One of the common questions we hear before endometriosis excision surgery is, “Do I really need to do the bowel prep?” It’s a fair question. Some may know that bowel preparation is not routinely recommended as part of Enhanced Recovery After Surgery (ERAS) protocols for most gynecologic procedures. However, surgery for endometriosis is complex and there are several important reasons why we at Pacific Endometriosis and Pelvic Surgery (PEPS) recommend bowel prep preoperatively.

The first reason is simple: many of our patients struggle with chronic constipation even before surgery. After any operation, temporary slowing of the bowels is common, and pain medications can make constipation even worse. Starting the postoperative recovery period with an empty colon can help patients stay ahead of the game rather than trying to catch up afterward. Anyone who has experienced constipation while recovering from surgery knows how uncomfortable it can be. We also want to minimize the need for straining during bowel movements, especially when incisions are healing. 

The second reason relates directly to the surgery itself. Complete excision of endometriosis requires a careful and thorough examination of the pelvis, including deep areas such as the cul-de-sac (the space behind the uterus). When the bowel is empty, it is generally easier to gently move it out of the way and fully visualize the structures underneath. This can make it easier for the surgeon to inspect the pelvis and assess for endometriosis in areas that are often difficult to see. Because endometriosis surgery frequently involves working deep within the pelvis, having adequate visualization is crucial.

Finally, bowel prep provides an added layer of safety when bowel endometriosis is present. Endometriosis can involve the surface of the bowel and, in some cases, may require a shaving procedure or removal of a deeper portion of the bowel. Occasionally, a full-thickness opening into the bowel may be intentionally created as part of a complete excision or, rarely, occur unintentionally during a partial thickness resection. When the bowel has been “prepped”, there is less stool present, which reduces contamination of the surgical field and can make these situations safer to manage.

At PEPS, we recognize that bowel preparation is not a routine recommendation before every gynecologic surgery. We also recognize that there are far better ways to spend the day before surgery than in your bathroom. However, the patients we care for and the surgeries we perform are different from the average gynecologic case. Because so many of our patients struggle with constipation, because thorough evaluation of the pelvis is critical during excision surgery, and because bowel involvement is not uncommon in endometriosis, we feel the benefits outweigh the short-term burden of the bowel prep. If you have questions about your preoperative instructions, please don’t hesitate to ask us to clarify.  At Pacific Endometriosis and Pelvic Surgery, we believe it’s important for patients to understand the rationale behind our recommendations, and we are always happy to provide further explanation.