On October 23rd, 2014, we updated our
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• Preoperative care is the preparation and
management of a patient prior to surgery.
• It includes both physical and psychological
• Surgical treatment of the patients with
gynecologic diseases is warranted only when
all the conservative treatment approaches
have been exhausted.
• Many postoperative problems can be
anticipated preoperatively, and eliminated or
• There are two groups of indications for
Absolute - when surgery must be undertaken,
when its cancellation is life threatening.
Relative - when surgery can be postponed till the
most appropriate occasion for its performing.
• The surgeon is obliged to introduce to the
patient all the reasons of the surgical
• The patient must submit an informed written
consent to confirm that she takes the risk of
the planned surgical treatment.
• discussion regarding consent should be held
with a qualified interpreter present.
• The presence of an interpreter should be
included in the documentation.
• The informed consent discussion should include
– Unexpected findings at surgery
– Personnel who will be involved in the surgery.
• Used to 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
– 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.
• A comprehensive history is the first step
helping surgeons to determine the scope of
general physical examination, laboratory, and
• The patients undergoing minor surgery can be
examined by their surgeon and
anesthesiologist on the operation day during
preoperative preparation but
• those with more serious conditions should be
examined at least a week before surgery,
allowing the time for risk assessment,
specialist consultations, and preparation.
General medical history: includes
• Personal and family diseases
• History of drug use
• Allergies to drugs, foods, and other environmental
• Earlier diseases (including previous operations and
tolerance of anesthetics).
• Important family data refer to
malignancies, cardiovascular diseases, diabetes
mellitus, cerebrovascular diseases, and osteoporosis.
Gynecologic and obstetric history
• should contain the data about major
complaints of the current disease (beginning,
• past pregnancies (description of each,
duration, complications, type of delivery)
• menstrual cycle data (intervals, duration,
copiousness, dysmenorrhea, premenstrual
syndrome, intermenstrual bleeding)
• menarche; data on the last menstruation
• if the patient is age at menopause, recent
vaginal bleeding, vasomotor symptoms,
hormone replacement therapy.
• birth control (if sexually active - active
contraception, methods in the past; if
sterilized - time and mode of sterilization).
• sexual history
• birth control (conception difficulties, infertility
• infections (vaginal discharge, previous vaginal
infections, sexually transmitted diseases).
Clinical (physical) examination
• The aim of the physical examination is to
establish the physical, health status, in view of
history and medical condition.
• Full physical examination is needed.
• detailed exam of the abdomen and pelvis, as
the main component of the procedure.
Anesthesiologic preoperative examination
• An anesthesiologist has to examine the patient
before her operation.why?
– b/c it helps him to get an insight into the general health
– to assess whether the patient is able to tolerate the risks and
duration of anesthesia for the planned surgery.
• A special stress is put on the state of
consciousness and vital functions of the heart,
blood vessels, liver, and kidneys.
Anesthesiologic surgical risk is assessed based on
the assessment of physical status created by the
American Society of Anesthesiology – ASA:
• Group I- original disease, if it is without a
• Group II - moderate systemic disease without
• Group III - severe systemic disease with serious
• Group IV- severe systemic life-threatening disease
• Group V- moribund patient, with 24 hours;
• Group VI- confirmed brain death
• Preoperative indications for laboratory tests
– Patient age
– diagnosis of the disease and
– risk of the procedure with careful and detailed
history and physical examination.
• blood group determination
• complete blood count with the leukocyte
formula, sedimentation, bleeding and
coagulation time, thrombocytes, fibrinogen.
• Renal function test
• liver function test
• Blood glucose level
• General analysis of the urine and urine culture
• Pregnancy test
Pregnancy testing should be performed shortly
before surgery on all fertile women who could be
• Imaging studies
are often performed to select patients who will
not benefit from surgery (eg, metastatic disease)
to help biopsy tissue for diagnosis of suspicious
• Imaging study includes
An intravenous pyelogram (IVP)
Computed tomography (CT)
magnetic resonance imaging (MRI), and
NB:Preoperative chest x-rays should not be
• Investigation specific to patients problem.
• It is important to allow adequate time for
preparation prior to surgery. This includes:
1-Correction of anemia: Strategies to correct
anemia preoperatively are: Iron supplementation
Medical treatment of abnormal uterine
Patients undergoing elective surgery should
be advised to stop smoking at least eight
weeks before surgery.
Preoperative smoking cessation may decrease
wound complications, particularly wound
3-Medical consultation and stabilization
The consultant should be asked specific
questions, such as
is thyroid replacement adequate
hypertension well controlled
CHD optimally managed, and
diabetes under control
The gynecologic surgery literature does not
address the safety and efficacy of mechanical
In general, you can expect to:
Modify the diet
Take a laxative or bowel preparation medication
Increase fluid intake
Provision of optimal local immunity to
infection is primarily a surgical task.
A single dose of antibiotic immediately before
the operation is sufficient for most surgical
If the operation is going to take more than 3
hours, administration of antibiotics should be
• In time consuming interventions
intramuscular administration of antibiotics is
• Prophylactic use of antibiotics have been
demonstrated to be more successful for
vaginal compared to abdominal operations.
• Adequate use of antibiotics is able to reduce
the rate of infections, as well as morbidity and
associated costs .
Recommendation for choosing antibiotcs in
postoperative infection prophylaxis:
• Cephalosporins first generation: up to 2,0
• Metronidazole 0,5 - 1,0 grammes +
gentamicin 1,5 mg/kg iv.
• Clindamycin 600 - 900 mg iv + Gentamicin 1,5
• Ciprofloxacin 400 mg iv
reduces the incidence of symptomatic DVT or
Types of thromboprophylaxis —
Pharmacologic prophylaxis includes
Low-dose unfractionated heparin (LDUH) —
5000 units subcutaneously (SC) every 8 to
Low molecular weight heparin (LMWH) —
Dalteparin 2500 units or enoxaparin 40 mg
NB: The use of aspirin for prophylaxis is
NOT recommended, as other
measures are more efficacious.
• Mechanical methods of thromboprophylaxis
are placed on the patient just prior to the start
of surgery and used continuously until
• Most commonly used methods in gynecologic
Intermittent pneumatic compression boots (IPC)
Graduated compression stockings (GCS)
Which patients need thromboprophylaxis?
The ACCP recommendations for women undergoing
gynecologic surgery are:
Low risk (ie, minor surgery in mobile patients) AND/OR
entirely laparoscopic procedures with NO additional VTE
risk factors — Do not require specific prophylaxis, but early
and frequent ambulation is advised.
Entirely laparoscopic procedures WITH additional VTE risk
factors — Mechanical, pharmacologic thromboprophylaxis,
Major gynecologic surgery for benign disease with
NO additional risk factors — IPC or pharmacologic
Major gynecologic surgery for malignancy
AND/OR in patients WITH additional risk factors —
Pharmacologic therapy (LDUH should be given
every eight hours).
Patients who have undergone major surgery for
malignancy AND/OR have a previous history of
VTE should continue LMWH for up to 28 days.
• Preoperative patient preparation for
gynecologic surgery is
to avoid or minimize both intra and
postoperative complications, and
enabling a successful outcome of
• Up to date 19.3; Preoperative evaluation and
preparation of women for gynecologic surgery.
Author:William J Mann, Jr, MD.
• Danforth's Obstetrics & Gynecology, 9th
• Clinic of Gynecology and Obstetrics
• Bailey & Love’s short practice of surgery 25th