Page 36 - Journal of Laparoscopic Surgery

10.5005/jp-journals-10007-1137
JA Maseloane
REVIEW ARTICLE
The Role of Mechanical Bowel Preparation in

Gynecologic Laparoscopy

JA Maseloane
Consultant, Department of Obstetrics and Gynecology, Tembisa Hospital, Tembisa, South Africa

ABSTRACT

Various combinations of dietary restriction, antibiotic regimens and mechanical preparations have become routine in preoperative
surgical planning for elective colon surgery. This practice has also become commonplace in the field of gynecology, either for planned
bowel surgery or in complex cases that are believed to be high risk for inadvertent bowel injury. As the trend in gynecologic surgery
shifts toward more minimally invasive approaches, the complexity of cases being performed by laparoscopy and robotics continues to
increase. In addition, laparoscopic surgical techniques have a different set of inherent risks and challenges as compared with open
pelvic operations. This review summarizes the available data surrounding the use of mechanical bowel preparations, specifically with
regard to gynecologic laparoscopy.
Keywords: Mechanical bowel preparation, Minimally invasive gynecological surgery, Laparoscopic surgery.

INTRODUCTION polyethylene glycol (PEG), lactulose, sorbitol, glycerine]; and
stimulants that increase intestinal peristalsis (e.g. casanthranol,
Although therapeutic colonic cleansing has been documented
1
as far back as 1500 BC in Egyptian medical writings, the modern senokot, bisacodyl and castor oil). Many of the regimens
application of bowel preparation to elective surgery was refined mentioned above are limited by patient tolerance, including
issues, such as gastrointestinal distress, dehydration and
as recently as the 1950s. Innovative surgeons of the time were
searching for ways to decrease postoperative mortality given electrolyte disturbances. In elderly patients or those with
underlying renal dysfunction, mechanical bowel preparation
that the mortality rate for a primary colectomy in 1940 was
2
estimated to be 30%. Since then, various combinations of may incur a significant risk of fluid shifts and severe electrolyte
1
derangement. Regarding choice of cathartic, sodium phosphate
dietary restriction, antibiotic regimens and mechanical has been compared with PEG and found to be associated with
preparations have become routine in preoperative surgical lower complication rate, less intraoperative bowel spillage and
planning for elective colon surgery. This practice has also improved patient tolerance. 3,4
become commonplace in the field of gynecology, either for
Although not the primary focus of this review, the goal of
planned bowel surgery or in complex cases that are thought to antibiotic pretreatment is to decrease the concentration of
be high risk for inadvertent bowel injury. As the trend in bacteria in the colon. A landmark meta-analysis published in
gynecologic surgery shifts toward more minimally invasive 1981 concluded that the evidence supporting antibiotic bowel
approaches, the complexity of cases being performed by preparation prior to colorectal surgery was such that further
laparoscopy and robotics continues to increase. In addition, studies including no treatment control groups should be
laparoscopic surgical techniques have a different set of inherent considered unethical. Antibiotic pretreatment can be
5
risks and challenges as compared with open pelvic operations. accomplished via oral and/or parenteral administration; the
This review summarizes the available data surrounding the use relative merits of each approach remain an area of debate among
of mechanical bowel preparations, specifically with regard to colorectal surgeons. Preoperative oral antibiotics have been
gynecologic laparoscopy.
shown to produce a four to five log decrease in enteric bacterial
6
concentration in resected colon, though proponents of
Regimens for Bowel Preparation
parenteral administration emphasize the importance of achieving
Mechanical bowel preparation aims to decrease the volume of adequate systemic antibiotic levels while minimizing
7
fecal content in the colon, which thereby decreases the total symptomatic gastrointestinal distress. Oral antibiotic bowel
colony count of bacteria. Various regimens exist, consisting of preparation regimens that were popularized in the 1970s included
diets such as low residue or clear liquid in the day(s) prior to erythromycin and neomycin; however, many regimens have
surgery or cathartic pharmacotherapy that may be delivered been subsequently studied without a consensus on the
orally or per rectum. Medications commonly used include optimal agent. A recent Cochrane review on the topic concluded
emollients that soften the stool, allowing it to move more freely that antibiotics should be given prior to colorectal surgery and
through the colon (e.g. ducosate); osmolar agents that cause should include coverage for anaerobic as well as aerobic
8
colonic water retention [e.g. sodium or magnesium preparations, bacteria. This review suggests that a combination of oral and
166
JAYPEE