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This is the first Enhanced Recovery After Surgery (ERAS) guideline dedicated to standardizing and optimizing perioperative care for women undergoing minimally invasive gynecologic surgery (MIGS). The guideline was rigorously formulated by an AAGL taskforce of US and Canadian gynecologic surgeons with special interest and experience in adapting ERAS...
Contexts in source publication
Context 1
... optimization: Anemia Target Hgb ≥12 g/dL for elective MIGS through pharmacotherapy to treat and prevent blood-loss anemia (Table 3). ...Context 2
... women undergoing elective gynecologic surgery, attempts should be made to achieve a preoperative Hgb level of >12 g/dL with iron supplementation and/or suppression of uterine bleeding. Intraoperative adjuncts (both medical and surgical) to minimize blood loss should also be considered (Table 3), as should restrictive thresholds for perioperative transfusion (Hgb level <7 g/dL) [22]. Reliance on red blood cell transfusion alone is not a good strategy because correction of anemia with perioperative transfusion has not been shown to sufficiently mitigate adverse postoperative outcomes [16]. ...Context 3
... optimization: Anemia Target Hgb ≥12 g/dL for elective MIGS through pharmacotherapy to treat and prevent blood-loss anemia (Table 3). ...Context 4
... women undergoing elective gynecologic surgery, attempts should be made to achieve a preoperative Hgb level of >12 g/dL with iron supplementation and/or suppression of uterine bleeding. Intraoperative adjuncts (both medical and surgical) to minimize blood loss should also be considered (Table 3), as should restrictive thresholds for perioperative transfusion (Hgb level <7 g/dL) [22]. Reliance on red blood cell transfusion alone is not a good strategy because correction of anemia with perioperative transfusion has not been shown to sufficiently mitigate adverse postoperative outcomes [16]. ...Citations
... Anesthesia and perioperative pain control: The Enhanced Recovery After Surgery (ERAS) guideline [11] was considered within the conventional rules. ...
Study objective:
To investigate diverse hysterectomy techniques to determine their influence on patient outcomes, including pain levels, sexual function, anxiety, and quality of life. Of particular focus is the comparison between vessel sealing and traditional suturing in abdominal, vaginal, and laparoscopic hysterectomies. This study is unique in its comprehensive evaluation, considering patient satisfaction, recommendation rates, recovery times, and various other aspects.
Method:
Our prospective cohort study adhered to ethical guidelines, involving a meticulous assessment of patients, including medical history, anxiety levels, pelvic pain, sexual function, and quality of life. Surgical methods were explained to patients, allowing them to actively participate in the decision-making process. Sociodemographic information was collected, and exclusion criteria were applied. Hysterectomy methods included total abdominal hysterectomy (TAH), laparoscopic hysterectomy (TLH), vaginal hysterectomy (VH), and a modified vaginal technique known as VH Mujas. Several parameters were recorded, including operation indications, uterine volume, hospital stay, operation duration, pre-operative and post-operative complications, and more.
Results:
In all groups, a statistically significant increase was found in pre-operative-post-operative FSFI sexual function values (p < 0.001). The patient's basal Beck Anxiety Scale scores significantly decreased following the decision for vaginal surgery, both in the VH and VH Mujas groups (p < 0.05). However, Beck Anxiety Scale scores at patients' initial assessments significantly increased following the decision for abdominal and laparoscopic surgery (p < 0.001). According to the results of the SF-36 quality of life assessment, an increase was observed in all post-operative quality of life parameters in patients who underwent surgery with different methods due to VH (p < 0.05).
Conclusions:
Our comprehensive comparison of hysterectomy techniques demonstrated that VH, particularly when utilizing the Mujas technique, outperforms other hysterectomy methods regarding patient safety and post-operative satisfaction but also offers the benefit of minimal invasiveness. Notably, this is reflected in improved quality of life, enhanced sexual function, lower pain scores, and favorable cosmetic results. The success of a hysterectomy procedure depends on precise indications, surgical planning, proper patient selection, and effective communication. This study emphasizes the significance of these factors in achieving optimal outcomes. The development of specialized vascular closure devices can further enhance the feasibility of vaginal hysterectomy, making it a preferable choice in gynecological surgery. The study contributes valuable insights into selecting the most suitable hysterectomy method for patients and optimizing their recovery.
... Yet, the authors also recommended testing for patients scheduled for vascular and orthopedic surgery due to their elevated risks [84]. Generally, HbA1c above 8.0-8.5% has been set to be the threshold for recommending additional glycemic control interventions prior to proceeding with non-time-sensitive moderate to high-risk surgery [85][86][87]. HbA1c of 8.5% is reflective of an average serum glucose level of 200 mg/dL, suggesting high likelihood of significant hyperglycemia on the day of surgery and Table 1 Pregnancy Reasonably Excluded Guide (PREG) for pregnancy assessment [95] I am pregnant. D I am 14-17 years old. ...
Purpose of Review
Ambulatory anesthesia has experienced a rapid expansion in procedural breadth and patient complexity. Proper patient selection via preoperative evaluation and testing is imperative to ensure the safety of patients with major comorbidities and advanced age who undergo procedures in ambulatory surgical settings.
Recent Findings
New developments and controversies have arisen in the preoperative considerations for ambulatory surgical patients with class III obesity, obstructive sleep apnea, pulmonary hypertension, cardiomyopathy, heart failure, and other severe diseases. The value of preoperative laboratory testing is also debated.
Summary
There are controversies and new developments with important implications for current and future practice in ambulatory anesthesia. With careful preoperative evaluation, testing, and patient selection process, patients with severe diseases may safely undergo ambulatory surgery. Individualized evaluations should dictate which patients are appropriate for ambulatory surgery.
... Robotics, with their complex dexterity and improved visualization, redefine the limits of surgical accuracy. Surgical navigation systems, utilizing real-time imagery, offer surgeons dynamic guidance, allowing for exceptional precision in navigating intricate anatomical structures [16]. ...
... Historically, surgical safety has primarily been associated with a reduction in immediate perioperative complications [5]. However, contemporary perspectives emphasize a broader, more holistic approach, considering long-term outcomes, quality of life, and patient satisfaction [6]. 1 2 3 4 5 6, 7 8 1 9 The evolving landscape of surgical safety is characterized by a paradigm shift from a reactive to a proactive model. Traditionally, safety measures were often implemented in response to identified risks or adverse events. ...
... As the understanding of surgical safety deepens and the demands for improved patient outcomes increase, there is a pressing need for innovative approaches. The traditional methods that have served the medical community well must be augmented by novel strategies that leverage technological advancements, data analytics, and interdisciplinary collaboration [6]. ...
... Antibiotic resistance, an escalating worldwide issue, presents a substantial risk to managing infections in surgical environments, necessitating strategic methods for antibiotic utilization and strict adherence to sterile procedures. The increasing number of elderly individuals, who often have many simultaneous medical conditions, makes preoperative decision-making more complex [6]. This requires tailored strategies to reduce risks. ...
By encompassing a wide range of best practices within the ever-changing realm of modern surgical care, this exhaustive narrative compendium attempts to unravel the complex tapestry of novel approaches to safe surgery. Within the context of a dynamic surgical environment, this research endeavors to illuminate and integrate state-of-the-art methods that collectively methodically improve patient safety. The narrative elucidates a diverse array of practices that seek to revolutionize the paradigm of safe surgery, emphasizing technological progress, patient-centric approaches, and global viewpoints. The combined effectiveness of these methods in fostering an all-encompassing culture of safety, improving surgical precision, and decreasing complications is revealed by the results obtained from their implementation. The recognition of the dynamic interplay among multiple components, including the active participation of patients, the integration of cutting-edge technologies, and the establishment of comprehensive quality improvement programs, is fundamental to this narrative. By their collective composition, these components support the notion that secure surgical practices are intricate and interrelated. The present synthesis functions as a fundamental resource for healthcare professionals, policymakers, and researchers, providing an enlightening examination of the current condition of secure surgical practices. By emphasizing the promotion of innovation, continuous development, and the utmost quality of patient care, it offers a strategic guide for navigating the complex terrain of safe surgery. In the ever-evolving landscape of surgical care, this narrative synthesis serves as a guiding principle for stakeholders striving to understand better and implement safe surgical procedures in various healthcare environments.
... This pathway was initially developed for colorectal surgeries [1] and has since been implemented for a wide array of surgical subspecialties. ERAS has since become well established in the field of gynecologic surgery [2][3][4][5][6][7]. ...
Study objective: This study aimed to determine the effect of the implementation of the Enhanced Recovery After Surgery (ERAS) protocol among patients receiving minimally invasive gynecologic surgery.
Design and setting: This retrospective cohort study was performed in a tertiary care hospital.
Patients: A total of 328 females who underwent minimally invasive gynecologic surgeries requiring at least one overnight stay at Keck Hospital of University of Southern California (USC), California, USA, from 2016 to 2020 were included in this study.
Interventions: The institutional ERAS protocol was implemented in late 2018. A total of 186 patients from 2016 to 2018 prior to the implementation were compared to 142 patients from 2018 to 2020 after the implementation. Intraoperatively, the ERAS group received a multimodal analgesic regimen (including bilateral quadratus lumborum (QL) blocks) and postoperative care geared toward a satisfactory, safe, and expeditious discharge.
Measurements and main results: The two groups were similar in demographics, except for the shorter surgical time noted in the ERAS group. The median opioid use was significantly less among the ERAS patients compared with the non-ERAS patients on postoperative day 1 (7.5 vs. 14.3 mg; p<0.001) and throughout the hospital stay (17.4 vs. 36.2 mg; p<0.001). The ERAS group also had a shorter median hospital length of stay compared to the non-ERAS group (p<0.01). Among patients with a malignant diagnosis, patients in the ERAS group had significantly less postoperative day 1 and total opioid use and a shorter hospital stay (p<0.01). Within the ERAS group, 20% of the patients did not end up receiving a QL block. Opioid use and length of stay were similar between patients who did and did not receive the QL block.
Conclusions: The ERAS pathway was associated with a reduction in opioid use postoperatively and a shorter length of hospital stay after minimally invasive gynecologic surgery. There was a more significant decrease in opioid use and hospital length of stay for patients with malignant diagnoses compared to patients with benign diagnoses. Further research can be done to fully delineate the effect of QL blocks in ERAS protocols.
... This realization led to a call to action from the United States Surgeon General in 2016 for safer opioid prescribing practices [7]. The recent 2023 update of the gynecologic oncology guidelines specifically addresses implementation challenges including creating successful SDD programs through collaboration, education, patient selection, and ERAS perioperative principles, including appropriate postoperative opioid prescribing [4,8]. The aim of this review was to summarize the impacts of ERAS in patients undergoing minimally invasive gynecologic oncology surgery. ...
Enhanced recovery after surgery (ERAS) has established benefits in open gynecologic oncology surgery. However, the benefits for gynecologic oncology patients undergoing minimally invasive surgery (MIS) are less well defined. We conducted a review of this topic after a comprehensive search of the peer-reviewed literature using MEDLINE and PubMed databases. Our search yielded 25 articles, 14 of which were original research articles, in 10 distinct patient cohorts describing ERAS in minimally invasive gynecologic oncology surgery. Major benefits of ERAS in MIS included: decreased length of stay and increased rates of same-day discharge, cost-savings, decreased opioid use, and increased patient satisfaction. ERAS in minimally invasive gynecologic oncology surgery is an area of great promise for both patients and the healthcare system.
... Perioperative treatment with opioids may also cause opioid-induced hyperalgesia [2,3], and studies have shown that there is 6-8 % risk of persistent opioid use in opioidnaive patients after both minor and major surgery [4][5][6]. Therefore, current guidelines for management of postoperative pain, as well as ERAS guidelines recommend multimodal opioid-sparing techniques [7][8][9]. ...
Objectives
Opioids are important for postoperative analgesia but their use can be associated with numerous side effects. Transcutaneous electrical nerve stimulation (TENS) has been used for acute pain treatment and has dose-dependent analgesic effects, and therefore presents an alternative to intravenous (iv) opioids for postoperative pain relief. The aim of this meta-analysis was to compare high-frequency, high-intensity (HFHI or intense) TENS to iv opioids with regard to postoperative pain intensity, recovery time in the Post Anesthesia Care Unit (PACU) and opioid consumption after elective gynecological surgery.
Methods
We searched Medline, Embase, Web of Science, Cochrane, Amed and Cinahl for RCTs and quasi-experimental studies (2010–2022), and WHO and ClinicalTrials.gov for ongoing/unpublished studies. Meta-analysis and subsequent Trial Sequential Analysis (TSA) was performed for all stated outcomes. Quality of evidence was assessed according to GRADE.
Results
Only three RCTs met the inclusion criteria (362 participants). The surgical procedures involved surgical abortion, gynecologic laparoscopy and hysteroscopy. The applied TENS frequency was 80 Hz and intensity 40–60 mA. There was no difference in pain intensity according to Visual Analogue Scale (VAS) at discharge from PACU between the TENS and opioid group (MD VAS −0.15, 95 % CI −0.38 to 0.09) (moderate level of evidence). Time in PACU was significantly shorter in the TENS group (MD −15.2, 95 % −22.75 to −7.67), and this finding was manifested by TSA (high-level of evidence). Opioid consumption in PACU was lower in the TENS group (MD Morphine equivalents per patient mg −3.42, 95 % −4.67 to −2.17) (high-level of evidence).
Conclusions
There was no detectable difference in postoperative pain relief between HFHI TENS and iv opioids after gynecological surgery. Moreover, HFHI TENS decreases recovery time and opioid consumption in PACU. HFHI TENS may be considered an opioid-sparing alternative for postoperative pain relief after gynecological surgery.
Systematic review registration
PROSPERO CRD42021231048.
... 13,14 The few systematic reviews, published in the literature on Enhanced Recovery After Surgery (ERAS) after gynaecological procedures, performed as open surgery or minimally invasive gynaecological surgery (MIGS), have presented an assessment of the advantages of this approach. 6,[15][16][17][18][19] We reviewed the published literature on ERAS programmes in gynaecology to assess outcomes and potential key elements for a successful programme, including preoperative patient counselling, no bowel preparation, a multimodal approach to pain management, rational fluid management, minimally invasive interventions, and early mobilisation and feeding. It is important to emphasise the interdisciplinary principle of teamwork and the active participation of the patient in the recovery process. ...
The Enhanced Recovery After Surgery (ERAS), or Fast Track Surgery, aims to minimise the physiological stress of surgery and optimise patient rehabilitation. However, data on surgical interventions in obstetrics and gynaecology are limited. The aim of the study was to analyse the use of elements of the ERAS programme in gynaecologic surgery clinics and to assess the benefits of this approach. Analytical processing was carried out on systematic reviews and meta-analyses, articles and scientific reports published before June 2023, found and available through the PubMed, EMBASE, Cochrane Central Register of Controlled Trials databases. The data were obtained from relevant published studies, including changes in quality of life, postoperative pain, use of opioids or anaesthesia, postoperative nausea and vomiting, rate of readmission, cost of hospitalisation, and clinically significant increase in patient satisfaction. The ERAS programme is a multimodal and multidisciplinary programme aimed at optimising perioperative treatment and improving postoperative outcomes in operative gynaecology by minimising the patient’s stress response, promoting functional recovery and achieving rapid recovery, where the patient is in the field of view of a number of specialists. The presented publications demonstrate that this concept of FTS is a fundamentally new approach to the surgical treatment of gynaecological patients and covers all stages of perioperative therapy: preoperative, intraoperative and postoperative. Conclusions. The initial stage of the surgeon’s and anaesthetist’s acquaintance with the patient is very important, as communication and rational presentation of information using illustrative and video material helps the patient understand the disease, consciously choose the proposed method of treatment, reduces anxiety, increases the role of the surgical team in treatment and satisfaction with its outcome, reduces the risk of dissatisfaction from false expectations (duration of the perioperative period, pain, changes in nutrition and mobility, sutures, etc.). The introduction of evidence-based medicine into the practice of operative gynaecology restructures classical approaches and principles of patient treatment, raises awareness of doctors and heads of surgical departments, and also contributes to the improvement of the outcome of operations.
... During the study period, the focus on 'Enhanced Recovery After Surgery' increased in general in our hospital, both for RAM and AM (Stone et al., 2021). Despite this, the hospital stay for patients undergoing RAM or AM differed markedly in our cohort. ...
Background: Myomectomy is often the preferred treatment for symptomatic patients with myomas who wish to preserve their fertility, with a shift from open surgery towards minimally invasive techniques. Objectives: Retrospective study assessing patient and surgery characteristics, follow-up, and outcomes of robot-assisted myomectomy (RAM) and abdominal myomectomy (AM) in women treated between January 1, 2018, and February 28, 2022, in a Belgian tertiary care hospital. Materials and Methods: A descriptive analysis was conducted on consecutive patients who underwent myomectomies. 2018 was considered the learning curve for RAM. Main Outcome Measures: We assessed rate of open surgery, operation time, postoperative hospital stay, and operative complications. Results: In total, 94 RAMs and 15 AMs were performed. The rate of AMs was 56.5% in 2018 versus 2.3% after the learning curve. The median operation time for RAM was 136.5 minutes and 131 minutes for AM. Conversion rate for RAM was 0%. The median postoperative hospital stay after RAM was 1 night and 4 nights for AM. Postoperative complication rate was low, with only 14.9% and 33.3% of patients requiring pharmacological treatment of complications after RAM or AM, respectively. No surgical re-intervention was needed in any group. Conclusions: Implementation of RAM at our centre resulted in a significant reduction of open surgery rate. RAM demonstrated shorter hospital stays and a lower incidence of complications compared to AM. What is new? Our study highlights the successful adoption of RAM, showcasing its potential to replace AM even in complex cases. The findings affirm the safety and feasibility of RAM, supporting its use as a valuable technique for minimally invasive myomectomy.
... These benefits have contributed to its widespread recognition as standard of care among many institutions and across various surgical specialties. ERAS guidelines continue to develop as demonstrated by the updated recommendations in gynecologic surgery [8] and gynecologic oncology [9]. ...
Objective:
To determine the effectiveness of implementing an Enhanced Recovery After Surgery (ERAS) program, including continuous intraoperative and postoperative intravenous (IV) lidocaine infusion, on perioperative opioid use.
Methods:
This was a single-institution retrospective pre- post- cohort study. Consecutive patients undergoing planned laparotomy for known or potential gynecologic malignancy were identified after implementation of an ERAS program and compared to a historical cohort. Opioid use was calculated as morphine milligram equivalents (MMEs). Cohorts were compared using bivariate tests.
Results:
A total of 215 patients were included in the final analysis, 101 patients received surgery before ERAS implementation and 114 received surgery after. A reduction in total opioid use was observed in ERAS patients compared with historical controls (MME 26.5 [9.6-60.8] versus 194.5 [123.8-266.8], p<0.001). Length of stay (LOS) was reduced by 25% in the ERAS cohort (median 3 days, range 2-26, versus 4 days, range 2-18; p<0.001). Within the ERAS cohort, 64.9% received IV lidocaine for the planned 48 hours, and 5.6% had the infusion discontinued early. Within the ERAS cohort, patients who received IV lidocaine infusion used less opioids compared to those who did not (median 16.9, range 5.6-55.1, versus 46.2, range 23.2-76.1; p<0.002).
Conclusion:
An ERAS program including a continuous IV lidocaine infusion as the opioid-sparing analgesic strategy was noted to be safe and effective, leading to decreased opioid consumption and LOS compared with a historic cohort. Additionally, lidocaine infusion was noted to decrease opioid consumption even among patients already receiving other ERAS interventions.
