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INTRODUCTION

As surgeons, gynecologists play a key role in preventing perioperative morbidity by assessing a patient’s preoperative status. This process is often multidisciplinary and aims to identify and improve modifiable risk factors.

PREOPERATIVE PATIENT EVALUATION

A properly performed preoperative evaluation serves three important functions. It uncovers comorbidities that require further evaluation and improvement to avert perioperative complications. Second, evaluation allows effective use of operating room resources (Roizen, 2000). Last, potential problems are anticipated, and plans addressing these are devised (Johnson, 2008).

In many cases, a thorough history and physical examination averts the need for medical consultation. However, if a poorly controlled or previously undiagnosed medical condition is discovered, consultation with an internist offers benefits. Preoperative internal medicine consultation does not provide “medical clearance” but rather provides a risk assessment of a woman’s current medical state. For consultation, the surgical illness and planned procedure are summarized, and clear questions are posed to the consultant (Fleisher, 2009; Goldman, 1983). A complete history and physical examination and medical records that report already completed testing should be available to the consulting physician. This can prevent unnecessary surgical delays and cost from redundant testing.

PULMONARY EVALUATION

Risk Factors

Common postoperative pulmonary morbidities include atelectasis, pneumonia, and chronic lung disease exacerbation. In gynecologic surgeries performed for various indications, pulmonary complications develop in 1 to 3 percent of cases (Burks, 2017; Solomon, 2013; Wysham, 2015).

Pulmonary morbidity may arise from procedure-related or patient-related factors. Of surgery-related risks, upper abdominal incisions as they approach the diaphragm can worsen pulmonary function through mechanisms shown in Figure 39-1 (Warner, 2000). The poor diaphragmatic movement that results from these three can produce persistent declines in vital capacity and in functional residual capacity. These diminished capacities predispose to atelectasis. Another procedure-associated factor is surgery duration. Operations in which patients receive general anesthesia for longer than 3 hours are associated with nearly double the rate of postoperative pulmonary complications. Last, emergency surgery remains a significant independent risk. Although these factors are largely unmodifiable, an appreciation of their sequelae ideally prompts greater postoperative vigilance.

FIGURE 39-1

Surgical factors producing respiratory muscle dysfunction. These factors can reduce lung volumes and produce hypoventilation and atelectasis. (Reproduced with permission from Warner DO: Preventing postoperative pulmonary complications: the role of the anesthesiologist. Anesthesiology 92(5):1467, 2000.)

Of patient-associated factors, age older than 65 years is linked with a higher postoperative pulmonary complication rate (Bapoje, 2007). Those between 60 and 69 have a twofold greater risk, and for those older than 70 years, the risk rises threefold (Qaseem, 2006). Functional status is another risk, and status or sensorium changes may be an early indicator ...

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