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Perioperative Management and Implementation of Enhanced Recovery Programs in Gynecologic Surgery for Benign Indications

Carey, Erin, T., MD, MSCR; Moulder, Janelle, K., MD, MSCR

doi: 10.1097/AOG.0000000000002696
Gynecology: Clinical Expert Series: PDF Only

Enhanced recovery after surgery (ERAS) programs are a multimodal approach to optimize the surgical experience. Intraoperative and postoperative pain management is essential because the stress of surgery results in significant neurohormonal and metabolic shifts that can influence patient analgesia. Enhanced recovery after surgery programs address the physiologic and psychological factors that contribute to pain outcomes and overall satisfaction scores. A multimodal approach to recovery throughout the perioperative surgical experience is representative of successful pathways. Enhanced recovery after surgery programs begin in the outpatient and preadmission setting by targeting behavioral changes and modifiable risk factors for pain in addition to cultivating patient expectations. Preoperatively, ERAS allows for patients to enter surgery without a fluid deficit that was previously seen with prolonged fasting and mechanical bowel preparations. Opioid-sparing analgesic agents are provided preemptively and many have synergistic effects when administered together, resulting in fewer opioids administered in the postoperative setting. Intraoperatively, euvolemia and normothermia are essential in reducing the adverse metabolic effects of surgery. Postoperatively, pain management, reduction in postoperative nausea and vomiting, proactive mobilization, and early enteral feeing minimize patient discomfort and decrease the duration until return to baseline. Although incorporation of all phases of the ERAS pathway will maximize patient benefit, stepwise incorporation of the phases of the pathway can still improve the surgical experience at minimal cost.

Enhanced recovery pathways are multimodal, modifying preoperative, intraoperative, and postoperative practices to optimize acute pain management and improve postoperative outcomes.

Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina; and the Department of Obstetrics and Gynecology, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee.

Corresponding author: Erin T. Carey, MD, MSCR, 101 Manning Drive, CB7570, Chapel Hill, NC 27599; email:

Financial Disclosure Dr. Carey has been a consultant for Teleflex Medical and served as a medical expert in litigation within the last 3 years. Dr. Moulder has been a consultant for Teleflex Medical within the last 3 years.

Continuing medical education for this article is available at

Each author has indicated that she has met the journal's requirements for authorship.

Received November 2, 2017. Received in revised form January 1, 2018. Accepted January 19, 2018.

© 2018 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.