Overview of preoperative evaluation and preparation for gynecologic surgery
- William J Mann, Jr, MD
William J Mann, Jr, MD
- Section Editor — Gynecologic Surgery
- Clinical Professor
- Department of Obstetrics and Gynecology
- Virginia Commonwealth University School of Medicine
The preoperative evaluation and preparation prior to gynecologic surgery addresses issues that will potentially affect the woman during her surgical procedure and recovery. The surgeon should use this time to review the patient's history and physical examination, identify physical limitations, gather information required to plan surgery, optimize medical status, and educate about what to expect from the procedure and during the recovery period.
Many postoperative problems can be anticipated preoperatively, and eliminated or minimized; systematically addressing these issues at the preoperative evaluation may result in a shorter hospitalization with fewer complications and a more satisfied patient. The surgeon may also rethink the aggressiveness and necessity of a planned operative procedure after thoughtful discussion with patients who have severe medical problems. As an example, a woman with symptomatic congestive heart failure and uterine procidentia may be better served with a pessary than by vaginal hysterectomy and sacrospinous suspension. This discussion is mainly regarding scheduled surgery. Urgent cases require an expedited preoperative evaluation process to provide appropriate care.
The preoperative evaluation and preparation of women for gynecologic surgery will be reviewed here. General principles of preoperative evaluation and preparation are discussed separately. (See "Overview of the principles of medical consultation and perioperative medicine" and "Preoperative medical evaluation of the healthy patient".)
INFORMED CONSENT AND PATIENT EXPECTATIONS
The preoperative process should include comprehensive counseling of the patient regarding alternative treatment options (including expectant management) and risks and benefits of the procedure. For some procedures, particularly those that have variable outcomes and impact quality of life (eg, pelvic organ prolapse repair), patient expectations and goals should be discussed in detail. The expected duration and requirements of the recovery period should also be reviewed. Anticipatory guidance during preoperative office visits will enhance a patient's acceptance and compliance during the immediate postoperative period and may help to shorten hospital stay .
The surgeon should confirm that the patient has understood the discussion and desires to proceed with the procedure. This discussion should be documented in the medical record and on the procedure consent form.
- Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002; 183:630.
- Manley S, de Kelaita G, Joseph NJ, et al. Preoperative pregnancy testing in ambulatory surgery. Incidence and impact of positive results. Anesthesiology 1995; 83:690.
- Ramm O, Gleason JL, Segal S, et al. Utility of preoperative endometrial assessment in asymptomatic women undergoing hysterectomy for pelvic floor dysfunction. Int Urogynecol J 2012; 23:913.
- Jacobs VR, Morrison JE Jr, Paepke S, Kiechle M. Body piercing affecting laparoscopy: perioperative precautions. J Am Assoc Gynecol Laparosc 2004; 11:537.
- Oyos TL. Intubation sequence for patient presenting with tongue ring. Anesthesiology 1998; 88:279.
- Rosenberg AD, Young M, Bernstein RL, Albert DB. Tongue rings: just say no. Anesthesiology 1998; 89:1279.
- Muensterer OJ. Temporary removal of navel piercing jewelry for surgery and imaging studies. Pediatrics 2004; 114:e384.
- Eason E, Wells G, Garber G, et al. Antisepsis for abdominal hysterectomy: a randomised controlled trial of povidone-iodine gel. BJOG 2004; 111:695.
- Amstey MS, Jones AP. Preparation of the vagina for surgery. A comparison of povidone-iodine and saline solution. JAMA 1981; 245:839.
- Lewis LA, Lathi RB, Crochet P, Nezhat C. Preoperative vaginal preparation with baby shampoo compared with povidone-iodine before gynecologic procedures. J Minim Invasive Gynecol 2007; 14:736.
- Monif GR, Thompson JL, Stephens HD, Baer H. Quantitative and qualitative effects of povidone-iodine liquid and gel on the aerobic and anaerobic flora of the female genital tract. Am J Obstet Gynecol 1980; 137:432.
- Buppasiri P, Chongsomchai C, Wongproamas N, et al. Effectiveness of vaginal douching on febrile and infectious morbidities after total abdominal hysterectomy: a multicenter randomized controlled trial. J Med Assoc Thai 2004; 87:16.
- Wenzel RP. Minimizing surgical-site infections. N Engl J Med 2010; 362:75.
- http://www.hibigeebies.com/about_safety.asp (Accessed on September 14, 2010).
- Shippey SH, Malan TK. Desquamating vaginal mucosa from chlorhexidine gluconate. Obstet Gynecol 2004; 103:1048.
- Culligan PJ, Kubik K, Murphy M, et al. A randomized trial that compared povidone iodine and chlorhexidine as antiseptics for vaginal hysterectomy. Am J Obstet Gynecol 2005; 192:422.
- Biggar RJ, Miotti PG, Taha TE, et al. Perinatal intervention trial in Africa: effect of a birth canal cleansing intervention to prevent HIV transmission. Lancet 1996; 347:1647.
- Rouse DJ, Hauth JC, Andrews WW, et al. Chlorhexidine vaginal irrigation for the prevention of peripartal infection: a placebo-controlled randomized clinical trial. Am J Obstet Gynecol 1997; 176:617.
- Gaillard P, Mwanyumba F, Verhofstede C, et al. Vaginal lavage with chlorhexidine during labour to reduce mother-to-child HIV transmission: clinical trial in Mombasa, Kenya. AIDS 2001; 15:389.
- Saleem S, Rouse DJ, McClure EM, et al. Chlorhexidine vaginal and infant wipes to reduce perinatal mortality and morbidity: a randomized controlled trial. Obstet Gynecol 2010; 115:1225.
- American College of Obstetricians and Gynecologists Women's Health Care Physicians, Committee on Gynecologic Practice. Committee Opinion No. 571: Solutions for surgical preparation of the vagina. Obstet Gynecol 2013; 122:718.
- Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e227S.
- Clarke-Pearson DL, Abaid LN. Prevention of venous thromboembolic events after gynecologic surgery. Obstet Gynecol 2012; 119:155.
- Committee on Practice Bulletins--Gynecology, American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 84: Prevention of deep vein thrombosis and pulmonary embolism. Obstet Gynecol 2007; 110:429.
- Mäkinen J, Johansson J, Tomás C, et al. Morbidity of 10 110 hysterectomies by type of approach. Hum Reprod 2001; 16:1473.
- Nick AM, Schmeler KM, Frumovitz MM, et al. Risk of thromboembolic disease in patients undergoing laparoscopic gynecologic surgery. Obstet Gynecol 2010; 116:956.
- Fanning J, Valea FA. Perioperative bowel management for gynecologic surgery. Am J Obstet Gynecol 2011; 205:309.
- Markus GR. The graying of America: major Social Security and Medicare battles are just beginning. Bull Am Coll Surg 1997; 82:25.
- National Center for Health Statistics. www.cdc.gov/nchs/data/hus/tables/2003/03hus027.pdf. (Accessed on March 08, 2005).
- Guralnik JM, Land KC, Blazer D, et al. Educational status and active life expectancy among older blacks and whites. N Engl J Med 1993; 329:110.
- Lubin MF. Is age a risk factor for surgery? Med Clin North Am 1993; 77:327.
- Parker DY, Burke JJ 2nd, Gallup DG. Gynecological surgery in octogenarians and nonagenarians. Am J Obstet Gynecol 2004; 190:1401.
- INFORMED CONSENT AND PATIENT EXPECTATIONS
- PREOPERATIVE EVALUATION
- - Medical comorbidities
- Physical examination
- Laboratory tests
- - Pregnancy test
- - Testing for genital tract infection
- Other testing
- PREOPERATIVE PREPARATION
- Medication management
- Blood loss preparation
- - Correction of anemia
- - Autologous blood transfusion
- Wrong person, site, procedure prevention
- Smoking cessation
- Piercings and umbilical jewelry
- SURGICAL SITE INFECTION PREVENTION
- Antibiotic prophylaxis
- Other measures
- - Vaginal preparation
- MEASURES FOR SELECTED USE OR THAT ARE NO LONGER RECOMMENDED
- Stress dose glucocorticoids
- Bowel preparation
- Endocarditis prophylaxis
- SPECIAL ISSUES
- Suspected malignancy
- Older adults
- Orthopedic issues or physical disabilities
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS