Documentation of surgical findings of endometriosis in teenagers and women attending the Canberra Endometriosis Centre: a best practice implementation project

Background Endometriosis is a complex disease and presents many challenges to documentation and classification of surgical findings during laparoscopy/laparotomy. Detailed and accurate recording of disease is important for women, surgeons and research consistency. Objectives To improve documentation of surgical findings of endometriosis in accordance to the best available evidence in teenagers and women undergoing laparoscopy at a tertiary hospital gynaecology unit. Methods A convenience sample of women undergoing surgery for diagnosed endometriosis through the Canberra Endometriosis Centre or gynaecology unit of the Canberra Hospital. This project followed a three phase pre/post implementation audit process using the Joanna Briggs Institute PACES and GRiP programs that included: a pre implementation retrospective audit of operation records, implementation of a simple surgical documentation tool and post implementation audit. Four criteria were applied to each lesion rather than each woman and included type, location, size and depth of lesion. Results In the baseline audit 12 women provided 55 lesions and in the post audit 5 women provided 23 lesions. In the pre audit, location of disease was documented in 98% cases, type of lesion in 45% and size and depth of lesions 14% and 16% respectively. Implementation of the documentation tool was successful and compliance was 100% excepting cases of adhesions where size was ‘not applicable’ (94%). Conclusion According to current best evidence and baseline auditing of surgical documentation more detailed surgical documentation of endometriosis is required. This project showed that this can be obtained through a simple documentation tool however further testing in surgeon's compliance is required.