The main objectives of the preoperative assessment are:

• Completion of a thorough history and physical examination

• Selection of the ideal surgery, considering both procedure and route

• Identification of potential limitations

• Optimization of the patient's medical condition

The goal is to decrease perioperative morbidity and complications and to optimize outcomes.

Informed Consent

• 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, with the goal to provide education and guidance without coercion.

• Risk discussion should include both general and specific procedural risks. These risks may include, but are not limited to: pain, bleeding and possible blood transfusion, infection, organ injury (bladder, ureter, bowel, vessel, or nerve), conversion of surgical approach, unanticipated organ removal, hernia, need for additional surgery, incomplete resolution of symptoms, myocardial infarction, congestive heart failure, thromboembolic complications, stroke, unexpected malignancy, disability, and perioperative death. Discussion of interventions to mitigate risks should be included (eg, perioperative antibiotics, venous thromboembolism [VTE] prophylaxis, etc.). 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 (eg, 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.

• Postoperative expectations should be reviewed as well, including expected symptoms during recovery, postoperative management, pain control, expected length of stay, restrictions, and anticipated follow-up.

Medical Evaluation and Optimization

• Preoperative evaluation

  History and physical (H&P). The overarching goal of the preop evaluation is to assess patient-specific surgical and anesthetic safety, identify need for further testing, and optimize medical comorbidities, which may involve referral to other medical specialists. Routine health maintenance evaluation and screening should be considered especially in the absence of regular medical care. The preoperative H&P should also assess functional status based on metabolic equivalents (METs); specifically, a patient's ability to perform 4 METs of activity or greater without chest pain, dyspnea, or fatigue.

  • A MET is a unit equal to the MET 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, the patient is considered to have a normal functional status and may proceed to intermediate-risk surgery without further cardiac testing. If 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).

• 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. Often, further testing will be determined by patient risk stratification (American Society of Anesthesiologists [ASA] classification), disease-specific management, and risk of planned surgical procedure. Guidelines are available from the ASA and American Heart Association (AHA)/American College of Cardiology (ACC).

  Preoperative cardiac evaluation. The preoperative cardiac evaluation should be directed toward the detection of symptoms suggestive of angina, heart failure, and arrhythmias. The 2014 ACC/AHA guidelines recommend electrocardiogram (ECG) for patients with known coronary artery disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, structural heart disease, and obesity with one risk factor for coronary heart disease. ECGs are not needed for low-risk procedures. 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 and known comorbidities.

  • Outlined below are common comorbidities and guidelines for additional preoperative testing (Table 60-1).

    Table 60-1 PreOperative Testing for Common Medical Comorbidities

    Disease	Preop Testing	Notes
    Diabetes Mellitus	BMP, ECG, A1c (within 3 mo of scheduled procedure), blood glucose on day of surgery	Patients with an A1c >8.0% may benefit from further evaluation prior to elective surgery to reduce surgical site infections
    Hypertension (Longstanding and/or Requiring 3+ Antihypertensives)	CBC, BMP, ECG	Consider additional cardiac workup and/or referral if symptomatic and no recent testing within 1 y
    COPD	PFTs	Recommended for patients on home O2, dyspnea, or change in function status or symptoms
    Anemia	CBC, coagulation studies, T&S	Correct or improve preoperative anemia. Consider crossing patient for blood if high risk of blood loss intraop Consider cell-saver
    Morbid Obesity (BMI >40)	CBC, CMP, ECG	Consider additional cardiac workup and/or referral if poor functional status and no recent testing within 1 y

    BMP, basic metabolic panel; CBC, complete blood count; CMP, comprehensive metabolic panel; PFT, pulmonary function tests; T&S, type and screen.

• Preoperative considerations specific to the Gyn surgical patient

  • Prior to surgery, gynecologic patients are strongly advised to have current Pap smear and endometrial sampling when indicated. Endometrial biopsy is recommended by ACOG for patients with abnormal uterine bleeding over the age of 45 or <45 years of age if risk factors are present or unresponsive to medical therapy.

  • Routine testing for genital tract infections is not indicated in the absence of symptoms; however, treatment of bacterial vaginosis (BV) is recommended if the patient is symptomatic. BV is a known risk factor for surgical site infection (SSI), and treatment with metronidazole 4 days prior to surgery has been demonstrated to decrease the risk of cuff cellulitis.

  • A pregnancy test will be required on all reproductive age patients (<50) with a uterus.

  • Imaging should be individualized, but pelvic ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI) may be helpful for illustrating anatomy and extent of disease, thereby optimizing surgical planning and counseling.

Preoperative Management

ENHANCED RECOVERY AFTER SURGERY (ERAS): ERAS, an evidence-based care improvement process for surgical patients, is a multidisciplinary approach to the care of surgical patients, focusing on improvements in clinical outcomes and cost saving. General principles including laxity of nil per os (NPO) restrictions prior to surgery, goal-directed intraoperative fluid management, focus on minimally invasive approach, early ambulation, and early enteral feeding. Common ERAS interventions outlined by perioperative phase of care are outlined in Table 60-2. The benefits of ERAS pathways have been demonstrated across the full spectrum of gynecologic surgeries, including both minimally invasive and open surgeries for both benign and malignant processes, and are widely used as standard of care.

• Thromboembolic prophylaxis. The approximate risk of deep venous thrombosis (DVT) in hospitalized patients after major gynecology procedures is 10% to 40%. It is the standard of care to offer DVT prophylaxis (Table 60-3).

  Table 60-3 Thromboprophylaxis for Gynecologic Procedures

  Level of Risk	Definition	Successful Prevention Strategies
  Low	Surgery <30 min in patients younger than 40 y with no additional risk factors	No specific prophylaxis; early and “aggressive” mobilization
  Moderate	Surgery >30 min in patients with additional risk factors Surgery <30 min in patients of age 40–60 y with no additional risk factors Major surgery in patients <40 y with no additional risk factors	Low-dose unfractionated heparin (UFH) (5000 units every 12 h), low–molecular-weight heparin (LMWH) (2500 units dalteparin or 40 mg enoxaparin daily), graduated compression stockings, or intermittent pneumatic compression device
  High	Surgery <30 min in patients >60 y or with additional risk factors Major surgery in patients >40 y or with additional risk factors	Low-dose UFH (5000 units every 8 h), LMWH (5000 units dalteparin or 40 mg enoxaparin daily), or intermittent pneumatic compression device
  Highest	Major surgery patients >60 y plus prior venous thromboembolism, cancer, or molecular hypercoagulable state	Low-dose UFH (5000 units every 8 h), LMWH (5000 units dalteparin or 40 mg enoxaparin daily), or intermittent pneumatic compression device/graduated compression stockings + low-dose UFH or LMWH Consider continuing prophylaxis for 2–4 wk after discharge

  Modified from Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on antithrombotic and thrombolytic therapy. Chest. 2004;126(3 Suppl):338S–400S. Copyright © 2004 The American College of Chest Physicians. With permission.

• Infectious disease testing (Covid). All patients undergoing elective surgery should be screened for symptoms of and exposure to COVID-19. Institutional protocols vary on mandatory preoperative testing and duration of delaying surgery from onset of symptoms or positive COVID test result.

• Smoking cessation. Patient should be encouraged to quit smoking as soon as possible before surgery, but ideally at least 4 weeks preoperatively. If 4 weeks is not feasible patients should be encouraged to cut down by at least half leading up to surgery. This includes for both tobacco and cannabis users.

• Reducing SSI. Measures should be taken to reduce the risk of SSI.

  • Do not shave the incision site. Use only electric clippers if hair removal is necessary.

  • Implement perioperative glycemic control with a goal serum glucose level of <200 mg/dL and Hemoglobin A1c <8.0.

  • Recommend preoperative bath or shower with a soap or an antiseptic agent for those scheduled to undergo an abdominal procedure.

  • Unless contraindicated, an alcohol-based agent (ie, chlorhexidine + 70% isopropyl alcohol) should be used for the preoperative surgical site skin preparation. It is important to understand the recommended dry times for alcohol-based agents to decrease the risk of fire.

  • Antibiotic prophylaxis. See Table 60-4 for preoperative antibiotic prophylaxis. Single-dose prophylaxis appears to be as effective as multiple doses, with less risk of adverse events and microbial resistance. To reduce SSI, cephalosporins are preferred for most patients. Cephalosporins have a low rate of cross reactivity in patients with a reported penicillin allergy. A combination of clindamycin or metronidazole plus gentamicin is recommended for those with severe penicillin allergy or anaphylaxis. However, emerging evidence shows that this alternative regimen is inferior to a cephalosporin for prevention of SSI. Many centers now offer penicillin allergy testing preoperatively as most adults who carry a history of penicillin allergy are not truly penicillin allergic.

    Antibiotics should be administered within 1 hour prior to incision. Antibiotics should be redosed according to half-life and blood loss (eg, cefazolin is redosed every 4 hours or if >1500 mL of blood loss).

    Postoperative antibiotic prophylaxis has not been shown to be effective for elective surgery.

    Table 60-4 Antibiotic Prophylaxis by Procedure

    Procedure	Antibiotic	Dose (Within 1 h Before Procedure)
    Hysterectomy (including supracervical) Vaginal Abdominal Laparoscopic Robotic	Cefazolin	2 g, 3 g IV for patients weighing >120 kg Redose at 4 h or if EBL >1500 mL If PCN allergic (anaphylaxis, urticaria, bronchospasm) use Flagyl or Clindamycin + Gentamicin or Aztreonam
    Uterine evacuation Suction D&C D&E	Doxycycline	200 mg
    Colporrhaphy Vaginal sling placement	Cefazolin	2 g, 3 g IV for patients weighing >120 kg Redose at 4 h or if EBL >1500 mL If PCN allergic (anaphylaxis, urticaria, bronchospasm) use Flagyl or Clindamycin + Gentamicin or Aztreonam
    Laparotomy without entry into bowel or vagina	Consider Cefazolin	2 g, 3 g IV for patients weighing >120 kg Redose at 4 h or if EBL >1500 mL If PCN allergic (anaphylaxis, urticaria, bronchospasm) use Flagyl or Clindamycin + Gentamicin or Aztreonam
    Cervical tissue excision procedures (LEEP, biopsy, endocervical curettage)	None
    Cystoscopy	None
    Endometrial biopsy	None
    Laparoscopy without entry into bowel or vagina	None
    Hysterosalpingograma Chromotubation Saline infused sonohysterogram	None
    Hysteroscopy Operative Diagnostic	None
    Intrauterine device insertion	None
    Oocyte retrieval	None
    D&C (nonobstetrical)	None
    Urodynamics	None

    D&C, dilatation and currettage; D&E, dilatation and evaculation; EBL, estimated blood loss; LEEP, loop electrical excisional procedure; PCN, penicillin.

    ^aAntibiotics (Doxycycline 100 mg twice a day for 5 days) should be given to patients with a history of PID or abnormal appearing tubes to prevent post-procedural PID.

    Reprinted with permission from Prevention of infection after gynecologic procedures. Practice Bulletin No. 195. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2018;131(6):e172–e189. Copyright © 2018 by The American College of Obstetricians and Gynecologists.

  • Bowel preparation. Mechanical bowel preparation has not been shown to improve visualization or outcomes and comes with risk of electrolyte abnormalities and dehydration. Generally speaking, bowel prep should be reserved for complex cases with a high likelihood of bowel involvement. If a bowel prep is required, current recommendations favor the use of both a mechanical and antibiotic bowel prep.

  • Medications. In general, antihypertensive, cardiac, reflux, psychiatric, asthma, and anti-seizure medications should be taken on the morning of surgery, with a sip of water.

    Diabetic patients should take one third of the long-acting insulin, and those with an insulin pump should be on their basal rate. Oral hypoglycemics should not be taken on the day of surgery. Sodium-glucose cotransporter-2 (SGLT2) inhibitors should be stopped 3 to 4 days before surgery. Glucagon-like peptide-1 (GLP-1) receptor agonists given weekly should be discontinued at least 7 days before surgery to decrease risk of aspiration due to delayed gastric emptying. GLP-1 agonists given daily can be held the day prior to surgery.

    Aspirin and Plavix should be discontinued ideally 7 days before surgery; other nonsteroidal anti-inflammatory drugs should be stopped 3 days before surgery. Patients on an anticoagulant will require a detailed plan of management in coordination with the prescribing physician.

    Herbal supplements are discontinued 1 to 2 weeks prior to surgery as many have anticoagulant or coagulopathic effects.

  • Perioperative β-blockade should be continued for patients who are already on them, to prevent cardiac events associated with surgery.

Hemorrhage Prevention Optimization

• Preoperative correction of anemia is important for optimizing surgical outcomes. Hormone suppression and use of oral or IV iron infusions can improve blood counts prior to surgery.

• For procedures at high risk for severe blood loss, preoperative optimization with uterine artery embolization may be prudent. Usually performed one day prior to surgery with admission overnight, this intervention has been shown to significantly reduce intraoperative blood loss.

• Patients who do not accept blood products for religious or personal reasons require particular preoperative counseling that includes a thorough review of what products a patient is or is not willing to accept in the event of a hemorrhage. These patients must be counseled of the potential consequences should they refuse blood products in the setting of extreme blood loss. If acceptable to the patient, the use of cell salvage systems can be of great value and consideration to these systems can also be given to any high blood loss procedure. Consultation with bloodless medicine specialists is recommended.

• The use of medications intraoperatively can also assist in reduction of blood loss. At the time of myomectomy or cervical procedures, injection of vasopressin (off-label use) can be used to decrease blood flow to the site of operation and by default, blood loss. The maximum recommended dose is 20 units, which can be diluted to meet the needs of the surgeon. The medication has a relatively short half-life and repeat administration may be necessary, with care taken to avoid intravascular injection due to the associated reflex cardiac changes.

• Prior to myomectomy, the placement of 400 to 800 µg of rectal misoprostol (off-label use) can also be considered to decrease blood loss.

• In the setting of acute bleeding intraoperatively, IV tranexamic acid can also be administered at a dosage of 10 mg/kg.