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Overview of preoperative evaluation and preparation for gynecologic surgery

Overview of preoperative evaluation and preparation for gynecologic surgery
Author:
William J Mann, Jr, MD
Section Editor:
Tommaso Falcone, MD, FRCSC, FACOG
Deputy Editor:
Kristen Eckler, MD, FACOG
Literature review current through: Dec 2022. | This topic last updated: Jun 02, 2022.

INTRODUCTION — The preoperative evaluation and preparation prior to gynecologic surgery addresses issues that will potentially affect the woman during her surgical procedure and recovery. The surgeon should use this time to review the patient's history and physical examination, identify physical limitations, gather information required to plan surgery, optimize medical status, and educate about what to expect from the procedure and during the recovery period.

Many postoperative problems can be anticipated preoperatively and eliminated or minimized; systematically addressing these issues at the preoperative evaluation may result in a shorter hospitalization with fewer complications and a more satisfied patient. The surgeon may also rethink the aggressiveness and necessity of a planned operative procedure after thoughtful discussion with patients who have severe medical problems. As an example, a woman with symptomatic congestive heart failure and uterine procidentia may be better served with a pessary than by vaginal hysterectomy and sacrospinous suspension. This discussion is mainly regarding scheduled surgery. Urgent cases require an expedited preoperative evaluation process to provide appropriate care.

The preoperative evaluation and preparation of women for gynecologic surgery will be reviewed here. General principles of preoperative evaluation and preparation are discussed separately. (See "Overview of the principles of medical consultation and perioperative medicine" and "Preoperative medical evaluation of the healthy adult patient".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.

INFORMED CONSENT AND PATIENT EXPECTATIONS — The preoperative process should include comprehensive counseling of the patient regarding alternative treatment options (including expectant management) and risks and benefits of the procedure. For some procedures, particularly those that have variable outcomes and impact quality of life (eg, pelvic organ prolapse repair), patient expectations and goals should be discussed in detail. The expected duration and requirements of the recovery period should also be reviewed. Anticipatory guidance during preoperative office visits will enhance a patient's acceptance and compliance during the immediate postoperative period and may help to shorten hospital stay [1].

The surgeon should confirm that the patient has understood the discussion and desires to proceed with the procedure. This discussion should be documented in the medical record and on the procedure consent form.

Informed consent is discussed in detail separately, including issues related to incompetent or incapacitated patients, adolescent patients, and issues regarding patients who refuse blood transfusion. (See "Informed procedural consent" and "Consent in adolescent health care" and "The approach to the patient who declines blood transfusion".)

PREOPERATIVE EVALUATION — Preoperative evaluation should identify areas that may emerge as intraoperative or postoperative problems. The surgeon can use this information to prepare the woman for surgery and plan for any perioperative measures needed to avoid or manage complications.

An overview of the evaluation of a patient prior to gynecologic surgery is discussed in this section. The preoperative evaluation of a healthy patient for any type of surgery is discussed in detail separately. (See "Preoperative medical evaluation of the healthy adult patient".)

History — The preoperative medical history should include the basic elements of the history (medical conditions, surgical history, medications, allergies), as well as those related to the following:

Medical condition for which the procedure is performed

Medical conditions and risk factors that increase the risk of perioperative complications

Personal or family history or risk factors for thromboembolism

Personal or family history of anesthesia-related complications

General questions for the preoperative patient are shown in the table (table 1).

Medical comorbidities — Women with known or suspected medical comorbidities should be identified prior to surgery and referred for appropriate consultation regarding surgical clearance and perioperative management. These issues are discussed in detail separately:

(See "Preoperative evaluation for anesthesia for noncardiac surgery".)

(See "Preoperative medical evaluation of the healthy adult patient".)

Physical examination — Prior to gynecologic surgery, a complete pelvic examination should be performed by the surgeon. In many cases, the pelvic examination is repeated after induction of anesthesia. (See "The gynecologic history and pelvic examination" and "Pelvic examination under anesthesia".)

Further components of the physical examination should be performed that are related to the condition for which the procedure is performed. As an example, if malignancy is suspected, the preoperative examination should include site of potential lymph node metastases. In addition, the physical examination should be used to evaluate the patient's ability to tolerate surgery or anesthesia.

Laboratory tests — Further testing of the preoperative patient depends upon the procedure and medical comorbidities. Routine testing in healthy preoperative patients is discussed in detail separately. (See "Preoperative medical evaluation of the healthy adult patient".)

Pregnancy test — Pregnancy should be excluded prior to gynecologic surgery in all women of reproductive age (table 2). This also applies to patients for whom there is uncertainty about sexual activity, effectiveness of contraception, or about menopausal status. (See "Clinical manifestations and diagnosis of early pregnancy", section on 'Human chorionic gonadotropin'.)

If the patient is pregnant, procedures that may cause fetal harm or loss should be cancelled or postponed. Decisions regarding nonelective procedures that do not interfere with the pregnancy should be individualized and surgical planning should include measures to safeguard and monitor the pregnancy. (See "Preoperative medical evaluation of the healthy adult patient", section on 'Pregnancy testing'.)

The prevalence of unrecognized pregnancy was illustrated in a prospective study that performed pregnancy tests on all women of childbearing potential (defined as menstruating women without prior hysterectomy or tubal ligation) scheduled for ambulatory surgery [2]. Testing revealed 7 previously unrecognized pregnancies in 2056 women (0.3 percent), including 2 patients scheduled to undergo fertility procedures. All of the pregnant women cancelled or postponed their procedures.

Issues regarding surgical procedures in pregnant women are discussed in detail separately. (See "Anesthesia for nonobstetric surgery during pregnancy".)

Testing for genital tract infection — In the absence of symptoms, routine preoperative screening for genital tract infections is generally not necessary; women with symptoms or risk factors for infections should be tested and treated as part of usual gynecologic care. Certain types of infections are clinically important for particular procedures, including:

Bacterial vaginosis is associated with an increased risk of vaginal cuff infection following hysterectomy. Women with symptoms or pelvic examination findings consistent with bacterial vaginosis should be evaluated and treated prior to hysterectomy. (See "Bacterial vaginosis: Initial treatment", section on 'Individuals undergoing gynecologic procedures'.)

Cervical infections with Chlamydia trachomatis or Neisseria gonorrhea are associated with an increased risk of endometritis following surgical pregnancy termination. These infections are managed with universal use of prophylactic antibiotics prior to the procedure rather than a screen and treat strategy. (See "Overview of pregnancy termination", section on 'Antibiotic prophylaxis'.)

COVID-19 testing — Patients scheduled for elective surgery should be screened for exposure to or symptoms of coronavirus disease 2019 (COVID-19). Protocols for preoperative testing vary by institution and geographic region [3]. In areas of high prevalence, testing prior to non-emergency surgery is advised. (See "COVID-19: Perioperative risk assessment and anesthetic considerations, including airway management and infection control", section on 'Preoperative screening and testing'.)

Other testing — Other testing (eg, pelvic imaging) should be performed as needed based upon the indication and procedure. Routine pelvic imaging is not required if there is no clinical indication [4].

PREOPERATIVE PREPARATION — Preoperative preparation includes issues that are addressed in the clinic and operating room prior to surgery.

Operating room safety is discussed in detail separately. (See "Safety in the operating room".)

Medication management — A discussion of perioperative medication management can be found separately. (See "Perioperative medication management".)

Blood loss preparation

Correction of anemia — Preoperative correction of anemia for gynecologic surgery is discussed in detail separately. (See "Management of hemorrhage in gynecologic surgery" and "Management of hemorrhage in gynecologic surgery", section on 'Correction of anemia' and "The approach to the patient who declines blood transfusion".)

Autologous blood transfusion — If significant blood loss is anticipated, preoperative preparations can be made to use autologous blood in the event a transfusion is necessary. (See "Management of hemorrhage in gynecologic surgery", section on 'Autologous transfusion methods'.)

Prophylactic tranexamic acid — We routinely administer tranexamic acid (TXA) to patients with no history of thrombotic events prior to gynecologic surgery for benign indications.

Dose and timing – We administer TXA at a dose of 10 mg/kg intravenously on entry to the operating room. This approach has been reported to reduce blood loss by 200 to 250 mL per surgery (including elective cesarean delivery and myomectomy) [5,6].

Supporting data – Prophylactic administration of TXA, an anti-fibrinolytic, has been associated with reduced intraoperative blood loss in both obstetric and gynecologic surgery [5-8]. In a meta-analysis of 216 trials including over 125,000 patients of all ages and medical disciplines, pre- or intraoperative TXA reduced overall mortality and bleeding-related mortality without increasing the risk of thromboembolic events [9].

Wrong person, site, procedure prevention — Practicing safe, high-quality operating room care begins with accurately identifying the patient, surgical site, and procedure. The United States Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is shown in the table (table 3). (See "Safety in the operating room", section on 'Wrong procedure or wrong site'.)

Smoking cessation — The preoperative evaluation provides an opportunity to discuss the benefits of smoking cessation. Current cigarette smokers have an increased risk for postoperative pulmonary complications, although the incremental risk is small in the absence of chronic lung disease. (See "Strategies to reduce postoperative pulmonary complications in adults", section on 'Smoking cessation'.)

Piercings and tattoos — Oral and nasal jewelry (eg, tongue and nose rings) can interfere with intubation during administration of general anesthesia and body piercing at any site can conduct electric current if electrosurgery is performed [10-12]. It is recommended that all metallic jewelry be removed to prevent complications, as well as loss of the jewelry [10]. (See "Body piercing in adolescents and young adults", section on 'Removal'.)

The presence of umbilical jewelry, such as rings, is relatively common in women. Our preference is to have the patient remove the ring the day prior to the procedure and cleanse the umbilicus thoroughly. An alternative approach is temporary removal of the jewelry and replacement with a nonmetallic spacer (eg, sterile plastic sutures or thin tubing) [13]. Postoperatively, most navel jewelry can be replaced after the skin of the laparoscopy incision has sealed (preferably after two or more days) [10]. We ask the patient not to replace the ring until after follow-up examination five to seven days postoperatively. Both the jewelry and skin site should be disinfected prior to reinsertion. Antibiotics are not necessary and ointments should be avoided because they clog the piercing tract.

Women who require an incision through an existing tattoo are counseled that the repair may permanently alter the tattoo image. On occasion, surgical incision sites have been altered to incorporate the tattoo borders and reduce the appearance of the subsequent scar [14]. In some cases, consultation with a plastic surgeon may be helpful. Although supporting data are lacking, we prefer not to make an incision through a tattoo that has not yet completely healed.

Intrauterine device — For procedures not including the uterine cavity, intrauterine devices (IUDs) do not need to be removed prior to surgery, including for loop electrosurgical excision procedures. For procedures involving the uterine cavity (eg, dilation and curettage, endometrial polyp removal), the IUD is removed prior to the surgery.

SURGICAL SITE INFECTION PREVENTION — The most important factors in the prevention of surgical site infection (SSI) are timely administration of effective preoperative antibiotics and meticulous operative technique.

Bundled interventions — In response to data from varying surgical specialities suggesting that bundled interventions aimed at reducing SSI were effective [15-17], the American College of Obstetricians and Gynecologists convened the Council on Patient Safety in Women's Health Care. After reviewing existing guidelines and evidence-based recommendations, the Council released practice recommendations for a patient care bundle that, while aimed at preventing SSI in women undergoing hysterectomy, can be applied to all gynecologic surgery [18,19]. The bundle is divided into four domains: readiness, recognition and prevention, response, and reporting and systems learning. Key features include patient education, assessment of preoperative patient risk (table 4), standardization of perioperative antibiotics and normothermia, and data collection and evaluation (table 5). One limitation of this approach is that the specific intervention(s) that resulted in the decreased infection rate are not known, and therefore the entire package of interventions must be implemented in order to reduce infection.

As examples, retrospective review of 825 open gynecologic cancer surgeries for uterine or ovarian cancer reported the overall risk of SSI dropped 82 percent after initiation of an SSI intervention bundle, with the absolute percent of cases dropping from 6.0 to 1.1 percent [20]. Preintervention steps to reduce SSI included patient education, 4% chlorhexidine gluconate shower before surgery, antibiotic administration, preoperative skin preparation with 2% chlorhexidine gluconate and 70% isopropyl alcohol, and cefazolin re-dosing three to four hours after incision. The bundled intervention consisted of these elements plus sterile closing tray and staff glove change for fascia and skin closure, dressing removal at 24 to 48 hours postoperatively, patient shower with 4% chlorhexidine gluconate after dressing removal, and a follow-up nursing phone call. Of note, approximately 40 percent of women undergoing surgery for ovarian cancer required bowel resection. A subsequent study including nearly 2100 hysterectomy procedures reported a decrease in surgical site infections from 4.5 to 1.9 percent after implementation of a hysterectomy-specific bundle aimed at reducing surgical site infections [21].

Antibiotic prophylaxis — To prevent SSI, antibiotics should be given prior to gynecologic surgery or procedures that enter the bowel or vagina tract [19]. When antibiotics are indicated, cefazolin is the preferred drug in most instances; exceptions include patients with allergy or those undergoing uterine evacuation. Guidelines are shown in the table (table 6).

Support for cephalosporin SSI prevention – In a retrospective cohort study of over 21,000 women undergoing hysterectomy (abdominal, vaginal, laparoscopic, and robotic), those who received a standard beta-lactam antibiotic had lower risk of SSI compared with those who received either an alternative regimen (clindamycin with gentamicin or quinolone) or nonstandard regimen (compared with beta-lactam coverage, SSI odds ratio of 1.7 for alternative beta-lactam regimens and 2.0 for nonstandard antibiotic regimens) [22].

Role of metronidazole – While retrospective data have suggested the addition of metronidazole further reduces SSI risk, we will continue to use cefazolin alone unless supporting prospective comparative trial data become available because use of more broad-spectrum antibiotics could contribute to increased adverse events and antibiotic resistance (table 6) [19]. In a retrospective cohort study of over 18,000 women undergoing hysterectomy (all types), those receiving either cefazolin or a second-generation cephalosporin had more than double the risk of SSI compared with those receiving combined treatment with cefazolin and metronidazole (compared with combined treatment, adjusted odds ratio for cefazolin 2.30, 95% CI 1.06-4.99, and second-generation cephalosporin adjusted odds ratio 2.31, 95% CI 1.21-4.41) [23].

General principles of SSI prevention have been published by the United States Centers for Disease Control and Prevention (CDC) and are reviewed separately. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)

Skin preparation — Preoperatively, the CDC advise that the entire body be washed (shower or tub) with either soap (antimicrobial or non-antimicrobial) or an antiseptic agent on the night prior to surgery [24]. Some practices give patients chlorhexidine gluconate solution at their preoperative evaluation to facilitate appropriate preoperative skin cleansing.

Intraoperatively, we use 4% chlorhexidine gluconate solution with 70% isopropyl alcohol for preoperative skin preparation because alcohol-based chlorhexidine is at least as effective, and likely more effective, for some procedures compared with iodine solutions [19,24]. Alcohol-based chlorhexidine is associated with reduced infection risk for open surgeries, including open abdominal hysterectomy and cesarean delivery [25-28]. For gynecologic laparoscopy, the type of skin preparation does not appear to impact infection risk. In a trial of 640 patients randomly assigned to one of three different skin preparations (alcohol-based chlorhexidine, water-based povidone-iodine, or alcohol-based iodine) at the time of benign gynecologic laparoscopy, port-site infection rates were similar across the groups (11.4, 10.3, and 8.8 percent, respectively) [29]. The infection rates for the three groups were also similar for infection of any organ space, urinary tract infection, endometritis or vaginal vault infection, and infection of any surgical site.

We do not ask women to perform a specific preoperative body wash. In a meta-analysis of seven trials including over 10,000 participants, preoperative bathing or showering with chlorhexidine or other products was not associated with reduced rates of surgical site infection [30]. (See "Overview of control measures for prevention of surgical site infection in adults", section on 'Skin antisepsis'.)

Vaginal preparation — Either povidone-iodine (PVP-I) or chlorhexidine gluconate with a low (4%) concentration of isopropyl alcohol is acceptable for vaginal preparation as both significantly reduce rates of postoperative infectious morbidity [19,31]. While PVP-I is commonly used in the United States for vaginal preparation, chlorhexidine is commonly used elsewhere because it may provide a greater reduction in skin flora than PVP-I and is not inactivated in the presence of blood. Despite common use of chlorhexidine gluconate with 4 percent isopropyl alcohol outside of the United States, the manufacturer's label states that chlorhexidine gluconate is for external use only and should not be used in genital areas [32]. Generalized allergic reactions, irritation, and sensitivity have been reported. In addition, a case report noted vaginal desquamation after application of chlorhexidine gluconate [33]. However, several studies that totaled over 7000 women reported no significant adverse effects from vaginal application of chlorhexidine [34-38]. One randomized trial (n = 50) comparing chlorhexidine (4 percent with 4 percent isopropyl alcohol) with PVP-I for preparation for vaginal hysterectomy found no cases of vaginal irritation or postoperative infection in either group [34]. Based on the above data demonstrating lack of adverse effects with vaginal chlorhexidine, we support the use of chlorhexidine with 4 percent isopropyl alcohol for vaginal preparation, although both PVP-I and chlorhexidine are reasonable options.

For surgeons who choose vaginal preparation with PVP-I, some use PVP-I gel in addition to PVP-I solution, but there are conflicting data regarding this practice. It appears that bacterial counts return to near baseline levels within 30 minutes after vaginal painting with PVP-I solution; however, vaginal PVP-I gel lowers bacterial counts for at least three hours [39]. Randomized trials have yielded inconsistent results regarding whether vaginal preparation with PVP-I in both solution and gel form compared with solution alone reduces the overall risk of postoperative infectious morbidity [40,41]. One trial reported that combined use of solution and gel reduced the risk of postoperative pelvic abscess [40].

When the patient is allergic to PVP-I and the vaginal use of chlorhexidine is prohibited, vaginal preparation can be performed with sterile saline or baby shampoo. In our practice, if a saline preparation is used and the peritoneal cavity is entered, we use prophylactic antibiotics and irrigate the field thoroughly at the conclusion of the case. If the peritoneum is not entered and antibiotic prophylaxis is not typically required for the case, then the risk of surgical site infection is balanced against the risks of Clostridioides difficile infection and antibiotic resistance.

Other measures — Additional measures for prevention of surgical site infection include skin antisepsis, hair removal, drapes, surgical hand hygiene, surgical technique, and negative pressure wound therapy. These interventions are presented separately.

(See "Overview of control measures for prevention of surgical site infection in adults".)

(See "Negative pressure wound therapy".)

THROMBOPROPHYLAXIS — The risk of venous thromboembolism (VTE; ie, deep vein thrombosis [DVT] or pulmonary embolism) is significantly increased during and after surgery. Surgery and other risk factors associated with higher rates of thrombosis are listed in the table (table 7). (See "Overview of the causes of venous thrombosis".)

Thromboprophylaxis reduces the incidence of symptomatic DVT or pulmonary embolism. Decisions regarding the method, dose, and timing of prophylaxis depend upon balancing a patient's risk of thrombosis (eg, Caprini score) versus perioperative bleeding [42]. The Caprini score (table 8) is balanced with the risk of bleeding complication to determine the approach to treatment. A detailed discussion of thromboprophylaxis for patients undergoing surgery can be found separately. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)

The management of women already on anticoagulants for coexistent conditions is reviewed separately. (See "Perioperative management of patients receiving anticoagulants".)

MEASURES FOR SELECTED USE OR THAT ARE NO LONGER RECOMMENDED

Stress dose glucocorticoids — Use of stress doses of glucocorticoids has become a common perioperative practice for patients on glucocorticoid therapy. However, use of "stress dose" glucocorticoids is not necessary for all patients with recent glucocorticoid use. The current approach is to determine glucocorticoid coverage based upon the patient's history of glucocorticoid intake, as well as the type and duration of surgery. (See "The management of the surgical patient taking glucocorticoids".)

Bowel preparation — Bowel preparation is no longer standard practice prior to gynecologic surgery as it does not reduce the risk of surgical site infection or anastomotic leakage [43,44]. Bowel preparation may be performed prior to procedures with the potential for injury to the bowel (eg, patients with advanced endometriosis, staging for gynecologic malignancies). In some institutions, surgical injury to unprepared bowel is treated with diverting bowel loop and ostomy. Thus, preoperative bowel preparation is reasonable for those at increased risk for surgical injury.

Endocarditis prophylaxis — The American Heart Association (AHA) guidelines do not classify any gynecologic procedures as high risk for resulting in infective endocarditis and therefore do not recommend routine use of antibiotic prophylaxis, even in patients with the highest risk cardiac conditions.

SPECIAL ISSUES

Risk of occupational HPV exposure — Smoke generated from excisional and ablative procedures for cervical intraepithelial neoplasia can expose the operative team to human papillomavirus (HPV) infection [45]. In one study of 700 gynecologists, HPV infection rate was higher in the nasal epithelial cells of those who performed electrosurgery or loop electrosurgical excision procedures compared with those who did not (9 to 10 versus 2 to 3 percent) [46]. In addition, HPV-positive rates were lower among those wearing an N-95 mask compared with a non-N-95 surgical mask (0 versus 14 to 16 percent). This exposure may increase the risk of developing HPV-associated oropharyngeal disease. Although the magnitude of this risk is unknown, at least four case reports have described oropharyngeal cancer and laryngeal papillomatosis in health care workers with an occupational exposure to HPV [47-49].

The entire operative team, including physicians, nurses, and the operating room staff, should be aware of this risk. Health care workers should use personal protective equipment (eg, N-95 mask) in addition to a smoke evacuation system, and the American Society for Colposcopy and Cervical Pathology suggests that they receive the HPV vaccine, if not already vaccinated [50]. This is discussed in more detail separately. (See "Human papillomavirus vaccination", section on 'Health care workers at risk for occupational exposure'.)

Suspected malignancy — If gynecologic malignancy is suspected, the surgery should be performed by a surgeon with experience with surgical staging, typically a gynecologic oncologist. (See "Abdominal hysterectomy", section on 'Malignancy' and "Approach to the patient with an adnexal mass", section on 'Patients at increased risk of malignancy'.)

Older or medically unfit adults — The number of women over the age of 65 years will grow from 32 million in 1990 to 40 million in 2010 and 75 million in 2050 [51]. Consequently, the gynecologic surgeon must develop competency dealing with geriatric surgical patients. In the United States, a 75-year-old female can expect an additional 12.4 years of life [52]. During most of these years, the women will be functional and independent [53].

Age alone is not a contraindication to surgery. Decisions on operability should be based upon health status and discussion of treatment options with the patient; family members or other caregivers should be involved if they participate in the care of the patient [54,55]. Appropriate preoperative medical consultations should be obtained to address medical comorbidities. (See 'Medical comorbidities' above.)

The evaluation of the status of the older adults and management of anesthesia and hospital care in this patient population are discussed in detail separately. (See "Comprehensive geriatric assessment" and "Anesthesia for the older adult" and "Hospital management of older adults".)

Patients with obesity — In addition to routine planning, preoperative preparation of obese patients (defined as body mass index [BMI] of 30 kg/m2 or greater) includes evaluation by history and physical examination for comorbidities that may increase the risk of perioperative complications (eg, diabetes, hypertension, obstructive sleep apnea, cardiac disease) and relevant surgical planning (eg, choice of incision, special equipment needs) [56]. Women are counseled that the risk of surgical site infections [57], wound complications [58], and venous thromboembolism [59] increases as BMI rises. There are no specific preoperative ancillary tests recommended for the obese patient [56].

Preoperative consultation with an anesthesiologist is requested for patients with obstructive sleep apnea, cardiac disease, or a difficult airway [56]. Management of anesthesia in obese patients is discussed in detail separately. (See "Anesthesia for the patient with obesity".)

Perioperative considerations specific to obese patients include preventing venous thromboembolism, dosing of prophylactic antibiotics, positioning the patient on the operating table, and facilitating surgical access. Obese women are considered to have baseline moderate risk for venous thromboembolism and should receive prophylaxis, unless contraindicated by risk of bleeding [56]. Prophylactic measures are typically continued postoperatively until the woman is fully ambulatory. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients", section on 'Assess risk for thrombosis'.)

Routine prophylactic antibiotic dosing recommendations may not result in adequate tissue levels in obese patients [60]. Prophylactic cefazolin is given at doses of 2 g intravenously for patients weighing more than 80 kg and 3 g intravenously for patients who weigh more than 120 kg [61]. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Antibiotic administration'.)

Surgical positioning faces the dual challenges of providing surgical access and protecting the patient from injury [56]. The operating table needs to accommodate the size and weight of the patient and provide secure belts or pads to prevent patient movement during the surgery, particularly if the patient is to be placed in Trendelenburg or reverse Trendelenburg positions. The stirrup must accommodate the patient's weight and avoid pressure that could lead to nerve injury. In addition, tucking the patient's arms parallel to, rather than perpendicular to the operating table, may improve access to the patient. (See "Patient positioning for surgery and anesthesia in adults".)

Obese patients may have a very large panniculus which can limit the surgeon's ability to get to the operative site. Panniculectomy has the advantage of removing the panniculus from the operative field, which may allow use of standard sized instruments and retractors, and facilitate the entire operation. However, panniculectomy is associated with a significant blood loss within the tissue being removed, usually requires placing closed suction drains at the conclusion of the procedure, may require removing or moving the umbilicus, and can be associated with very long postoperative healing. (See "Complications of abdominal surgical incisions", section on 'Obesity'.)

Orthopedic issues or physical disabilities — Women planning gynecologic surgery should be asked about orthopedic issues (eg, chronic back pain, recent hip or knee surgery) that may affect positioning during surgery. Appropriate positioning to avoid neural injury is discussed separately. (See "Nerve injury associated with pelvic surgery".)

Women with physical disabilities may require perioperative accommodations, including alternative positions or equipment. In addition, limited mobility is a risk factor for thromboembolism. Planning for surgery should include discussions with the patient, her caregivers and operating room personnel with experience with the logistics and regulations regarding these issues. Consultation regarding thromboprophylaxis should be obtained, if necessary. (See 'Thromboprophylaxis' above.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gynecologic surgery" and "Society guideline links: Preoperative medical evaluation and risk assessment".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Questions to ask if you are having surgery or a procedure (The Basics)")

SUMMARY AND RECOMMENDATIONS

Surgical consent – The informed consent process should include comprehensive counseling of the patient regarding alternative treatment options (including expectant management) and risks and benefits of the procedure. Patient expectations and goals and the expected duration and requirements of the recovery period should also be reviewed. (See 'Informed consent and patient expectations' above.)

Preoperative evaluation – The preoperative evaluation should include a medical and surgical history, medications, and allergies, as well as a detailed history regarding the indication for the procedure and risk factors for surgical or anesthetic complications. A focused physical examination should be performed. (See 'History' above and 'Physical examination' above.)

Medical consultation should be obtained for patients with medical comorbidities and regarding perioperative management of medications. (See 'Medical comorbidities' above and 'Medication management' above.)

Preoperative tests

Pregnancy test – Pregnancy testing should be performed prior to gynecologic surgery in all women of reproductive age.

Genital and sexually transmitted infections – In the absence of symptoms, routine preoperative screening for genital tract infections is generally not necessary. The exception to this is bacterial vaginosis; women with symptoms or pelvic examination findings consistent with bacterial vaginosis should be evaluated and treated prior to hysterectomy to reduce the risk of postoperative infection. (See 'Testing for genital tract infection' above.)

Preoperative patient preparation

Prevention of surgical site infection

-Systemic antibiotics – Systemic antibiotics should be given prior to gynecologic procedures to prevent surgical site infection if the reproductive tract is entered (eg, hysterectomy) or there is likely to be contamination of the peritoneal cavity from the vagina (eg, surgical abortion, hysterosalpingogram in patients with risk factors for infection) (table 6).

-Vaginal preparation – We suggest cleansing preparation of the vagina if a procedure includes a vaginal incision or transvaginal use of instruments (Grade 2C). (See 'Vaginal preparation' above.)

Thromboprophylaxis – Use of thromboprophylaxis is guided by the risk category based on characteristics of the patient (table 8) and procedure. (See 'Thromboprophylaxis' above.)

Supplemental glucocorticoids – Use of "stress dose" glucocorticoids is not necessary for all patients with recent glucocorticoid use. The current approach is to determine glucocorticoid coverage based upon the patient's history of glucocorticoid intake, as well as the type and duration of surgery. (See 'Stress dose glucocorticoids' above.)

Bowel preparation – Bowel preparation is not required prior to gynecologic surgery. (See 'Bowel preparation' above.)

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