The obstetrician–gynecologist should thoroughly evaluate a patient’s reproductive tract complaints prior to entertaining the possibility of surgical management. In addition to evaluating the pelvic condition, it is vital to conduct a preoperative search for physical or psychologic comorbidities. Only when armed with this global information can the surgeon objectively present the risks, benefits, and alternatives and realistically relate the expected outcome of the entire spectrum of accepted medical and surgical options. Medical and noninvasive options for therapy should be considered prior to operative intervention. Following the failure of or mutual decision to bypass medical management, appropriate surgical management should be discussed. This information should be processed and presented to the patient (and other support persons when appropriate) clearly and respectfully, using understandable language that allows and facilitates an informed decision and consent process.

Although the preoperative diagnostic period may be deemed routine by the surgeon and staff, many women consider the prediagnostic interval to be the most stressful time of treatment. This psychologic stress contributes to difficulty in understanding the importance and results of diagnostic studies or results and potentially clouds the information covered during preoperative discussions. Decisions, options, and alternatives, as they relate to the potential need for postoperative therapy, can be lost. The preoperative use of illustrative drawings, pamphlets, videos, or other visual educational materials often can be of assistance in improving patient (and family) comprehension of medical alternatives, operative indications, associated risks, and expected treatment outcomes.

Typically, this preoperative encounter (or encounters) to discuss surgical options and obtain consent is best undertaken in a private setting, completed in a manner that is conducive of a two-way flow of communication. Eye contact, a caring touch, an unhurried approach, and other reassuring physician behaviors lower communication barriers and facilitate and support a patient’s comprehension. The complexity of preoperative discussion and necessary time expenditure may vary dramatically with the surgical indications as well as with the medical alternatives to the proposed procedure. Regardless, the algorithm of care, surgical risks, and outcome expectations should be detailed, recognizing that modification may be required secondary to important or imperative patient desires (e.g., a patient desiring retention of ovaries or fertility). Regardless of the extent of preparation and best surgical technique, any unexpected or adverse intraoperative or postoperative event can alter dramatically the final surgical procedure and ultimate result. The apparently “simple” laparoscopic salpingo-oophorectomy may be complicated by uncontrolled bleeding, intestinal injury, or the finding of an ovarian malignancy. Postoperative myocardial infarction (MI), infection, or thromboembolism may occur. During an explanation of surgical risks, it is reasonable to discuss with the patient adverse events that occur at a frequency of 1% or more. All preoperative consent discussions should include discussion of the risk of death or permanent disability. The consent process also allows an opportunity for significant patient education, which has been shown to decrease the need for postoperative analgesia and improve postoperative outcomes. Unless the clinical situation is emergent or life threatening, these discussions are best undertaken at a time remote from the day of surgery. Timely entered, complete, and legible chart documentation should follow all of these discussions.

Before moving ahead with surgical intervention, the surgeon is faced with a number of other important procedural questions including the route (i.e., vaginal vs. abdominal vs. laparoscopic approach) as well as who should perform the procedure. Reported data confirm that even among subspecialists, individual surgical skills and outcomes of specific procedures can differ dramatically. These differences may relate to the surgeon’s innate technical ability, the specifics of the individual’s previous training and experience, patient selection, or factors unrelated to the physician. New training demands of subspecialties have altered the overall extent of residency surgical experience, resulting in fewer major operative procedures being completed per trainee. Coupled with the increasing ratio of physicians in practice to annual operative procedures and the increasing technical procedural subspecialization, it is easily understood how difficult it is for the pelvic surgeon to obtain, maintain, or refine new surgical skills, even in the restricted subspecialty where the surgical focus is entirely on reproductive tract procedures. These factors lend credence to the adage “no one can be all things to all people,” and each physician must individualize the decision to operate, consult, or refer. Success of many procedures is related to increasing surgical experience, surgical volume, and expertise. Arguments against consultation or referral have little scientific merit and may not be in the patient’s best interest. Although circumstances may prohibit actual patient referral, the ready availability of curbside, personal, telephone, and Internet consultation should encourage information dissemination, and utilization of available resources should improve patient care.

Every operative procedure requiring anesthesia should be viewed as a physiologic stress test. The intensity of the stress response varies in direct proportion to the extent of the
actual surgical procedure and is associated with a clinically and biochemically measurable adverse effect. Nearly every organ system is adversely affected by general anesthesia. General anesthesia results in 20% reduction in resting heat production and an increase in body surface heat loss. These two factors increase a patient’s predisposition to hypothermia which causes an increased risk of adverse cardiac events, altered pulmonary reponse to hypercarbia and hypoxemia, impaired coagulation, and poor wound healing. The untoward anesthesia-related pulmonary effects of impaired oxygenation and altered lung mechanics are likely well tolerated by the 40 year old, but they may have catastrophic consequences in the elderly or in those with coexisting pulmonary disease. Most inhalational drugs directly create increased cardiac risk by altering myocardial oxygen supply and demand kinetics. Myocardial depression, increased arrhythmogenicity (as high as 27% incidence), and altered neural tone form the triad for predisposing women to adverse cardiovascular effects. Importantly, these risks are not lessened with spinal anesthesia compared with risks associated with general anesthesia. Reduction in renal blood supply (decreased by 30% to 70%), suppression of the immune system, ileus, and stress-related gastric ulceration represent but a few of the other quantitative adverse effects of anesthesia. Many of these effects can be correlated with the duration of operation, and every effort should be made to increase operative efficiency in an attempt to safely shorten the procedure and minimize risks.

Despite these anesthesia-enhanced risks, only a small percentage of operative deaths are attributable solely to anesthesia. Less than 18% of surgical mortality is directly attributable to the surgical procedure. The vast majority of surgical mortality (79%) can be related directly to problems created in great part from the patient’s coexisting medical disease. This mortality risk further illustrates the need to undertake a diligent preoperative search to identify and potentially modify the adverse effects of any significant coexisting medical condition.

The diagnostic power contained in a carefully obtained history and a thorough physical examination is enormous. The reproducible validity of this simple, easily obtainable evaluation is underscored when recognizing that as many as 98% of abnormalities found with preoperative laboratory and radiologic screening can be predicted by historical or physical findings.

Although studies relating to the pelvic process (i.e., urodynamics) frequently are necessary to delineate the need for surgery, attempts to obtain important historical information regarding diagnosed medical comorbidities and clinically silent medical disease are vital to direct additional preoperative evaluation. Review of pertinent medical records combined with initial direct questioning about previous hospitalizations, current treating physicians, concurrent diagnoses, use of prescribed and over-the-counter medications, and allergies will assist in the detection of coexisting medical disease. This information may be vital to the preoperative plan regarding the continuation (e.g., cardiac, hypertensive) or discontinuation (e.g., aspirin, oral contraceptives, anticoagulants) of medications. Over-the-counter and herbal medication usage can create the potential for additional untoward complications and should be evaluated in a nonjudgmental fashion (Table 45.2).

An area that should not be overlooked is the importance of determining a patient’s functional status. The functional status of any given patient, but particularly elderly patients, may be an important predictor of surgical risk. Functional status is defined as the capacity to perform activities of daily living and includes aspects of both social and cognitive functioning. Recent data reveals that these functional measures may be even more important than acute physiologic scores in predicting mortality in hospitalized patients. A patient’s performance status can be determined adequately during a thorough review of systems while also giving the clinician an opportunity to diagnose previously undetected medical disease. Although intended to cover multiple systems, simple questions as to the patient’s ability to walk a mile, climb two flights of stairs, or blow out a match from 12 inches away may suffice as a screen for significant cardiopulmonary disease. Various published functional status indices exist and can be useful tools to determine the degree of physiologic stress that a given patient can tolerate under routine circumstances. Historical information obtained by questionnaire can be considered valid; however, the presence or absence of significant symptoms should be confirmed by the clinician in the perioperative period.

A thorough multisystem physical examination is an essential part of every preoperative evaluation. Specific attention to the cardiopulmonary system assists in the detection of important coexisting disease that may alter outcome adversely and can also direct additional investigation. Every system carries some import, and abnormal findings allow
for appropriate morbidity-reducing, cost-effective adjustments in the perioperative plan.

The primary goal of preoperative laboratory preparation is to obtain results that allow reduction of those inherent risks related to the proposed procedural component as well as those risks associated with occult or recognized coexisting medical morbidities. It has become apparent that a “broadly cast net” preoperative laboratory screening strategy confers little patient benefit for the following reasons: (a) the majority of laboratory abnormalities can be predicted by findings noted in the history and physical examination, and it is rare to detect an unexpected abnormality; (b) the physiologic, psychologic, and economic costs associated with the evaluation of abnormal laboratory (including false-positive) studies bring little value and rarely influence clinical care; (c) as many as 60% of abnormal preoperative test results are not known or evaluated preoperatively, creating potential liability, and multiple reports suggest that nearly 70% of ordered preoperative laboratory tests are not indicated by facts obtained in the history and physical examination.

This information reiterates the importance of the history and physical examination and suggests that a directed preoperative laboratory testing strategy (Table 45.3) for routine procedures is both safe and cost-effective. All preoperative testing should be justified based on a specific sign, symptom, or diagnosis. Obviously, special studies such as tumor markers (e.g., CA-125) are appropriate during evaluation and management of women with pelvic malignancies, because they offer diagnostic assistance, facilitate decisions regarding patient triage, are potentially prognostic, and are of significant value during postoperative management. Although care should be individualized, it has become apparent that directed preoperative laboratory testing forms a firm foundation for quality preoperative care for patients undergoing elective procedures.

Although advances in blood banking technology have lessened the risk of transfusion and favorably affected the outcomes of many surgical procedures, it is apparent that women do not need to have a type and cross match performed prior to the majority of obstetric or gynecologic surgical procedures. Although maximal surgical blood order schedules have been established, they should be validated at each institution. When deemed necessary, a type and screen allows for identification of specific antibodies and assures rapid availability (≤20 min) of red blood cell products. Individual decisions regarding blood bank strategies should be related to the patient’s preoperative status (i.e., hemoglobin and hematocrit, blood volume), anticipated losses, and existing comorbidities that might
carry an early transfusion trigger. Anemia is not uncommon among women undergoing pelvic surgery. Although it may constitute an indication (menorrhagia associated with leiomyomas) or result from an indication (cervical cancer), its presence should prompt an evaluation. As deemed appropriate, a preoperative search for other causes or losses should be undertaken. Additionally, preoperative discussions regarding procedure-associated blood loss and its attendant risks represent an important aspect of informed consent.

Critically ill patients may benefit from having their serum hemoglobin levels maintained at about 10 g/dL, but data suggest little effect of transfusion on survival in patients whose hemoglobin levels are between 8 and 10 g/dL. Aside from the special situations mentioned above, the majority of women can safely undergo elective procedures without a type and screen.

Routine imaging studies can be obtained safely as directed by findings of the history and physical examination. The indications for a preoperative chest radiograph are relatively straightforward and should be limited to assessment for the presence of acute, progressive, or chronic changes of cardiac or pulmonary disease. Abnormalities found on preoperative chest radiographs are associated with an increased risk of perioperative pulmonary complications. Unfortunately, unnecessary chest radiographs and many additional, sometimes unnecessary, undirected diagnostic preoperative imaging studies are obtained frequently.

Diagnostic ultrasonographic examination, pelvic and abdominal computed tomography (CT), and magnetic resonance imaging studies are performed in patients with suspected or known gynecologic malignancies. These studies may suggest the benefit of preoperative triage to a subspecialist but rarely influence the surgical approach. Their results should not be considered binding, typically contribute little to clinical care, and often add significantly to health care costs. Although the radiologist’s suggestions for additional studies are noted frequently, the astute pelvic surgeon should combine physical findings, patient symptoms, and laboratory results to develop the perioperative care plan.

Although proponents of preoperative “radiologic staging studies” suggest relative accuracy, the pelvic surgeon must recognize the subjective aspects of interpretation. In general, their routine use has not been associated with an alteration in perioperative clinical care. Although findings may alter approach, negative results do not exclude the finding of significant pathology. However, it appears that in specific situations, CT scans have a significant false-negative result rate (e.g., for the evaluation of extraovarian disease). Radiologic investigation adds little to clinical care in patients with endometrial cancer in the absence of physical findings. There is little clinical value for intravenous pyelography (IVP) to evaluate ureteral location or displacement, because it is not a substitute for intraoperative ureteral identification. In the absence of malignancy, hydronephrosis is likely related to displacement and is easily corrected or managed during the operative procedure.

A notable exception to the recommended “less is more” strategy toward preoperative radiologic investigation is an abnormal finding on a clinically indicated routine cancer screening study (e.g., mammography). In this case abnormal results may have a significant impact on clinical care, particularly in those women undergoing “elective pelvic procedures.”

There is little evidence to suggest the value of multiple endoscopic procedures prior to most routine gynecologic procedures. However, it is certainly appropriate to consider obtaining history-directed or disease-specific (e.g., inflammatory bowel disease, previous colon cancer) or recommended cancer screening endoscopic procedures prior to elective procedures. For example, endoscopy performed prior to rectovaginal or vesicovaginal fistula repair may render significant and important information and cause the physician to alter the surgical approach or initiate referral.

Preoperative assessment to detect undiagnosed heart disease and direct appropriate perioperative treatment of women with long-standing or newly diagnosed cardiac disease is of vital importance. The majority of inhalational anesthetics are myocardial depressants, modify neural tone, and are arrhythmogenic, creating cardiac risk even in the healthy patient. Nearly 50,000 perioperative MIs occur annually. Approximately 20,000 are fatal, and hundreds of thousands of related serious extracardiac complications occur, resulting in poor outcome. The prevalence of cardiovascular disease increases directly with increasing age, and within the aging population, serious cardiac events occur regularly. Gynecologic procedures represent a significant increase in the incidence of necessary major intra-abdominal procedures in the aging population, potentially increasing the absolute risk of cardiac morbidity. Although heart disease may not be readily apparent, the answers to carefully framed historical questions can assist in unmasking occult cardiac risk factors. Gynecologists should feel compelled to become familiar with the important aspects of perioperative cardiac care in order to improve individual patient outcome.

Proper preoperative cardiac assessment requires a systematic approach, typically undertaken in close coordination with qualified consultants. Attention to history, physical findings, and the effects of comorbid diseases forms the foundation for initial evaluation. These findings
assist in the direction of ordering ancillary cardiac studies, which can clarify risk and improve predictive power for perioperative morbidity associated with the proposed gynecologic surgery. They also allow institution of a sound plan for perioperative monitoring and management. A disease-specific approach is important, specifically addressing signs, current symptoms, and management of coronary artery disease (CAD), hypertension, heart failure, valvular heart disease, arrhythmias, pacemakers, pulmonary vascular disease, and type and extent of surgery.