Operative Reports Before Ligation Reversal Surgery
Undergoing a tubal ligation reversal at Chapel Hill Tubal Reversal Center is an important endeavor and we want to maximize every patient’s chance of ligation reversal success. Operative reports are important because they allow us to determine the likely success of tubal ligation reversal surgery.
When a surgeon performs an operation on a patient they are required to keep a written record describing the entire procedure. This is an important part of patient care and many hospitals provide transcription services to assist with creating operative reports. After surgery is completed, the physician will dictate an operative report. Operative reports contain the pre-operative diagnosis, post operative diagnosis, operative procedure, surgeon’s name, findings of the surgery, and what was done during the surgery.
There are two types of operative reports: vague and detailed.
A vague operative report gives generalized information regarding your surgery. Such a report might read, for example, “The tubes were tied in a standard fashion”, or “The tubes were burned in 3 separate areas,” or “A segment of each tube was removed.” These vague reports leave much to the imagination because there is no recognized ’standard fashion’ and we do not really know how far apart ’separate’ burns are.
A detailed operative report will give very specific and easy to understand information regarding your tubal sterilization. Such a detailed report might read, for example, “The tubes were tied in the isthmic (middle) section and a 2 cm interval segment was removed.” or ” The tubes were cauterized (burned) in 3 adjacent areas in the isthmic portion.” These reports give very specific information about what was done and where it happened.
There is no substitute for a detailed operative report. A good operative report can give us enough information to formulate what the likely success of any reversal procedure will be. In general, we can give ligation reversal success based upon the type of ligation a patient has had. If an operative report is ominous, then this allows us to advise patients to consider either a screening laparoscopy or in vitro fertilization (IVF) before attempting ligation reversal. This can prevent having an operation that would have a limited chance of success.
If an operative report can not be obtained then consideration should be given to having a screening laparoscopy. Patients should also be aware that most tubal ligation procedures can be reversed and only a small minority of ligation procedures can not be reversed.
Patients with any questions regarding operative reports, tubal ligation reversal, or tubal reversal success rates should contact a nurse at Chapel Hill Tubal Ligation Reversal Center.
Frequently asked questions regarding operative reports
What is an operative report?
An operative report is a typed report describing exactly what the doctor saw and did during your tubal ligation procedure.
Where can tubal ligation operative reports be obtained?
Tubal ligation operative reports can be obtained from the hospital or health care facility where you had your tubal ligation surgery. Your doctor may have a copy of your operative report in their office. The hospital will have a copy of the report in your hospital record and will keep them on file for a limited time.
How long does the hospital keep my operative report?
The time a health care facility will keep records will vary by state. Most states have laws specifying how long records must be kept. If a state does not have laws regarding keeping medical records, then the state medical board will have guidelines which the board encourages physicians to follow. North Carolina, for instance, has no state laws mandating how long medical records will be kept. The North Carolina State Medical Boards recommends physicians keep records for a minimum of 10 years. Medicare and Medicaid records are recommended to be kept for a minimum of five years.
The physician’s office or hospital will typically keep records in their file room for a limited time and then transfer the files to another storage area for several years. Some facilities will create digital records of your health care information and store this information indefinitely.
How can I obtain an operative report?
Contact the medical records department of the hospital where your tubal ligation was performed. You will have to fill out a medical records release form. The operative report can be mailed or faxed to you and to our facility. Please be aware some medical facilities are very busy and have limited medical record personnel. This means they may take some time to send records and you might have to keep a close watch to make sure the records are actually sent in a timely fashion. Chapel Hill Tubal Reversal Center has instructions and  a form you can use to obtain a copy of your operative report.
What happens if I can not get my operative report?
If you can not get your operative report you can try to get your doctor to give you more information about the type of ligation surgery you had. Although this is not as accurate as an operative report, this can provide some information. Many doctors will do their tubal ligation surgeries the same way over many years and they should be able to tell you how your procedure was done.
Your best option is to consider a screening laparoscopy. This involves placing a small telescope under your umbilicus (belly button) and looking at the fallopian tubes. This provide quick and accurate information about the condition of your fallopian tubes. When the screening laparoscopy is performed here, we proceed immediately with the tubal repair. If the laparoscopy shows that the tubes cannot be repaired, the procedure is ended without the laparotomy incision and a partial refund is given to the patient.
Will Chapel Hill Tubal Reversal do my reversal surgery if I do not have an operative report?
Yes. We frequently encounter many patients who are unable to obtain their operative report. The choice of whether to start with screening laparoscopy is up to the individual patient. Since most tubal ligation procedures are reversible, it is an option, and not a requirement.
May 24th, 2008 at 5:18 pm
This is great information and I know that it will help many women get started on their journey for tubal reversal surgery. With the experience and dedication of the physicians at Chapel Hill Tubal Reversal Center, it is also nice knowing that even without an operative report, tubal reversal surgery can be done.
May 24th, 2008 at 5:33 pm
It still amazes me how some tubal ligation doctors give a great amount of detail, but others hardly describe the tubal ligation at all in the operative report. Luckily, because Dr. Berger has performed over 7,000 reversals he usually knows whether a ligation should be reversible or not even with little detail. Overall, Dr. Berger is able to reverse the tubal ligations in 98% of our patients.
May 27th, 2008 at 12:59 pm
It is always helpful to gather as much information as possible when assessing whether or not a patient is a candidate for outpatient tubal reversal surgery. By having a detailed operative report from a tubal ligation procedure, Dr. Berger and Dr. Monteith are able to look at the big picture and determine if a patient is a candidate. It is nice to know, though, that Dr. Berger is able to perform tubal reversals in 98% of cases, regardless of whether or not we ever received an operative report.
May 28th, 2008 at 7:43 am
As Jennifer mentioned, it also amazes me when a vague report is received and the assessment is made that reversal should be possible. Experience is definitely the key to success.
May 28th, 2008 at 7:48 am
This should help our patients better understand how helpful an operative report is to Drs. Berger and Monteith and how one can be obtained.
May 29th, 2008 at 6:40 am
Operative reports are very important in conveying exactly what was done during an operation. We always would like to receive detailed operative reports, although not all doctors provide detailed accounts of their surgical procedures. At Chapel Hill Tubal Reversal Center, we take great pride in writing precise and detailed operative reports so that anyone will be able to clearly understand the details of operations performed here.
May 29th, 2008 at 9:29 am
In Dr. Berger’s extensive surgerical experience with tubal reversal he has seen most every unusual situation imaginable. His expertise is evident by the fact that he repairs 98% of cases. Women should be assured that he will repair what is possible.
June 6th, 2008 at 11:55 am
This is very helpful information, Dr. Monteith, in starting the process of obtaining information on a patient and her type of tubal ligation. If a patient is unable to get a report on the type of tubal ligation or information on the health of her tube, the screening laparoscopy option can supply that information and the process of tubal reversal can move forward.