Hysterectomy (Robotic / Total Laparoscopic)
[Symptomatic uterine fibroids / Abnormal uterine bleeding refractory to medical management / Adenomyosis / Endometrial intraepithelial neoplasia]
Same
[Robotic-assisted total laparoscopic / Total laparoscopic] hysterectomy with [bilateral salpingectomy / bilateral salpingo-oophorectomy][, cystoscopy]
[***, MD/DO]
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old female with [symptomatic uterine fibroids / abnormal uterine bleeding refractory to medical management / adenomyosis / endometrial intraepithelial neoplasia]. Hysterectomy was recommended. The risks, benefits, and alternatives, including nonsurgical and uterus-sparing options, were discussed. The patient elected [bilateral salpingectomy with ovarian conservation / bilateral salpingo-oophorectomy], and informed consent was obtained.
The uterus was [normal in size / enlarged, approximately [X]-week size, with [fibroids / adenomyosis]]. The fallopian tubes and ovaries were [normal / ***]. The posterior cul-de-sac was [free / involved by endometriosis / obliterated]. The upper abdomen was [normal / ***]. The ureters were identified bilaterally along the pelvic sidewall.
The patient was placed in the dorsal lithotomy position in padded stirrups with the arms tucked. The abdomen, perineum, and vagina were prepped and draped in the usual sterile fashion. A Foley catheter was placed. A surgical time-out was performed. A uterine manipulator with a [X cm] colpotomy cup was placed.
Pneumoperitoneum to [15 mmHg] was established via [Veress needle / optical trocar / open Hasson] entry. [[X] 8-mm robotic ports and a [5 / 12]-mm assistant port / A [X]-mm umbilical port and three 5-mm ports] were placed under direct vision. The patient was placed in steep Trendelenburg [and the robot was docked].
The ureters were identified bilaterally along the pelvic sidewall and protected throughout. The round ligaments were coagulated and divided bilaterally, and the anterior and posterior leaves of the broad ligament were opened. [The mesosalpinx was coagulated and divided from the fimbriated end to the cornu bilaterally, and the utero-ovarian ligaments were then coagulated and divided, conserving the ovaries. / A window was created in the posterior leaf of the broad ligament between the infundibulopelvic ligament and the ureter, and the infundibulopelvic ligaments were coagulated and divided bilaterally.] The vesicouterine peritoneum was incised, and the bladder was dissected off the lower uterine segment and cervix below the rim of the colpotomy cup.
The uterine vessels were skeletonized, coagulated, and divided at the level of the internal os bilaterally. The cardinal and uterosacral ligament complexes were coagulated and divided medial to the uterine pedicles down to the colpotomy cup. A circumferential colpotomy was made along the rim of the cup with [monopolar scissors / a monopolar hook / ultrasonic shears]. The specimen was removed [intact through the vagina / through the vagina by contained manual morcellation within a specimen bag].
The vaginal cuff was closed with [a running 0 barbed suture / interrupted 0 polyglactin figure-of-eight sutures], taking full-thickness bites [and incorporating the uterosacral ligaments at the angles]. The pelvis was irrigated, and hemostasis was confirmed at all pedicles and the cuff under reduced insufflation pressure.
[Cystoscopy demonstrated an intact bladder and brisk bilateral ureteral efflux.]
[The robot was undocked.] The ports were removed under direct vision and the abdomen was desufflated. [The fascia at port sites 10 mm or larger was closed with 0 polyglactin suture.] The skin was closed with [4-0 absorbable subcuticular suture / skin adhesive]. Sponge, needle, and instrument counts were correct.
None
[Uterus, cervix, and bilateral fallopian tubes / Uterus, cervix, bilateral fallopian tubes, and ovaries], sent to pathology[; uterine weight [X g]]
[X] mL
None
The patient was extubated and taken to the PACU in stable condition [for anticipated same-day discharge / for overnight observation]. The Foley catheter was removed [at the end of the case / on postoperative day 1], followed by a voiding trial.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Robotic-assisted total laparoscopic / Total laparoscopic] hysterectomy with [bilateral salpingectomy / bilateral salpingo-oophorectomy][, cystoscopy]
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: .PTAGE-year-old .PTSEX with ***. Hysterectomy recommended. Risks, benefits, and alternatives discussed. Patient elected ***. Consent obtained.
FINDINGS: Uterus ***. Tubes and ovaries ***. Cul-de-sac ***. Upper abdomen ***. Ureters identified bilaterally.
PROCEDURE:
Dorsal lithotomy, arms tucked. Prepped and draped. Foley placed. Time-out. Uterine manipulator with *** cm colpotomy cup. Pneumoperitoneum via ***. [*** 8-mm robotic ports and *** mm assistant port / *** mm umbilical port and three 5-mm ports] under direct vision. Steep Trendelenburg[, robot docked]. Ureters identified and protected. Round ligaments divided, broad ligament opened. [Mesosalpinx divided fimbria to cornu, utero-ovarian ligaments divided, ovaries conserved. / IP ligaments divided after ureter identified.] Bladder flap developed below cup rim. Uterine vessels coagulated and divided at the internal os. Cardinal and uterosacral complexes divided to the cup. Circumferential colpotomy on the cup. Specimen removed vaginally [intact / by contained morcellation in a bag]. Cuff closed with [running barbed / interrupted figure-of-eight] suture. Irrigation, hemostasis confirmed. [Cystoscopy: bladder intact, bilateral ureteral efflux.] [Robot undocked.] Ports removed, desufflated. [Fascia closed at ports 10 mm or larger.] Skin closed. Counts correct.
EBL: *** mL
SPECIMENS: Uterus, cervix, *** to pathology. Weight *** g.
COMPLICATIONS: None
DISPOSITION: PACU, stable. Foley out ***.
Signed: .ME, .MYDEGREE
.TODAYVariants
Vaginal Hysterectomy (VH)
The patient was placed in the dorsal lithotomy position in [Allen / candy cane] stirrups. The vagina and perineum were prepped and draped in the usual sterile fashion, a Foley catheter was placed, and a surgical time-out was performed. A weighted speculum was placed and the cervix was grasped with a tenaculum. [The cervicovaginal junction was infiltrated with [dilute vasopressin / lidocaine with epinephrine].] A circumferential incision was made at the cervicovaginal junction. The posterior cul-de-sac was entered sharply. The bladder was advanced off the cervix and the anterior cul-de-sac was entered.
The uterosacral ligaments were clamped, divided, and suture-ligated with 0 polyglactin bilaterally, and the pedicles were tagged. The cardinal ligaments and then the uterine vessels were clamped, divided, and suture-ligated bilaterally. [The uterus was debulked by [wedge morcellation / bivalving / intramyometrial coring] to permit delivery.] The fundus was delivered [posteriorly / anteriorly], the utero-ovarian ligaments and fallopian tubes were clamped, divided, and doubly ligated bilaterally, and the uterus and cervix were removed.
[Each fallopian tube was grasped, and the mesosalpinx was clamped, divided, and ligated from the fimbriated end to the cornual pedicle bilaterally. / The infundibulopelvic ligaments were clamped, divided, and doubly ligated bilaterally, and the tubes and ovaries were removed. / The adnexa were inspected and left in situ.] Hemostasis was confirmed at all pedicles.
[A modified McCall culdoplasty was performed with [X] sutures through the uterosacral ligaments and the intervening posterior cul-de-sac peritoneum, tied after cuff closure.] The uterosacral pedicles were incorporated into the cuff angles, and the vaginal cuff was closed [vertically / transversely] with interrupted 0 polyglactin sutures. [Cystoscopy demonstrated an intact bladder and brisk bilateral ureteral efflux.] Sponge, needle, and instrument counts were correct.
Total Abdominal Hysterectomy (TAH)
The patient was placed supine. A Foley catheter was placed, the abdomen and vagina were prepped and draped in the usual sterile fashion, and a surgical time-out was performed. A [Pfannenstiel / low midline] incision was made and the abdomen was entered. A [Balfour / Bookwalter / Alexis] retractor was placed and the bowel was packed out of the pelvis. The uterus was elevated with clamps across the cornua.
The round ligaments were clamped, divided, and suture-ligated bilaterally, and the anterior and posterior leaves of the broad ligament were opened. The ureters were identified in the retroperitoneum bilaterally and protected throughout. [The mesosalpinx was clamped, divided, and ligated from the fimbriated end to the cornu bilaterally, and the utero-ovarian ligaments were then doubly clamped, divided, and suture-ligated, conserving the ovaries. / A window was created in the posterior leaf of the broad ligament above the ureter, and the infundibulopelvic ligaments were doubly clamped, divided, and suture-ligated bilaterally. / The utero-ovarian ligaments and fallopian tubes were doubly clamped, divided, and suture-ligated bilaterally, conserving the adnexa.] The vesicouterine peritoneum was incised, and the bladder was dissected off the lower uterine segment and cervix.
The uterine vessels were skeletonized, clamped at the level of the internal os, divided, and suture-ligated bilaterally. The cardinal and uterosacral ligaments were serially clamped, divided, and suture-ligated medial to the uterine pedicles. The vagina was entered below the cervix, and the uterus and cervix were amputated from the vaginal cuff and removed. The cuff angles were secured with sutures incorporating the uterosacral ligaments, and the vaginal cuff was closed with [running locked / interrupted figure-of-eight] 0 polyglactin sutures.
The pelvis was irrigated, and hemostasis was confirmed at all pedicles. [Cystoscopy demonstrated an intact bladder and brisk bilateral ureteral efflux.] The packs and retractor were removed. The fascia was closed with running [0 polyglactin / looped 1 polydioxanone] suture. The skin was closed with [4-0 absorbable subcuticular suture / staples]. Sponge, needle, and instrument counts were correct.
Supracervical Hysterectomy (Robotic / Laparoscopic)
The patient was placed in the dorsal lithotomy position in padded stirrups with the arms tucked. The abdomen, perineum, and vagina were prepped and draped in the usual sterile fashion. A Foley catheter and a uterine manipulator were placed. A surgical time-out was performed. Pneumoperitoneum was established via [Veress needle / optical trocar / open Hasson] entry. [[X] 8-mm robotic ports and a [5 / 12]-mm assistant port / A [X]-mm umbilical port and three 5-mm ports] were placed under direct vision. The patient was placed in steep Trendelenburg [and the robot was docked].
The ureters were identified bilaterally along the pelvic sidewall and protected throughout. The round ligaments were coagulated and divided bilaterally, and the broad ligaments were opened. [The mesosalpinx was coagulated and divided from the fimbriated end to the cornu bilaterally, and the utero-ovarian ligaments were then coagulated and divided, conserving the ovaries. / A window was created in the posterior leaf of the broad ligament between the infundibulopelvic ligament and the ureter, and the infundibulopelvic ligaments were coagulated and divided bilaterally.] The vesicouterine peritoneum was incised and the bladder was mobilized below the internal os. The uterine vessels were skeletonized, coagulated, and divided at the level of the internal os bilaterally.
The manipulator was removed. The uterine corpus was amputated from the cervix at the level of the internal os with [monopolar scissors / a monopolar loop / ultrasonic shears]. The endocervical canal was cauterized with monopolar energy. [The cervical stump was closed with 0 polyglactin suture.] The specimen was placed in a containment bag, contained [power / manual] morcellation was performed through [an extended port site / a minilaparotomy], and the bag was removed intact.
The pelvis was irrigated, and hemostasis was confirmed at the cervical stump and all pedicles. [The robot was undocked.] The ports were removed under direct vision and the abdomen was desufflated. [The fascia at port sites 10 mm or larger was closed with 0 polyglactin suture.] The skin was closed with [4-0 absorbable subcuticular suture / skin adhesive]. Sponge, needle, and instrument counts were correct.
Charting Tips
- Document the reason for the surgical route. ACOG recommends vaginal hysterectomy for benign disease when feasible, so note the factor that led to a robotic, laparoscopic, or abdominal route (uterine size, limited vaginal access, adnexal pathology, adhesions).
- Record the adnexal decision in the indications. Opportunistic bilateral salpingectomy with ovarian conservation is the usual choice at benign hysterectomy in premenopausal patients. State whether the ovaries were conserved or removed and that this was discussed.
- Document ureter identification and protection. Ureteral injury occurs in about 0.1–1% of hysterectomies, most often near the uterine artery or the cuff angle. State where the ureters were seen.
- Universal cystoscopy detects more bladder and ureteral injuries intraoperatively than selective use. If performed, record the agent used to color the urine (IV sodium fluorescein 0.25–1 mL of 10% solution, or oral phenazopyridine) and efflux from both ureteral orifices.
- Document vaginal cuff closure: suture type, technique, full-thickness bites, and whether the uterosacral ligaments were incorporated. Cuff dehiscence is more common after laparoscopic and robotic hysterectomy than after vaginal or abdominal routes.
- Record uterine weight from the OR scale or final pathology. Laparoscopic, robotic, and vaginal hysterectomy codes split at 250 g, and the note should support the code billed.
- If the specimen is morcellated, document containment in a bag, the method (manual or power), and that the bag was removed intact. FDA guidance limits power morcellation to contained systems in appropriately selected patients, so record the preoperative malignancy evaluation (endometrial sampling, cervical screening, imaging) in the indications.
- For endometrial cancer, document the nodal assessment performed (sentinel node mapping, pelvic or para-aortic lymphadenectomy), the mapping agent, laterality of mapping, and node counts by region.
Documentation & Reimbursement Considerations
- Primary service: Report Hysterectomy (Robotic / Total Laparoscopic) as the primary service when it is the definitive operation performed.
- Laparoscopic hysterectomy codes (total and supracervical) are selected on two axes, uterine weight (250 g or less vs. more than 250 g) and whether tubes or ovaries are removed. Robotic and standard laparoscopic approaches use the same codes. Vaginal and laparoscopic-assisted vaginal hysterectomy follow the same two axes, while total abdominal hysterectomy uses a single code with or without salpingo-oophorectomy.
- 90-day global period: drain removal, wound checks, vaginal cuff inspection, and routine follow-up are bundled. Vaginal cuff dehiscence requiring OR repair within the global period uses the unplanned-return-to-OR modifier.
- For malignant indication, pelvic and para-aortic lymphadenectomy is separately billable with the multiple-procedure modifier, using laparoscopic or open lymphadenectomy codes to match the approach. Document the node template, count per region, and any sentinel mapping performed.