Gynaecological Surgery

Introduction

Surgery has a central aim of helping people to live a longer or better life. Translated into medical terminology, this means improved survival and enhanced quality of life (QOL). QOL is a subjective measure, reported by the patient, and multiple factors affect how QOL would be rated at any point in time. An operation is in the middle of a much longer process of selecting the patients in whom surgery is most likely to bring short- or long-term benefit. A surprisingly small part of the process involves what are thought of as traditional surgical skills, such as incising, dissecting, and knot tying.

Preoperative Care

One of the assumptions underlying this framework is that people wishing to have surgery want to improve their survival and QOL. This can transpire in many person-specific forms. From a surgical perspective, it can mean performing surgery in an attempt to alleviate the underlying cause of a symptom which had been negatively affecting QOL, such as removal of an infected and inflamed appendix, with an immediate physical benefit. It could also mean performing surgery to remove both ovaries and fallopian tubes to improve something more intangible, such as ‘raised risk of developing cancer in the future’. In this situation, the benefit in QOL is psychological in the short term and, if successful, in the long term will avoid a future reduction in QOL by preventing the development of cancer.

The baseline, or preoperative, QOL represents what is at risk to the patient if the operation results in complications. A myomectomy (removal of a fibroid), intended to improve fertility, can rarely result in hysterectomy to control bleeding during the operation. This would mean a risk of a permanent, opposite effect on fertility and QOL to that hoped for preoperatively.

Knowing what patients hope to gain from an operation, how any complications would impact their overall QOL, and what they would consider an acceptable compromise are important when the decision to operate is made. An important question to ask is what would happen if no action was taken instead of performing an operation. In the case of myomectomy discussed earlier, the woman is likely to continue to have suboptimal fertility but would avoid the risk of a surgical complication which might remove fertility completely.

Unexpected findings or complications, by definition, occur during the operation. One of the options facing the surgeon is to continue with the operation in the knowledge that the discussion prior to surgery means that they know how to act in the best interests of the patient. Alternatively, the operation can be curtailed, with a subsequent explanation and further discussion with the patient of the implications of the new findings. This leads to an updated decision of whether to proceed with the surgery or not.

All of these factors are input into the consent process. The culmination of this process is represented by the consent form, completed by the patient and the surgeon. This process is ongoing—either party can veto the decision to proceed - even if the doctor thinks the patient is choosing the ‘worse’ option by declining surgery. This issue is sometimes raised in patients who would decline a blood transfusion. In the United Kingdom, any medical procedure, including transfusion, performed without the consent of the person may be considered assault from a legal standpoint. There are multiple forms of consent—implied, verbal, and written—and, typically, there are exceptions for emergency situations, for instance, when an unconscious patient is given lifesaving treatment. Legal definitions of an adult, a person able to give or withhold consent, and capacity for decision-making vary from country to country.

Preoperative optimisation improves the odds of a good outcome from the operation for the patient. The factors, which can be modified, depend on how much time there is available to do so before the operation. An unwell patient with hypovolaemic shock secondary to bleeding might need a blood transfusion while simultaneously being prepared for anaesthesia. In contrast, a patient who mentions a symptom such as angina incidentally could have a less urgent operation postponed to allow for further investigations. The ‘optimisation’ might take the form of other major surgery, such as a coronary artery bypass graft. Proceeding to surgery without optimisation can still be preferable if the risks of delaying surgery for preoperative optimisation are thought to be worse. Reducing or stopping smoking is almost always helpful, as is having a body mass index in the normal range. Medications to reduce blood loss and replace iron stores are frequently used for preoperative optimisation prior to gynaecological surgery in women who have heavy menstrual bleeding and anaemia.

The preoperative review of the patient on the day of planned surgery is the final chance to confirm or change the plan. Is the operation still required? Could it be that the heavy menstrual bleeding has stopped or the ovarian cyst has resolved spontaneously? This would mean that physiology has removed the potential gains in QOL hoped for from the operation and would greatly change the balance of benefit and harm to the patient from going ahead. A change in heart from a woman about wishing to try for a pregnancy in the future can mean that a previously planned operation could have the opposite effect to what is now desired.