What the Anesthesiologist Should Know before the Operative Procedure
Vulvectomy is the surgical removal of all or part of the vulva. A vulvectomy can vary greatly in the extent of the surgery, from a skinning vulvectomy, which removes only the outer layer of skin, to the full radical vulvectomy, which removes the entire vulva and accompanying deep tissues and lymph nodes.
1. What is the urgency of the surgery?
What is the risk of delay in order to obtain additional preoperative information?
The urgency of vulvar surgery ranges from urgent to elective; there are no emergency vulvar surgeries. Many of the lesions that are removed during vulvectomy are precancerous or cancerous and these should be treated as urgent in nature. Such lesions often occur in women of advanced age and time should be taken to ensure proper preoperative testing.
Appropriate preoperative testing includes standard tests for specific groups; women with comorbidities such as diabetes, obesity, and hypertension require electrocardiograms and a thorough history to determine whether heart disease exists. Given the association between diabetes and hypertension and kidney dysfunction, kidney function should be measured if it has not been tested recently in the patient. Bleeding histories should be obtained, and a blood count and coagulation factors should be obtained if bleeding has occurred or a large blood loss is expected during the operation. Also, type and screen samples should be obtained if large blood loss is anticipated.
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In some cases, other lesions that are not precancerous or cancerous may be removed for cosmetic purposes and these should be regarded as elective procedures.
2. Preoperative evaluation
The preoperative evaluation for a vulvectomy varies depending on the extent of surgery and the type of anesthetic chosen. There are no specific medical conditions to evaluate prior to the procedure. If the surgery is expected to be extensive, regional anesthesia with an epidural may be considered for post-operative pain control. After review of the patient’s medical history and/or patient preferences, regional anesthesia with a spinal may be considered. If regional anesthesia will be used, coagulation studies should be ordered in addition to standard preoperative testing.
Vulvar lesions, like many other cancers, often present in patients over the age of 60 years. Also, thorough neurologic, cardiovascular, and pulmonary histories are necessary as part of the preoperative evaluation. Further evaluation should occur is a patient has unstable or changing symptoms.
Patients with symptoms suggestive of unstable angina or heart failure need to be evaluated with tests specific for these conditions, including stress tests and/or cardiac catheterization, depending on symptoms and signs, for unstable angina and echocardiograms for heart failure or stress tests if heart failure is due to ischemia. Similarly, new or increasing dyspnea may reflect new pulmonary disease, which requires radiographic studies and may require further testing or intervention, depending on the findings. New or increasing dyspnea may also suggest dyspnea due to heart failure.
Delaying surgery may be indicated if further testing is necessary after the initial evaluation. Also, if the patient was receiving an anticoagulant prior to surgery, and the effects of the drug have not had time to dissipate, surgery should be delayed until the patient is no longer coagulopathic. This is especially important if regional anesthesia is to be used, either as the sole anesthetic or for postoperative pain control.
3. What are the implications of co-existing disease on perioperative care?
Dysplasia of the vulvar region is not typically associated with other coexisting diseases. Patients should be evaluated with respect to their general overall health and optimized for surgery and anesthesia.
As part of the perioperative evaluation, patients should be evaluated with respect to their general overall health. Care should be taken to evaluate their cardiopulmonary status (i.e., functional capacity) and neurologic status (history of strokes or TIA). Also, these procedures can often be performed on an outpatient basis with a laryngeal mask airway (LMA), so careful questioning of a history of gastroesophageal reflux is warranted. If the surgery is planned on a woman in child bearing years, she should be questioned about the possibility of pregnancy and, if she is unsure, a pregnancy test should be performed.
If the planned procedure involves laser therapy or local excision, it may be performed on an outpatient basis and appropriate postoperative nausea and vomiting prevention should be implemented. If the planned procedure is a radical vulvectomy or a pelvic exenteration, a hospital stay is required and the patient should be treated to reduce the risk of deep venous thrombosis (DVT) and pulmonary embolism. In cases requiring hospitalization, incentive spirometry should be encouraged.
b. Cardiovascular system
All acute or unstable cardiovascular conditions should be address prior to the vulvectomy, irrespective of the size of the resection.
Stable coronary artery disease should be evaluated and treated per the ACC/AHA guidelines.
c. Pulmonary
If the patient has COPD, a careful history with emphasis on functional status should be obtained. Many vulvectomies, especially those that are planned to be performed on an outpatient basis, may be safely performed with an LMA in patients with COPD. The advantage of using an LMA is a decreased risk of exacerbating the reactive component of COPD, if it exists. If the planned procedure calls for a more extensive resection, the patient should be offered an epidural for postoperative pain control, which would benefit respiratory function. If the patient has severe COPD, the option of regional anesthesia with sedation should be explored.
Patients with reactive airways disease, such as asthma, should be seen and optimized as much as possible with long-acting bronchodilator therapies. If planning to instrument the airway, consider an albuterol or other immediate-acting treatment prior to entering the operating room. Consider using regional anesthesia with sedation in cases of severe reactive airway disease.
d. Renal-GI:
In rare cases of extensive disease, the urinary tract may be involved. In such cases, an evaluation of renal function, as well as patency of the urologic tract, should be performed.
A careful, focused, history, with emphasis on the presence and severity of reflux disease, should be obtained in all patients. Particular attention should be paid to those planning to undergo LMA general anesthesia.
e. Neurologic:
Acute neurologic issues should be fully evaluated prior to proceeding to the operating room. If the patient has had a recent stroke or TIA, a full evaluation to determine the cause of the malady should be determined. All interventions that may be required, such as a carotid endarterectomy, should be performed prior to the vulvectomy.
Chronic neurologic problems need to be evaluated and stabilized, as much as possible.
f. Endocrine:
If the patient has endocrine problems, such as diabetes or hypothyroidism, they should be seen by their primary care provider and be placed on a stable treatment regimen prior to the vulvectomy.
g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
N/A
4. What are the patient's medications and how should they be managed in the perioperative period?
Patients should stop herbal supplements, as well as any nonsteroidal anti-inflammatory medications, a week prior to surgery.
h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
N/A
i. What should be recommended with regard to continuation of medications taken chronically?
Patients should continue their preoperative cardiac medications, with the exception of any angiotensin-converting enzyme (ACE) inhibitors. ACE inhibitors should be held 24 hours before surgery owing to the risk of hypotension postinduction.
All pulmonary medications should be continued during the perioperative period. In addition, immediate-acting bronchodilators should be considered prior to entering the operating room.
Patients should continue any neurologic and psychiatric medications they are taking, including anticonvulsants.
Patients may be on antiplatelet medication for treatment of neurologic disease (stroke and/or TIA) or as part of their treatment regimen for coronary artery disease, which may include drug-eluting stents. Careful consideration must be taken before recommending stopping these medications. A discussion with the surgical team, weighing the risks of stopping these medications with the risk of bleeding, should occur.
j. How To modify care for patients with known allergies –
Nothing case specific
k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
Nothing case specific.
l. Does the patient have any antibiotic allergies- – Common antibiotic allergies and alternative antibiotics]
Nothing case specific.
m. Does the patient have a history of allergy to anesthesia?
Malignant hyperthermia
If a patient has a documented history of malignant hyperthermia, avoid all trigger agents, such as succinylcholine and inhalational agents.
5. What laboratory tests should be obtained and has everything been reviewed?
Standard preoperative laboratory values should be obtained and evaluated.
Common laboratory normal values will be same for all procedures, with a difference by age and gender.
Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
Depending on the size and extent of the planned surgery, the choice of anesthesia can range from monitored anesthesia care to general endotracheal anesthesia with epidural placement for post-operative pain control.
a. Regional anesthesia
In many vulvectomies, regional anesthesia can be the primary anesthetic, in which case either a spinal or epidural with sedation can be utilized.
Spinal anesthesia reliably provides a dense bilateral block. It is useful for patients who have limited disease and predictable operating times. It is also favored by patients who have a fear of general anesthesia. Spinal anesthesia should also be considered in patients who have severe reactive airway disease in whom instrumentation of the airway could precipitate severe bronchospasm.
Epidural anesthesia, while not as reliable as spinal anesthesia, produces surgical anesthesia in nearly all patients. It is more “flexible” than spinal anesthesia owing to the fact that additional amounts of local anesthetics can be administered, whereas spinal anesthesia involves only one administration. If used as the primary anesthetic, epidural anesthesia should be considered in patients for whom the amount of disease is not clearly known and the operative time is less predictable.
Epidural anesthesia, like spinal anesthesia, can be considered in patients with a fear of general anesthesia or severe reactive airway disease. Epidural anesthesia should also be considered for postoperative pain control in patients with extensive disease requiring a large operation and debulking.
After neuraxial anesthesia, there is the risk of a postdural puncture headache. Neuraxial anesthesia should not be placed in patients on antiplatelet agents, such as clopidogrel, or anticoagulants, such as Coumadin. Follow ASRA guidelines for the timing of neuraxial block following antiplatelet or anticoagulant agents.
The sympathetic blockage that occurs after placement of neuraxial blockade may not be well tolerated, such as in patients with aortic stenosis. If used in the outpatient setting, patients should be made aware that they may have a prolonged recovery; they may be fully alert, but full motor and urologic functions have not returned.
Patient considerations have to be taken into account and addressed prior to institution of neuraxial block. Patients need to be coached and participate in positioning. Any fears they have about nerve damage or awareness during the procedure need to be fully explained. All risks and benefits need to be understood.
A peripheral nerve block is not appropriate for this procedure.
b. General anesthesia
There are many benefits to general anesthesia. Importantly, better control of the airway is achieved. Many of these cases will be performed on an outpatient basis with an LMA. While an LMA is not a secure airway, it does provide the anesthesia provider with increased information, including a more reliable end-tidal CO2 and ET volatile agent. Alternatively, an endotracheal provides a secure airway.
Also, given the location of this disease and procedure, patients are very anxious. General anesthesia provides quick and reliable anxiolysis, as well as amnesia during the procedure. Last, positioning for this surgery can require Trendelenburg, sometimes quite steep, which is better tolerated by patients under general anesthesia.
However, general anesthesia may increase the risk of postoperative nausea and vomiting. Complaints of a sore throat are very common after general anesthesia.
c. Monitored anesthesia care
Monitored anesthesia care should only be considered for superficial disease in conjunction with local infiltration by the surgeons.
Monitored anesthesia care has a greatly reduced risk of postoperative nausea and vomiting, compared with general anesthesia. Recovery time is also reduced, compared with general and neuraxial anesthesia, which allows patients to be discharged more quickly from recovery.
Drawbacks of monitored anesthesia care include an unsecured airway, an inability of the patient to tolerate the Trendelenberg position needed for surgical exposure, and movement of the patient during the procedure.
6. What is the author's preferred method of anesthesia technique and why?
My preferred technique depends on the extent of the disease and type of surgery. For skinning and simple vulvectomies, I prefer general anesthesia with an LMA. I will only use an LMA if the surgeon does not require steep Trendelenburg and the patient does not have any contraindications for an LMA, such as gastroesophageal reflux disease, oropharyngeal disease, history of glottic surgery, or morbid obesity.
Anxiolysis with 2 mg midazolam should be considered unless the patient is of advanced age or has other contraindications. Antibiotics, according to the current SCIP recommendations, should be administered prior to incision. Standard intravenous induction with fentanyl typically 100 mcg, lidocaine 60-80 mg, and propofol 2 mg/kg is given prior to insertion of LMA. Anesthesia is maintained with a volatile agent, with sevoflurane or desflurane preferred in an outpatient setting. Also, during the maintenance of anesthesia, additional opiates should be given, as determined by the anesthesia provider, titrating to blood pressure and respiratory rate. Antiemetic medication should be considered prior to emergence.
For a full radical vulvectomy, in which the entire vulva, surrounding deep tissues, and clitoris are removed, I prefer general endotracheal anesthesia with the patient given the option of an epidural for postoperative pain control. Because this is a much more extensive surgery, I discuss the option of an epidural for postoperative pain control with the patient if there are no contraindications.
If the patient elects to have an epidural, it should be place preoperatively with mild sedation. It is important that the patient be comfortable, but still able to communicate, and aid with positioning. The epidural should be placed in the lumbar region to cover the dermatomes innervating the surgical site. After placement of the epidural and a negative test dose is determined, the patient should be laid back and anesthesia induced. Standard intravenous induction with fentanyl 200 mcg, lidocaine 60-80 mg, propofol 2 mg/kg, and a muscle relaxant, such as vecuronium 0.1 mg/kg, should be given, followed by endotracheal intubation. Anesthesia is maintained with a volatile agent of choice.
I prefer to start the epidural intraoperatively and use it to supplement the volatile agent to cover surgical stimulation. The area of the operation is highly vascular so the chance for significant blood loss it possible and good intravenous access is required. An arterial line should also be considered if the patient has significant comorbidities, including coronary artery disease, chronic obstructive pulmonary disease, or diabetes. Furthermore, the positioning (in stirrups) makes the evaluation of blood loss more difficult, as it may drip down out of the field rather than be suctioned to suction canisters. Antiemetic medication should be considered prior to emergence.
a. Neurologic:
N/A
b. If the patient is intubated, are there any special criteria for extubation?
There are no special criteria for extubation.
c. Postoperative management
What analgesic modalities can I implement?
If you have elected to use an epidural for postoperative pain management, a low-dose local anesthetic with an opiate should be used with a patient-controlled epidural pump. If you have performed neuraxial anesthesia, once the block has started to recede, but before the patient is experiencing discomfort, intravenous opiates should be started.
If you have performed general anesthesia, either with an endotracheal tube or LMA, long-acting opiates should be administered intraoperatively to help cover pain in the postoperative period. If the procedure is being done on an outpatient basis, consider a shorter-acting opiate like fentanyl in the recovery area. If the patient is being admitted to the hospital, I recommend continuing the long-acting opiate used during the intraoperative period.
What level bed acuity is appropriate?
The level of acuity will depend on the extent of the resection. Skinning or simple vulvectomy may be performed on an outpatient basis if the patient is an appropriate candidate. Full and radical vulvectomy patients can typically be admitted to the floor, if the patient does not have confounding comorbidities or extensive blood loss during the surgery.
What are common postoperative complications, and ways to prevent and treat them?
The most common postoperative complications are wound infection and break down, urinary tract infections, and DVT. The anesthesia provider can help prevent wound infections by administering the current SCIP-recommended antibiotics within the prescribed time of surgical incision. The anesthesia provider can help prevent DVT and thromboembolism by ensuring the appropriate prophylaxis was given prior to induction.
What's the Evidence?
Polterauer, S, Dressler, C, Grimm, C. “Accuracy of preoperative vulva biopsy and the outcome of surgery in vulvar intraepithelial neoplasia 2 and 3”. Int J Gynecol Pathol. vol. 28. 2009. pp. 559-62. (This study documents the problem with the accuracy of preoperative biopsies; the biopsies do not reveal the extent of lesions. The mean age of the patients in this report was 51 years of age.)
Fuh, KC, Berek, JS. “Current management of vulvar cancer”. Hematol Oncol Clin North Am. vol. 26. 2012. pp. 45-62. (A very thorough review of staging, prognosis, and current therapy.)
Dittmer, C, Fischer, D, Diedrich, K, Thill, M. “Diagnosis and treatment options of vulvar cancer: a review”. Arch Gynecol Obstet. vol. 285. 2012. pp. 183-93. (A review of databases that suggest that there is a trend for less radical surgery and a need for more collaborative studies.)
“Vulvo-vaginal cancers: risks, evaluation, prevention and early detection”. Obstetr Gynecol Clin N Am. vol. 34. 2007. pp. 783-802.
Abeloff. “Vulvar dystrophy”. In Abeloff's Clincial oncology. 2008.
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