Introduction
Enhanced recovery after surgery (first introduced by Danish anesthetist Henrik Kehlet in 1997) is a range of optimized, perioperative management approach throughout a patient’s stay in the hospital—including extensive preoperative counseling, without bowel preparation, preoperative carbohydrate loading, multimodal analgesia, minimally invasive surgery, adequate perioperative fluid infusion, maintenance of normothermia, early postoperative feeding, and ambulation. These steps aim to mitigate the surgical stress response and accelerate postoperative recovery and not compromise morbidity or the readmission rate. Initially used in colorectal surgery, enhanced recovery after surgery (ERAS) has now been widely adopted for multiple abdominal procedures, including gynaecologic operations.1 The implementation of ERAS in both benign and malignant gynaecologic services has showed positive results, including a 1- to 2-day reduction in length of stay (LOS) for all approaches, a 20.8% to 97.4% drop in narcotic use, and a 9.25% to 21.7% reduction in the average hospital cost, without compromising mortality or the readmission rate.2
Another unprecedented intervention during the last two decades—the laparoscopic approach—has proven its superiority over laparotomy and is considered to be a key element in an ERAS program. ERAS combined with laparoscopic techniques in colorectal surgery was also associated with shorter hospital stay, a lower postoperative complication rate, and reduced hospital costs.3
However, a large majority of randomized controlled trials (RCT) on ERAS in the case of gynaecologic surgery have only included patients undergoing an open abdominal approach, and there is a paucity of evidence regarding the potential benefits of an ERAS program in laparoscopic surgery.4-10 The possible overlap of benefits between an ERAS program and laparoscopy has raised the question of whether the combination of the two interventions further improves the perioperative outcomes, particularly for those patients undergoing simple procedures (i.e. laparoscopic ovarian cystectomy, myomectomy, and hysterectomy, etc.) who might already have achieved a faster recovery.
In addition, a full ERAS program contains more than 20 different items, and implementing those components can be demanding. The gynaecologic service at our hospital has already embraced some of the ERAS concepts, including early catheter removal, feeding, ambulation, and most importantly, a laparoscopic approach—which collectively constitutes the so-called “limited ERAS pathway.” This simplified ERAS management has become the standard of care at many medical centers. However, the lack of data with which to evaluate each component of the pathway makes it difficult to determine the critical elements that benefit the outcomes.11
In the present single-center, open-label, randomized trial, we aimed to determine which form of perioperative treatment—either a full or limited ERAS program combined with simple laparoscopic procedures—was the optimal approach for patients in gynaecology department; and to identify which elements of ERAS were critical for an improved perioperative outcome.