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INTRODUCTION

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Gynecologic surgery is used to treat a broad spectrum of underlying pathology. As a result, the list of surgical procedures is extensive, but in general, techniques maximize tissue healing and patient recovery. Successful outcomes depend on appropriate patient and procedure selection, sound intraoperative technique, and preparation for possible complications.

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ANESTHESIA SELECTION

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Many anesthetic options are available for patients undergoing gynecologic procedures and include general anesthesia, regional analgesia, or local paracervical blockade with or without conscious sedation. These anesthetic techniques are provided by clinicians who are skilled with their placement and capable of managing their side effects. Thus, paracervical blockade and intravenous sedation may be provided by gynecologists. General and regional anesthesia typically are delivered and managed by anesthesiology staff.

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Anesthesia selection for gynecologic surgery is complex and influenced by the procedure planned, extent of disease, patient comorbidities, and personal preferences of the patient, anesthesiologist, and surgeon. Last, the providing hospital or clinic may further define options based on their practicing norms and availability of personnel or equipment. For example, an outpatient gynecology clinic may be equipped to provide paracervical blockade or intravenous conscious sedation, but may lack sophisticated equipment or expertise required for regional or general anesthesia.

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In all cases, both the anesthesia provider and the surgeon communicate regarding patient and surgery progress and are prepared for potential problems. Difficult patient intubation may complicate general anesthesia, and regional anesthetic procedures may lead to higher than anticipated levels of blockade and respiratory muscle dysfunction. Cases using paracervical blockade may be complicated by inadequate levels of anesthesia, or conversely by anesthetic toxicity. Conscious sedation may also fail to provide adequate analgesia, or alternatively may lead to respiratory depression. Thus, no procedure is free of risk, and contingency plans for each should be in place.

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Paracervical Block

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Paracervical block is used most commonly during first-trimester pregnancy evacuation but also may be selected for cervical ablative or excisional procedures, transvaginal sonographically guided oocyte retrieval, and in-office hysteroscopy. Some studies have also described preemptive analgesia with paracervical block for vaginal hysterectomy (Long, 2009; O’Neal, 2003). Paracervical blockade is often combined with nonsteroidal antiinflammatory drugs (NSAIDs) or intravenous conscious sedation or both. Conscious sedation may be achieved with several agents, but intravenous midazolam (Versed) and fentanyl (Sublimaze) is a frequent combination (Lichtenberg, 2001).

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Technique
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The cervix, vagina, and uterus are richly supplied by nerves of the uterovaginal plexus (Fig. 38-13). Also known as Frankenhäuser plexus, this plexus lies within the connective tissue lateral to the uterosacral ligaments. For this reason, paracervical injections are most effective if placed immediately lateral to the insertion of the uterosacral ligaments into the uterus (Rogers, 1998). Thus, divided doses are given at the 4 and 8 o’clock positions at the cervical base (Fig. 40-1).

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