1. Do we need mechanical bowel preparation before benign gynecologic laparoscopic surgeries? A randomized, single blind, controlled trial
Dr. Burak Karadağ & Dr. Barış Mülayim
Department of Obstetrics and Gynecology Antalya Education and Research Hospital

2. AIM oral sodium phosphate sodium phosphate enema
no mechanical bowel preparation

3. AIM Patient’s preoperative overall discomfort
The utility of mechanical bowel preparation (MBP) when removing large uteri
Patients who have a high BMI.
And we also analyzed

4. Methods
This trial was conducted between June 2016 and December 2016 at Antalya Education and Research Hospital.

5. Exclusion criteria included
Methods
Non-pregnant women ages years undergoing elective laparoscopic surgery for benign gynecologic conditions were included.
Inability to perform oral or enema agent
Unable to complete MBP regimen
Suspicion of malignancy or pregnancy
Associated non-gynecological surgical pathologies
Suspicion of deep infiltrative endometriosis
Conversion to laparotomy
Exclusion criteria included

6. Methods
Oral NaP group were instructed to ingest 45 mL of NaPsolution (from B.T., Yenişehir Laboratories, Ankara, Turkey) in the evening on the day before surgery.
NaP enema group were instructed to self-administer a single 177 mL NaP enema (from B.T., Yenişehir Laboratories, Ankara, Turkey) rectally at bedtime the evening before the surgery.
Fasting only group and both MBP groups were allowed a clear liquid diet in the evening on the day before surgery and were not to ingest anything by mouth including liquids after midnight.

7. Methods
All surgical procedures were carried out by the same primary surgeon.
At the end of surgery, the primary surgeon completed a questionnaire, which asked him to rate intra-operative visualization of the surgical field, ease of bowel handling and overall ease of the surgery.
A Five-point scale; visual analog scale (VAS) was used for this evaluation (poor/very difficult; 1, sufficient/ moderately difficult; 2, medium /average difficulty; 3, good / easy; 4, excellent/ very easy; 5).
Finally the surgeon was asked to guess whether the patient had performed MBP or not.

8. Methods
The next morning (before surgery), all patients were interviewed by an independent investigator about preoperative overall discomfort levels with a 5-point scale, using VAS for this evaluation
Finally, patients in mechanical bowel preparation groups (oral NaP and NaP enema) were asked if they would recommend the type of mechanical bowel preparation to other patients undergoing the same procedure.

10. Results Oral NaP (n=85) NaP Enema (n=88) Fasting Only (n=89) p Age (y)
40.8±13.2
41.4±10.4
41.1±11.6
0.799
Body mass index (kg/m2)
27.1±5.5
27±5.2
25.9±5.3
0.155
Parity
1 (0-6)
2 (0-8)
2 (0-9)
0.191
Medical history
None
73 (85.9%)
73 (83%)
72 (80.9%)
0.544 HT
7 (8.2%)
11 (12.5%)
10 (11.2%) DM
3 (3.5%)
4 (4.5%)
3 (3.4%)
HT+DM
2 (2.4%) -
Prior abdominal surgery
29 (34.1%)
30 (34.1%)
32 (36%)
0.957
Surgical procedure
Hysterectomy
40 (47.1%)
45 (51.1%)
40 (44.9%)
0.942
Cystectomy
9 (10.6%)
9 (10.2%)
12 (13.5%)
Salpingo-oophorectomy
2 (2.2%)
Diagnostic
6 (7.1%)
11 (12.4%)
Myomectomy
8 (9.4%)
6 (6.8%)
7 (7.9%)
Sacrocolpopexy
Ovarian drilling
13 (15.3%)
8 (9.1%)
Operative time (min)
71.6±45.6
82.5±49.8
79.8±54.6
0.280
Estimated blood loss( mL)
76.4±95.9
108.3±123
103.1±131.2
0.091
Hemoglobin difference (g/dL)
1.53±0.98
1.72±0.95
1.58±2.1
0.149
Uterus weight (gr)
344.4±210
334.6±255.8
346.4±216.8
0.445
Length of stay (h)
46.5±17.7
54±23
51.5±21
0.104

11. Surgeon questionnaire scores using VAS.
Results
Oral NaP
(n=85)
NaP Enema
(n=88)
Fasting Only (n=89) p
Intraoperative visualization of the surgical field
4 (1-5)
0.926
Ease of bowel handling
3 (1-5)
0.400
Overall ease of the surgery
0.634
Surgeon questionnaire scores using VAS.

12. Results BMI<30kg/m2 BMI≥30kg/m2
Oral NaP
(n=65)
NaP
Enema
(n=64)
Fasting
Only (n=69) p‡
(n=20)
Enema (n=24)
Only (n=20)
Intraoperative visualization of
the surgical field
4 (2-5)
4 (1-5)
0.964
3 (1-5)
0.840
Ease of bowel handling
0.508
3.5 (2-5)
3 (2-5)
0.560
Overall ease of the surgery
0.544
0.692
Surgeon questionnaire scores using VAS when analyzed according to the BMI

13. Results
<350gr
≥350gr
Oral NaP
(n=65)
NaP
Enema
(n=64)
Fasting
Only (n=69) p‡
(n=20)
Enema (n=24)
Only (n=20)
Intraoperative visualization of
the surgical field
4 (1-5)
3 (2-5)
0.937
4.5 (2-5)
4 (2-5)
0.261
Ease of bowel handling
3.5 (1-5)
0.521
0.267
Overall ease of the surgery
3.5 (1-5)
0.869
0.264
Surgeon questionnaire scores using VAS when analyzed according to the uterine weight in patients underwent total laparoscopic hysterectomy

14. Results
Primary surgeon was correct in his assessment of the use of MBP 51.5% of the time.

15. Results
The preoperative symptoms investigated among all patients, using a VAS regarding overall discomfort was better in NaP enema group 3 (1-5) compared with oral NaP group 3 (1-5) but the difference was not significant (p=0.189). The preoperative overall discomfort score was significantly better in fasting only group 4 (3-5) when compared with oral NaP and NaP enema groups (p<0.001).
64% of patients in oral NaP group and 68% of patients in NaP enema group reported that they would recommend their use to a friend undergoing the same procedure.

16. Conclusion
MBP using oral sodium phosphate and sodium phosphate enema and no MBP patients have similar effect with respect to intra-operative visualization of the surgical field, ease of bowel handling and overall ease of the surgery.
Moreover there is no benefit of MBP when removing large uteri or operating on patients who have a high BMI.

17. Thank you for your attention!