It is 2021 and conferences around the world still debate the pros and cons of mechanical bowel prep (MBP). It is baffling how a safe intervention used millions of times every day for screening colonoscopies is a subject of fierce discussions amongst colleagues, in book chapters, and lectures when applied to patients undergoing colorectal resection. Although we believe that for patients with advanced ovarian cancer undergoing cytoreductive surgery there are other quintessential questions to debate about, we understand that the debate over this issue is far from resolved and expert majority opinion has vacillated over the past decade. With all this in mind, as a disclaimer the authors are allowed to change their minds.

The use of MBP remains a controversial issue. After its adoption in the 1800s it began to fall out of favor when studies including a Cochrane meta-analysis reported that omitting MBP was not associated with increased postoperative complication. However, it is important to note that these studies compared MBP alone and not in combination with oral antibiotics (OABP). In more recent years, the use of MBPs has been reincorporated into clinical practice, however now it is used in conjunction with OABPs after several key trials demonstrated benefit to the combination therapy. Among these benefits are a decrease in surgical site infections, anastomotic leaks, and readmission rates. These findings led multiple large societies to recommend the routine use of combination bowel preparation prior to planned colorectal resections. Based on these recommendations and recent literature, we recommend the use of combination OABP with MBP be tailored towards patients at greatest risk of requiring colorectal resections, which entails a large portion of patients undergoing primary debulking surgery for a gynecologic malignancy. Surgeon assessment of the risk for colonic or rectal resection through clinical history, pelvic exam, and radiological findings can aid in tailoring the need for combination bowel preparation.