Surgeon Grade: Consultant Staff Grade Spr Training Fellow Other

Operative data

Date of operation: …………………………………….

Surgeon name: …………………………………………

Surgeon grade: Consultant □Staff grade □SpR □Training Fellow □ Other □

Joint case with Colorectal surgeon:Yes □No □

Joint case with Urologist:Yes □No □

Type of Surgery

Is this a one stage operation?Yes □No □

Is this the first stage?Yes □No □n/a □

Is this the second stage?Yes □No □n/a □

Were GnRH analouges given?Yes □ No □

Planned laparoscopyYes □No □

Planned laparotomyYes □No □

Converted to laparotomyYes □No □ Why:……………………………………………….

Distribution of endometriosis

Peritoneal- SuperficialYes □No □

Peritoneal- DeepYes □ No □

Left ovary endometriomaYes □No □

Right ovary endometriomaYes □No □

Left deep sidewallYes □No □

Right deep sidewallYes □ No □

Left deep uterosacralYes □No □

Right deep uterosacralYes □No □

Obliteration of PODComplete □ Partial □Clear □

BowelInvolvement:

Recto-vaginal noduleYes □No □

Rectal involvementYes □No □

Large bowelYes □No □

Small bowelYes □No □

Recto-sigmoidYes □No □

Diaphragm Yes □No □

Others Describe:……………………………………………………………………………..

Bladder Involvement:

SuperficialYes □No □

DeepYes □No □

Deep utero-vesicalYes □No □

Right ureter Yes □No □

Left ureter Yes □No □

Surgical treatment

Mono-polar diathermyYes □No □

Bipolar -diathermyYes □No □

Ultrasound scalpelYes □No □

LaserYes □No □

ScissorsYes □No □

Other (please specify)______

Operative Management

Peritoneal diseaseAblated □Excised □Ablated & Excised □ Not treated □

Left deep pelvic sidewallAblated □Excised □Ablated & Excised □ Not treated □

Right deep pelvic sidewallAblated □Excised □Ablated & Excised □ Not treated □

Left uterosacral ligamentAblated □Excised □Ablated & Excised □ Not treated □

Right uterosacral ligamentAblated □Excised □Ablated & Excised □ Not treated □

Page 1 of 3

BSGE-ECDB- OPSheet- updated Feb2014 v1

Left Endometrioma

AblatedYes □ No □

ExcisedYes □ No □

OophorectomyYes □ No □

DrainedYes □ No □

Not treatedYes □ No □

Right Endometrioma

AblatedYes □ No □

ExcisedYes □ No □

OophorectomyYes □ No □

DrainedYes □ No □

Not treatedYes □ No □

Page 1 of 3

BSGE-ECDB- OPSheet- updated Feb2014 v1

Para-rectal Space

DissectedYes □No □ n/a □

Rectovaginal nodule

AblatedYes □No □ n/a □

ExcisedYes □No □ n/a □

Vagina openedYes □No □ n/a □

Not treatedYes □No □ n/a □

Bowel treatment:

ShaveYes □No □ n/a □

Disc resectionYes □No □ n/a □

Segmental resectionYes □No □ n/a □

Stoma (colostomy/ileostomy)Yes □No □ n/a □

Not treatedYes □No □ n/a □

Bladder treatment:

AblatedYes □No □ n/a □

ExcisedYes □No □ n/a □

Excised with bladder openingYes □No □ n/a □

Ureteric nodule excisedYes □No □ n/a □

Not treatedYes □No □ n/a □

Ureteric Stents

JJ StentYes □No □ n/a □

Ureterlysis (Right)Yes □No □ n/a □

Ureterolysis (Left)Yes □No □ n/a □

Hysterectomy Yes □No □ n/a □

Perioperative Complications:

Haemorhage > 1 litreYes □No □

Ureteric injuryYes □No □

Unexpected bowel injuryYes □No □

Unexpected bladder injuryYes □No □

Unexpected vascular injuryYes □No □

Conversion to laparotomyYes □No □

ColostomyYes □No □

IleostomyYes □No □

Others: ……………………………………………………………………………………………………………………………..

Length of hospital stay (no of days): ………………………………………………………………………………….

Late complications- to be noted at first follow up visit

Pelvic heamatomaYes □No □

Pelvic AbscessYes □No □

Urinary tract leakYes □No □

Bowel leakYes □No □

Urinary tract fistulaYes □No □

Bowel fistulaYes □No □

Severe sepsisYes □No □

DVT / Pulmonary embolismYes □No □

Histological confirmation of endometriosis

Histological confirmationYes □No □

of endometriosis

Malignant transformationYes □No □

Page 1 of 3

BSGE-ECDB- OPSheet- updated Feb2014 v1