Page 37 - Journal of Laparoscopic Surgery

WJOLS

The Role of Mechanical Bowel Preparation in Gynecologic Laparoscopy

intravenous antibiotics will likely give the best results, though Mechanical Bowel Preparations in
timing of oral antibiotics remains unclear. Confounding the issue Gynecologic Laparoscopy
further, oral antibiotic preparation has not been studied in Although the majority of the evidence regarding bowel
isolation from mechanical bowel preparation.
preparations is found in colorectal surgery literature, studies
Mechanical Bowel Preparations: Controversy have also been performed specifically targeting a gynecologic
From General Surgery Literature population. With regard to gynecologic laparoscopy in
particular, one proposed role for bowel preparation includes
Since, first proposed by Sir William Halsted in 1887, the use of cases where bowel resection is planned or thought to be high
some form of mechanical bowel preparation to decrease risk for inadvertent bowel injury (e.g. severe adhesive disease,
infectious complications and anastomotic breakdown in elective endometriosis, previously irradiated operative field,
colorectal surgery has been considered surgical dogma. 9 malignancy). Bowel injury is a rare complication of laparoscopy;
Benefits of decreased fecal content of the bowel were thought the incidence has been reported at 0.13% by a 2004 literature
to include minimized bacterial contamination, decreased passage review. Compounding this fact that only a limited number of
18
of hard stool over newly formed anastomotic sites and gynecologic cases that will result in bowel injury, the data from
10
facilitation of intraoperative bowel manipulation. Initial data colorectal surgery support abandoning routine mechanical
supporting this practice were mainly observational; it was not bowel preparation.
until the 1970s that this practice was called into question when In addition, it has been proposed that clearing of bowel
a randomized trial demonstrated no benefit of mechanical bowel contents may aid in visualization and handling of intestines
preparation with regard to wound infection, peritonitis or death during laparoscopic surgery. In a randomized trial, Muzii et al
11
when used in elective colorectal surgery. Data from emergency studied the effects of bowel preparation with oral sodium
colorectal surgery in the 1980s further supported the view of phosphate solution in patients undergoing laparoscopy for
bowel preparation as unnecessary. Traditionally, emergency benign gynecologic indication; the authors did not find any
surgery on unprepared bowel was treated with a diverting advantage regarding preparation of surgical field, operative time,
colostomy, extensive resection of ascending colon and/or intra or postoperative complications or length of stay. 19
intraoperative colonic lavage. Observations from emergency Conversely, the mechanical bowel preparation group reported
left-sided colorectal surgery, often performed due to significantly greater preoperative discomfort. Another
obstructions caused by malignancy, supported the safety of randomized study compared mechanical bowel preparation to a
12
primary anastomosis in these settings. Further randomized 7-day minimal residue diet in patients undergoing laparoscopy
trials in patients undergoing elective colorectal surgery 20
suggested increased morbidity when mechanical bowel for benign gynecologic disease. The precolonoscopy, low-
residue diet demonstrated minimal colonic fecal residue and
preparation was used, including increased postoperative
infections, extraabdominal complications and longer hospital may potentially decrease colonic gaseous distension. In the
study mentioned, both groups were found to have similar
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stays. Suggested mechanisms for the increased infectious
morbidity associated with mechanical bowel preparations surgical field exposure; however, the low-fiber diet was better
include enhanced bacterial translocation across the lumen and tolerated.
increased bowel inflammation. 13-15 It has also been reported SUMMARY AND RECOMMENDATION
that inadequate mechanical bowel preparation results in higher
incidence of liquid bowel content with a corresponding increase An emerging body of evidence suggests lack of benefit—and
16
in peritoneal spillage intraoperatively. The 2009 updated potential for harm—with routine use of mechanical bowel
Cochrane review concluded that prophylactic mechanical bowel preparation in colorectal surgery. Despite a paucity of
preparations have no proven benefit and should be abandoned literature specific to gynecologic surgery, it is reasonable to
8
in most cases. Potential situations where bowel preparations extrapolate from the general surgery data a recommendation
may remain useful include those wherein an intraoperative against mechanical bowel preparation for the indication of
colonoscopy is performed. The Cochrane review further decreasing infectious complications related to bowel injury or
21
comments that future research on this topic is needed, resection. Antibiotic bowel preparation, however, has been
specifically with well-designed trials that include allocation proven beneficial in colorectal surgery and can reasonably
concealment, stratification of colon versus rectal surgery, be used in complicated gynecologic cases at high risk for
comments on history of radiation and inclusion of laparoscopic bowel involvement. A caveat to this recommendation is the
surgery. Despite the large pool of data supporting the omission importance of understanding the clinical practices of consulting
of mechanical bowel preparations and changing guidelines, colorectal surgeons at individual institutions. Should an
clinical practice has been slow to change; a 2005 survey of unexpected bowel injury occur in a patient who did not undergo
Northern European surgeons found that between 50 and 95% preoperative mechanical bowel preparation and who requires
continue to use preoperative bowel preparation. 17 the services of a surgical consultant to assist with repair? The

World Journal of Laparoscopic Surgery, September-December 2011;4(3):166-168 167