The consent process reflects the entire discussion and counseling between the surgeon and the patient.  During the consent process, patients are informed of their diagnosis, including the anticipated course of the disorder, with various interventions (medical, surgical, non-medical, and expectant).  Each option's risks, benefits, and alternatives should be discussed in detail, with a specific discussion of the potential risks and anticipated benefits of the procedures under consideration. Further information surrounding the anticipated postoperative course, including time away from activities of daily living, work, exercise, and the need for pelvic rest, should be disclosed.  If the surgical procedure will be performed at an institution with learners (medical students, residents, fellows, etc.), patients should be made aware of the role of trainees in their surgery and perioperative care. 

It is critical that surgeons clearly understand the patient’s goals and priorities before proceeding to the operating room, as the intervention for various gynecologic pathologies may vary dramatically based on the patient’s desires. For example, surgical management of fibroids can differ significantly depending on whether the goal is to improve fertility or to have definitive treatment. Collaboration between the surgeon and the patient allows the development of an individualized treatment plan that incorporates medical, surgical, and alternative management options.  Similarly, the surgeon should provide realistic expectations for surgical outcomes based on evidence-based literature.

Improving medical conditions, such as anemia or significant fibroid burden, can improve the likelihood of successful surgery for many patients.  In the setting of fibroids, preoperative treatment with gonadotropin-releasing hormone agonist (GnRH-a) or selective progesterone receptor modulators (PRMs) can be used for this purpose (Donnez et al et al 2012). Furthermore, inducing amenorrhea in combination with iron therapy before surgery in patients with heavy menstrual bleeding may also help improve preoperative anemia(Musallam et al 2011, Richards et al 2015). 

Most women presenting for elective gynecologic surgery, such as surgical intervention for treating fibroids, are relatively healthy. In such cases, routine laboratory and diagnostic investigations are typically not indicated(NICE 2016).  Resting echocardiography, chest x-ray, lung function tests, kidney function tests, hemostasis tests, and glycated hemoglobin (HbA1C) are no longer recommended to be routinely offered(NICE 2016). Instead, preoperative testing should be tailored to the individual patient based on her medical risk factors.  Surgeons should familiarize themselves with the consultation services, such as internal medicine or anesthesiology, available at their local institution if assistance with preoperative medical optimization is desired. 

The individuals that create the surgical team are essential to surgical success.  Surgical assistants, circulating room nurses, and the anesthesiology team should be considered preoperatively.  More straightforward procedures can be performed with personnel with limited skill or experience in gynecologic procedures.  However, complex cases require a team of individuals with expertise and knowledge of the specific procedure, the various surgical approaches to gynecologic pathology, and potential variations from the routine procedure.  A second surgical assistant may be required for more challenging cases to provide retraction, uterine manipulation, or assistance with delineating critical structures surrounding the target anatomy (i.e., rectal probe).