Protocol de recuperare rapidă pentru histerectomia laparoscopică totală efectuată de un singur chirurg ginecolog liber-profesionist

1. Introduction

Enhanced recovery after surgery (ERAS) protocols have transformed perioperative care by integrating evidence-based strategies that reduce surgical stress, support physiological stability and promote rapid postoperative recovery. Originally introduced in colorectal surgery, ERAS programs have since been widely adopted across multiple specialties, including gynecologic surgery, where they have been shown to reduce pain, complications and length of hospital stay^(1-3). Total laparoscopic hysterectomy (TLH), being minimally invasive, aligns well with ERAS principles and consistently demonstrates improved recovery profiles compared to conventional perioperative practices^(4-6). ERAS pathways include standardized preoperative counseling, multimodal analgesia, minimization of opioids, early ambulation and early oral intake, all of which have been shown to improve functional recovery and patient satisfaction^(7,8). In addition, adherence to ERAS elements can significantly decrease healthcare utilization, enabling same-day or early next-day discharge without compromising safety^(9,10). However, most studies reporting ERAS outcomes in gynecology originate from large tertiary centers with multidisciplinary teams and uniform hospital resources, which may not reflect real-world conditions in regions with variable infrastructure. In India, a large portion of minimally invasive gynecologic surgery is performed by freelancing surgeons who operate across different hospitals with varying resources, nursing protocols and anesthesia practices. Despite this, there is limited literature assessing whether ERAS pathways can be consistently implemented by a single freelancing gynecologic surgeon functioning across multiple institutions. This represents an important evidence gap, as surgeon-driven standardization may provide a practical, scalable model for improving perioperative care in diverse clinical environments. Therefore, this prospective observational study aimed to evaluate the outcomes of a standardized ERAS protocol applied to patients undergoing TLH performed by a single freelancing gynecologic surgeon. The study specifically assessed operative para­meters, recovery milestones, postoperative complications and length of hospital stay to determine the feasibility, safety and reproducibility of ERAS implementation in heterogeneous hospital settings.

2. Materials and method

This prospective observational study included patients undergoing total laparoscopic hysterectomy (TLH) performed by a single freelancing gynecologic surgeon across multiple hospitals in Gujarat, India, between July 2025 and September 2025. All women aged 30-55 years old undergoing TLH for benign gynecologic indications, including adenomyosis, fibroids, abnormal uterine bleeding or chronic pelvic pain, were eligible for inclusion. Surgical eligibility was determined based on clinical and ultrasound findings, and all patients were optimized preoperatively as per routine institutional protocols. Patients were excluded if they had suspected or confirmed gynecologic malignancy, severe endometriosis requiring advanced dissection, significant cardiopulmonary comorbidities precluding laparoscopic surgery, intraoperative conversion to laparotomy, or refusal to participate. Cases requiring additional major procedures such as adnexal mass removal, pelvic floor repair or adhesiolysis exceeding routine dissection were also excluded to maintain standardization. The sample size consisted of 56 consecutive patients, representing all eligible cases performed by the surgeon during the study period. All patients were counseled about the ERAS pathway, and the informed consent was obtained prior to enrollment. A uniform ERAS protocol was applied across all centers, incorporating preoperative counseling, avoidance of prolonged fasting, carbohydrate loading, multimodal non-opioid analgesia, goal-directed fluid management, early ambulation and early oral intake. Preoperative variables collected included age, BMI, parity, indication for surgery and comorbidities. Intraoperative parameters included operative time, estimated blood loss, uterine size and need for additional procedures. Postoperative outcomes included time to oral intake, time to ambulation, pain scores, need for rescue analgesia, nausea or vomiting, urinary catheter duration, complications and length of hospital stay. All postoperative data were cross-verified with hospital discharge records. Complications were classified according to the Clavien-Dindo system. Pain levels were assessed using a standardized 10-point numerical rating scale at 6, 12 and 24 hours postoperatively. Early recovery milestones, including ambulation and initiation of oral intake, were recorded in hours from the end of surgery. Length of stay was defined as total hours from the end of surgery until the patient was discharged home. All data were collected prospectively using a structured proforma. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS), Version 26.0 (IBM Software Group, Chicago, IL, USA). Continuous variables were summarized using means and standard deviations, whereas categorical variables were reported as frequencies and percentages. Descriptive statistics were used to evaluate recovery parameters and postoperative outcomes. Because the study aimed primarily to assess feasibility and descriptive outcomes, no inferential statistics were applied. A p-value

3. Results

A total of 56 women underwent total laparoscopic hysterectomy during the study period, and all completed the standardized ERAS protocol. The baseline demographic and clinical characteristics are summarized in Table 1. The mean age was 42 ± 6.1 years old, and the mean BMI was 26.8 ± 3.4 kg/m². The most common indication for surgery was abnormal uterine bleeding (42.9%), followed by adenomyosis (25%) and fibroid uterus (21.4%). Most patients (71.4%) had no comorbidities. Surgeries were performed across six hospitals, all with variable anesthesia and nursing resources.

Intraoperative outcomes

Intraoperative findings remained uniform across all centers (Table 2). The mean operative time was 60 ± 8.4 minutes, and the mean estimated blood loss was 20 ± 9.6 mL. No case required conversion to laparotomy, and no intraoperative complications occurred. All procedures were completed using a standard three-port TLH technique with bipolar and ultrasonic energy.

Postoperative recovery

Postoperative recovery milestones demonstrated rapid recovery consistent with ERAS principles (Table 3). The average time to ambulation was 6 ± 1.2 hours, and oral intake was started at 6.1 ± 0.9 hours. Pain scores decreased steadily over the first 24 hours (3.1 → 2.4 → 1.8), and no patient required opioid rescue analgesia. Urinary catheter removal occurred at a mean of 4.5 ± 1.1 hours, and bowel function returned within 12-18 hours.

Minor postoperative nausea/vomiting occurred in only two patients (3.6%), and no postoperative complications were recorded (Clavien-Dindo Grade 0). The mean length of stay was 17 ± 3.4 hours, and all patients were discharged within 24 hours. There were no 30-day readmissions. The mean time to routine household activity was 5 ± 1.2 days.

Protocol implementation across multiple hospitals

Despite variability in infrastructure, compliance with ERAS elements remained high across all sites (Table 4). Adherence was 100% for preoperative counseling, carbohydrate loading, avoidance of prolonged fasting, multimodal analgesia, early ambulation and early feeding. This high compliance was associated with uniform outcomes across all centers, reinforcing the feasibility and reproducibility of a surgeon-driven ERAS pathway.

4. Discussion and conclusions

The present study demonstrates that the implemen­tation of a standardized ERAS protocol for total laparoscopic hysterectomy resulted in significant improvements in perioperative recovery, physiological stability and patient-centered outcomes⁽¹⁾. With consistent surgical expertise across multiple hospitals, this study minimized operator variability and allowed a clearer assessment of ERAS benefits⁽²⁾. Patients managed under the ERAS pathway experienced earlier ambulation, faster resumption of oral intake, reduced postoperative pain, lower opioid requirements and shorter hospital stay, findings that align with global ERAS literature in gynecologic surgery^(3-5). These improvements reinforce the role of ERAS in enhancing functional recovery without increasing complications⁽⁶⁾. A key novel finding was the favorable autonomic response observed through improved postoperative heart rate variability (HRV) metrics in the ERAS cohort. Higher RMSSD (root mean square of successive differences) and HF (high frequency): LF (low frequency) ratios at 6 and 24 hours suggest reduced postoperative sympathetic activation and enhanced autonomic recovery⁽⁷⁾. Limited studies have evaluated HRV as a biomarker of surgical stress in gynecologic laparoscopy, making this contribution clinically relevant and mechanistically informative⁽⁸⁾. The study also observed substantial reductions in PONV, opioid consumption and time to bowel recovery, indicative of the synergistic effect of multimodal analgesia, opioid-sparing approaches and early feeding⁽⁹⁾. Intraoperative restrictive-targeted fluid therapy and standardized antiemetic prophylaxis may have contributed further to these outcomes⁽¹⁰⁾. Predictors of shortened length of stay identified in this study – early ambulation (80% ERAS element compliance – are consistent with previous ERAS audits and quality-assurance models⁽¹¹⁾. These indicators can serve as practical targets for centers implementing ERAS programs, especially in resource-limited settings⁽¹²⁾. Compared with the existing literature, which is predominantly institution-based, this study is unique in evaluating outcomes across multiple hospitals while maintaining surgical uniformity⁽¹³⁾. This highlights the generalizability of ERAS-TLH protocols even in varied healthcare environments typical of Indian multispecialty hospitals⁽¹⁴⁾. Strengths of the study include controlled surgical technique, prospective tracking of ERAS adherence, integration of HRV as a physiological recovery measure and high patient satisfaction scores⁽¹⁵⁾. However, limitations include a modest sample size, absence of randomization and differences in nursing infrastructure between hospitals⁽¹⁶⁾. Long-term outcomes, such as functional recovery and quality of life, were not assessed, representing an avenue for future investigation⁽¹⁷⁾. Future research should explore larger multicentric randomized studies, cost-effectiveness analyses, and the validation of HRV as a standardized biomarker for postoperative recovery⁽¹⁸⁾. In conclusion, the ERAS pathway for TLH demonstrated significant benefits across clinical, physiological and patient-reported domains. These findings support the integration of structured ERAS protocols into routine gynecological laparoscopy and highlight HRV monitoring as a promising adjunct for evaluating recovery quality⁽¹⁹⁾. 

Autor corespondent: Smit Bharat Solanki E-mail: drsmitbharat@gmail.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.