Gynecologic surgery is used to treat a broad spectrum of underlying pathology. As a result, the list of surgical procedures used in gynecology is extensive, but in general, techniques maximize tissue healing and patient recovery. Successful outcomes depend upon appropriate patient and procedure selection as well as anticipation and preparation for possible complicating factors. During any procedure, intraoperative complications may be encountered, and surgeons should be familiar with these challenges and their management.
Perioperative morbidity and mortality rates may be significantly lowered by thorough preoperative evaluation and management. This process is the responsibility of the surgeon in concert with appropriate consultants and is discussed in detail in Chapter 39.
Many anesthetic options are available for patients undergoing gynecologic procedures. Typically, general anesthesia, regional epidural, or spinal technique is selected. However, paracervical blockade using local anesthetic agents may be used alone or more commonly with conscious sedation for dilation and curettage or hysteroscopy.
The delivery of these anesthetic techniques should be provided by clinicians who are skilled with their placement and are capable of managing their side effects. In general, paracervical blockade and intravenous sedation may be provided by gynecologists. General, epidural, and spinal anesthesia typically are delivered and managed by anesthesiology staff.
The selection of anesthesia for gynecologic surgery is complex. Clinical factors such as the procedure planned, extent of disease, and patient comorbidities weigh heavily in the decision process. Moreover, personal preferences of the patient, anesthesiologist, and surgeon influence choice. Lastly, 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 have supporting personnel and equipment sufficient for paracervical blockade or intravenous conscious sedation but may lack sophisticated equipment or expertise required for regional or general anesthesia.
In all cases, both the anesthesia provider and the surgeon should be prepared for potential problems. Difficult patient intubation may complicate general anesthesia, whereas 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 potential risk, and contingency plans for each should be in place.
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. Studies have also demonstrated improved postoperative pain control in women given preemptive analgesia with paracervical blockade prior to general anesthesia 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 ...