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Chapter 47: Perioperative, Intraoperative, & Postoperative Complications in Gynecologic Surgery

Cecilia K. Wieslander; Kyle Bukowski

PREOPERATIVE COMPLICATIONS

One of the main purposes of the preoperative history and physical exam is to identify any preoperative medical comorbidity that may lead to an increased perioperative morbidity or mortality. If comorbidities are identified, the surgeon should obtain medical consultation to ensure that the patient’s medical conditions are optimized and stable enough to proceed with surgery at an acceptable risk.

CARDIOVASCULAR DISEASE

Clinical Findings

Most gynecologic surgeries fall in the category of low (< 1%) or intermediate (1–5%) risk of cardiac death or nonfatal myocardial infarction (Table 47–1). It is crucial to obtain a careful preoperative history to discover cardiac and/or comorbid diseases that would place the patient in a high surgical risk category. If the patient is found to have active cardiac conditions, such as unstable coronary syndrome, decompensated heart failure, significant arrhythmias, or severe valvular disease, the surgery should be delayed or cancelled (unless emergent), and the patient should be evaluated and treated (Table 47–2).

Table 47–1.Cardiac risk (cardiac death and nonfatal myocardial infarction) for noncardiac procedures.
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Table 47–1. Cardiac risk (cardiac death and nonfatal myocardial infarction) for noncardiac procedures.
Risk Stratification Examples of Procedures
High (vascular surgery) (reported risk > 5%)

Aortic and other major vascular surgery

Peripheral vascular surgery
Intermediate (reported risk 1–5%)

Intraperitoneal surgery

Intrathoracity surgery

Carotid endarterectomy

Head and neck surgery

Orthopedic surgery

Prostate surgery
Low risk (reported risk < 1%)

Endoscopic procedures

Superficial procedures

Cataract surgery

Breast surgery

Ambulatory surgery

Modified with permission from Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol 2007 Oct 23;50(17):1707–1732.

Table 47–2.Clinical risk factors for increased perioperative cardiovascular complications (myocardial infarction, heart failure, death).
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Table 47–2. Clinical risk factors for increased perioperative cardiovascular complications (myocardial infarction, heart failure, death).
Active cardiac conditions that requires intensive management and may result in delay or cancellation of surgery unless the surgery is emergent

Unstable coronary syndromes

 Including unstable or severe angina or recent myocardial infarction (within 30 days)

Decompensated heart failure

 Including NYHA functional class IV or worsening or new-onset heart failure

Significant arrhythmias

 Including high-grade AV block, Mobitz II AV block, third-degree AV block, symptomatic ventricular arrythmias, supraventricular arrythmias (including atrial fibrillation) with uncontrolled ventricular rate (> 100 bpm at rest), symptomatic bradycardia, newly recognized ...

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