Enhanced Recovery Implementation in Major Gynecologic Surgeries: Effect of Care Standardization

Obstet Gynecol. 2016 Sep;128(3):457-66. doi: 10.1097/AOG.0000000000001555.


Objective: To examine implementing an enhanced recovery after surgery (ERAS) protocol for women undergoing major gynecologic surgery at an academic institution and compare surgical outcomes before and after implementation.

Methods: Two ERAS protocols were developed: a full pathway using regional anesthesia for open procedures and a light pathway without regional anesthesia for vaginal and minimally invasive procedures. Enhanced recovery after surgery pathways included extensive preoperative counseling, carbohydrate loading and oral fluids before surgery, multimodal analgesia with avoidance of intravenous opioids, intraoperative goal-directed fluid resuscitation, and immediate postoperative feeding and ambulation. A before-and-after study design was used to compare clinical outcomes, costs, and patient satisfaction. Complications and risk-adjusted length of stay were drawn from the American College of Surgeons' National Surgical Quality Improvement Program database.

Results: On the ERAS full protocol, 136 patients were compared with 211 historical controls and the median length of stay was reduced (2.0 compared with 3.0 days; P=.007) despite an increase in National Surgical Quality Improvement Program-predicted length of stay (2.5 compared with 2.0 days; P=.009). Reductions were seen in median intraoperative morphine equivalents (0.3 compared with 12.7 mg; P<.001), intraoperative (285 compared with 1,250 mL; P<.001) and total intravenous fluids (-917.5 compared with 1,410 mL; P<.001), immediate postoperative pain scores (3.7 compared with 5.0; P<.001), and total complications (21.3% compared with 40.2%; P=.004). On the ERAS light protocol, 249 patients were compared with 324 historical controls and demonstrated decreased intraoperative and postoperative morphine equivalents (0.0 compared with 13.0 mg; P<.001 and 15.0 compared with 23.6 mg; P<.001) and decreased intraoperative and overall net intravenous fluids (P<.001). Patient satisfaction scores showed a marked and significant improvement on focus questions regarding pain control, nurses keeping patients informed, and staff teamwork; 30-day total hospital costs were significantly decreased in both ERAS groups.

Conclusion: Implementation of ERAS protocols in gynecologic surgery was associated with a substantial decrease in intravenous fluids and morphine administration coupled with reduction in length of stay for open procedures combined with improved patient satisfaction and decreased hospital costs.

MeSH terms

  • Adult
  • Aged
  • Analgesics, Opioid / therapeutic use*
  • Clinical Protocols
  • Female
  • Fluid Therapy / statistics & numerical data*
  • Gynecologic Surgical Procedures* / rehabilitation
  • Gynecologic Surgical Procedures* / statistics & numerical data
  • Hospital Costs / statistics & numerical data
  • Humans
  • Length of Stay / statistics & numerical data
  • Middle Aged
  • Pain, Postoperative / prevention & control*
  • Patient Care Management* / methods
  • Patient Care Management* / organization & administration
  • Patient Care Management* / standards
  • Patient Satisfaction / statistics & numerical data*
  • Postoperative Period
  • Quality Improvement / organization & administration
  • Virginia


  • Analgesics, Opioid