1]
  • Follow-up: [2–4 weeks] for wound check / pathology review
Source: Schwartz's Principles of Surgery, 11th ed.; Berek & Novak's Gynecology
Notes on customization:
  • Add BSO steps only if ovaries were removed
  • Add pelvic lymphadenectomy section if indicated (e.g., endometrial cancer staging)
  • Document any adhesiolysis, cystoscopy, or additional procedures separately
  • Document EUA findings if an exam under anesthesia was performed before incision
  • Include intraoperative cystoscopy confirmation of ureteral integrity if performed
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