**3. Prevention of SSI**

### **3.1 Preoperative risk factors**

Preoperative medical optimization is critically important in risk reduction for SSI prior to hysterectomy. Eliminating particular risk factors for SSI contributes vastly to perioperative care. This includes taking an in-depth medical history, performing a comprehensive physical exam, and addressing the patient's medical comorbidities. Patients should be counseled on modifiable and nonmodifiable risk factors such as smoking status, diabetes stabilization, anatomic anomalies, renal comorbidities, hydrosalpinx, endometrioma, prior laparotomy, and untreated pelvic inflammatory disease (PID) or bacterial vaginosis [17–20]. Optimal diabetes control is critical in preventing postoperative SSI with both spot glucose levels ≤200 mg/dl and hemoglobin A1C levels below 8.5–9.0% [21, 22].

Preoperative screening for genital tract infections is generally not necessary; however, certain types of infections are clinically important prior to hysterectomy. It has been well established that bacterial vaginosis (BV) is associated with an increased risk of postoperative cuff cellulitis and subsequent pelvic abscess formation after hysterectomy [23]. Treatment of BV prior to scheduled hysterectomy will decrease this risk.

### **3.2 Intraoperative interventions**

Practicing safe, high-quality, evidence-based operating room care begins first with accurate identification of the patient, surgical site, and procedure.

In an AAGL white paper, "Enhanced Recovery and Surgical Optimization Protocol for Minimally Invasive Gynecologic Surgery", infection prophylaxis can be achieved via the implementation of SSI prevention bundles [24]. Quality or safety bundles provide a framework for the implementation of evidence-based practices. They have been validated across multiple disciplines to actually decrease SSI [25–28]. The ACOG Council on Patient Safety in Women's Health Care has published a consensus bundle on prevention of SSI prior to gynecologic surgery. This provides a framework for hospitals to develop, implement, and practice evidencebased prevention of SSIs [29].

An example of a hysterectomy bundle is as follows:

