Preoperative preparation and postoperative period of gynecological patients

Every surgical operation affects the vital processes of the body as a whole. Along with physical trauma, one should also take into account the psychological impact, pain, the effect of drugs on the body, loss of fluid, electrolytes, heat and many other factors. The success of the operation depends on:

• correct assessment of indications and contraindications for surgical intervention;
• thoroughness of examination of the patient and preoperative preparation;
• choice of anesthesia method, time and nature of the operation;
• techniques for performing the operation;
• therapeutic and preventive measures in the postoperative period.

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Indications for surgical treatment

Indications for surgery can be absolute and relative.

Absolute indications are conditions that directly threaten the life of a woman, accompanied by a picture of acute abdomen (bleeding during ectopic pregnancy, rupture or perforation of the uterus, twisting of the ovarian cystadenoma stalk, rupture of an abscess of the uterine appendages with the leakage of pus into the abdominal cavity and the development of peritonitis, etc.) or external bleeding (with malignant tumors of the female genital organs, submucous uterine myoma) with posthemorrhagic anemia.

Examples of relative indications for surgical intervention include prolapse of the vaginal and uterine walls, malformations of the genital organs that do not cause concomitant complications, etc.

Selecting the method of operation

When choosing a possible method and volume of surgical treatment, the following data are taken into account: the nature of the underlying disease, the presence of concomitant diseases, the patient's age, living and working conditions, and bad habits. In young women without malignant tumors, organ-preserving surgeries are advisable. In women of climacteric age and in menopause, more radical surgeries are performed. Concomitant extragenital diseases, as well as the elderly age of the patient, are an indication for a simpler, quicker and easier operation. The surgical plan may be changed during the operation. This depends on additional data obtained during the operation, as well as on the occurrence of complications (bleeding, collapse, shock, injury to adjacent organs, etc.).

For pain relief during gynecological surgeries, both local (including epidural) and general anesthesia are used. There are a large number of narcotic, analgesic drugs, muscle relaxants, neuropletics, ganglionic blockers and antihistamines that allow for modern anesthetic care during a wide variety of surgeries and for managing vital functions of the body during surgery.

Preoperative preparation

The duration of the preoperative period is determined by the nature of the underlying and concomitant diseases. In emergency surgeries, the duration of preoperative preparation is minimal. And in planned surgeries, especially in patients with severe concomitant diseases, it is calculated in days, sometimes weeks.

Preoperative examination

During preoperative preparation, the general condition of the patient is determined, the main diagnosis is specified, and concomitant diseases are identified. The examination begins in the outpatient setting, which significantly reduces the patient's stay in the hospital before the operation. There is a volume of clinical and laboratory tests that are carried out on patients regardless of the nature of the disease.

The scope of examination of gynecological patients before surgery

For minor and diagnostic operations

• Clinical blood test.
• Clinical urine analysis.
• Blood test for RW.
• Blood test form 50.
• Blood test for HBAg.
• Chest X-ray.
• Analysis of vaginal smear for biocenosis.
• Cervical smear analysis for atypia.

For abdominal operations

• Clinical blood test (platelets + clotting time).
• Clinical urine analysis.
• Crop analysis on RW.
• Blood test form 50.
• Blood test no HBAg.
• Chest X-ray.
• Certificate of oral cavity sanitation.
• Analysis of vaginal smear for biocenosis.
• Cervical smear analysis for atypia.
• Biochemical blood test (total protein, bilirubin, glucose, ALT, AST).
• Coagulogram (prothrombin).
• ECG.
• A therapist's conclusion that there are no contraindications to surgical treatment.
• Diagnostic curettage data (for uterine tumors)

If concomitant diseases are detected (chronic tonsillitis, bronchitis, caries, colpitis, endocervicitis, etc.), the patient must first undergo appropriate treatment.

For examination of gynecological patients, in addition to the usual ones, additional research methods are used (according to indications), the scope of which is determined by the underlying disease.

Considering the cyclical hormonal changes that occur in the female body, the first days after the end of menstruation are considered a favorable time for surgery. Planned surgeries should not be performed during menstruation.

Preparing the patient for surgery

The duration and nature of preoperative preparation may vary depending on the general condition of the patient, the underlying and concomitant diseases, and age.

Before the operation, the functional state of the body's vital systems and their reserve capabilities are assessed. The planned operation is performed against the background of stable compensation and remission of concomitant diseases.

Evaluation of the cardiovascular system consists of analyzing the contractility of the myocardium, changes in the vascular system as a whole and in its individual basins (pulmonary circulation, cerebral vessels, myocardium). If pathological changes are detected, preoperative preparation of the patient is carried out in a therapeutic hospital (department).

When assessing the respiratory system, attention is paid to the manifestation of chronic diseases. Prevention of postoperative complications includes physiotherapeutic measures aimed at normalizing external respiration. According to indications, drug therapy is carried out aimed at restoring the patency and drainage function of the respiratory tract.

Preparation of the gastrointestinal tract requires special attention. The oral cavity and nasopharynx are sanitized beforehand. The diet in the preoperative period should be high in calories, but not abundant. The intestines should be emptied daily. On the eve of the operation, all patients are given a cleansing enema. Laxatives are rarely prescribed for preparation for surgery at present, since their action can result in acidosis and intestinal paresis. When preparing patients for intestinal surgery (grade III perineal ruptures, intestinal-vaginal fistulas), a laxative is prescribed 2 days before the operation, and a cleansing enema is given the day before and on the day of the operation.

Liver preparation. Dietary restrictions on the day of surgery and after it lead to significant glycogen consumption, so it is recommended to administer glucose immediately before and during the operation. Persistent impairment of the main liver functions is a contraindication to surgery.

Preparation of patients for vaginal surgeries. The operation is performed with normocenosis or intermediate type of vaginal biocenosis. In case of dysbiotic and/or inflammatory processes, therapy is carried out aimed at restoring normal microflora. In case of bedsores, tampons with fatty ointments or emulsions, sea buckthorn oil are used, and medicinal forms containing estriol are administered. Since treatment of bedsores takes a lot of time, it is recommended to carry it out on an outpatient basis.

General preparation. The doctor is obliged to conduct psychoprophylactic preparation of the patient, explain to her the nature of the upcoming operation, strengthen confidence in the successful outcome of the surgical intervention. Bekhterev's mixture or tranquilizers (trioxazine, chlordiazepoxide, or elenium, etc.) are prescribed for several days before the operation. The result of general preoperative preparation is obtaining written informed consent from the patient for the surgical intervention. On the eve of the operation, premedication is started on the recommendation of the anesthesiologist.

The patient has the right to refuse the operation right up until its very beginning.

Contraindications to surgical treatment

When deciding on surgical treatment, it is necessary to take into account contraindications to surgery. These include, in particular, severe cardiovascular diseases, diseases of the respiratory system, liver, kidneys and other organs and systems that sharply disrupt the general condition of the body and its compensatory and adaptive mechanisms. However, in some cases of emergency care for vital indications, surgery must be performed despite the existing contraindications. Contraindications to planned surgeries in gynecological patients usually include concomitant acute infectious diseases (flu, acute respiratory diseases, etc.), pyoderma, bedsores on the vaginal part of the cervix, inflammation of the vaginal mucosa (before vaginal surgeries).

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Complications in the postoperative period

The most serious postoperative complication is bleeding. It may occur when the ligature slips off the vessel, from a vessel that was not ligated during the operation, with purulent melting of the vessel wall, and also from small vessels with a violation of the coagulation and anticoagulation systems of the blood. The clinical picture of internal bleeding is characterized by pallor of the skin and mucous membranes, shortness of breath, a collapsed state, a frequent small pulse, and a decrease in blood pressure. To clarify the diagnosis of internal bleeding, a vaginal examination is necessary. If there is liquid blood in the abdominal cavity, then a bulge of the posterior vaginal fornix is usually determined. In the case of retroperitoneal bleeding, a hematoma is palpated (most often between the layers of the broad ligaments of the uterus). Percussion reveals free fluid in the abdominal cavity or dullness of sound over the hematoma. The diagnosis can be clarified by performing ultrasound and MRI of the abdominal organs, which reveal free fluid in the abdominal cavity. The presence of internal bleeding is an indication for repeated laparotomy to ligate the bleeding vessels. Bleeding with the formation of a hematoma can be from the vessels of the anterior abdominal wall: In this case, ligation of the bleeding vessel and removal of blood clots are indicated. In case of bleeding after vaginal operations, it is easier to make a diagnosis, since there is external bleeding. To stop it, ligation of the vessels or vaginal tamponade are performed.

Shock and collapse are severe complications of the postoperative period. Shock occurs after long and traumatic operations accompanied by massive blood loss. In the pathogenesis of its development, the leading role belongs to hemodynamic disorders and all vital functions of the body. Clinically, shock manifests itself in mental depression, apathy while maintaining consciousness, a small, frequent pulse, pale skin, cold sweat, decreased temperature and blood pressure; oliguria or anuria may be observed. At the same time, metabolism is disrupted, acidosis occurs, the number of erythrocytes increases, and blood volume decreases.

Collapse is caused by primary damage to the vascular system and is accompanied first by hemodynamic disturbances and then by changes in the central nervous system. Collapse is characterized by the following clinical symptoms: loss of consciousness, general weakness, severe pallor, cyanosis, cold sweat, frequent and small, sometimes arrhythmic pulse, frequent shallow breathing, decreased arterial pressure.

Treatment for shock and collapse should be started immediately. The patient should be placed in the Trendelenburg position (tilt angle of about 15°). The main method of treatment is jet transfusion of blood-substituting fluids to stabilize hemodynamics. Of the blood-substituting fluids, it is better to administer low-molecular, saline solutions, and a solution of hydroxyethyl starch, since they remain in the vascular bed longer and stabilize arterial pressure. At the same time, it is recommended to administer corticosteroids. Cardiac glycosides are used to improve cardiac activity. Intravenous sodium bicarbonate is recommended for decompensated acidosis.

Anuria is a serious complication of the postoperative period. Its causes may be shock and collapse, accompanied by a decrease in arterial pressure and reflex spasm of the renal vessels, sudden anemia of the patient, transfusion of blood incompatible by the Rh factor or the ABO system, septic infection, injury or ligation of the ureters. Treatment of anuria is determined by its etiology and should be started immediately.

Postoperative pneumonia is observed after long operations, with sputum retention in the bronchi, aspiration of gastric contents, atelectasis and congestion in the lungs, as well as pulmonary infarction. Pneumonia most often occurs in people with chronic respiratory diseases, in weakened elderly and senile patients. In the treatment of postoperative pneumonia, an important role is played by the correct prescription of antibiotics (according to the sensitivity of the microbial flora to them). The use of indirect anticoagulants (neodicoumarin, phenylin, sinkumar, etc.) in an individually selected dosage is indicated.

Intestinal paresis, which occurs on the 2nd-3rd day of the postoperative period, and intestinal obstruction, which develops on the 4th-5th day, are characterized by cramping abdominal pain, nausea, vomiting, gas and stool retention. Subsequently, peristalsis stops, the pulse quickens, the temperature rises, and the general condition of the patient worsens. When X-raying the abdominal cavity in a vertical position, gas bubbles with horizontal fluid levels under them (Kloyber cups) are detected. When conducting therapy for intestinal paresis, it is recommended to drain and wash the stomach, and administer proserin intramuscularly. To stimulate intestinal peristalsis, hypertonic enemas are given, and if necessary, siphon enemas. If the diagnosis of mechanical intestinal obstruction is confirmed, surgery is indicated.

Postoperative peritonitis develops as a result of infection of the abdominal cavity and is characterized by rigidity and pain in the anterior abdominal wall, pronounced symptoms of peritoneal irritation, rapid pulse, high temperature, nausea, vomiting and severe general condition of the patient. Currently, peritonitis is characterized by an erased course of peritonitis: the patient's condition remains relatively satisfactory, symptoms of peritoneal irritation are absent or weakly expressed, there is no nausea and vomiting. Intestinal peristalsis may be heard, there may be independent stool. Leukocytosis, a left shift in the leukocyte formula, and an increase in ESR are noted in the peripheral blood. Peritonitis is treated surgically - relaparotomy, removal of the source of infection and wide drainage of the abdominal cavity. Important components of treatment are antibacterial, desensitizing, anticoagulant and general strengthening therapy. In severe purulent peritonitis, peritoneal dialysis is performed.

Thrombosis and thrombophlebitis in the postoperative period most often occur in the veins of the lower extremities and pelvis. The development of these complications is facilitated by obesity, varicose veins of the lower extremities, previous thrombophlebitis, cardiovascular insufficiency. Signs of thrombosis are pain in the extremities, swelling, fever, tenderness during palpation along the vessels. In the treatment of thrombosis, complete rest, elevated position of the limb, antibiotics and direct and indirect anticoagulants are necessary.

Surgical wound suppuration is more common in patients operated on for malignant neoplasms of the genitals and purulent processes of the uterine appendages. When an infection develops in the area of the surgical wound, pain, tissue infiltration, hyperemia of the skin, and an increase in temperature appear. In such cases, several stitches should be removed to create conditions for the discharge to drain, the wound should be treated with hydrogen peroxide, and drainage should be inserted, moistened with a 10% sodium chloride solution. Dressings and wound toilet should be done daily.

A rare complication is complete divergence of the wound edges and prolapse of intestinal loops - eventration. When secondary sutures are applied for eventration, drains are inserted into the abdominal cavity to drain the contents and administer antibiotics.

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Prevention of infectious complications

Postoperative wound infections worsen the results of surgical treatment, increase the duration of hospitalization and the cost of inpatient treatment. One of the effective approaches to reducing the incidence of postoperative suppuration, along with improving surgical technique and observing the rules of asepsis and antisepsis, is antibiotic prophylaxis. Rational implementation of antibiotic prophylaxis in certain situations allows to reduce the incidence of postoperative infectious complications from 20-40% to 1.5-5%. Currently, the advisability of antibiotic prophylaxis in surgical operations is beyond doubt.

Antibiotic prophylaxis, in contrast to antibiotic therapy, involves the administration of an antibacterial agent in the absence of an active infectious process and a high risk of infection development in order to prevent its development. Preventive use of antibiotics is their administration before microbial contamination of the surgical wound or the development of a wound infection, as well as in the presence of signs of contamination and infection, when the primary treatment method is surgical intervention, and the administration of an antibiotic is aimed at minimizing the risk of wound infection.

Depending on the risk of developing postoperative infectious complications, all surgical interventions are usually divided into 4 categories.

Characteristics of types of operations

Conditional characteristic	Features of the intervention
"Clean"	Non-traumatic elective surgeries without signs of inflammation that do not involve the oropharynx, respiratory tract, gastrointestinal tract or genitourinary system, as well as orthopedic surgeries, mastectomy, strumectomy, herniotomy, phlebectomy in patients without trophic disorders, joint replacement, arthroplasty, operations on the aorta and arteries of the extremities, heart surgery
"Conditionally clean"	Clean operations with risk of infectious complications (planned operations on the oropharynx, digestive tract, female genital organs, urological and pulmonary operations without signs of concomitant infection), phlebectomy in patients with trophic disorders, but without trophic ulcers, repeated intervention through a "clean" wound within 7 days, internal osteosynthesis for closed fractures, urgent and emergency operations. according to the criteria included in the "clean" group, blunt injuries without rupture of hollow organs
"Contaminated"	Surgical interventions on the biliary and genitourinary tracts in the presence of infection, on the gastrointestinal tract in case of high contamination, operations in case of asepsis failure or in the presence of an inflammatory process (but not purulent inflammation). Operations for traumatic injuries, penetrating wounds, treated within 4 hours
"Dirty"	Surgical interventions on obviously infected organs and tissues, in the presence of concomitant or previous infection, wounds or perforation of the gastrointestinal tract, proctogynecological operations, penetrating wounds and traumatic wounds treated after 4 hours, phlebectomy in patients with trophic disorders and ulcers, operations for purulent inflammation on infected tissues

Antibiotic prophylaxis is indicated for all "conditionally clean" and "contaminated" operations. In clean operations, prophylaxis is carried out in cases where a potential infection poses a serious threat to the life and health of the patient, as well as in the presence of risk factors for the development of postoperative infections in the patient, which include:

• age over 70 years;
• nutritional disorders (obesity or hypotrophy);
• cirrhosis;
• renal failure, heart failure;
• diabetes mellitus;
• alcoholism or drug addiction;
• malignant neoplasms;
• congenital or acquired immunodeficiency states;
• treatment with corticosteroids or cytostatics;
• antibiotic therapy before surgery;
• blood transfusions;
• blood loss;
• - duration of the operation exceeds 4 hours;
• - long hospitalization before surgery.

Management of patients in the postoperative period

Any surgical intervention has a pronounced stress effect on the patient's body. The components of surgical stress are:

• emotional and mental status of the patient;
• an operation that involves pain, mechanical impact and blood loss.

Postoperative management of patients largely determines the success of surgical treatment, since it is known that no matter how skillfully the operation is performed, there is always a possibility of complications, including fatal outcomes. Prevention of complications in the postoperative period should be carried out in patients admitted for planned surgical treatment at the outpatient stage with the involvement of specialists in related specialties. The "risk group" for complications includes patients with obesity, anemia, varicose veins, with clinical signs of insufficiency of the cardiovascular, pulmonary, renal and other systems and organs, as well as older women.

The duration of the early postoperative period in gynecological patients is 7-10 days. The duration of the late postoperative period, if uncomplicated, is limited to three months after surgical treatment.

The early postoperative period is characterized by a decrease in daily diuresis, which is due to sodium retention in the blood serum and relative hypokalemia and hyperkaliumuria, which persist until the 6th day of the postoperative period. Hypoproteinuria, an imbalance of protein fractions in the blood also manifests itself until the end of the first week of the postoperative period, which is associated with the adrenocorticoid phase of catabolism.

An increase in body temperature in the first week of the postoperative period is a physiological reaction of the body to the absorption of decay products of injured tissues, blood and wound secretions. In elderly and senile women, leukocytosis and temperature reaction are less pronounced than in young patients.

Prevention of thromboembolic complications in the postoperative period includes non-specific measures and specific prevention. Non-specific prevention includes:

• early activation;
• bandaging the shins immediately before surgery with elastic bandages.

Specific prophylaxis is performed for patients with obesity, varicose veins, chronic thrombophlebitis, and cardiovascular insufficiency. Prophylaxis begins 2 hours before surgery and includes the use of heparin and its low-molecular derivatives (fraxiparin, clexane, etc.); in the postoperative period, these drugs are administered for 6-7 days.

Treatment and rehabilitation

Therapy and rehabilitation in the postoperative period are divided into 4 stages.

At the first stage, the patient is in the intensive care unit. Intensive monitoring is based on early detection of symptoms indicating an unfavorable course of the postoperative period or inadequate patient responses to treatment, which helps prevent the occurrence of critical conditions.

Intensive monitoring in the anesthesiology and resuscitation department (AED) or in the intensive care unit (ICU) differs from traditional monitoring in terms of continuity and purposefulness and can be visual, laboratory, monitoring, and combined.

For each patient in the OAR and ORIT, an hourly observation card with a list of appointments is created. During the observation time of the patient in the department, every 1-3 hours, the respiratory rate, blood circulation, body temperature, diuresis, the amount of discharge through catheters and drains are recorded, and the volume of fluid introduced and removed is taken into account.

Visual observation is one of the simplest and most accessible, used in any conditions. An experienced doctor and nurse are able to detect the most insignificant changes in the functions of the external vital systems of the body. In this case, special attention is paid to the patient's behavior, the color and temperature of the skin, the frequency and depth of breathing, the participation of auxiliary muscles, the presence of a cough, the nature of sputum.

Monitoring the functional state of the organs (shape and degree of abdominal distension, its participation in the act of breathing, condition of the dressings in the area of the postoperative wound, presence of signs of internal or external bleeding, tension of the muscles of the anterior abdominal wall) is of great help in assessing the patient's condition. Nausea, regurgitation, vomiting deserve attention. The ability to determine the time of restoration of intestinal motor function (appearance of peristalsis, passage of gases and feces).

The use of monitoring devices significantly facilitates the process of monitoring patients and increases its information content. Monitoring equipment allows for continuous monitoring of the respiratory function (respiratory rate, respiratory volume, minute respiratory volume, saturation, CO2 content), blood circulation (heart rate, arterial and central venous pressure, ECG, pressure in the heart cavities), central nervous system (EEG), thermoregulation (body temperature). The use of computer technology makes it possible not only to promptly recognize acute disorders of vital functions of the body, but also to eliminate them.

Visual and monitoring observation does not exclude the value of laboratory diagnostics. Express laboratory allows studying many indicators and includes determination of hemoglobin and hematocrit content, circulating blood volume (CBV), coagulogram, oxygen-base state (OBS), blood gas content, plasma and erythrocyte electrolytes, degree of hemolysis, total blood protein level, functional state of kidneys and liver, etc. A number of these indicators must be studied dynamically as intensive therapy is carried out, including at night.

To prevent postoperative complications, it is extremely important in the early postoperative period:

• providing adequate pain relief using narcotic and non-narcotic analgesics;
• elimination of hypovolemia;
• early expansion of the motor regime.

At the second stage, the patient is in the general department. Here, the condition of the postoperative sutures is monitored, the therapy started is continued, and prevention and diagnosis of purulent-inflammatory complications that usually appear on the 6th-7th day of the postoperative period are carried out.

From a clinical point of view, the most accessible and reliable indicator for diagnosing postoperative purulent-inflammatory complications (PPIC) is the determination of the leukocyte intoxication index (LII). The leukocyte intoxication index, proposed in 1941 by Ya. Ya. Kalf-Kalif:

(s.y. + 2 p.y. + 3 y. + 4 myelocyt.) (plasma, cells + 1) / (monocytes + lymphocytes) (eosinophils + 1)

Normally, this indicator is from 0.5 to 1.5. An increase in the index characterizes an increase in the inflammatory reaction. Various modifications of the LII are still widely used in clinical practice.

A new approach to diagnostics and prognosis of PHVO may be the use of the leukocyte formula of the blood as an integral indicator reflecting the features of the neurohumoral reaction of the body to stress effects of varying strength. According to L. Kh. Garkavi (1990), reactions of acute and chronic stress are caused by the action of a strong irritant. Weak irritants cause a training reaction, and medium-strength irritants cause reactions of calm and increased activation. Adverse reactions include reactions of stress, training and activation, occurring with desynchronization phenomena, which indicates a decrease in the natural resistance of the body and a worsening of the clinical course of the disease.

One of the traditional methods of preventing PHVO is currently intraoperative antibiotic prophylaxis.

By now, surgical practice has accumulated experience in using immunomodulatory drugs (thymolin, thymogen, interleukin) for the prevention of PHVO. It demonstrates the possibility of enhancing the natural defense mechanisms of the macroorganism and, thus, managing the course of the postoperative period.

Today, immunotherapy is represented not only by drugs of natural or synthetic origin. Various physical and chemical factors, such as ultrasound, magnetic field, extracorporeal methods of detoxification, acupuncture and laser puncture, are also considered full-fledged means of immunotherapy.

In order to increase immunoreactivity and improve the healing of surgical wounds in gynecological patients, transfusions of laser- and ultraviolet-irradiated autoblood are used.

At the third stage, the patient is observed at the antenatal clinic at her place of residence. Great emphasis is placed here on physiotherapy procedures and resorption therapy.

The fourth stage involves rehabilitation measures for women in a specialized sanatorium. In addition to general strengthening treatment, patients may be prescribed balneotherapy and mud therapy according to indications.