Chest x-ray: Over age 60 years undergoing major surgery American Society of Anesthesiologists (ASA) 3 or greater Cardiovascular disease
Electrocardiogram (5): Over age 60 years undergoing major surgery Any cardiovascular disease or diabetes
Complete blood count: Major surgery ASA 3 or greater
Renal function: Recognized renal or cardiovascular disease Coagulation studies (activated partial thromboplastin time [APTT], prothrombin time [PT], platelet count): Not recommended unless patient has history of bleeding or liver disease (6) Urinalysis: Not recommended; may be considered given symptoms or history
Imaging of adjacent organ systems should be undertaken in individual cases as follows: 1.
CT urography is helpful to delineate ureteral patency and course, especially in the presence of a pelvic mass, gynecologic cancer, or congenital m¨ullerian anomaly. A CT urogram is not of value in the evaluation of most patients undergoing pelvic surgery (7).
2.
Upper endoscopy, colonoscopy, barium enema, or upper gastrointestinal studies with small bowel assessment may be of value in evaluating some patients before undergoing pelvic surgery. Because of the proximity of the female genital tract to the lower gastrointestinal tract, the rectum and sigmoid colon may be involved with benign (endometriosis or pelvic inﬂammatory disease) or malignant gynecologic conditions. Conversely, a pelvic mass could have a gastrointestinal origin such as a diverticular abscess or a mass of inﬂamed small intestines (Crohn disease) or, rarely, a gastric or pancreatic carcinoma. Any patient with gastrointestinal symptoms should be further evaluated.
3.
Other imaging studies, including ultrasonography, CT scanning, or magnetic resonance imaging (MRI), may be useful in selected patients such as in the evaluation of a pelvic mass.
The preoperative discussion should include a description of the surgical procedure, its expected outcome and risks and is the basis for obtaining signed informed consent (8,9). Informed consent is an educational process for the patient and her family and fulfills the physician’s need to convey information in understandable terms. The items listed in Table 22.2 should be discussed, and, after each item, the patient and family should be invited to ask questions. Documentation of the discussion is an important component of the patient’s record that the physician should always include with the preprinted consent form.
Following are components of the informed consent process: 1. A discussion of the nature and the extent of the disease process should include an explanation in lay terms of the significance of the disease or condition. Printed materials, computer-based learning programs, and videotapes may assist in this process. The patient’s competency to understand the discussion and written consent should be assessed. If the patient speaks a different language, a qualified interpreter should be present and the presence of the interpreter documented.
Table 22.2 Outline of Key Points of the Preoperative Informed Consent Discussion 1.
The nature and extent of the disease process 2.
The extent of the actual operation proposed and the potential modifications of the operation, depending on intraoperative findings 3.
The anticipated benefits of the operation, with a conservative estimate of successful outcome 4.
The risks and potential complications of the surgery 5.
Alternative methods of therapy and the risks and results of those alternative methods of therapy 6.
The results likely if the patient is not treated 2.
The goals of surgery should be discussed in detail. Some gynecologic surgical procedures are performed purely for diagnostic purposes (e.g., dilation and curettage, cold knife conization, diagnostic laparoscopy), whereas most are aimed at correcting a specific problem. The extent of the surgery should be outlined, including which organs will be removed. Most patients like to be informed regarding the type of surgical incision and the estimated duration of anesthesia.
3.