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Evidence-Based Gynecologic Surgery Best Practices: The AHRQ Safety Program


The AHRQ, American College of Surgeons and Armstrong Institute at Johns Hopkins have developed a safety program to assess and help incorporate evidence-based practices into surgical care. An evidence review of gynecologic surgery was conducted, supporting the protocol elements in the AHRQ Safety Program that include the following best practices


Patient Education

  • ‘Potential’ association between preoperative patient education and improved outcomes (low level evidence)

Immediate Preoperative

Bowel Prep

  • Minimally invasive gyn surgery
    • Oral mechanical bowel prep should be abandoned (strong level evidence)
  • When bowel prep is desired (patients at high risk such as colorectal resection)
    • Based on colorectal surgery evidence, oral mechanical bowel prep alone is not effective
    • Use one of the following regimens (moderate level evidence)
      • Oral mechanical bowel prep and oral antibiotic
      • Oral antibiotic alone
    • Note: The review states “Data from non-randomized studies suggest that bowel preparation may be omitted within a well-developed ERP (enhanced recovery pathways) that incorporates a SSI reduction bundle even when bowel resection is anticipated”



  • Routine nasogastric tube
    • Associated patient discomfort with no known benefit (high level evidence)
  • Routine peritoneal drains
    • Prophylactic use is not beneficial following lympadenectomy for gyn surgery
    • Avoid unless there is a rectal anastomosis within 6 cm of the anal verge and no diversion or patient at high risk for pelvic collections (moderate level evidence)


Early Mobilization

  • Beneficial – avoid prolonged bedrest (moderate level evidence)

Early Alimentation

  • Early oral feeding is safe (high level of evidence)
    • Well tolerated
    • Shorter hospital length of stay
    • Initiate as early as 4 hours following gyn surgery with or without bowel resection

Early Urinary Bladder Catheter Removal

  • Use catheters for <24 hours (moderate level evidence)
    • However, it is appropriate to consider fall risk and necessity of urine output monitoring for some patients
  • Uncomplicated surgeries
    • Removal at 6 hours balances rates of infection vs retention
  • Complicated surgeries (e.g., urogynecologic or gynecologic oncology procedures)
    • Morning after may be more appropriate

Prevention of Ileus and accelerate return of bowel function

  • Standardized use of postoperative laxatives
    • Recommended for gyn surgery (low level evidence)
    • Examples: Senna with docusate | Docusate | Magnesium oxide or magnesium hydroxide | Bisacodyl
  • Chewing gum
    • Recommended for gyn surgery (high level of evidence)
  • Alvimopan (novel peripheral μ-opioid antagonist)
    • May not be beneficial in benign gyn surgery
    • May decrease ileus in ovarian cancer surgery and can be considered for use in patients undergoing bowel resection (moderate level evidence)

Early IV Fluid discontinuation

  • Discontinue maintenance IV fluids within 12 to 24 hours following surgery, especially with early fluid and solid intake (low level of evidence)
    • Urine output as low as 20 mL/hour
      • Recognize as normal perioperative stress response
      • Intervention not required


Other Evidence-Based Perioperative Interventions

  • Surgical site infection bundles (see ‘Related ObG Topics’ below)
    • Use of surgical site infection bundles should be considered (high level evidence)
  • Glucose management
    • Perioperative glucose goal: ≤ 180 mg/dL (10.0 mmol/L) (high level evidence)

Venous Thromboembolism (VTE) Prophylaxis

  • Preoperative
    • Intermittent pneumatic compression alone for (moderate level evidence)
      • Minimally invasive surgery for any indication or
      • Laparotomy for benign disease
    • Add preoperative pharmacologic prophylaxis for patients undergoing laparotomy for gynecologic malignancies
      • Weak level evidence from observational studies but consideration given to high rate of VTE in this population
      • Supported by multiple societies
    • Postoperative
      • Use mechanical prophylaxis for the duration of hospitalization in all gynecologic surgical patients and mechanical and/or pharmacologic prophylaxis for gynecologic oncology surgical patients (high level of evidence)
      • Gyn oncology: Extend VTE chemoprophylaxis for 4 weeks following surgery
        • Supported by multiple guidelines, but further research required on long-term benefits

Learn More – Primary Sources:

Surgical Technical Evidence Review for Gynecologic Surgery Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery Related Website link