The medical history should include detailed questions to identify any medical illnesses that might be aggravated by surgery or anesthesia. Coronary artery disease, pulmonary diseases, and obesity are the most common causes of postoperative complications.
2.
Medications currently being taken (including nonprescription drugs) and those discontinued within the month before surgery should be recorded. Information about the use of “alternative therapies,” herbs, and vitamins should be elicited (1,2). Specific instructions must be given to the patient regarding the need to discontinue any medications before surgery (e.g., aspirin, antiplatelet agents, diuretics, hormone replacement, or oral contraceptives), and those medications that should be continued (e.g., beta-blockers, α-2 agonists, statins, H2 blockers, and proton pump inhibitors). Collaboration with the anesthesiologist in making decisions about continuing preoperative medications is essential. In the case of herbal medications, there is no evidence that herbal medications improve surgical outcomes and many may increase complications (Table 22.1). It is recommended that all herbal medications be discontinued at least a week before surgery.
3.
The patient should be questioned regarding known allergies to medications (e.g., sulfa and penicillin), foods, or environmental agents. A history of sensitivity to shellfish may be the only clue of iodine sensitivity, which could be fatal if intravenous contrast is administered without corticosteroid preparation.
4.
Previous surgical procedures, and the patient’s course following those surgical procedures, should be reviewed to identify and protect against potential complications. The patient should be asked about specific complications, such as excessive bleeding, wound infection, venous thromboembolism, peritonitis, or bowel obstruction. Prior pelvic surgery should alert the gynecologist to the possibility of distorted surgical anatomy such as adhesions or ureteral stricture from previous periureteral scarring. In such cases, it may be prudent to identify any preexisting abnormality by performing computed tomography (CT) or other imaging. Many patients may not be entirely clear about the extent of the previous surgical procedure or the details of intraoperative findings. Therefore, operative notes from previous procedures should be obtained and reviewed.
5.
Family history may identify familial traits that might complicate planned surgery.
A family history of excessive intraoperative or postoperative bleeding, venous thromboembolism, malignant hyperthermia, and other potentially inherited conditions should be sought.
6.
The review of systems should be detailed to identify any coexisting medical or surgical conditions. Inquiry about gastrointestinal and urologic function is particularly important before undertaking pelvic surgery because many gynecologic diseases involve adjacent nongynecologic viscera. The patient may have less serious symptoms, which could be corrected along with performing the primary surgery (e.g., stress urinary incontinence, fecal soiling, symptomatic cystocele).
7.
Although many women undergoing gynecologic surgical procedures are otherwise healthy, with pathology identified only on pelvic examination, other major organ systems should not be neglected in the physical examination. Identification of abnormalities, such as a heart murmur, pulmonary compromise, hernia, or osteoarthritis of hips or knees should lead the surgeon to obtain additional testing and consultation to minimize intraoperative and postoperative complications.
Table 22.1 Potential Effects of Common Herbal and Dietary Supplements “Routine” preoperative laboratory testing of healthy women is to be discouraged as abnormal results are infrequent and are rarely of consequence in the surgical or anesthetic management of the patient (3). Despite well-established guidelines, approximately 90% of patients undergo unnecessary testing in a major university medical center (4). The selection of appropriate preoperative laboratory studies should depend on the type of the anticipated surgical procedure and the patient’s medical status.