Laboratory Studies
Complete blood cell count
In general, one of the few required laboratory evaluations in a healthy patient is a complete blood cell count.
Anemia increases the risk of anesthetic complications and infections, both at the operative site and the skin incision. In addition, patients who are anemic have less of a safety margin in the uncommon case of significant operative blood loss. For elective surgery, every effort should be made to provide effectual treatment for anemia prior to surgery.
Pregnancy test
Many surgeons recommend routine pregnancy tests for all patients prior to elective surgery because both surgery and anesthesia should be avoided during pregnancy. Although the most commonly used anesthetics show little evidence of causing either teratogenicity or increased risk of spontaneous abortion, the medicolegal implications of electively performing surgery and administering anesthesia during pregnancy justifies establishing pregnancy status prior to surgery. Exceptions are usually made for patients who are surgically sterile or who are known to be pregnant.
A urine pregnancy test is adequate in most cases because these modern tests accurately detect beta-human chorionic gonadotropin levels of 50 mIU/mL or more, a level usually reached by 4 weeks from the last menstrual period. Because this type of pregnancy test can be performed in the presurgical area, delays related to waiting for results should be uncommon. Because no test can accurately determine very early pregnancy (prior to the expected next menstrual period), all patients should also be carefully questioned about whether they could be pregnant and about the date of their last menstrual period immediately prior to surgery.
An alternative to performing routine pregnancy tests prior to surgery is to schedule all elective surgery during the follicular phase (ie, within 2 wk of the last menstrual period). Not only does this minimize the risk of performing surgery during an undiagnosed pregnancy, but it also avoids manipulation of the endometrium and tubes around the time of ovulation and implantation.
Urinalysis
Many laparoscopists obtain a urinalysis prior to surgery. Urinalysis may help detect an unsuspected systemic disease, such as diabetes, which should be completely evaluated prior to elective surgery.
More commonly, urinalysis results may indicate the presence of a subclinical urinary tract infection that may be exacerbated by catheterizing the patient. Treating these infections prior to surgery may help avoid postoperative discomfort and potentially serious sequelae in susceptible patients.
Other laboratory evaluations
In patients with known health problems, other laboratory tests, such as liver function tests or electrolyte evaluations, may be indicated.
A thorough preoperative medical evaluation, including appropriate laboratory studies, is appropriate in anyone with significant medical problems.
Imaging Studies
Chest radiography
A routine preoperative chest radiograph (CXR) is probably unnecessary for patients with no risk factors. [31]
In patients with coexisting bronchopulmonary conditions, cardiac conditions, or abnormal clinical cardiopulmonary findings, a preoperative CXR certainly is important. CXR is also part of the basic workup for anyone who may have a gynecologic malignancy.
Intravenous pyelograph or kidney ultrasound
Radiographic or sonographic evaluation of the urinary tract is important in women with uterine anomalies, those known to have severe endometriosis, and those with an ovarian mass fixed in the pelvis. Women with uterine anomalies are at risk for concomitant urologic anomalies; thus, an intravenous pyelogram should be performed to determine kidney location and the state of the ureters.
In select cases of severe endometriosis or when a fixed pelvic mass is present, preoperative evaluation for possible ureteral involvement is also important. Hydronephrosis, indicating partial or complete obstruction of the ureter, can be excluded with the aid of a kidney ultrasound image in these cases.
Barium enema
Severe endometriosis can sometimes involve the colon. In patients with colonic symptoms, such as cyclic hematochezia or narrowing caliber of stool, a preoperative evaluation is important. However, most patients with bowel endometriosis will have normal study results. Therefore, the studies are performed to rule out other causes of the symptoms.
Alternatively, colonoscopy may be helpful in patients with these suggestive symptoms.
Other Tests
Electrocardiogram
A routine preoperative electrocardiogram (ECG) prior to laparoscopy is not indicated in a young, healthy woman. A preoperative ECG should be considered in all women older than 50 years because the risk of heart disease increases at this time. Although this often depends on the local requirements.
In addition, any woman with a history of cardiac disease or any physical finding or disease history that puts her at increased risk of cardiac disease (eg, diabetes mellitus, hypertension, thromboembolic diseases, stroke, renal impairment, chronic pulmonary disease) should have a preoperative ECG regardless of age.
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Gynecologic laparoscopy. Anterior abdominal wall anatomy of a patient who is obese, as seen on magnetic resonance imaging. Image courtesy W.W. Hurd, MD.
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Gynecologic laparoscopy. Changes in the anterior abdominal wall anatomy with weight for patients in 3 groups, based on body mass index (BMI) measurements: nonobese (BMI 2), overweight (BMI 25-30 kg/m2), and obese (BMI >30 kg/m2). An 11.5-cm Veress needle is superimposed on each view for comparison.
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Gynecologic laparoscopy. Location of deep and superficial vessels of the anterior abdominal wall. Blue circles indicate recommended locations for trocar placement.
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Single-incision total laparoscopic hysterectomy performed in a 40-year-old woman with dysmenorrhea and cervical carcinoma in situ. Part 1. Video courtesy of Tarek Bardawil, MD.
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Single-incision total laparoscopic hysterectomy performed in a 40-year-old woman with dysmenorrhea and cervical carcinoma in situ. Part 2. Video courtesy of Tarek Bardawil, MD.
