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CHAPTER 40: Intraoperative Considerations

INTRODUCTION

Gynecologic surgery is used to treat a broad spectrum of underlying pathology. As a result, the list of 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.

SURGICAL SAFETY

Communication between all members of the surgical team is vital to operative success and avoidance of patient harm. The Joint Commission (2018) established the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery. This protocol encompasses three components: (1) preprocedural verification of all relevant documents, (2) marking the operative site, and (3) completion of a “time out” prior to procedure initiation. The “time out” requires attention of the entire team to confirm that patient, site, and procedure are correctly identified. Important interactions also include introduction of the patient-care team members, verification of prophylactic antibiotics, estimation of procedure length, and communication of anticipated complications. Additionally, special instrumentation is requested preoperatively to prevent potential patient compromise that may accompany lacking an instrument at the time it is needed. Communication lapses are common across pre-, intra-, and postoperative phases of care and are linked to adverse events (Nagpal, 2010). Specifically, the transfer of a patient to a new care team or location is a particularly vulnerable time (Greenberg, 2007; Jones, 2018).

Checklists can enhance quality and safety. These cognitive aids standardize care, enhance teamwork, and improve communication (American College of Obstetricians and Gynecologists, 2016). The World Health Organization (WHO) Surgical Safety Checklist (2009) is widely used and lowers patient morbidity and mortality in many but not all instances (Table 40-1) (Haynes, 2009; Molina, 2016; Urbach, 2014). Checklist efficacy may be better measured by assessing associated good catches rather than solely evaluating patient harm (Putnam, 2016).

TABLE 40-1Surgical Safety Checklist Modified from World Health Organization
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TABLE 40-1 Surgical Safety Checklist Modified from World Health Organization
Before Anesthesia Induction Before Skin Incision Before Patient Leaves Operating Room
Patient confirms her identity, site, procedure, and consent?
□ Yes

Site marked?
□ Yes
□ Not applicable

Anesthesia machine and medication check complete?
□ Yes

Functioning pulse oximeter on patient?
□ Yes

Known patient allergy?
□ No
□ Yes

Difficult airway or aspiration risk?
□ No
□ Yes; equipment/assistance available?

Risk of >500 mL blood loss?
□ No
□ Yes; two IVs/central access and volume resuscitation planned?		 □ All team members state name and role

□ Confirm patient name, procedure, and site

Antibiotic prophylaxis given in last 60 minutes?
□ Yes
□ Not applicable

Anticipated critical events:
To surgeon:
□ Critical or nonroutine steps?
□ Case duration?
□ Anticipated blood loss?
To anesthesia provider:
□ Patient-specific concerns?
To nursing team:
□ Surgical-site sterility confirmed?
□ Fire ...

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