This prospective cohort study enrolled 90 patients who presented to the Hospital Regional Universitario de Málaga from October 2017 to October 2019. Patients who were scheduled for a laparoscopic hysterectomy for benign causes were included, while those who required conversion to open surgery, resided outside our province, and whose ASA score was > II were excluded.
These patients were categorized into two groups: 1) the ERAS group (n=30, patients in whom the ERAS protocol was implemented) and 2) the control group (n=60, patients in whom the traditional protocol was implemented). All patients were followed for six months.
Pre-surgical visits are one of the pillars of our protocol. During this visit, patients were informed of the procedure to be performed, and the procedure itself was optimized for surgery. Pre-surgical visits were always managed by a gynecologist from our surgery unit.
The surgeries themselves were performed by the gynecological surgery unit of our hospital, and were attended by at least one senior surgeon. Furthermore, all personnel involved in the process, i.e., the surgeons, anesthesiologists, and nurses, received specific training on the phases and procedures defined in the ERAS protocols. Likewise, our center’s protocol was also developed by adapting the evidence gathered in the available clinical guidelines (Table 1) [3,4,6].
Table 1. The ERAS Protocol.
Inform the patient of her surgery and the protocol to be followed in the consultation
Give up tobacco, alcohol and ACHOs 4 weeks before surgery, correcting anaemia
Carbohydrate-rich diet the day before surgery
6-hour fast for solids and 2-hour fast for clear liquid
Abdominal and vaginal shaving (if necessary) of the patient.
No mechanical bowel preparation
Anaesthetic induction and anaesthetic maintenance with short-acting agents.
Maintain temperature 36ºC +/- 0.5 (thermal blankets, hot sera)
Pneumatic compression stockings
Fluid therapy in continuous perfusion balanced solution. (3-5 ml/kg/h for laparoscopy). Maintain Euvolemia
Haemodynamic optimisation through objective-guided fluid therapy (FGO) in risk patients.
Postoperative nausea and vomiting prophylaxis with double therapy.
No drainage. No nasogastric tube.
Infiltration of the laparoscopy ports with Bupivacaine
Active temperature maintenance. Maintenance of FiO2 0.5 2 hours after the end of the operation.
Analgesia according to the operation. Minimum morphic administration. AVOID OPIODS
Restrictive fluid therapy.
Start of oral tolerance at 6 hours post-surgery, If positive oral tolerance, liquid diet in the evening and removal of intravenous fluids.
Beginning of mobilization and prophylaxis of the thromboembolism. at 6 hours after surgery
Blood test the morning after the intervention
Normal balanced diet according to tolerance.
Removal of bladder catheter 12-24 h after surgery
Oral analgesia according to protocol. Avoiding morphs. Breathing incentive.
Assess discharge from laparoscopic surgery (24-48 h)
After discharge, the patients underwent an in-person check-up one month after the surgery, and were followed for up to six months to confirm a return to normal activity and to rule out any complications. All post-operative complications were classified according to the Clavien–Dindo classification .
- Achieve the implementation of an ERAS protocol in laparoscopic gynecological surgery.
- Assess ERAS protocol influence on the postoperative stay and the morbidity, mortality, and readmission rates.
- Asses patients’ adherence to ERAS protocol
All statistical analyses were performed using the SPSS package v25 (IBM). Qualitative variables were described by counts and frequencies, while quantitative variables were described by means, medians, and ranges. The patient characteristics and distribution were compared between the two groups by using the Student’s t-test and the χ2 test. The level of statistical significance was set at α = 0.05.
All the patient were informed and consented to the elaboration and publication of this review. Similarly, the ethics committee of our centre gave its approval