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Enhanced recovery after gynecologic surgery: Components and implementation

Mallika Anand, MD, MS
Emanuel C Trabuco, MD, MS
Section Editors
Girish P Joshi, MB, BS, MD, FFARCSI
Tommaso Falcone, MD, FRCSC, FACOG
Deputy Editor
Kristen Eckler, MD, FACOG


Enhanced recovery after surgery (ERAS) programs are perioperative protocols of evidence-based interventions that have been grouped together with the goals of speeding functional recovery and improving postoperative outcomes. Also known as "enhanced recovery protocols" (ERP) or "fast-track surgery," ERAS programs typically include multidisciplinary and multimodal interventions aimed at minimizing the physiologic changes associated with surgery. Patient benefits associated with ERAS include reduction in postoperative opioid use and length of stay.

This topic will review ERAS programs as they apply to gynecologic surgery with a planned overnight stay, although many elements of the ERAS programs discussed here can be adapted for same-day major gynecologic surgery, such as same-day hysterectomy. Related topics on ERAS in colorectal surgery and general postoperative care are presented separately.

(See "Enhanced recovery after colorectal surgery".)

(See "Overview of post-anesthetic care for adult patients".)

(See "Overview of postoperative fluid therapy in adults".)

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Literature review current through: Nov 2017. | This topic last updated: Oct 31, 2017.
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  1. Scientific Impact Paper No. 36. Enhanced Recovery in Gynaecology. Royal College of Obstetricians and Gynaecologists. February, 2013. https://www.rcog.org.uk/globalassets/documents/guidelines/scientific-impact-papers/sip_36.pdf (Accessed on June 27, 2017).
  2. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78:606.
  3. www.erassociety.org (Accessed on June 22, 2017).
  4. de Groot JJ, Ament SM, Maessen JM, et al. Enhanced recovery pathways in abdominal gynecologic surgery: a systematic review and meta-analysis. Acta Obstet Gynecol Scand 2016; 95:382.
  5. Miralpeix E, Nick AM, Meyer LA, et al. A call for new standard of care in perioperative gynecologic oncology practice: Impact of enhanced recovery after surgery (ERAS) programs. Gynecol Oncol 2016; 141:371.
  6. Modesitt SC, Sarosiek BM, Trowbridge ER, et al. Enhanced Recovery Implementation in Major Gynecologic Surgeries: Effect of Care Standardization. Obstet Gynecol 2016; 128:457.
  7. Muallem MZ, Dimitrova D, Pietzner K, et al. Implementation of Enhanced Recovery After Surgery (ERAS) Pathways in Gynecologic Oncology. A NOGGO-AGO* survey of 144 Gynecological Departments in Germany. Anticancer Res 2016; 36:4227.
  8. Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg 2017; 152:292.
  9. Nelson G, Altman AD, Nick A, et al. Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations--Part I. Gynecol Oncol 2016; 140:313.
  10. Nelson G, Altman AD, Nick A, et al. Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations--Part II. Gynecol Oncol 2016; 140:323.
  12. Oppedal K, Møller AM, Pedersen B, Tønnesen H. Preoperative alcohol cessation prior to elective surgery. Cochrane Database Syst Rev 2012; :CD008343.
  13. Thomsen T, Villebro N, Møller AM. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev 2014; :CD002294.
  14. Smith MD, McCall J, Plank L, et al. Preoperative carbohydrate treatment for enhancing recovery after elective surgery. Cochrane Database Syst Rev 2014; :CD009161.
  15. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg 2017; 152:784.
  16. Johnson MP, Kim SJ, Langstraat CL, et al. Using Bundled Interventions to Reduce Surgical Site Infection After Major Gynecologic Cancer Surgery. Obstet Gynecol 2016; 127:1135.
  17. Kalogera E, Dowdy SC. Enhanced Recovery Pathway in Gynecologic Surgery: Improving Outcomes Through Evidence-Based Medicine. Obstet Gynecol Clin North Am 2016; 43:551.
  18. Steinberg AC, Schimpf MO, White AB, et al. Preemptive analgesia for postoperative hysterectomy pain control: systematic review and clinical practice guidelines. Am J Obstet Gynecol 2017; 217:303.
  19. Kalogera E, Bakkum-Gamez JN, Weaver AL, et al. Abdominal Incision Injection of Liposomal Bupivacaine and Opioid Use After Laparotomy for Gynecologic Malignancies. Obstet Gynecol 2016; 128:1009.
  20. Gasanova I, Alexander J, Ogunnaike B, et al. Transversus Abdominis Plane Block Versus Surgical Site Infiltration for Pain Management After Open Total Abdominal Hysterectomy. Anesth Analg 2015; 121:1383.
  21. Committee on Gynecologic Practice. Committee Opinion No 701: Choosing the Route of Hysterectomy for Benign Disease. Obstet Gynecol 2017; 129:e155.
  22. Holte K, Sharrock NE, Kehlet H. Pathophysiology and clinical implications of perioperative fluid excess. Br J Anaesth 2002; 89:622.
  23. Rahbari NN, Zimmermann JB, Schmidt T, et al. Meta-analysis of standard, restrictive and supplemental fluid administration in colorectal surgery. Br J Surg 2009; 96:331.
  24. Kalogera E, Bakkum-Gamez JN, Jankowski CJ, et al. Enhanced recovery in gynecologic surgery. Obstet Gynecol 2013; 122:319.
  25. Archer S, Montague J, Bali A. Exploring the experience of an enhanced recovery programme for gynaecological cancer patients: a qualitative study. Perioper Med (Lond) 2014; 3:2.
  26. Armstrong KA, Coyte PC, Brown M, et al. Effect of Home Monitoring via Mobile App on the Number of In-Person Visits Following Ambulatory Surgery: A Randomized Clinical Trial. JAMA Surg 2017; 152:622.
  27. Debono B, Bousquet P, Sabatier P, et al. Postoperative monitoring with a mobile application after ambulatory lumbar discectomy: an effective tool for spine surgeons. Eur Spine J 2016; 25:3536.
  28. Jaensson M, Dahlberg K, Eriksson M, et al. The Development of the Recovery Assessments by Phone Points (RAPP): A Mobile Phone App for Postoperative Recovery Monitoring and Assessment. JMIR Mhealth Uhealth 2015; 3:e86.
  29. Dahlberg K, Jaensson M, Eriksson M, Nilsson U. Evaluation of the Swedish Web-Version of Quality of Recovery (SwQoR): Secondary Step in the Development of a Mobile Phone App to Measure Postoperative Recovery. JMIR Res Protoc 2016; 5:e192.
  30. Sjetne IS, Krogstad U, Ødegård S, Engh ME. Improving quality by introducing enhanced recovery after surgery in a gynaecological department: consequences for ward nursing practice. Qual Saf Health Care 2009; 18:236.
  31. Wodlin NB, Nilsson L, Kjølhede P. Health-related quality of life and postoperative recovery in fast-track hysterectomy. Acta Obstet Gynecol Scand 2011; 90:362.
  32. Chapman JS, Roddy E, Ueda S, et al. Enhanced Recovery Pathways for Improving Outcomes After Minimally Invasive Gynecologic Oncology Surgery. Obstet Gynecol 2016; 128:138.
  33. de Groot JJ, van Es LE, Maessen JM, et al. Diffusion of Enhanced Recovery principles in gynecologic oncology surgery: is active implementation still necessary? Gynecol Oncol 2014; 134:570.
  34. Barber EL, Van Le L. Enhanced Recovery Pathways in Gynecology and Gynecologic Oncology. Obstet Gynecol Surv 2015; 70:780.
  35. Dickson E, Argenta PA, Reichert JA. Results of introducing a rapid recovery program for total abdominal hysterectomy. Gynecol Obstet Invest 2012; 73:21.
  36. Miller EC, McIsaac DI, Chaput A, et al. Increased postoperative day one discharges after implementation of a hysterectomy enhanced recovery pathway: a retrospective cohort study. Can J Anaesth 2015; 62:451.
  37. Marx C, Rasmussen T, Jakobsen DH, et al. The effect of accelerated rehabilitation on recovery after surgery for ovarian malignancy. Acta Obstet Gynecol Scand 2006; 85:488.
  38. Eberhart LHJ, Koch T, Plöger B, et al. Enhanced recovery after major gynaecological surgery for ovarian cancer - An objective and patient-based assessment of a traditional versus a multimodal “fast track” rehabilitation programme. Anasth Intensivmed 2008; 49:180.
  39. Gerardi MA, Santillan A, Meisner B, et al. A clinical pathway for patients undergoing primary cytoreductive surgery with rectosigmoid colectomy for advanced ovarian and primary peritoneal cancers. Gynecol Oncol 2008; 108:282.
  40. Nelson G, Kalogera E, Dowdy SC. Enhanced recovery pathways in gynecologic oncology. Gynecol Oncol 2014; 135:586.
  41. Yoong W, Sivashanmugarajan V, Relph S, et al. Can enhanced recovery pathways improve outcomes of vaginal hysterectomy? Cohort control study. J Minim Invasive Gynecol 2014; 21:83.
  42. Dickson EL, Stockwell E, Geller MA, et al. Enhanced Recovery Program and Length of Stay After Laparotomy on a Gynecologic Oncology Service: A Randomized Controlled Trial. Obstet Gynecol 2017; 129:355.
  43. Relph S, Bell A, Sivashanmugarajan V, et al. Cost effectiveness of enhanced recovery after surgery programme for vaginal hysterectomy: a comparison of pre and post-implementation expenditures. Int J Health Plann Manage 2014; 29:399.
  44. Philp S, Carter J, Pather S, et al. Patients' satisfaction with fast-track surgery in gynaecological oncology. Eur J Cancer Care (Engl) 2015; 24:567.
  45. de Groot JJ, Maessen JM, Slangen BF, et al. A stepped strategy that aims at the nationwide implementation of the Enhanced Recovery After Surgery programme in major gynaecological surgery: study protocol of a cluster randomised controlled trial. Implement Sci 2015; 10:106.
  46. McDonald R. Enhanced recovery clinical education programme improves quality of post-operative care. BMJ Qual Improv Rep 2015; 4.