Perioperative care for patients undergoing major pelvic operations

Enhanced recovery after surgery (ERAS) combines multiple perioperative principles in a dynamic system which reduces complication rates and decreases length of hospital stay. It affects all aspects of peri-operative care, resulting in decreased perioperative stress and less disturbance of homeostasis. Pre-operative considerations include information, education and counseling of the patient regarding the proposed procedure, optimization of medical conditions and improvement of nutrition, whether through nutritional support, carbohydrate loading, reduced fasting, or avoidance of unnecessary mechanical bowel preparation. Intra-operative protocols should avoid excess fluid and sodium replacement and reduce postoperative pain, nausea and vomiting, thus decreasing insulin resistance and metabolic stress. They include the use of multi-modal analgesia, short acting anesthetic agents, goal-directed fluid therapy, laparoscopic surgery and closely monitored normothermia. The exclusion of non-essential drains and tubes is advantageous in the post-operative period and we avoid their routine use. Post-operatively, effective multimodal and opiate sparing analgesia, early oral intake and the removal of all unnecessary tubes contribute to early mobilization and improvements in recovery. Finally appropriate data collection and audit of practice are needed in order to monitor and improve outcomes. The application of an ERAS protocol will improve recovery after conventional open surgery as well as maximizing the benefits when a minimal access approach is possible. In addition to improving recovery, an established program will reduce hospital stay without increasing readmissions.