Abstract
Modern lifestyle has led to an increased number of surgical patients having comorbidities, often related to increased perioperative morbidity and mortality. Early recognition of risk factors and optimization of the patients can improve outcomes. The continuous trend of minimal access procedures in gynaecology and the application of enhanced recovery programmes have improved clinical and cost effectiveness. Following the COVID-19 pandemic, surgical waiting lists in Gynaecology have grown to levels not seen in a decade. Day case surgery has been promoted to reduce the pressure on hospitals and improve the patient experience. National and global organizations, as the National Institute for Health and Care Excellence (NICE), the World Health Organization (WHO), the Centre for the Perioperative Care (CPOC) and the Enhanced Recovery after Surgery Society (ERAS), are producing guidance, promoting knowledge, understanding and research regarding optimal perioperative care. In this review we summarize the current evidence and discuss its applications in modern gynaecology practice.
Introduction
Approximately 7 million surgical procedures take place yearly in the UK, with an estimated mortality rate of 1.1%. Of these deaths, 80% occur in patients with medical co-morbidities, known as high-risk patients. High-risk patients are estimated to make up approximately 10% of the overall inpatient surgical workload. They are at an increased risk of mortality and morbidity, and require increased resource utilization. The hospital mortality rate for these patients amounts to 10–15%. Reliable and accurate early identification of these patients offers the opportunity to optimize their conditions prior to surgery and minimize the risk of complications.
Modern perioperative medicine has dramatically improved the care for patients undergoing major surgery. Common co-morbidities can be managed pre-operatively by the surgical host team, with more complex cases require multidisciplinary team input. Standardized enhanced recovery programmes (ERP) combined with minimally invasive surgical techniques have led to reduction in length of stay, morbidity and costs, and improved outcomes. Perioperative management adapted against COVID-19, during the recent pandemic, aiming to detect positive patients, prevent spread of infection and reduce complications. Since the pandemic subsided, there has been an acceleration of a shift towards day case surgery as a response to the prolonged waiting lists.
However, the aging of the population, combined with the rising incidence of chronic illnesses, as the result of poor lifestyles, poor nutrition and physical inactivity, pose a continuous challenge to modern healthcare. National and global organizations as the National Institute of Health and Care Excellence (NICE), the Royal College of Anaesthetists (RCA), the British Association of Day Surgery (BADS) and the World Health Organization (WHO) have recently published guidance on Perioperative Care, which could be considered a newly rising medical specialty.
In this article we outline the current considerations in the perioperative care of the gynaecological patient.
Pre-operative considerations
Risk assessment
Early identification of comorbidities is necessary to enable preoperative optimization and to quantify the individualized surgical risk. Discussing the patient’s risks and surgical options at the time of booking can allow informed shared decision making. NICE recommends the use of validated risk stratification tools to supplement clinical assessment when planning surgery. Common comorbidities can be managed by the host surgical team, while more complex patients might need multidisciplinary team input, including cardiologist, haematologist, anaesthetist or any other specialist depending on the pre-existing conditions.
Smoking
Smoking cessation reduces the risk of smoking-related disease, and perioperative complications are no exception. Smoking cessation is associated with a reduction in the risk of postoperative pulmonary and cardiovascular complications. The frequency of complications in patients who have been abstinent for several months approaches that of patients who have never smoked. Although at least two months of preoperative abstinence is required for full benefit, even brief preoperative abstinence may be beneficial. For example, lower exhaled carbon monoxide concentrations are correlated with a decreased frequency of electrocardiographic abnormalities during general anaesthesia. Clear referral pathways for smoking cessation programmes should be aligned with preoperative services.
Obesity
Obesity and its sequelae significantly increase the risk of surgical (infection, bleeding) and non-surgical (difficult airway, pulmonary, cardiovascular, venous thromboembolism, postoperative cognitive dysfunction) complications. Loss of 10–15% of body weight can be beneficial by improving the patient’s metabolism. Delaying the surgery to allow weight loss can be considered when managing benign conditions. Careful planning is important. Technical aspects related to positioning, monitoring, and vessel cannulation can all be challenging due to obesity. Drug-dosing requires special consideration, given changes in drug distribution and clearance.
Laparoscopy in obese patients confers certain advantages such as early mobilization and shorter hospital stay, less post-operative pain and fewer wound infections. Minimal-access surgery has been demonstrated as safe and effective in obese patients. However, specific surgical strategies and operative techniques may need to be adopted. Trendelenburg position may worsen the patient’s already challenging ventilation, while often open operations can be completed without general anaesthetic. Careful preoperative assessment and multidisciplinary team approach can improve outcomes.
Diabetes
15% of all operations taking place in the UK each year are in people with diabetes. This group continues to have a longer length of stay and higher rates of adverse postoperative outcomes compared to those without diabetes. In March 2021, the Centre for the Perioperative Care (CPOC) published the ‘Guideline for Perioperative Care for People with Diabetes Mellitus Undergoing Elective and Emergency Surgery’. The guidance includes detailed recommendations starting from the initial patient’s referral, to intra and post-operative considerations for diabetics. Hospitals should appoint Leads and implement local policies optimizing the patient preoperatively and manage diabetes during and after hospital stay.
Anaemia
Anaemia is common in gynaecological patients, undergoing surgery for heavy menstrual bleeding or gynaecological cancers. Early recognition of anaemia may allow optimization prior to surgery and reduction of the rate of blood transfusion. NICE recommends early administration of oral iron preoperatively. Intravenous iron may be considered when oral iron is not tolerated, in cases of functional anaemia, or when the interval between the diagnosis of anaemia and surgery is too short for oral iron to be effective. Local pathways of intravenous iron administration should be available for patients undergoing surgery. Cell salvage, blood and blood components transfusion can be planned for high risk for bleeding procedures. The centre of Preoperative Care (CPOC) has recently published guidance in response to the national blood shortage. Early recognition and treatment, transfusion of only one unit when possible, avoiding blood transfusion when haemoglobin >70 g/L and the use of intraoperative tranexamic acid are recommended.
Anticoagulation
A significant number of women, requiring gynaecological surgery, receive oral anticoagulants for the prevention of thromboembolism due to atrial fibrillation, placement of a mechanical heart-valve prosthesis, or previous history of venous thromboembolism. In addition, the number of women receiving anti-platelet treatment following the placement of a coronary stent has dramatically increased. Anticoagulation may not need to be stopped for some low risk for bleeding procedures, as hysteroscopies. However, most surgical procedures require interruption of anticoagulation or bridging. In 2016, the British Committee for Standards in Haematology (BCSH) published guidance on the perioperative management of anticoagulation and antiplatelet therapy (amended in 2022). The aim is to provide adequate intra-operative haemostasis, without increasing the risk for thromboembolism. While in most cases the host surgical team should be able to manage patients following local policies, haematology input may be required in more complex cases. A detailed plan, including discharge planning, should be documented and discussed with the patient. Emergency surgery when the patient is on anticoagulation, often requires reversal of anticoagulants or administration of clotting factors, and discussion with the on call haematologist is crucial.
Enhanced recovery programmes
A range of measures to optimize patient performance and recovery have been investigated, in order to reduce complications and the cost of prolonged hospital stay. Enhanced recovery programmes (ERP) have been adopted by most surgical units. ERPs utilize multiple interventions derived from available research evidence to mitigate the perioperative physiological stress response and preserve anabolic homeostasis. These span the entire journey of a patient from preadmission to the preoperative, intraoperative, and the postoperative periods. ERPs include interventions as oral preoperative hydration, early removal of catheters, stimulation of gut motility, prevention of nausea and vomiting, Non-opiate oral analgesics, routine mobilization, heating in theatre, short incisions and avoiding drains. Patients’ education throughout their journey is very important for a quick recovery. Patients should be encouraged to take an active role in both their ‘prehabilitation’ and rehabilitation from surgery. Surgery might present as an opportunity to deal with long standing lifestyle issues such as smoking or obesity.
Day case surgery in gynaecology
Following the COVID-19 pandemic and the associated disruption to the delivery of elective surgical care, the waiting lists for gynaecological surgery have been prolonged. The evidence to date is that it is safe and reliable for many procedures, including hysterectomies, to be performed as day procedures. This is important to relieve the pressure on hospitals and improve the patient experience. In September 2021 NHS England launched the GIRFT Programme (Getting It Right First Time). The use of day surgery is encouraged for a number of gynaecological procedures ( Table 1 ). In accordance with the BADS (British Association of Day Surgery) recommendations, GIRFT sets a target for 50% of laparoscopic hysterectomies and 60% of vaginal hysterectomies to be performed as day cases. A holistic perioperative approach is crucial for successful implementation, including admission, anaesthesia, postoperative analgesia and support after discharge. Managing the patient’s expectations early on in the decision-making pathway is very important.
