REVIEW
Perioperative care
in gynaecology
Ivilina Pandeva
Mahmood I Shafi
Abstract
Perioperative care in gynaecology aims at optimizing patient’s condition
prior to surgery, ensuring the provision of most individually appropriate
treatment, minimizing postoperative morbidity, improving patient’s expe-
rience and reducing the length of stay in hospital.
Recent concept of care for patients undergoing elective surgery is
enhanced recovery programme. This is an evidence-based approach to
care in which the patient plays an important role through shared and
informed decision making.
It is designed to prepare patients, reduce the overall impact of surgery
and help them recover quickly. The process starts as early as at the GP
and at the point of referral with thorough preoperative assessment, iden-
tification of patient-specific risk factors, their optimization and appro-
priate preparation for surgery and planning of both inpatient and
outpatient postoperative care.
Keywords antibiotic prophylaxis; consent; day surgery; enhanced
recovery; gynaecology; perioperative care; postoperative complications;
preoperative assessment; preoperative tests; thromboprophylaxis
Introduction
Perioperative care in gynaecological surgery in conjunction with
the concept of enhanced or accelerated recovery aims at ensuring
that:

The patient’s condition is at its best prior to surgery e the
process starts as early as at the General Practitioner (GP) or
preassessment clinic and aims at identifying and address-
ing co-morbidities such as anaemia, hypertension, and
diabetes.

Patient receives the best possible care in the intraoperative
and postoperative period e receives the most appropriate
use of anaesthesia, minimally invasive operative tech-
niques where possible, optimal fluid balance management
and pain relief.

Patient experiences the best postoperative rehabilitation e
availability of rehabilitation service, aiming at early
Ivilina Pandeva MBBS RCOG/RCR Dip is a Speciality Registrar in Obstetrics and
Gynaecology at Addenbrooke’s Hospital, Cambridge University Hospital
NHS Foundation Trust, Cambridge, UK. Conflicts of interest: none declared.
Mahmood I Shafi MB BCh MD DA FRCOG is a Consultant Gynaecological
Surgeon and Oncologist at Addenbrooke’s Hospital, Cambridge
University Hospitals NHS Foundation Trust, Cambridge, UK. Conflicts of
interest: none declared.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 22:2
mobilization after surgery, early recovery and discharge
from hospital.

Improve overall patient’s satisfaction.
Preoperative care
Referral from primary care
Optimizing patient’s condition prior to surgery should commence
at the level of primary care with the GP playing a major part at
the time of referral.
By using ‘fit for list’ health screening, GPs could identify and
address causes for increase morbidity prior to referral such as
anaemia, hypertension, sub-optimal diabetic control, impaired
renal function, obesity, smoking, early screening for social
problems or needs which could affect postoperative discharge.
Detection and treatment in the community of anaemia,
uncontrolled diabetes, hypertension, hypercholesterolaemia that
are recognized risk factors for delay of surgery. Optimizing these
conditions prior to referral reduce the potential increased length
of stay, morbidity, mortality, High Dependency Unit (HDU) or
Intensive Therapy Unit (ITU) admissions and re-admissions.
The use of programmes such as smoking cessation, weight
reduction and encouraging self-management, patient’s condition
and satisfaction is improved by direct involvement in their own
care.
Preoperative assessment
Preoperative assessment is performed in specialist setting once
surgery has been chosen as an option.
The selection of the appropriate procedure for the appropriate
patient occurs in the gynaecology outpatient clinic, where patient
should be given all the necessary information for the procedure
including the alternative options of non-treatment.
Leaflets and contact telephone numbers should be provided if
further queries arise in-between the initial appointment and day
of surgery, as only 10% of the information given in clinic is
retained by the patient.
The preoperative assessment is the time when the patient has
the opportunity to establish relationship of trust and confidence
with the healthcare provider by sharing information about the
proposed procedure and answering any questions that might
have occurred.
Clinical history and examination
The assessment of the patient should include review of the
medical, surgical, anaesthetic and drug history by using methods
of interview, review of available medical records or the use of
organ system based questionnaires.
The physical examination should include airway, pulmonary
and cardiovascular examination to assess the risk of anaesthetic
complications. Occasionally abdominal and pelvic examination
is necessary to ensure no further pathology could be identified as
this could alter the surgical management. However the need for
this would be directed by the history as in most cases, gynae-
cological examination has been undertaken in gynaecological
outpatient clinic at the time of discussion of appropriate treat-
ment for the particular case.
38 Ó 2011 Elsevier Ltd. All rights reserved.

Consent
Obtaining consent could be performed in the gynaecological
outpatient clinic at the decision for certain procedure. A more
appropriate time for this would be at the preassessment
appointment, when the patient has had time to weigh her
options, collate the provided information in outpatient clinic
such as written materials and DVDs, and discuss with family,
friends and GP. This gives opportunity for questions or uncer-
tainties to be addressed and ensures that through a process of
informed and shared decision making, the patient has been fully
informed and understands the potential risks, benefits, alterna-
tive treatments and recovery paths.
The Royal College of Obstetricians and Gynaecologists has
issued guidance on the process of consent. The risks and likeli-
hood of complications with the proposed procedure should be
portrayed in a way that is easy to be understood. Risk should be
ideally quantified as a frequency with the use of numerical aids
rather than percentages (Table 1).
The consent should include any further procedure that might
be necessary in event of complications such as laparotomy for
visceral or vascular damage that occurs during laparoscopy.
Any procedure that the patient would object to needs to be
specifically and clearly documented.
Consent for treatment prior to surgery, including the benefits,
potential risks and management of intraoperative complications
should be taken by someone, capable of performing the proce-
dure or has good experience of the procedure. The operating or
supervising surgeon should confirm this on the day of operation.
Preoperative test
Preoperative tests should be considered only after the assessment
of the patient. Performing unnecessary and expensive investiga-
tions for healthy, asymptomatic patients should be avoided, as this
could potentially add to the anxiety levels and increase the cost,
without having positive effect on the management of the patient.
According to the National Institute for Clinical Excellence
(NICE) preoperative tests should be undertaken with the
consideration of patient’s age, physical American Society of
Anaesthesiologists (ASA) status (Table 2), the grade and extent
of the surgery (Table 3) and the presence of co-morbidity.
The abridged version of the NICE guidance presents the
different combinations of these four parameters and the appro-
priate tests needed.
The preoperative investigation that might be required and
considered by NICE include:
Presenting information on risk
Very common 1/1e1/10 A person in
Common 1/10e1/100 A person in
Uncommon 1/100e1/1000 A person in
Rare 1/1000e1/10,000 A person in
Very rare <1/10,000 A person in
Royal College of Obstetricians and Gynaecologists
Table 1
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 22:2
REVIEW
American society of anaesthesiologists (ASA) physical
status classification
C A normal healthy patient
C A patient with mild systemic disease
C A patient with severe systemic disease
C A patient with severe systemic disease that is a constant threat
to life
C A moribund patient who is not expected to survive without the
operation
C A declared brain-dead patient whose organs are being removed
for donor purposes
Table 2

Plain chest X-ray

Resting electrocardiogram (ECG)

Full blood count

Haemostasis e including prothrombin time, activated
partial thromboplastin time and international normalized
ratio (INR)

Renal function (including tests for potassium, sodium,
creatinine and/or urea levels)

Random blood glucose

Urine analysis (urine dipstick test e test for pH, protein,
glucose, ketones, blood/haemoglobin)

Blood gases e for ASA grades 2 and 3 only

Lung function (peak expiratory flow rate, forced vital
capacity and forced expiratory volume) e for ASA grades 2
and 3 only.
Prior to surgery, women of childbearing age should have
a pregnancy test performed with woman’s consent as certain
procedures carry anaesthetic and surgical risk to the fetus.
MRSA screening
Methicillin-resistant Staphylococcus aureus (MRSA) is resistant to
commonly used anti-staphylococcal antibiotics such as penicillins,
Classification of surgical interventions in different
intensity (and risk) categories
Grade 1 (minor) Excision of lesion of skin; drainage of breast
abscess; carpal tunnel release; nasal septum correction
Grade 2 (intermediate) Primary repair of inguinal hernia; excision of
varicose vein(s) of leg; tonsillectomy/adenotonsillectomy; knee
arthroscopy; endoscopic bladder procedure; eye lens substitution
Grade 3 (major) Total abdominal hysterectomy; endoscopic resec-
tion of prostate; lumbar discectomy; thyroidectomy; diaphragmatic
family
hernia repair; operations on trachea; prosthetic femoral head
street
replacement
village
Grade 4 (majorþ) Total joint replacement; lung operations; radical
small town
neck dissections; organ transplantations
large town
Neurosurgery
Cardiovascular surgery
Table 3
39 Ó 2011 Elsevier Ltd. All rights reserved.
 REVIEW
cephalosporins, erythromycin and ciprofloxacin. MRSA potentially
could cause sepsis, endocarditis, and pneumonia, particularly in
elderly and immuno-compromised patients.
In accordance with the policy issued by the Department of
Health (DH) and Regional Strategic Health Authority (SHA), all
patients admitted for elective surgery, including day case
admissions should have MRSA status checked. Usually this is
performed at the preassessment appointment. It is the clinician’s
responsibility to follow up this result prior to proceeding with the
surgical intervention.
If a patient is found to be MRSA positive, treatment should be
started and the patient’s GP notified.
The decision to proceed with the operation would depend on
the clinical urgency, the type and extent of surgery and the
potential risk of MRSA infection.
If surgery is necessary in an MRSA positive patient, precau-
tions are undertaken such as theatres need to be informed, the
patient should be last on the operative list and there should be
a side room available for the care of the patient in the post-
operative period.
Venous thromboembolism (VTE) assessment
Following gynaecological surgery there is 16% incidence of deep
venous thrombosis (DVT) and 1% of symptomatic pulmonary
embolism (PE) without thromboprophylaxis. It is a mandatory
requirement now in the UK that all patients undergo venous
thromboembolism risk assessment prior to surgery and hospital
admission. Depending on the calculated risk, patients receive
gradual compression thromboembolitic stockings or low molec-
ular weight heparin (LMWH) either alone or in combination.
LMWH (Enoxaparin, Tinzaparin) have wide application in view
of their relatively short half-life, easy administration and lack of
need for close therapeutic monitoring.
Drug history and current medications
Careful evaluation of patient’s current medications should be
undertaken, as some medications need to be reconsidered or
stopped prior to surgery. Patients should be advised on which
medication to omit or take on the day of surgery.
Anticoagulant therapy
Considering surgery on patients on oral anticoagulants is a risk-
benefit balance. The major concerns are of haemorrhage versus
the risk of thromboembolism.
Prior to major surgery in most cases, patients on long-term
oral anticoagulant therapy will need to be converted to low
molecular weight heparin (LMWH), aiming for the international
normalized ratio (INR) to be <1.5 on the day of the procedure.
Following the operation, when the risk of bleeding is low, the
oral anticoagulant needs to be re-introduced together with the
low molecular weight heparin (LMWH), until the INR reaches
therapeutic range.
This process could contribute to delayed discharge, therefore
it is important to have preoperative plans in place and close
collaboration with GP and anticoagulant clinic.
Antiplatelet medications
Vast majority of patients receive antiplatelet agents as a part of
a prophylaxis or treatment for cardiovascular disease. Most
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 22:2
commonly used are Aspirin and Clopidogrel both of which
inhibit platelet aggregation and increase the perioperative
bleeding risk. This risk increases to around 1% with their
simultaneous application/dual regimen.
Both Aspirin and Clopidogrel can be continued through the
operative period if the risk of bleeding does not exceed the
benefits.
However in gynaecological surgery usually these agents are
stopped 5e7 days prior to the day of operation, which corre-
spond to the platelet half-life.
In cases of significant haemorrhage, pooled platelet trans-
fusion or antifibrinolytic agent such as tranexamic acid could be
considered.
Oral contraceptive pill and hormone replacement therapy
(HRT)
It is generally advised that the combined oral contraceptive pill
should be stopped 4e6 weeks prior to major surgery, as this
increases the risk of venous thromboembolism. Alternative
methods of contraception need to be put in place. The risks of
pregnancy need to be balanced with the risk of venous throm-
boembolism prior to discontinuing oral contraception.
It is not necessary to discontinue oral contraception for minor
surgery, as the risk of venous thromboembolism is low with
early mobilization and appropriate hydration. The progesterone
only pill increases minimally the risk for VTE; therefore this does
not need to be stopped prior to an operation.
HRT equally adds minimally to the risk of venous thrombo-
embolism. The age group taking HRT will likely require
prophylactic thromboprophylaxis; therefore it is not necessary to
stop the HRT prior to surgery.
Cardiovascular disease drugs
The general recommendation is for all anti-hypertensive, anti-
arrhythmic and diuretic agents for the treatment of cardiovas-
cular disease to be continued as usual in the perioperative period,
including the day of surgery.
Respiratory disease drugs
Same principles apply for anti-asthmatic and chronic obstructive
pulmonary disease (COPD) agents. Discontinuing these medica-
tions would increase the risk of exacerbation of the chronic
condition; therefore their use is advocated throughout the peri-
operative period.
Anti-epileptic medications
There is increased risk of seizures in the perioperative period in
patients with seizure disorders. All anti-epileptic agents should
be continued throughout, including the day of surgery.
Diabetes
Patients with diabetes should ideally be planned to be first on the
operating list to decrease the nil by mouth period and minimize
the glucose metabolism disruption.
In patients with type 1 insulin-dependant diabetes, undergoing
major surgery, their usual insulin is omitted on the day of surgery
and an intravenous ‘sliding scale’ insulin regimen started.
In the postoperative period the usual insulin regimen is
restarted once oral feeding is re-established.
40 Ó 2011 Elsevier Ltd. All rights reserved.
 REVIEW
In type 2 non-insulin dependant diabetes, the oral hypo-
glycaemic medications are omitted on the day of surgery. Insulin
sliding scale is considered in cases of major surgery, capillary
blood glucose level of more than 12 mmol/l, ketonuria or if delay
in establishing enteral feeding following the operation is
anticipated.
Day-case surgery
Day surgery is the admission of selected patients to hospital for
a planned surgical procedure and discharge home on the same
day. The day surgery programme has been a key stand of the
NHS modernization for the last 10 years. The NHS aims for 75%
of all elective procedures to be performed as day cases (Day
surgery: Operation guide. Department of Health, 15 August
2002).
With the appropriate patients’ selection, the benefits of day-
case surgery are:

Faster recovery at the patient’s own home

Reduced risk of cancellations due bed shortage

Reduced risk of hospital acquired infections

Reduction in waiting lists

In-patients bed availability for major cases

Cost-effective health care.
The aim to use more and more minimally invasive surgical
techniques, as part of the enhanced recovery programme, has
added to the goal of performing day-case surgery. In gynaeco-
logical surgery many of the procedures can be performed lapa-
roscopically if appropriate. Laparoscopy has the benefits of less
surgical trauma, small incision, less postoperative pain, faster
recovery. Patients undergoing laparoscopic surgery have shorter
hospital stay, are able to return sooner to their normal activities
and have higher satisfaction from the overall care.
Intraoperative care
Anaesthetic factors
Meticulous intraoperative fluid balance and optimal analgesia are
keys for smooth postoperative recovery and shorter hospital stay.
Regional anaesthetic techniques and nerve blocks have been
recommended over the use of long-acting opiates.
For postoperative pain control in particular in open abdominal
surgery the use of epidural analgesia or when not appropriate
patient-controlled analgesia (PCA) seems to have good effect on
convalescence.
The use of regular paracetamol and non-steroidal anti-
inflammatory agents can be effective and decreases the use of
opiates.
Nausea and vomiting
Intraoperative anti-emetics could be considered as appropriate,
however their routine use is not practiced.
Anti-emetics as first line or “as required” should be prescribed
on the patient’s drug chart and administered at first symptoms.
Surgical factors
Incision: as mentioned previously the aim should be at per-
forming surgery with minimal access techniques when possible,
to reduce the surgical trauma to the patients and aid their faster
recovery.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 22:2
When this is not feasible, transverse suprapubic incision is the
norm unless suspected/diagnosed ovarian cancer or difficult
surgery is anticipated, when midline incision is used.
Drains: the routine use of drains is not practiced, as this does not
reduce the postoperative morbidity. On the contrary they
increase the risk of infection, decrease patient’s mobility and
prolong hospital admission.
They have a role to play in certain high risk and complex
procedures and should be dictated by clinical need.
Antibiotic prophylaxis: it is commonly used in gynaecological
surgery as part of the aim to reduce postoperative infection rate.
The decision for antibiotic administration depends on the
patient’s co-morbidities, allergy status, extent of the procedure,
local antimicrobial policy and surgeon’s preference.
The World Health Organization (WHO) Safer Surgery check-
list recommends, to achieve maximum antibiotic tissue concen-
tration, antimicrobial prophylaxis should be given 60 min or less
before “knife to skin”.
Minor procedures involving instrumentation of the uterus
(hysteroscopy, insertion of intra-uterine device) do not require
the routine use of antibiotics, however in the high-risk group of
sexually transmitted infection (age < 20, nulliparity, multiple
sexual partners), screening should be offered prior to surgery. If
the results are not known, postoperative Chlamydia prophylaxis
with doxycycline or azithromycin should be given. Similar
principles apply for surgical termination of pregnancy with the
addition of oral metronidazole.
Hypothermia: body temperature should be maintained above
36.5  C to decrease postoperative complications. Routine moni-
toring of patient’s temperature in theatre, the use of air-warming
system and intravenous fluid warmers can prevent hypothermia.
Information and education of the patients regarding hypo-
thermia, encouraging them to bring extra clothing to hospital and
to report feeling cold to staff adds to prevent hypothermia in the
pre- and postoperative period.
Postoperative period
In the postoperative period the emphasis is on the patients
receiving optimal care to aid with the recovery.
Pain management
Optimizing pain relief in the postoperative period aids signifi-
cantly with the recovery process, early nutrition and rehabilita-
tion. In most hospitals there are Trust-established guidelines on
postoperative pain management and the use of step-down
analgesia.
In major abdominal surgery, especially with midline lapa-
rotomy, combined regimen of analgesia for the first 24e48 h is
preferred with either a thoracic epidural, spinal or patient-
controlled analgesia. Mobile epidural could be considered to
allow early mobilization. Spinal analgesia has advantages of
lower insertion rate failure, lower risk of complications and not
affecting patient’s mobility on the morning following surgery.
Step-down analgesia is contemplated as part of the recovery
process with combination of regular paracetamol, a non-steroidal
41 Ó 2011 Elsevier Ltd. All rights reserved.
 REVIEW
anti-inflammatory medication and mild opioid such as codeine
sulphate, unless contraindicated. For breakthrough pain stronger
opioid such as oramorph or oxycodone could be used.
Anti-emetics and stool softeners should be prescribed to
minimize side effects.
Nutrition
Early postoperative nutrition is encouraged as this has been
shown to reduce the postoperative hospital stay with no effect on
the incidence of ileus or vomiting. This can be started with sips of
water and built up as tolerated by the patient. In addition, energy
drinks could be used in the immediate postoperative period.
Where there is delay in feeding or previous malnutrition, the
input of dietician is important to consider further supplements or
parenteral feeding in severe cases.
Early rehabilitation
Early mobilization aids with decreasing the risk of venous
thromboembolism, abdominal distension secondary to gas
entrapment and promotes gut function. This also empowers the
patients and actively involves them in the process of enhanced
recovery. The physiotherapists play a major role in the reducing
hospital stay and improving patient’s satisfaction and shortening
the period of returning to normality. Chest physiotherapy in the
postoperative period significantly reduces the incidence of chest
infection in particular in elderly patients undergoing major
gynaecological surgery.
Patients could be encouraged once able to change in to their
usual clothes to aid mobilization by reducing the feeling of
discomfort of the hospital environment.
Bladder care
Depending on the type of surgery and anaesthesia used, an
indwelling catheter is sited to monitor urine output and aid with
the bladder emptying in the immediate postoperative period
without the need to mobilize. In recent practice the aim is to
remove catheters as soon as possible after surgery to help with the
early rehabilitation and reduce the risk of urinary tract infection.
Catheter removal after major surgery requires calculating residual
bladder volumes to ensure complete voiding. Residuals higher
that 150 ml may require recatheterization and discharge of the
patient with indwelling catheter and a leg bag. Plan for review in
7e10 days for a trial without a catheter is adopted and if this fails
then intermittent self-catheterization is taught.
Postoperative complications
Bleeding
Intra-abdominal bleeding in the immediate postoperative period
is a recognized complication of abdominal surgery, despite
meticulous surgical technique and careful intraoperative atten-
tion to haemostasis.
Sudden drop in the blood pressure associated with marked
tachycardia and deterioration in the patient’s condition should
raise the suspicion of postoperative bleeding and medical review
should be performed as a matter of emergency.
Assessment should be performed using ABC approach with the
aim to initially stabilize the patient and consider re-exploration.
The decision for the latter is taken at a senior level. Large bore
intravenous access should be obtained and FBC and cross match of
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 22:2
4e6 Units of blood considered. Initial fluid replacement is per-
formed with the use of crystalloids as they have good effect on the
extra-cellular compartment, and colloids to replace intravascular
volume. Blood transfusion should be commenced as soon as
possible in cases of significant blood loss. Early haematology
involvement is recommended in case of major haemorrhage, as
there is increased risk of consumptive coagulopathy.
Postoperative infection
Single episode of raised temperature of 37.6  C and above in the
immediate postoperative period usually resolves spontaneously.
However if the pyrexia persists on consecutive assessments
and beyond 24 h of surgery, site of infection should be sought.
Review of the history and full clinical assessment should take
place including examination of chest, heart sounds, abdomen,
wound appearance and legs/calves to look for signs of DVT.
FBC, U&E, LFTs and CRP should be requested for evaluation
of inflammatory markers, look for anaemia and exclude renal or
liver function compromise.
Blood cultures, mid-stream urine or catheter specimen,
wound swabs or sputum for culture if indicated should be sent
for culture and sensitivity.
If wound infection is suspected antibiotic of choice is Flu-
cloxacillin or a macrolide in case of Penicillin allergy such as
Clarithromycin.
Initially if no source of infection is identified, empiric broad-
spectrum intravenous antibiotic could be started. As soon as
culture sensitivity results are available, the choice of antibiotic
should be reviewed to ensure the most appropriate treatment is
administered. Close collaboration with microbiology sometimes
is essential in the correct management of postoperative pyrexia.
Imaging techniques such as chest X-ray, USS or CT scan could
aid in identifying localized source of infection such as pelvic
collection, abscess, pneumonia, atelectasis etc.
Injury to internal organs
Bowel: bowel injury occurs rarely in gynaecological surgery with
incidence between 0.3% and 0.8%. Risk factors include major
gynaecological oncology surgery, the presence of endometriosis,
previous pelvic inflammatory disease, abdominal or pelvic
radiotherapy.
Suspicion for this is raised in cases of persistent nausea,
vomiting, abdominal distension and commonly with the absence
of bowel sounds.
CT imaging usually helps with the diagnosis and initial
management is of stabilizing the patient by rehydration, insertion
of naso-gastric tube and starting broad-spectrum antibiotics.
Multidisciplinary team involvement is necessary for consid-
eration of re-exploration.
Injury to urinary tract
This includes injury to the urinary bladder and ureters and is
a recognized complication of hysterectomy. The incidence of
bladder injury ranges between 0.2% and 1.8% and that of
ureteric injury between 0.03% and 1.5%.
Common sites of ureteric injury are at the level of the
infundibulo-pelvic ligament, the uterosacral ligament where the
ureter crosses under the uterine artery and at ureteric insertion
into the bladder.
42 Ó 2011 Elsevier Ltd. All rights reserved.

Many of these injuries are not recognized until the post-
operative period.
Ureteric injury usually presents with loin pain, pyrexia,
raising creatinine and urea levels, reduced or absent urine output
in case of bilateral ureteric transection.
Thromboembolism
The incidence of postoperative venous thromboembolism has
significantly decreased after the implementation of mandatory
VTE risk assessment and thromboprophylaxis.
However if suspicion of DVT or PE is raised in the post-
operative period, careful assessment and further investigations
will be necessary. Doppler ultrasound will help in the diagnosis
of a DVT (sensitivity of 97%). However in cases with high
suspicion and negative venous ultrasound, therapeutic dose of
LMWH should be continued and USS repeated in 1 week’s time.
Computerized tomography pulmonary angiogram (CTPA) is
the recommended modality in the investigation of suspected
pulmonary embolism. VQ-scan could be considered in cases of
a normal chest X-ray and the absence of cardiopulmonary disease.
If PE is confirmed then therapeutic dose of LMWH should be
started and converted to oral anticoagulant (Warfarin) once the
risk of postoperative bleeding is low. Anticoagulant clinic referral
should be made for continuation of therapy for 3e6 months and
further follow.
Discharge
In accordance with the overall tendency of reducing hospital
stay, a planned discharge date or expected hospital stay should
be discussed with the patient at the preadmission assessment.
This would help the patient to make relevant arrangements and
also highlight social problems prior to admission, which could
inevitably delay discharge. It is important that patients are dis-
charged when this is clinically appropriate and they feel that they
could safely cope at home and have the necessary support.
A clear discharge summary should be provided with infor-
mation on the perioperative events, immediate management,
analgesia and follow up.
Patients should be given information and contact numbers in
case of an emergency arising from their surgery. A C
FURTHER READING
American Society of Anesthesiologists; ASA relative value guide, http://
www.asahq.org/clinical/physicalstatus.htm; 2002.
Day surgery: operation guide. Department of Health, August 2002.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 22:2
REVIEW
Delivering enhanced recovery: helping patients to get better sooner after
surgery. Department of Health, March 2010.
Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of
antithrombotic therapy: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines (8th edn). Chest Jun 2008;
133(6 suppl): 299Se339.
MRSA screening e operational guidance. Department of Health, July
2008.
National Institute for Clinical Excellence. Clinical guidance: CG3. Preop-
erative tests. The use of routine preoperative tests for elective
surgery; NICE, August 2003. http://www.nice.org.uk/pdf/PreopTests_
Apps.pdf Association of Anaesthetists of Great Britain and Ireland.
Pre-operative assessment. The role of the anaesthetist; 2001.
National Institute for Clinical Excellence. Clinical guidance: CG46. Venous
thromboembolism: reducing the risk of venous thromboembolism
(deep vein thrombosis and pulmonary embolism) in patients under-
going surgery. London: NICE, April 2007.
National Institute for Clinical Excellence. Clinical guidance: CG65.
Management of perioperative hypothermia in adults. London: NICE,
April 2008.
Royal College of Obstetricians and Gynaecologists. Clinical governance
advice no.6. Obtaining valid consent. London: RCOG, December 2008.
Royal College of Obstetricians and Gynaecologists. Clinical guidance no.
19. Hormone replacement therapy and thromboembolism. London:
RCOG, May 2011.
Practice points
C Preoperative assessment is based mainly on history and
examination with avoidance of routine preoperative tests for
healthy individuals
C The presence of concurrent disease will require liaison with
anaesthetist and other specialists
C Choice of best procedure, adequate access, use of minimally
invasive techniques where possible, minimizing use of drains,
routine antibiotic prophylaxis and avoiding hypothermia are
widely practiced
Adequate pain control, early nutrition and early rehabilitation
aid with fast recovery
C Daily reviews for early identification of potential postoperative
complications and their prompt management
C Patients should receive postoperative advice on expected
recovery rates, levels of discomfort, activities
43 Ó 2011 Elsevier Ltd. All rights reserved.