Completion of a thorough history and physical examination
Selection of the ideal surgery
Identification of potential limitations
Optimization of the patient’s medical condition
Informed consent should include the rationale and explanation of the procedure as well as alternatives such as expectant management, nonsurgical interventions, and other surgical options. An interactive dialogue should occur between physician and patient. When more than one option is available, the surgeon should provide education and guidance without coercion. Ultimately, the patient must determine which of the options is appropriate.
Risk discussion should address the specific procedure as well as general surgical risks and should be accompanied by a discussion of interventions intended to minimize those risks. These risks include, but are not limited to, bleeding and possible blood transfusion (Table 27-1), organ injury (bladder, ureter, bowel, vessel, or nerve), unanticipated organ removal, need for additional surgery, myocardial infarction, congestive heart failure, thromboembolic complications, infection, and perioperative death. Injury and failure rates should be cited based on personal data and current literature when available. Discussion of interventions such as perioperative antibiotics, deep vein thrombosis (DVT) prophylaxis, and postoperative incentive spirometry should be included. Possible changes in plans due to intraoperative surgical findings should be included in the consent document, as well as the possibility of a change in mode of access (e.g., laparoscopic to open procedure, vaginal to abdominal procedure). Documentation of the preoperative discussions and the patient’s response and acceptance of risk, including informed refusal, is crucial.
Preoperative evaluation: History and physical examination are essential for evaluating surgical eligibility and the need for further testing or consultation. Identifying occult disease and optimizing preexisting conditions are of utmost importance. Abnormal findings and comorbid conditions need to be evaluated appropriately. Routine health maintenance evaluation and screening should be considered especially in the absence of regular medical care. It may be beneficial for patients with complex preexisting conditions to be comanaged with a medical specialist. Preoperative consultation with an anesthesiologist is important for the medically
complicated patient, those with known difficult airways, and those with a history of anesthesia complications.
TABLE 27-1 Risks of Blood Transfusion
Bacterial contamination of platelet components
1:12,000
Bacterial contamination from packed red cells
1:5 million
Hepatitis C virus
1:1.6 million
Hepatitis B virus
1:180,000
HIV
1:1.9 million
Fatal red cell hemolytic reaction
1:250,000-1.1 million
Delayed red cell hemolysis
1:1,000-1,500
Transfusion-related acute lung injury (TRALI)
1:5,000
Febrile red cell nonhemolytic reaction
1:100
Allergic urticarial reaction
1:100
Anaphylactic reaction
1:150,000
From Jones HW, Rock WA. Control of pelvic hemorrhage. In Rock JA, Jones HW, eds. Te Linde’s Operative Gynecology, 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2003, with permission.
Preoperative testing and imaging: Preoperative testing should be based on risk factors for abnormal physiology, including comorbid conditions, tobacco use, exercise intolerance, and irregular examination findings. Mild and even asymptomatic conditions that may be exacerbated by medical and surgical interventions should be anticipated. Guidelines are available from the American Society of Anesthesiologists (ASA) and American Heart Association (AHA)/American College of Cardiology.
Gynecologic patients are strongly advised to have current Pap smear and mammography results. Red blood cell type and screen should be performed on most patients, with exceptions made for very minor outpatient procedures. A pregnancy test will be required on all reproductive age women (<50 years), and endometrial biopsy is recommended by the American College of Obstetricians and Gynecologists for women with abnormal uterine bleeding older than the age of 45 years. Imaging should be individualized, but computed tomography (CT), magnetic resonance imaging (MRI), and pelvic ultrasound are helpful for illustrating anatomy and extent of disease, thereby optimizing surgical planning.
Preoperative cardiac evaluation: The preoperative cardiac evaluation should be directed toward the detection of symptoms using directed questioning looking for conditions such as angina, heart failure, and arrhythmias. For women older than the age of 50 years, general preoperative workup includes detailed history and physical examination, as well as electrocardiogram (ECG). Additional cardiac workup depends on the planned surgery and the patient’s functional status.
In low-risk procedures (minimally invasive, minimal blood loss and fluid shifts), no additional workup or treatment is needed, and most patients can proceed directly to surgery.
Major intraperitoneal surgery is considered intermediate risk with a reported cardiac risk of 1% to 5%. These patients should be assessed by their functional status.
Functional status is based on a patient’s ability to perform 4 metabolic equivalents (METs) of activity or greater without chest pain, dyspnea, or fatigue.
A MET is a unit equal to the metabolic equivalent of oxygen uptake while quietly seated. Four METs is equal to walking on a flat surface or climbing a flight of stairs. If the patient can perform 4 METs of activity without dyspnea or fatigue, she is considered to have a normal functional status and may proceed to intermediate-risk surgery without further cardiac testing. If her functional status is <4 METs, additional evaluation may be indicated based on clinical risk factors that include history of ischemic heart disease, history of compensated or prior heart failure, history of cerebrovascular disease (stroke), diabetes mellitus, and chronic kidney disease (defined as a creatinine >2 mg/dL).
For gynecologic surgeries that are considered high risk (prolonged surgeries that involve large fluid shifts), patients with a functional capability <4 METs and one to three risk factors may warrant further cardiac testing, such as cardiac stress test or echocardiogram.
Thromboembolic prophylaxis: The approximate risk of DVT in hospitalized patients after major gynecology procedures is 10% to 40%. It is the standard of care to offer DVT prophylaxis (Table 27-2).
Antibiotic prophylaxis: See Table 27-3 for preoperative antibiotic prophylaxis. Evidence supports the use of antibiotics in cases of hysterectomy, with data on abdominal and vaginal routes generalized to laparoscopic hysterectomy. Single-dose
prophylaxis appears to be as effective as multiple doses, with less risk of adverse events and microbial resistance. To reduce surgical site infections (SSI), firstgeneration or second-generation cephalosporins are preferred for most patients or clindamycin with gentamicin for those with severe penicillin allergy.
TABLE 27-2 Thromboprophylaxis for Gynecologic Procedures
Procedure
Risks
Recommended Thromboprophylaxis
Minor procedures
No additional risk factors
Early and frequent ambulation
Entirely laparoscopic
No additional risk factors
Early and frequent ambulation
Entirely laparoscopic
VTE risk factors are present.
One or more of LMWH, LDUH, IPC, or GCS
Major gynecologic surgery
No additional risk factors
LMWH, LDUH, or IPC started just before surgery and used continuously while the patient is not ambulating
Major gynecologic surgery
VTE risk factors are present.
LMWH or LDUH three times daily or IPC started just before surgery and used continuously while the patient is not ambulating. Alternatives include combined LMWH or LDUH plus mechanical thromboprophylaxis with GCS or IPC, or fondaparinux.
Extensive surgery for malignancy
Same as above for major surgery with VTE risks
For major gynecologic procedures, recommend that thromboprophylaxis continue until discharge from hospital. For selected high-risk gynecology patients, including some of those who have undergone major cancer surgery or have previously had venous thromboembolism (VTE), consider continuing thromboprophylaxis after hospital discharge with LMWH for up to 28 days.
LMWH, low-molecular-weight heparin; LDUH, low-dose unfractionated heparin; IPC, intermittent pneumatic compression; GCS, graduated compression stockings.
Adapted from Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th ed.). Chest 2008;133(6)(suppl 1):381S-453S.
Antibiotics should be administered prior to incision. Antibiotics should be redosed according to half-life and blood loss (e.g., cefazolin is redosed every 3 to 4 hours or if >1,500 mL of blood loss).
Postoperative antibiotic prophylaxis has not been shown to be effective.
Preoperative treatment of bacterial vaginosis (BV) is recommended. BV is a known risk factor for SSI, and treatment with metronidazole 4 days prior to surgery has been demonstrated to decrease the risk of cuff cellulitis.
Antibiotic prophylaxis for subacute bacterial endocarditis: The AHA no longer recommends routine prophylaxis for bacterial endocarditis for routine genitourinary (GU) or gastrointestinal (GI) tract procedures. One exception is in patients undergoing a GU or GI procedure in the setting of active infection.
TABLE 27-3 Antibiotic Prophylaxis for Gynecologic Procedures
Procedure
Antibiotic
Dose
Hysterectomy or
Cefazolin1
1 or 2 g IV2
Urogynecologic procedure, including those involving mesh
Clindamycin3 plus
Gentamycin or
Aztreonam or
Quinolone4
Metronidazole plus
Gentamycin or
Quinolone4
600 mg IV
1.5 mg/kg IV
400 mg IV
600 mg IV
1.5 mg/kg IV
600 mg IV
400 mg IV
Laparoscopy5
None
Laparotomy
None
Hysteroscopy6
None
Doxycycline
100 mg BID PO × 5 days
D&C for induced abortion
Doxycycline
100 mg 1 hr before procedure and 200 mg PO after or
Metronidazole
500 mg BID PO × 5 days
IUD insertion
None
Endometrial biopsy
None
Urodynamics
None
IV, intravenous; PO, by mouth; D&C, dilation and curettage; IUD, intrauterine device; BID, twice daily.
1 Acceptable alternatives include cefotetan, cefoxitin, cefuroxime or ampicillin-sulbactam.
2 A 2 g dose is recommended in women with a BMI ≥35 or weight greater than 100 kg or 220 lbs.
3 Regimen of choice in patients with a history of immediate hypersensitivity to penicillin.
4 Ciprofloxicin or levofloxacin or moxifloxacin.
5 Including diagnostic and operative procedures (e.g., sterilization).
6 Including diagnostic and operative procedures (e.g., endometrial ablation, sterilization).
7 Only in cases with dilated fallopian tubes.
Adapted from American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 104: antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2009;113:1180-1189, with permission.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
