ERAS Program: Enhancing the Effectiveness of Gynecologic Surgery at University Medical Center Ho Chi Minh City

Gynecologic surgery plays an important role in the treatment of various conditions affecting women's health. To optimize the recovery process and minimize complications, the ERAS (Enhanced Recovery After Surgery) program has been widely implemented. This article provides an in-depth overview of the significant benefits of ERAS, particularly in the context of gynecologic surgery at University Medical Center Ho Chi Minh City.

1. What Is ERAS?

1.1. Definition and Core Principles

ERAS is a multimodal, evidence-based approach designed to optimize patient care throughout the preoperative, intraoperative, and postoperative periods. The primary goals of ERAS are to minimize the body's stress response to surgery, accelerate functional recovery, reduce the incidence of complications, shorten hospital stays, and improve patient satisfaction [1, 2].

The core principles of ERAS include optimizing the patient's medical condition before surgery, effective pain management, optimal fluid management, early oral intake, and early mobilization [1].

1.2. History and Objectives

The ERAS program was first introduced by Professor Henrik Kehlet in the 1990s, initially for colorectal surgery [1, 2, 8]. Since then, ERAS has been expanded to various surgical specialties, including gynecology. The ERAS Society, established in 2010, has played an important role in developing and disseminating evidence-based guidelines for various types of surgery [1].

The goal of ERAS is to improve postoperative outcomes by maintaining normal patient physiology and minimizing surgery-related stressors such as prolonged fasting, immobility, and excessive opioid use [2].

2. Significant Benefits of ERAS in Gynecologic Surgery

The implementation of ERAS in gynecologic surgery offers numerous significant benefits, as demonstrated by multiple studies:

2.1. Shorter Hospital Stays

Studies have shown that ERAS programs can reduce postoperative hospital stays by 30% to 50% [1]. Another study indicated that the average hospital stay decreased from 4 days to 3 days when ERAS was implemented in gynecologic surgery [3].

2.2. Reduced Pain and Limited Opioid Use

ERAS focuses on multimodal pain management, combining various non-opioid analgesics and regional anesthesia techniques to reduce the need for opioids. This helps minimize opioid-related side effects such as nausea, vomiting, and constipation [2, 3]. One study reported a 50% reduction in postoperative opioid use in the ERAS group [3].

2.3. Reduced Postoperative Complications

Although some studies have not demonstrated a significant difference in overall complication rates [3], ERAS components such as maintaining normothermia, optimal fluid management, and prophylactic antibiotics have been shown to reduce the risk of surgical site infections, cardiovascular complications, and blood loss [2].

2.4. Early Bowel Function Recovery and Mobilization

ERAS encourages early oral intake and early mobilization immediately after surgery. This helps stimulate intestinal motility and reduce the risk of postoperative ileus [2]. Patients following ERAS protocols generally recover bowel function 1 day earlier than those who do not follow ERAS protocols [3]. Early mobilization also helps prevent venous thromboembolic complications and improves respiratory function [2].

2.5. Improved Patient Satisfaction

By reducing pain, nausea, and vomiting and accelerating the recovery process, ERAS significantly contributes to improved patient experience and satisfaction [1, 2]. Studies have demonstrated high satisfaction rates among patients managed according to ERAS protocols [4].

2.6. Economic Efficiency

Shorter hospital stays and reduced complication rates can significantly decrease overall treatment costs [1, 2]. Some estimates indicate that ERAS can save USD 2,200 to USD 2,500 per patient, and that every USD 1 invested in ERAS can generate an additional USD 3.8 in savings [2].

2.7. Improved Treatment Outcomes in Gynecologic Cancer

For patients with gynecologic cancer, ERAS facilitates faster recovery, allowing adjuvant therapies, such as chemotherapy, to be initiated on schedule, which may improve long-term cancer treatment outcomes [1, 5].

3. Key Components of the ERAS Program in Gynecologic Surgery

The ERAS program consists of a set of care measures implemented throughout the three main stages of the surgical process [1, 2, 5]:

3.1. Preoperative Phase

Patient Counseling and Education: Patients are provided with detailed information about the surgical procedure, anesthesia, recovery plan, and what to expect after surgery. This helps reduce anxiety and encourages active patient participation in the recovery process [2, 5].
Optimization of Health Status: This includes smoking cessation and reducing alcohol consumption for at least 4 weeks before surgery, treatment of anemia, and optimization of underlying conditions such as diabetes and hypertension [2, 5].
Bowel Preparation and Carbohydrate Loading: Prolonged fasting is minimized, allowing clear liquids up to 2 hours and light meals up to 6 hours before surgery. Preoperative carbohydrate-containing drinks are encouraged to reduce insulin resistance and improve patient comfort [2, 5]. Mechanical bowel preparation is not routinely recommended [5].

3.2. Intraoperative Phase

Optimal Anesthesia and Fluid Management: Short-acting anesthetic techniques and regional anesthesia, such as epidural anesthesia or transversus abdominis plane (TAP) block, are used to provide effective pain control and reduce opioid requirements [2, 5]. Goal-directed fluid therapy is used to maintain stable intravascular volume and avoid fluid overload or fluid deficit [2, 5].
Minimally Invasive Surgical Techniques: Minimally invasive surgical approaches, such as laparoscopy, are preferred whenever possible to reduce tissue trauma, pain, and recovery time [1].
Temperature Control: Maintaining normothermia throughout surgery helps prevent hypothermia, which can lead to complications such as coagulation disorders and infection [2, 5].

3.3. Postoperative Phase

Multimodal Pain Management: A combination of non-opioid analgesics, such as paracetamol and NSAIDs, and regional analgesia techniques is continued to achieve effective pain control while minimizing opioid use and its associated side effects [2, 5].
Early Oral Nutrition: Patients are encouraged to drink water and consume liquid or soft foods once they are awake and able to tolerate oral intake, usually within 24 hours after surgery [2, 5].
Early Mobilization: Patients are encouraged to sit up and walk as early as the day of surgery or the first postoperative day to improve respiratory and circulatory function and intestinal motility [2, 5].
Wound and Drain Care: The use of drains and urinary catheters is minimized, with removal as early as possible to reduce the risk of infection and facilitate postoperative mobilization [2, 5].

4. Patients Suitable for ERAS in Gynecologic Surgery

4.1. Types of Gynecologic Surgery That May Benefit

The ERAS program can be applied to various types of gynecologic surgery, including:

Gynecologic Oncology Surgery: Total hysterectomy, oophorectomy, lymph node dissection, and cytoreductive surgery [1, 5].
Benign Gynecologic Surgery: Hysterectomy for uterine fibroids, endometriosis surgery, and ovarian cyst surgery [1, 4].
Gynecologic Laparoscopic Surgery: Total laparoscopic hysterectomy, laparoscopic myomectomy, and ovarian cystectomy [4].

4.2. Patient Selection Criteria

Most patients undergoing gynecologic surgery can participate in an ERAS program. However, each case should be individually assessed. Patients with stable health conditions and without serious contraindications to ERAS components, such as uncontrolled severe coagulation disorders, shock, or sepsis, are generally ideal candidates [5]. Patient cooperation and adherence are also important factors determining the success of the program [3].

5. Challenges and Considerations in ERAS Implementation

5.1. Multidisciplinary Healthcare Team Requirements

Implementing ERAS requires close collaboration among multiple specialties, including surgeons, anesthesiologists, nurses, nutrition specialists, physiotherapists, and social workers. Lack of cooperation among healthcare professionals may constitute a barrier [2, 5].

5.2. Patient Adherence

Active patient participation is a key factor. However, some patients may have difficulty adhering to recommendations such as early mobilization or early oral intake because of anxiety, pain, or previous habits [4].

5.3. Certain Cases May Not Be Suitable

Although ERAS provides many benefits, it is not suitable for every patient. For example, patients with complex medical conditions, those undergoing emergency surgery, or those with specific contraindications to certain ERAS components may require a more individualized care pathway [3, 5].

6. Frequently Asked Questions (FAQ)

Can ERAS be applied to all types of gynecologic surgery? ERAS can be applied to most gynecologic surgeries, particularly major and oncologic procedures. However, implementation should be individualized according to the patient's condition and the type of surgery [5].
Do patients need special preparation before undergoing surgery under an ERAS program? Yes. Patients receive thorough counseling, health optimization, such as treatment of anemia and smoking cessation, and may be instructed to consume carbohydrate-containing drinks before surgery [2].
Does ERAS completely eliminate postoperative pain? ERAS provides more effective pain control through a multimodal approach and significantly reduces the need for opioids. However, mild pain may still occur and can be managed with appropriate analgesics [3].
What is the average recovery time with ERAS? Recovery and hospital discharge are generally significantly shortened, ranging from several days to less than one week depending on the type of surgery and the patient's condition [1, 3].
Are there any risks associated with participating in an ERAS program? ERAS is an evidence-based program that has been demonstrated to be safe. Risks generally do not increase compared with traditional care and may even be associated with a reduction in certain complications [2].

7. References

[1] Miralpeix, E., Nick, A. M., Meyer, L. A., Cata, J., Lasala, J., Mena, G. E., ... & Ramirez, P. T. (2016). A Call for New Standard of Care in Perioperative Gynecologic Oncology Practice: Impact of Enhanced Recovery After Surgery (ERAS) Programs. Gynecol Oncol, 141(2), 371–378. Accessed: 2025-12-31.
[2] Altman, A. D., Helpman, L., McGee, J., Samouëlian, V., Auclair, M. H., Brar, H., & Nelson, G. S. (2019). Enhanced recovery after surgery: implementing a new standard of surgical care. CMAJ, 191(17), E469–E475. Accessed: 2025-12-31.
[3] Joshi, T. V., Bruce, S. F., Grim, R., Buchanan Jr, T., Chatterjee-Paer, S., Burton, E. R., ... & Edelson, M. I. (2021). Implementation of an enhanced recovery protocol in gynecologic oncology. Gynecol Oncol Rep, 36, 100771. Accessed: 2025-12-31.
[4] Jin, O., Xu, T., Lai, J., He, J., Wu, Y., & Yang, X. (2025). Impact of enhanced recovery after surgery concept process optimization on the perioperative period of gynecologic laparoscopic surgery. BMC Womens Health, 25, 120. Accessed: 2025-12-31.
[5] Santiago, A. E., Silva Filho, A. L., Cândido, E. B., Ribeiro, P. A., Silva, J. C. R. E., Primo, W. Q. S. P., ... & Brito, L. G. O. (2022). Perioperative management in gynecological surgery based on the ERAS program. Rev Bras Ginecol Obstet, 44(2), 202–210. Accessed: 2025-12-31.

The information provided above is for reference purposes only and does not constitute a recommendation. Please consult a physician for detailed medical advice.