Residency · Residency · Obstetrics Gynecology
Perioperative Care in Gynecologic Surgery
Introduction
Perioperative care encompasses the preoperative, intraoperative, and postoperative phases of surgical management. The adoption of Enhanced Recovery After Surgery (ERAS) protocols in gynecology has transformed perioperative care, emphasizing evidence-based interventions that reduce surgical stress, minimize complications, and accelerate functional recovery.
Preoperative Assessment and Optimization
Risk Stratification
Medical history focuses on cardiovascular disease, pulmonary disease, diabetes, obesity, bleeding disorders, and prior surgical complications. The ASA classification provides standardized perioperative risk assessment. The Revised Cardiac Risk Index identifies patients at elevated cardiac risk. Functional capacity of 4 METs or greater (climbing stairs, brisk walking) generally predicts tolerance of surgery. Preoperative labs should be selective: CBC for expected blood loss, BMP for renal disease, coagulation studies for bleeding history, and type and screen based on anticipated loss.
Medication Management
Warfarin is discontinued 5 days preoperatively (target INR less than 1.5); DOACs are held 2-3 days. Beta-blockers are continued to avoid rebound tachycardia. Metformin is held on surgery day; long-acting insulin is reduced by 50-80% the evening before. Herbal supplements should be discontinued 2 weeks preoperatively.
Preoperative Preparation
Mechanical bowel prep is no longer recommended for most benign gynecologic procedures. Chlorhexidine-alcohol skin preparation is superior to povidone-iodine for reducing surgical site infection. Antibiotic prophylaxis consists of cefazolin 2 g IV (3 g if weight exceeds 120 kg) within 60 minutes of incision, with redosing for cases longer than 3 hours or blood loss exceeding 1,500 mL. VTE prophylaxis is risk-stratified using the Caprini score, with sequential compression devices for low-risk patients and pharmacologic prophylaxis continued for 28 days postoperatively after oncology procedures.
<image>Infographic illustrating the ERAS protocol timeline for gynecologic surgery, showing preoperative elements (carbohydrate loading, avoiding prolonged fasting, multimodal analgesia), intraoperative elements (goal-directed fluid therapy, normothermia, minimally invasive approach), and postoperative elements (early mobilization, early oral intake, multimodal pain management)</image>
Enhanced Recovery After Surgery (ERAS)
Preoperative ERAS Elements
Preoperative counseling sets expectations and reduces anxiety. Clear liquids are permitted up to 2 hours before anesthesia, solids up to 6 hours. Carbohydrate-rich drinks 2-3 hours preoperatively reduce insulin resistance. Preoperative gabapentin, acetaminophen, and celecoxib reduce postoperative opioid requirements.
Intraoperative ERAS Elements
A minimally invasive approach reduces tissue trauma and recovery time. Goal-directed fluid therapy (GDFT) targets euvolemia with crystalloids at 1-3 mL/kg/hr, guided by stroke volume variation or cardiac output monitoring. Active warming maintains core temperature above 36 degrees Celsius to prevent SSI, coagulopathy, and cardiac events. Routine nasogastric tube placement is not recommended.
Postoperative ERAS Elements
Early oral intake (clear liquids and diet advancement within hours) is safe and reduces ileus. Ambulation within 4-8 hours reduces VTE, ileus, and pulmonary complications. Urinary catheters are removed within 6 hours for uncomplicated cases. Multimodal pain management (scheduled acetaminophen and NSAIDs, TAP blocks, opioids only for breakthrough) reduces opioid consumption by 40-60%.
Postoperative Complications
Surgical Site Infection
SSI occurs in 2-5% of clean-contaminated gynecologic cases. Prevention includes appropriate antibiotics, chlorhexidine prep, normothermia, glycemic control (glucose less than 180 mg/dL), and subcuticular closure. Vaginal cuff cellulitis presents with fever, pelvic pain, and purulent discharge.
Ileus and Bowel Obstruction
Expected postoperative ileus lasts 24-72 hours. Prolonged ileus requires evaluation for mechanical obstruction, electrolytes, and opioid effects. Early SBO typically presents 5-7 days postoperatively and is evaluated with CT.
Genitourinary Complications
Urinary retention occurs in 10-15% after pelvic surgery. Vesicovaginal fistula typically presents 7-14 days postoperatively with continuous leakage, diagnosed by methylene blue instillation.
<image>Anatomical illustration showing the transversus abdominis plane (TAP) block technique with ultrasound guidance, demonstrating needle placement between the internal oblique and transversus abdominis muscles at the anterior axillary line, with anatomic layers labeled</image>
Discharge Criteria and Follow-Up
Discharge readiness requires adequate oral pain control, diet tolerance, independent ambulation, spontaneous voiding, and no signs of complications. Same-day discharge is safe for laparoscopic hysterectomy in selected patients. Activity restrictions include no heavy lifting for 4-6 weeks and no vaginal intercourse for 6-8 weeks after hysterectomy. Follow-up is typically at 2-4 weeks.
Clinical Pearls
ERAS protocols reduce length of stay by 1-2 days and opioid use by 40-60% without increasing complications or readmissions. Preoperative carbohydrate loading and avoidance of prolonged fasting improve metabolic parameters and patient comfort. Cefazolin is the first-line prophylactic antibiotic with weight-based dosing (3 g for patients over 120 kg). Goal-directed fluid therapy is superior to both liberal and restrictive fixed-volume strategies. Extended VTE prophylaxis (28 days) is recommended after major gynecologic oncology surgery.
References
- Nelson G, Bakkum-Gamez J, Kalogera E, et al. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations -- 2019 update. Int J Gynecol Cancer. 2019;29(4):651-668.
- Berrios-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017;152(8):784-791.
- American College of Obstetricians and Gynecologists. Prevention of venous thromboembolism in gynecologic surgery. Practice Bulletin No. 232. Obstet Gynecol. 2021;138(1):e1-e15.
