ACOG Committee Opinion No. 750: Perioperative Pathways: Enhanced Recovery After Surgery.

Gynecologic surgery is very common: hysterectomy alone is one of the most frequently performed operating room procedures each year. It is well known that surgical stress induces a catabolic state that leads to increased cardiac demand, relative tissue hypoxia, increased insulin resistance, impaired coagulation profiles, and altered pulmonary and gastrointestinal function. Enhanced Recovery After Surgery (ERAS) pathways were developed with the goal of maintaining normal physiology in the perioperative period, thus optimizing patient outcomes without increasing postoperative complications or readmissions. The basic principles of ERAS include attention to the following: preoperative counseling and nutritional strategies, including avoidance of prolonged perioperative fasting; perioperative considerations, including a focus on regional anesthetic and nonopioid analgesic approaches, fluid balance, and maintenance of normothermia; and promotion of postoperative recovery strategies, including early mobilization and appropriate thromboprophylaxis. Benefits of ERAS pathways include shorter length of stay, decreased postoperative pain and need for analgesia, more rapid return of bowel function, decreased complication and readmission rates, and increased patient satisfaction. Implementation of ERAS protocols has not been shown to increase readmission, mortality, or reoperation rates. These benefits have been replicated across the spectrum of gynecologic surgeries, including open and minimally invasive approaches and benign and oncologic surgeries. The implementation of the ERAS program requires collaboration from all members of the surgical team. Enhanced Recovery After Surgery is a comprehensive program, and data demonstrate success when multiple components of the ERAS pathway are implemented together. Successful ERAS pathway implementation across the spectrum of gynecologic care has the potential to improve patient care and health care delivery systems.