Evidence-Based Anesthesia

for Major Gynecologic

Surgery
Jeanette R. Bauchat, MDa,
Ashraf S. Habib, MBBCh, MSc, MHSc, FRCAb,*

KEYWORDS
 Enhanced recovery  ERAS  Gynecologic surgery  Fast track

KEY POINTS
 Studies on enhanced recovery after major gynecologic surgery are limited but seem to
have similar outcome benefits to populations who have had colorectal surgery.
 Effective regional anesthetic techniques used in gynecologic surgery include spinal
anesthesia, epidural analgesia, transversus abdominis plane blocks, local anesthetic
wound infusions, and intraperitoneal instillation catheters.
 Effective nonopioid analgesics known to reduce opioid consumption after gynecologic
surgery include pregabalin, gabapentin, nonsteroidal antiinflammatory drugs, cyclooxy-
genase 2 inhibitors, and paracetamol.
 A multimodal antiemetic strategy to reduce the baseline risk of postoperative nausea and
vomiting in conjunction with combination antiemetic therapy is imperative in this high-risk
population.
 Randomized controlled trials of the ideal fluid management strategies in this surgical
population are needed.

INTRODUCTION

The last 2 decades have seen significant changes in the surgical approach to gyneco-
logic surgery. Minimally invasive surgeries have been more commonly performed and
have been associated with comparable long-term outcomes compared with open sur-
gery.1 Although operative time is longer with minimally invasive surgery, hospital stay
is significantly shorter, and analgesic and antiemetic needs are significantly reduced
compared with open surgery.1,2 However, there has been little attention to optimizing
other surgical and anesthetic elements of the perioperative care of these patients.

The authors have no conflicts of interest.

a
Northwestern University, Feinberg School of Medicine, 250 East Huron Street, F5-704, Chi-
cago, IL 60611, USA; b Duke University Medical Center, Box 3094, Durham, NC 27710, USA
* Corresponding author.
E-mail address: [email protected]

Anesthesiology Clin 33 (2015) 173–207

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174 Bauchat & Habib

The concepts and practices of enhanced recovery after surgery (ERAS) are well
established for colorectal surgery but until recently have not been applied to gyneco-
logic surgery. High-quality meta-analyses have shown the effectiveness of ERAS
principles in reducing hospital length of stay and overall complications but not neces-
sarily surgical complications.3,4 Studies that assess fast-tracking or enhanced recov-
ery after major gynecologic surgery typically apply the ERAS guidelines derived
from colorectal surgery, because there are no specific guidelines for enhanced recov-
ery after major gynecologic surgery. In this article, major gynecologic surgery refers to
the surgeries listed in Box 1.
Some general concepts of the ERAS protocol apply to all surgical patient popula-
tions (Box 2).5 The means by which individual components of the ERAS protocol
are achieved may differ, depending on the patient population and type of surgery.
For example, unlike colorectal surgery, gynecologic surgery patients are all women.
It is well established that women differ significantly from men from a pharmacokinetic
and pharmacodynamic standpoint, which may influence the optimal anesthetic drug
choice and antiemetic or analgesic strategies in ERAS protocols for gynecologic
surgery compared with colorectal surgeries.6
This article focuses on meta-analyses, randomized controlled trials (RCTs), and
large prospective impact studies conducted in the gynecologic surgery population
investigating aspects of the ERAS protocol over which anesthesiologists exercise
the most influence. The best evidence is presented for 4 specific aspects of the
ERAS protocol: anesthetic choice, nonopioid multimodal pain management, post-
operative nausea and vomiting (PONV) prevention strategies, and fluid management.
This article concludes with the general ERAS principles applied to this specific patient
population, because anesthesiologists should be aware of all the ERAS interventions
as we become leaders of the perioperative surgical home.

ENHANCED RECOVERY AFTER MAJOR GYNECOLOGIC SURGERY

The first descriptive study exploring ERAS principles in major gynecologic surgery was
conducted 10 years ago.7 The benefits of implementation of ERAS principles in the
gynecologic surgery population were explored in 1 RCT,8 but mostly in preintervention
and postintervention studies. Studies assessing impact of ERAS protocol implemen-
tation on outcomes for major gynecologic surgeries are summarized in Table 1. All of
those studies reported a reduction in the duration of hospital stay, in addition to other

Box 1
Major gynecologic surgeries included in this article

Laparotomy for malignant gynecologic cancers

Hysterectomy, lymphadenectomy, omentectomy
Complex cytoreductive surgery
Urogynecologic pelvic organ prolapse surgery
Total or partial abdominal hysterectomy
Vaginal hysterectomy
Abdominal myomectomy
Salpingo-oophorectomy
Ovarian cystectomy
 Evidence-Based Anesthesia for Gynecologic Surgery 175

Box 2
Common aspects to all ERAS protocols

 Preoperative care
 Optimize preoperative care for specific diseases (eg, adjusting insulin or antihypertensive
medications before surgery)
 Preoperative counseling
 Intraoperative care
 Optimizing prophylactic antibiotic administration
 Use of regional anesthesia intraoperatively
 Use of minimally invasive surgery when feasible
 Maintenance of intraoperative normothermia
 Optimize fluid management
 Nausea and vomiting prophylaxis
 Optimize oxygen delivery
 Postoperative care
 Optimize sleep
 Ileus prevention (ie, early feeding, avoid nasogastric tube, early mobilization)
 Minimize drains, tubes, and catheters
 Opioid-sparing multimodal pain management
 Continue home medications
 Postoperative discharge planning
 Thromboembolic prophylaxis (ie, pneumatic compression devices, anticoagulation)

improvements. However, there was tremendous variation in the ERAS interventions

used and how each intervention was standardized. For instance, few studies attemp-
ted to standardize intraoperative anesthetic technique.8–11 The opioid-sparing anal-
gesic protocol varied from no standardization,12 to nerve blocks,13 multimodal
nonopioid oral analgesics,9 or different neuraxial analgesic techniques.8–11 Adminis-
tration of prophylactic antiemetics was standardized in 5 of those 8 studies, but
they differed markedly in the type and number of agents used.8,9,11,13,14 Intraoperative
fluid administration was clearly standardized in only 1 study.8

REGIONAL ANESTHETIC TECHNIQUES FOR ENHANCED RECOVERY AFTER MAJOR

GYNECOLOGIC SURGERY

Opioid-sparing analgesic regimens are believed to be an integral part of an ERAS

protocol, because opioids have been implicated in immunosuppression, postopera-
tive hyperalgesia, PONV, paralytic ileus, and delay of early mobilization as a result
of sedation.15–17 A variety of regional techniques, including neuraxial and peripheral
nerve blocks may be used to provide postoperative analgesia, reducing opioid
consumption and blunting the surgical stress response.18
There are no RCTs delineating the ideal intraoperative anesthetic protocol to sup-
port ERAS principles, even in guidelines already established for colorectal surgery.
Nonetheless, intraoperative neuraxial anesthesia has been implemented in multiple
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Bauchat & Habib
Table 1
Summary of studies using enhanced recovery principles for major gynecologic surgeries

Reference, Number of
Surgery Type Study Type Patients Implemented ERAS Interventions Summary of ERAS Outcomes
Kroon et al,8 RCT Control (N 5 26) Control ERAS Protocol Shorter recovery room length of stay
2010 ERAS (N 5 27) Preoperative: Preoperative: (median 180 vs 237 min)
Abdominal Paracetamol and Carbohydrate drink 2 h before Lower rate of PONV on day 1 (11%
hysterectomy NSAID or COX-2 surgery vs 50%)
inhibitor Paracetamol and NSAID or COX 2 Shorter time to oral intake (median
inhibitor 4 vs 5 h)
Intraoperative: Intraoperative: Shorter duration of indwelling
General anesthesia Spinal anesthesia bupivacaine 1 urinary catheter (median 9 vs 22 h)
N2O 1 volatile morphine 100 mg Reduced length of hospital stay
agent PONV prophylaxis (median 2 vs 3 d)
PONV prophylaxis betamethasone 1 droperidol 1
ondansetron ondansetron
IV fluid restricted 500 mL/h
Postoperative: Postoperative:
Paracetamol 1 IV fluids stopped with oral intake
morphine PCA Paracetamol 1 NSAID
DeGroot et al,135 Nonrandomized Pre (N 5 38) Preoperative: Reduced length of hospital stay
2014 prospective pre Post (N 5 77) Counseling (not specified) (median 5 vs 7 d)
Gynecologic and post Carbohydrate drink Increased rate of early feeding (oral
cancer surgery intervention Avoidance of bowel preparations fluids on POD 0 increased from
Intraoperative: 0% to 94%; normal diet on POD 1
Avoidance of long-acting anesthetic (not specified) increased from 0% to 58%)
Avoidance of opioids Reduced time to functional
Thoracic epidural analgesia recoverya (median 3 d vs 6 d)
Avoidance of NG tubes
Postoperative:
Oral fluids day of surgery
Normal diet POD 1
Early mobilization
>3 times POD 1
Kalogera et al,9 Retrospective Pre (N 5 235) Preoperative: Lower fluid administration (1 L less
2013 cohort pre and Post (N 5 241) Carbohydrate loading drink with no intraoperative
Laparotomy post intervention Fluids 4 h before surgery hypotension)
gynecologic No bowel preparation Reduced opioid usage (80%
cancer surgery Preoperative acetaminophen, COX-2 inhibitor, or reduction over 48 h)
Urogynecologic gabapentin Higher PONV rate (nausea 55.6% vs
organ prolapse Intraoperative: 38.5%; vomiting 17.3% vs 2.6%)
surgery Triple-agent antiemetic prophylaxis Faster return of bowel function
Minimize crystalloid, administer colloid if needed (1 d earlier)
Laparotomy analgesic medications: Reduced hospital length of stay
Ketorolac or ketamine by 4 d
LA wound infiltration Cost savings ($7600 per patient)
Pelvic organ prolapse analgesic medications: High patient satisfaction
Spinal anesthesia 1 hydromorphone

Evidence-Based Anesthesia for Gynecologic Surgery

Ketorolac
Postoperative:
Postoperative fluids 40 mL/h X 24 h or until oral intake
Early food intake POD 0 1 nutritional supplement
Early mobilization (out of bed night of surgery)
Scheduled nonopioid analgesics: ketorolac or tramadol,
paracetamol, oral hydromorphone as needed

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Table 1
(continued )

Bauchat & Habib

Reference, Number of
Surgery Type Study Type Patients Implemented ERAS Interventions Summary of ERAS Outcomes
Wijk et al,14 Retrospective pre Pre (N 5 120) Preoperative: Rate of target length of stay (2 d)
2014 and post Post (N 5 85) Counseling regarding ERAS protocol increased (53% vs 73%)
Abdominal intervention Malnourished patients given nutritional supplement Target length of stay correlated with
hysterectomyb Carbohydrate drink 2 h before surgery increasing number of ERAS
Preoperative paracetamol protocol parameter compliance
Preoperative oral antibiotic Reduced hospital length of stay
Intraoperative: (median 2.6 vs 2.3 d)
Maintain normothermia with forced air and warm IV
fluids
Standard antiemetic regimen: droperidol,
dexamethasone, in addition, for high-risk patients,
rescue treatment with ondansetron then
metoclopramide
Postoperative:
Standardized nonopioid analgesics: scheduled diclofenac
and paracetamol
IV fluids stopped with oral intake, normal diet 2 h after
surgery
Early mobilization (2 h after surgery)
Routine thromboprophylaxis
Clear discharge criteria (eat normally, independent
mobilization, oral analgesics, no bowel obstruction)
Sjetne et al,12 Nonrandomized Pre (N 5 35) Preoperative: Reduced hospital length of stay
2014 prospective pre, Post (N 5 45) Counseling regarding ERAS protocol (median days pre 4.7, post 3.4, 1 y
Abdominal immediately 1 y Post (N 5 45) Intraoperative: post 3.4)
hysterectomyb post, and 1 y None specified Reduced nursing workload (patient
Urogynecologic post intervention Postoperative: contact minutes Pre 86 min, post
organ prolapse IV and urinary catheter removed in recovery room 70.9 min, 1 y post 72.7 min)
surgery Normal diet within hours (not specified) after surgery
Stopped routine postoperative enemas
Mobilization within hours after surgery
Oral analgesics started immediately
Yoong et al,13 Retrospective Pre (N 5 50) Preoperative: Reduced hospital length of stay
2014 case-matched Post (N 5 50) Family support assessment (median 22 h vs 45.5 h)
Vaginal pre and post Counseling regarding surgery (1 h audiovisual session/ Increase number of women
hysterectomy intervention discussion) discharged in <24 h
Intraoperative: (78% vs 15.6%)
Surgical approach: avoid laparoscopy or abdominal Reduced rate of vaginal packing
incisions (82.2% vs 52%)
Regional anesthesia with pudendal and uterosacral nerve Reduced rate of urinary catheter use
blocks (96% vs 84.4%)
Maintain intraoperative normothermia >36 Cost savings ($159.45 per patient)
Standardized antiemetic protocol: dexamethasone 1
ondansetron, rescue agent cyclizine
Postoperative:
No routine vaginal packing
No routine urinary catheter

Evidence-Based Anesthesia for Gynecologic Surgery

Early feeding
Early mobilization
Hired RN discharge planner
Standardized assessment algorithm to evaluate discharge
readiness
Dickson et al,10 Retrospective Pre (N 5 100) Preoperative: Increased use of spinal anesthesia
2012 case-matched Post (N 5 100) Counseling regarding ERAS protocol (5% vs 83%)
Abdominal pre and post Intraoperative: Reduced length of hospital stay
hysterectomyc intervention Spinal anesthesia with intrathecal morphine (60–100 mg) (median 3 d vs 1 d)
Postoperative:
Early mobilization (day of surgery)
Normal diet (day of surgery)

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Table 1
(continued )
Reference, Number of
Surgery Type Study Type Patients Implemented ERAS Interventions Summary of ERAS Outcomes
Marx et al,11 Retrospective Pre (N 5 72) Preoperative: Reduced hospital length of stay
2006 pre and post Post (N 5 69) No premedication (median 6 d vs 5 d)
Laparotomy intervention Preoperative paracetamol Reduced severe complications
gynecologic No bowel preparation (12.5% vs 1.4%)
cancer surgery Thromboprophylaxis
Intraoperative:
Routine use of epidural anesthesia
Antiemetic prophylaxis (dexamethasone 1 ondansetron)
Routine antibiotic prophylaxis
Postoperative:
Routine use of epidural analgesia
Food and nutritional supplements 4 h after surgery
Magnesia (promotility agents)
Early mobilization day or surgery and standardized
mobilization
Schedule to remove urinary and epidural catheter

Abbreviations: IV, intravenous; LA, local anesthetic; NG, nasogastric; NSAID, nonsteroidal antiinflammatory drug; PCA, patient controlled analgesia; POD,
postoperative day; RN, registered nurse.
a
Functional recovery score is based on: resumption of normal oral and food intake, independent mobilization, and pain controlled on oral analgesics.
b
Malignant and benign indication.
c
Benign indication.
Data from Refs.8–14,135
 Evidence-Based Anesthesia for Gynecologic Surgery 181

fast-track protocols because of proven benefits on attenuating the physiologic surgi-

cal stress response and showing opioid-sparing effects.18 Table 218–28 summarizes
the potential benefits of neuraxial anesthesia on ERAS protocol goals, as shown by
several meta-analyses and RCTs. Despite the known benefits of regional anesthesia,
there are few RCTs comparing general anesthesia alone with either regional anes-
thesia alone or a combination of general anesthesia with regional anesthesia in major
gynecologic surgery.

Spinal Anesthesia
Most studies using regional anesthesia as a sole anesthetic are conducted in open
abdominal hysterectomies or pelvic organ prolapse surgery under spinal anesthesia.
Table 329–33 summarizes the RCTs that compare regional anesthesia as a sole tech-
nique or in combination with general anesthesia with general anesthesia alone on
ERAS outcomes. Most of these studies show a clear benefit of spinal anesthesia
compared with general anesthesia for reducing postoperative opioid consumption,
likely because of the addition of intrathecal morphine to the spinal injectate.29,30,32,33
Spinal anesthesia also seems to be more cost effective, in part because of shorter re-
covery room length of stays.31,32 The effect of spinal anesthesia on hospital length of
stay was mixed,29,32 but the evidence favors spinal anesthesia for hysterectomies to
enhance recovery in the immediate postoperative period.

Combined General and Epidural Anesthesia

Epidural anesthesia and analgesia is typically used as an adjuvant to general anes-
thesia and as a primary modality for postoperative pain management in hysterec-
tomies and laparotomies for complex gynecologic cancer surgeries. There are few
RCTs examining the impact of epidural analgesia on ERAS principles in this popula-
tion. Table 434–38 summarizes RCTs comparing epidural analgesia for intraoperative

Table 2
Potential positive impact of neuraxial anesthetic techniques on enhanced recovery principles

ERAS Principle Positive Impact of Regional Anesthesia

Attenuation of physiologic Reduced endocrine and metabolic response to surgery18
surgical stress response Thoracic epidurals reduced the incidence of myocardial
infarction19
Reduction of inflammation Reduced inflammatory markers20
Maintenance of normothermia Inhibits physiologic demand of shivering21
Nausea and vomiting prophylaxis Less nausea and vomiting than opioids if local anesthetics
are used alone22
Optimization of oxygen delivery Improve oxygen delivery23
Reduced pulmonary complications24
Opioid-sparing multimodal Reduces opioid consumption25
pain management Excellent analgesia22,26
Reduce chronic pain27
Optimization of sleep Excellent analgesia22,26
Ileus prevention/early feeding Promote gastric motility22
Early mobilization Thoracic epidural can promote early mobilization as a
result of excellent pain control 22
Thromboembolic prophylaxis Reduced deep vein thrombosis and pulmonary
embolism32
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Table 3
Summary of RCTs showing the impact of spinal anesthesia on ERAS outcomes

Anesthetic Technique Anesthetic Medication

Type of Surgery Study (Number of Patients) Administered Other ERAS Interventions ERAS Outcomes
Vaginal Sprung Spinal anesthesia IT: bupivacaine 1 Ketorolac 30 mg once Favors spinal:
hysterectomya et al,29 (N 5 45) clonidine 1 morphine Reduced morphine request rate in recovery
 urogynecologic 2006 (200 mg) room (70% vs 11%)
pelvic organ S: midazolam 1 propofol Reduced morphine use in first 12 h
prolapse surgery General anesthesia I: thiopental 1 fentanyl (median 7.9 vs 14.8 mg)
(N 5 44) M: isoflurane 1 N2O 1 More patients with no pain at
morphine postoperative wk 2 (69% vs 48%)
No difference:
Request for antiemetic medications
Hospital length of stay
Functional status at 12 wkb
Abdominal Castro- Spinal anesthesia IT: Bupivacaine 1 Scheduled ketoprofen Favors spinal:
hysterectomya Alves (N 5 34) fentanyl 1 morphine and metamizole Higher quality of recovery scores at 24 hc
et al,30 (60 mg) Standardized antiemetic (median difference of 17)
2011 S: Midazolam regimen Lower pain scores at rest and coughing at
General anesthesia I: propofol 1 fentanyl (dexamethasone 1 24 h (4 vs 0 and 5 vs 2, respectively)
(N 5 34) M: isoflurane 1 fentanyl ondansetron, rescue: Reduced morphine use in PACU (6 vs 0 mg)
metoclopramide) Reduced incidence of nausea (32% vs 12%)
Abdominal Borendal Spinal anesthesia IT: bupivacaine 1 Counseling regarding Favors spinal:
hysterectomya Wodlin (N 5 82) morphine (200 mg) surgical procedure More cost-effective ($969 savings per
et al,31 General anesthesia I and M: propofol 1 Preoperative paracetamol patient)
2011 (N 5 80) fentanyl Postoperative scheduled Shorter recovery room length of stay
paracetamol and NSAID (median 282 vs 234 min)
(not specified) Improved HRQoL scoresd
Early mobilization
Early feeding
 Abdominal Massicotte Spinal anesthesia IT: bupivacaine 1 No premedication Favors spinal:
hysterectomye et al,32 (N 5 20) fentanyl 1 morphine Postoperative scheduled Reduced morphine use in first 48 h
2009 (150 mg) indomethacin (median 19 vs 81 mg)
S: midazolam Shorter recovery room length of stay
General anesthesia I: propofol 1 sufentanil (median 52 vs 73 min)
(N 5 20) M: desflurane 1 Lower pain scores until the eighteenth
sufentanil hour (w30–50 lower VAS on a 100 VAS
scale)
Shorter hospital length of stay (median 2.2
vs 3.3 d)
No difference:
Nausea/vomiting
Abdominal Vaida Spinal and general IT: bupivacaine None Favors spinal:
hysterectomya et al,33 anesthesia I: midazolam Longer time to first request of analgesia

Evidence-Based Anesthesia for Gynecologic Surgery

2000 (N 5 15) M: isoflurane 1 N2O (median 48 vs 9 min)
General anesthesia I: midazolam Reduced opioid use in recovery room and
(N 5 15) M: isoflurane 1 N2O from 2–24 h (median 32 vs 40.5 mg)

Abbreviations: HRQoL, health-related quality of life; I, induction; IT, intrathecal; M, maintenance; N2O, nitrous oxide; PACU, postanesthesia care unit; S, sedation;
VAS, visual analog scale.
a
Benign indication.
b
Functional status as measured by the validated Short Form 36 health survey, which includes patient-perceived physical and social functioning, physical and
emotional activity limitations, mental health, vitality, and general health assessment.
c
Quality of recovery (QoR) score QoR-40 assesses physical comfort, physical independence, emotional state, psychological support, and pain. A 10-point differ-
ence in score reflects a 15% improvement in QoR.
d
HRQoL assesses mobility, self-care, ability to undertake usual activities, pain/discomfort, anxiety/depression. A score of 0 indicates death, 1 indicates full health.
e
Malignant and benign indication.
Data from Refs.29–33

183
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Bauchat & Habib
Table 4
Summary of RCTs showing the impact of epidural anesthesia on ERAS outcomes

Anesthetic Technique Anesthetic Medication Other ERAS

Type of Surgery Study (Number of Patients) Administered Interventions ERAS Outcomes
Gynecologic cancer Ferguson Preincision epidural PreE: bupivacaine 1 Scheduled ketorolac Favors epidural:
surgery et al,34 2009 anesthesia 1 general morphine for 24 h for 48 h Lower mean pain scores at rest POD 1
anesthesia (N 5 67) I and M: not specified Early mobilization (VAS 3.3 vs 4.3)
General anesthesia I and M: not specified POD 1 Lower mean pain scores at rest on POD
(N 5 68) Early feeding POD 1 2, 3, 4 (VAS 5.5, 5.0, 4.7 vs 6.7, 5.5, 5.7,
Thromboembolic respectively)
prophylaxis Higher patient satisfaction
No difference:
Combined postoperative complications
Nausea/vomiting
Hospital length of stay
Major gynecologic Katz et al,35 Preincision epidural PreE: lidocaine 1 None specified Favors preincision then postincision
surgerya 2003 anesthesia 1 general epinephrine 1 epidural over control:
anesthesia (N 5 45) fentanyl 1 dose Cumulative 24 h morphine use lowest
PostE: saline in preincision epidural (preE 57 mg vs
I: thiopental postE 59 mg vs control 72 mg)
M: N2O 1 isoflurane Cumulative 48 h morphine use lowest
Postincision epidural PreE: saline in preincision epidural (preE 90 mg vs
injection 1 general PostE: lidocaine 1 postE 95 mg vs control 113 mg)
anesthesia (N 5 49) epinephrine 1
fentanyl 1 dose
I: thiopental
M: N2O 1 isofluran
Sham epidural 1 general PreE: saline
anesthesia (N 5 47) PostE: saline
I: thiopental 1 fentanyl
M: N2O 1 isoflurane
Abdominal Jorgensen Preincision epidural PreE: lidocaine Scheduled Favor preincision epidural (no differences
hysterectomyb et al,36 2001 injection 1 general PostE: bupivacaine paracetamol for between postE or control groups):
anesthesia (N 5 20) for 24 h 48 h and ketorolac Reduced pain scores during rest,
I and M: see below for 72 h coughing and movement for 24 h
Postincision epidural PreE: saline Early feeding (VAS lower by 30 than other 2
injection 1 general PostE: bupivacaine Discharge planning groups)
anesthesia (N 5 20) for 24 h Reduced requests for morphine
I and M: see below (60%–70% fewer requests than
General anesthesia I: propofol 1 other 2 groups)
(N 5 20) alfentanil 1 fentanyl Shorter time to first flatus
M: propofol 1 fentanyl No difference:
Nausea/vomiting
Time to first defecation
Readiness for discharge

Evidence-Based Anesthesia for Gynecologic Surgery

Abdominal Chinachoti Preincision and PreE: ropivacaine Ketorolac for 24 h Favors continuing postoperative
hysterectomyb et al,37 2002 postincision epidural 1 PostE: ropivacaine epidural:
general anesthesia for 24 h Lower pain scores at rest (difference of
Preincision epidural 1 PreE: ropivacaine w30 VAS, AUCM pain difference –11)
general anesthesia PostE: saline for 24 h Lower pain scores during coughing
(difference of w30 VAS, AUCM pain
difference 11)
Equivalent:
Time to first mobilization

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Bauchat & Habib
Table 4
(continued )
Anesthetic Technique Anesthetic Medication Other ERAS
Type of Surgery Study (Number of Patients) Administered Interventions ERAS Outcomes
Abdominal Wattwil Preincision epidural 1 PreE: bupivacaine for None specified Favors epidural:
hysterectomyc et al,38 1989 general anesthesia 26–30 h Reduced pain scores (VAS mean 1.9
(N 5 20) I: thiopental vs 4.4)
M: isoflurane 1 N2O Shorter time to first flatus (mean 31
General anesthesia I: thiopental vs 58 h)
(N 5 20) M: isoflurane 1 N2O Shorter time to first defecation (mean
70 vs 103 h)
Lower postoperative blood glucose at
3, 6, 9 h
No difference:
Hospital length of stay

Abbreviations: AUCM, area under the curve measurement; I, induction; M, maintenance; N2O, nitrous oxide; POD, postoperative day; PostE, epidural injection
after incision or procedure; PreE, epidural injection before incision; VAS, visual analog scale.
a
Abdominal hysterectomy (malignant and benign indication, midline and horizontal incisions), myomectomy, salpingo-oophorectomy, ovarian cystectomy.
b
Indication not specified.
c
Malignant and benign indication.
Data from Refs.34–38
 Evidence-Based Anesthesia for Gynecologic Surgery 187

and postoperative pain management with an opioid-based analgesic regimen alone

after general anesthesia. Overall, these studies confirm the superiority of epidural
analgesia compared with patient-controlled opioid analgesia for postoperative pain
management after major gynecologic surgery.34–38 Two studies reported improved
gastrointestinal function.36,38 However, none of these studies reported that epidurals
could shorten the hospital length of stay despite improved pain control, reduced
opioid consumption, and faster return of gastrointestinal function.34,36,38 This finding
highlights the importance of incorporating other ERAS principles to optimize patient
outcomes.
Impact of epidural infusion medications on outcomes with epidural analgesia
A Cochrane database review including 22 studies22 concluded that epidural analgesia
promotes faster return of bowel function compared with intravenous (IV) opioids, but
there were not enough studies to ascertain whether epidural local anesthetic alone
promotes faster return of bowel compared with epidural local anesthetic with opioid.
Two RCTs39,40 reported slower uptake of paracetamol (an indirect measure of gastric
motility) in volunteers and patients receiving epidural morphine or fentanyl, with no ef-
fect on gastric motility in those receiving local anesthetic alone. In 1 RCT in major gy-
necologic surgery,41 the incidence of PONV was lower and the hospital length of stay
shorter with epidural bupivacaine 1 fentanyl compared with epidural bupivacaine 1
morphine, with no difference in return of bowel function. Four studies in the gyneco-
logic surgery population36,38,42,43 reported faster return of bowel function in patients
receiving epidural local anesthetic alone compared with a combination of local anes-
thetic with opioids. Although the meta-analysis22 reported that a combination of local
anesthetic and opioid provides better postoperative pain control than local anesthetic
alone, both groups had very low postoperative pain scores, and it may be beneficial to
avoid epidural opioids (morphine in particular) to promote faster return of bowel func-
tion and add them into the epidural solution only if there is inadequate analgesia.
Impact of epidural anesthesia on survival in gynecologic cancer surgery
Retrospective and nonrandomized prospective trials report conflicting evidence of
beneficial44–47 or detrimental effect48,49 of epidural analgesia with regards to tumor
spread and survival in gynecologic oncology surgeries. Most retrospective trials,50–52
but not all,53 report possible survival benefit in women receiving epidural analgesia for
gynecologic malignancies. Some studies15,54 suggest that epidurals may inhibit tumor
spread and growth because of intrinsic tumor suppression properties of local anes-
thetics and minimizing opioid-induced and surgically induced immunosuppression.
On the other hand, an RCT in women undergoing surgery for ovarian cancer55 re-
ported that patients receiving combined epidural and general anesthesia showed
higher antitumorigenic cytokines and natural killer cell cytotoxicity than women
receiving general anesthesia alone.
Other Regional Anesthetic Techniques Combined with General Anesthesia
Transversus abdominis plane block
Transversus abdominis plane (TAP) block can be used for Pfannenstiel or midline
incisions. A meta-analysis of 5 studies56 reported reduction in 24-hour pain scores
and opioid consumption (reduced morphine equivalents by 5–19 mg) in patients
who received a TAP block compared with no block for major open gynecologic
surgery. In a meta-analysis of 10 studies in all-type laparoscopic surgery,57 3 of which
were gynecologic, TAP blocks were shown to be effective in reducing postoperative
pain scores and opioid consumption, particularly when administered preoperatively.
The TAP block has shown conflicting data with regard to improvement in quality of
188 Bauchat & Habib

recovery scores or opioid consumption after laparoscopic gynecologic surgery, but in

line with the conclusions of the meta-analysis, it may be that the timing of TAP block
administration was the difference between benefit (preoperative)58 and no benefit
(postoperative).59
One prospective, case-matched study in laparoscopic colorectal surgery incorpo-
rated TAP blocks into an established ERAS protocol, enabling further reduction of
postoperative pain, opioid consumption, and hospital length of stay (median of 3 d
vs 2 d).60 The benefits of TAP blocks should be further studied in RCTs to assess their
value as a part of ERAS protocols in gynecologic surgery.

Local anesthetic wound infusion

A large systematic review of 45 RCTs61 reported that surgical wound catheter infiltra-
tion with local anesthetic provides effective postoperative analgesia, reducing overall
pain scores and minimizing opioid consumption compared with an opioid-based
analgesic technique. Although there were positive results for the subcategory of
gynecology-urology procedures, cesarean sections and prostatectomies comprised
50% of these studies. A summary of studies in gynecologic surgery alone is pre-
sented in Table 5. For major gynecologic surgery, the benefits of subcutaneous local
anesthetic wound infiltration were seen only with larger-volume (9 mL) intermittent
boluses62 but not lower-volume (2 mL) continuous local anesthetic infusions.63,64
The location of the catheter is important to provide effective analgesia, because
even higher-volume local anesthetic infiltration below the muscle layers did not pro-
vide effective analgesia as subcutaneous and intraperitoneal infiltration cathe-
ters.62,65,66 Subcutaneous infiltration provided better patient satisfaction and lower
pain scores and opioid consumption when compared directly with intraperitoneal
infiltration.65,67

Local anesthetic wound infiltration

RCTs using incisional and deep would infiltration with local anesthetic before skin
closure did not reduce opioid consumption in patients undergoing hysterec-
tomy.68,69 RCTs studying preincisional local anesthetic infiltration reported a mini-
mal reduction in opioid consumption in hysterectomies70 and no opioid-sparing
effect in laparotomies for gynecologic cancer.71 Neither preincisional nor postinci-
sional local anesthetic wound infiltration was effective in reducing pain scores or
opioid consumption for laparoscopic gynecologic surgery.72 Only 1 study in highly
motivated patients undergoing pelvic organ prolapse surgery73 reported that this
surgery could be performed under local anesthetic infiltration alone, and compared
with general anesthesia, this technique was more cost effective, but no benefit
was seen in opioid use, PONV, or hospital length of stay. Taken together, these trials
show little to no effect of local anesthetic wound infiltration for gynecologic
surgeries.

Intraperitoneal local anesthetics

The analgesic effect of intraperitoneal administration of a single dose of local anes-
thetics intraoperatively in patients undergoing open abdominal hysterectomy has
yielded conflicting results.74,75 However, a meta-analysis has confirmed the analgesic
efficacy of continuous infusion of intraperitoneal local anesthetics.76 Up to 40%
opioid-sparing effects were reported with this technique after open abdominal hyster-
ectomy,77 with better efficacy using a patient-controlled technique compared with a
continuous infusion.78 Opioid-sparing effects of intraperitoneal lidocaine were greater
compared with IV lidocaine after abdominal hysterectomy.79
 Evidence-Based Anesthesia for Gynecologic Surgery 189

OTHER OPIOID-SPARING MULTIMODAL ANALGESIC STRATEGIES FOR MAJOR

GYNECOLOGIC SURGERY
g-Aminobutyric Acid Analogs
In a recent meta-analysis of 6 RCTs,80 preoperatively administered pregabalin
reduced 24-hour morphine consumption (weighted mean difference 8.5 mg [95%
confidence interval (CI), 5.71 to 11.29]) and postoperative pain scores compared
with controls after major gynecologic surgery. There was a significant reduction in
PONV with pregabalin at the expense of increased dizziness.80 The dose range was
100 to 300 mg once or repeated every 8 to 12 hours.80 A recent meta-analysis81 sug-
gested that for acute pain outcomes, there does not seem to be a significant benefit
from repeated doses of pregabalin compared with a single dose administered before
surgery and that analgesia was comparable with doses ranging from 100 to 300 mg.
In a meta-analysis of 14 RCTs using preoperative gabapentin for abdominal hyster-
ectomy,82 overall 24-hour morphine consumption was reduced from 24.3 to 55.9 mg
to 13.2 to 42.7 mg, with a standardized mean difference of 0.67 (95% CI 1.2 to
0.07). When gabapentin was used preoperatively and postoperatively, the 24-hour
morphine consumption was reduced from 25.7 to 80 mg to 20.3 to 55 mg, with a stan-
dardized mean difference of 1.45 (95% CI 1.79 to 1.11).82 Most studies adminis-
tered gabapentin 1 to 2 hours preoperatively in a single dose of 1200 mg or with
smaller doses of 100 to 400 mg administered every 6 to 8 hours.82 Dose-ranging
studies in other patient populations suggest that the minimum effective dose of pre-
operative gabapentin is 600 mg.83 PONV was also reduced in the gabapentin group,
with no increased incidence of somnolence or dizziness compared with the control
group.82 Similar to pregabalin, combined preoperative and postoperative doses of
gabapentin did not confer advantages compared with preoperative-only administra-
tion.82 The potential side effects of these 2 drugs reported in meta-analyses of their
perioperative use include sedation and visual disturbances.81

Arachidonic Acid Metabolism Inhibitors

Arachidonic acid is converted into prostaglandins via 2 cyclooxygenase (COX-1 and
COX-2) pathways.84 The uterus expresses both COX-1 and COX-2 at different levels
throughout the menstrual cycle, making these ideal medications for use in gynecologic
surgeries.84
In a meta-analysis of nonsteroidal antiinflammatory drugs (NSAIDs) and COX-2 in-
hibitors in all types of surgery, morphine-sparing effects of those agents were compa-
rable with an approximate average reduction of 10 mg of morphine in 24 hours
compared with placebo,85 but the reduction in opioid-related side effects such as
nausea was seen only with NSAIDs. The opioid-sparing effect of these agents ranged
from 22% to 50 % in different studies in patients undergoing gynecologic surgery.86–96
Although increased risk of bleeding is a theoretical concern with perioperative use of
NSAIDs, a recent meta-analysis97 suggested that perioperative ketorolac does not in-
crease risk of bleeding.

Paracetamol (Acetaminophen) and Propacetamol

The IV formulation of paracetamol has been available in Europe since 2001 and was
approved in the United States in 2010. Systematic reviews85,98 show that both para-
cetamol and propacetamol reduce opioid consumption by 30%, which is equally effi-
cacious to NSAIDs in the postoperative period for all-type surgery. Most studies in the
gynecologic surgery population report an opioid-sparing effect of 30% to 40% with a
1-g to 2-g once-daily or twice-daily dosing regimen.99–101 These agents have been
 190
Bauchat & Habib
Table 5
Summary of the effects of wound infiltration catheters using local anesthetics on ERAS principles in major gynecologic surgery

Group Allocation Wound Infiltration Other ERAS

Type of Surgery Study (Number of patients) Catheter Interventions ERAS Outcomes
Laparotomy for Kushner LA catheter group Location: subcutaneous None specified No difference:
gynecologic et al,64 2005 (N 5 40) Infusion: continuous Pain scores
cancera Control catheter bupivacaine 0.5% or Opioid consumption
group (N 5 40) saline at 2 mL/h Time to first defecation
Hospital length of stay
Abdominal Leong LA catheter group Location: subcutaneous None specified No difference:
hysterectomyb et al,63 2002 (N 5 26) Infusion: continuous Pain scores
Control group: no bupivacaine 0.5% Opioid consumption
catheter (N 5 26) at 2 mL/h
Abdominal Zohar LA catheter group Location: subcutaneous Multimodal Favors subcutaneous instillation with LA:
hysterectomyc et al,62 2001 (N 5 18) Infusion: PCA analgesia Reduced pain scores (VAS w20 lower)
Control catheter Bupivacaine 0.25% or regimen Reduced morphine consumption in
group (N 5 18) saline 9 mL/h recovery room (mean 6 vs 12 mg)
Reduced meperidine consumption overall
(mean 29 vs 95 mg)
Lower incidence of nausea (antiemetic
treatment 44% vs 100%)
Higher patient satisfaction (78% vs 39%
rated analgesia good or excellent)
Shorter hospital length of stay (6 vs 7 d)
 Abdominal Kristensen LA catheter group Location: bilateral None specified No difference:
hysterectomyb et al,66 1999 (N 5 22) catheters on each side Pain scores
Control catheter of the incision, below Opioid consumption
group (N 5 19) muscle layer, above
peritoneum
Infusion:
bupivacaine 0.25%
or saline 15 mL each
catheter every 4 h
Abdominal Gupta LA catheter group Location: None specified Favors intraperitoneal instillation with LA
hysterectomyb et al,65 2004 (N 5 20) intraperitoneal Lower pain scores first 2 h (VAS w20 lower)
Control catheter supracervical area Reduced ketobemidone consumption
group (N 5 20) Infusion: at 4–24 h (mean 19 vs 31 mg)
levobupivacaine Reduced incidence of nausea (15% vs 50%)

Evidence-Based Anesthesia for Gynecologic Surgery

0.25% or saline at No difference:
5 mL/h Hospital length of stay
Time to mobilization

Abbreviations: LA, local anesthetic; PCA, patient-controlled analgesia.

a
Malignant and benign indication.
b
Benign indication.
c
Indication not specified.
Data from Refs.62–66

191
192 Bauchat & Habib

compared directly with NSAIDs in the gynecologic surgery patient population, with
equal efficacy to ketorolac102 but slightly less efficacy compared with diclofenac.87,103
A recent systematic review104 also reported a reduction in PONV with the use of IV
paracetamol. Additional opioid-sparing effects and PONV reduction are obtained
when combining NSAIDs with paracetamol than either drug alone.103,105

Lidocaine Infusion
Meta-analyses and systematic reviews106,107 reported that IV lidocaine infusions
reduced postoperative pain, decreased opioid consumption, led to faster return of
bowel function, and shortened hospital length of stay in abdominal surgeries. How-
ever, studies of patients undergoing open or laparoscopic hysterectomy have not
shown benefits in reducing pain scores, opioid consumption, improving quality of re-
covery, or shortening hospital stays,108–110 except for some reduction in inflammatory
mediators and pain scores in the early postoperative period in 1 study.110 The lack of
analgesic benefit may be because the lidocaine infusions were used only in the intra-
operative period in these trials. Although many studies of other abdominal surgeries
continued the lidocaine infusion in the postoperative period, some studies also re-
ported benefit after administration only in the intraoperative period.106

Ketamine Infusion
A meta-analysis of 70 studies111 concluded that ketamine infusions improve postop-
erative analgesia and reduce opioid consumption, particularly in upper abdominal,
thoracic, and major orthopedic procedures. Studies of ketamine use in women under-
going gynecologic surgery have yielded conflicting results. In an RCT in patients un-
dergoing hysterectomy, an intraoperative ketamine infusion reduced morphine
consumption by 35%, improved pain scores at 8 to 12 hours after surgery, and
improved patient satisfaction with analgesia but did not promote faster return of bowel
function or faster ambulation or reduce hospital length of stay.112 Another RCT in a gy-
necologic surgery patient population113 found that a preincision bolus followed by an
intraoperative infusion or a bolus of ketamine at wound closure was more effective at
reducing pain scores and morphine consumption (by 50%) than 1 preincision dose of
ketamine. In patients undergoing myomectomies or hysterectomies for fibroids, no
difference in pain scores or opioid consumption was found after a preincision bolus
and intraoperative and postoperative infusion of ketamine.108 The ketamine infusion
dosing regimens varied greatly between studies, with initial dosing of 0.3 mg/kg to
0.5 mg/kg and a continuous infusion of 50 mg to 600 mg/kg/h intraoperatively only or
up to 24 hours postoperatively.108,112,113 It is unclear whether ketamine would provide
routine benefit to gynecologic surgery patients or its use should be limited to certain
patients, such as those with chronic pain conditions who are on long-term opioids.

REDUCING POSTOPERATIVE NAUSEA AND VOMITING AFTER MAJOR GYNECOLOGIC

SURGERY

The Apfel simplified risk score for prediction of PONV includes 4 factors: female
gender, history of PONV or motion sickness, nonsmoking status, and need for post-
operative opioids.114 Most women in the United States (82%) are nonsmokers, and
major gynecologic surgery requires postoperative opioids, so this patient population
typically has starting PONV risk of 60% according to the Apfel score.115 Furthermore,
although it has been debated whether the type of surgery is a risk factor for PONV, a
meta-analysis of risk factors116 reported that gynecologic surgery is an independent
risk factor for PONV.
 Evidence-Based Anesthesia for Gynecologic Surgery 193

The Society for Ambulatory Anesthesia consensus guidelines for PONV recommend
combination antiemetic therapy in this high-risk patient population and adoption of
strategies to reduce the baseline risk of PONV.117

STRATEGIES TO REDUCE THE BASELINE RISK OF POSTOPERATIVE NAUSEA AND

VOMITING
Avoid General Anesthesia by Using Regional Anesthesia
The use of regional anesthesia has been associated with up to 9-fold reduction in the
incidence of PONV.118 However, the influence of neuraxial analgesia on PONV is
variable, depending on the technique used and the type of epidural medications
administered. Compared with general anesthesia with an opioid-based analgesic
technique, spinal anesthesia reduces PONV only if no or low-dose (60 mg) intrathecal
morphine is used.33,119
Most studies using epidural analgesia for major gynecologic surgery combine this
technique with general anesthesia, and this might not reduce PONV. Callesen and
colleagues119 compared PONV rates between an opioid-free combined spinal-
epidural (CSE) technique (local anesthetic alone) and a general anesthetic group
with epidural analgesia (local anesthetic and opioid) in patients undergoing hysterec-
tomy. The cumulative 72-hour incidence of PONV was 50% in the CSE group and
100% in the combined general anesthetic with epidural group.119 However, the
need for supplementary opioids was higher in the CSE group.
Avoid Inhaled Agents and Nitrous Oxide if General Anesthesia Is Used
Inhaled agents increase the risk of PONV, particularly in the early postoperative
period.120 Nitrous oxide is associated with increased risk of PONV, particularly in
women.121 Total IV anesthesia with propofol is associated with a reduction in the
risk of PONV, particularly in the first 6 hours after surgery, with a number needed to
treat of 5.122
Minimize Intraoperative and Postoperative Opioids
Opioid-sparing techniques are an integral part of ERAS protocols, because they not
only reduce PONV but also affect other opioid-related side effects that can affect
patients’ recovery and delay discharge, such as sedation and postoperative ileus.
Despite the opioid-sparing effects of these interventions, their effects on reducing
PONV are not consistent. A reduction in the risk of PONV was reported with intra-
peritoneal local anesthetic instillation catheters77,79 but not with TAP blocks or subcu-
taneous infiltration catheters.56,62,65 The g-aminobutyric acid analogs show consistent
reduction in PONV.80,82 A meta-analysis including all types of surgery123 reported a
reduction in PONV with NSAIDs but not with COX-2 inhibitors. In a systematic review
of 30 RCTs, IV paracetamol provided better analgesia and reduced PONV, despite no
reduction in opioid consumption.98,104
Adequate Hydration
Intraoperative fluid management and its effects on ERAS principles, including PONV,
seem to be highly dependent on the surgery, more specifically the length and extent of
surgical damage. A systematic review of 80 studies124 concluded that in minor and
moderate ambulatory surgeries, including laparoscopic gynecologic surgeries,
PONV could be reduced in patients receiving more liberal regimens (1–2 L of fluid).
In 1 RCT in women with 2 to 4 risk factors for PONV having laparoscopic gynecologic
surgery,125 the liberal fluid group (3 mL/kg/h of fasting) had lower rates of PONV (59%
vs 87%) than the restrictive group (2 mL/kg/h of fasting). Lower PONV rates were also
 194
Bauchat & Habib
Table 6
Summary of goal-directed fluid therapy on ERAS outcomes for major gynecologic surgery

Reference, Other ERAS

Surgery Type Study Type Description of Fluid Management (Number of Patients) Interventions Summary of ERAS Outcomes
McKenny RCT Control (N 5 50) Intervention (N 5 51) No ERAS No reduction in hospital
et al,131 2013 Fluid management at the SV measurement via esophageal protocol length of stay
Laparotomy anesthesiologist’s Doppler US in the No difference in postoperative
gynecologic discretion for: Algorithm: HES administered 3 mL/kg gynecologic morbidity score
cancer Urine output <0.5 mL/kg/h X1 surgery No difference in gastrointestinal
surgery Unspecified increase in SV >10% response, give another population recovery
heart rate 3 mL/kg, until SV responds <10%, at this
Unspecified decrease in SBP SV <10% response, repeat SV institution
Unspecified decrease in CVP measurement 15 min.
Replacement of estimated
intraoperative losses
Chattopadhyay Prospective Control Intervention No ERAS Favors goal-directed therapy in
et al,132 2013 observational Advanced stage (N 5 62) Advanced stage (N 5 44) protocol advanced-stage disease only:
Laparotomy study Early stage (N 5 57) Early stage (N 5 35) specified Goal-directed fluid therapy
gynecologic Hemodynamic-based fluid SV measurement via esophageal associated with earlier
cancer management Doppler US postoperative recoverya
surgery Not specified No algorithm specified (OR 2.8)
Less PONV in goal-directed
therapy (9% vs 24%)
 Gan et al,133 RCT Control (N 5 50) Intervention (N 5 50) No ERAS Favors goal-directed therapy:
2002 Bolus 5 mL/kg LR followed Bolus 5 mL/kg LR followed by 5 mL/ protocol Shorter length of hospital
Mixed major by 5 mL/kg/h infusion kg/h infusion during surgery specified stay in goal-directed
abdominal during surgery Algorithm: therapy (median 5 vs 7 d)
surgeryb 200 mL HES if FTcc <0.35 s Faster oral intake (3 vs 4.7 d)
If SV > or 5 by the fluid challenge Less PONV requiring
and FTc <0.35 s: fluid challenge antiemetic therapy
was repeated (14% vs 36%)
If SV >10% and FTc >0.35 s, fluid
challenge repeated until no
further increase in SV occurred
If FTc >0.40 s and 5 SV, further fluid
was not given until SV decreased
by 10% of the last value

Evidence-Based Anesthesia for Gynecologic Surgery

Abbreviations: CVP, central venous pressure; FTc, corrected flow time; HES, hydroxyethyl starch; LR, lactated Ringer; OR, odds ratio; SBP, systolic blood pressure; SV,
stroke volume; US, ultrasonography.
a
Early postoperative recovery defined as 2 of the following: mobilization on the first postoperative day, oral diet resumption on postoperative day 1; and
return of bowel function on postoperative day 4 or earlier.
b
Major elective general, urologic, or gynecologic surgery with anticipated blood loss >500 mL.
c
FTc: aortic systolic flow time corrected for heart rate: index of systemic vascular resistance that is sensitive to changes in left ventricular preload.
Data from Refs.131–133

195
196 Bauchat & Habib

reported126 in patients undergoing either laparoscopic gynecologic procedure or a

cholecystectomy in a liberal fluid management group 15 mL/kg bolus (23%) versus
the conservative fluid management group 2 mg/kg bolus (73%). A meta-analysis
including 15 studies, 11 of which included patients undergoing gynecologic surgery,
reported that compared with conservative fluid regimens, administration of supple-
mental IV crystalloids reduced the risk of early postoperative nausea (relative risk
0.73, 95% CI 0.59–0.89), postoperative nausea at 24-hour (relative risk 0.41, 95%
CI 0.22–0.76), and overall 24-hour postoperative nausea (relative risk 0.66, 95% CI
0.46–0.95). Liberal IV crystalloids also reduced overall 24-hour PONV (relative risk
0.48, 95% CI 0.29–0.79), late PONV (relative risk 0.27, 95% CI 0.13–0.54), and overall
24-hour PONV (relative risk 0.59, 95% CI 0.42–0.84), as well as the need for antiemetic
rescue treatment (relative risk 0.56, 95% CI 0.45–0.68).127

ANTIEMETIC PROPHYLAXIS

Because the gynecologic patient population is at high risk for PONV, combination anti-
emetic therapy should be used for prophylaxis. Studies have consistently reported the
superior antiemetic efficacy of combination therapy compared with single-agent anti-
emetic prophylaxis. The multimodal approach incorporates combination antiemetic
therapy in addition to measures to reduce the baseline risk of PONV, as discussed
earlier, and should be used in high-risk patients.117 The most commonly investigated
therapies include a combination of 5-HT3 antagonists with either dexamethasone or
droperidol, with both combinations having comparable antiemetic efficacy.128,129
Longer-acting antiemetics might provide additional protection against delayed
PONV and postdischarge nausea and vomiting. Those agents include palonosetron,
transdermal scopolamine, and the neurokinin-1 receptor antagonist aprepitant, with
the last one being significantly more effective than ondansetron in prophylaxis against
vomiting in women undergoing major gynecologic surgery.130

FLUID MANAGEMENT FOR MAJOR GYNECOLOGIC SURGERY

In contrast to ambulatory surgeries, in which PONV may be the primary outcome of

concern, for major nonvascular abdominal surgeries, goal-directed fluid management
improves major outcomes, such as cardiopulmonary function, gastric motility, and
wound healing, and reduces hospital length of stay.124 However, studies investigating
goal-directed therapy in gynecologic surgery are limited. Table 6131–133 summarizes
the studies in gynecologic surgery examining the impact of intraoperative fluid admin-
istration regimen on patients’ outcomes. A meta-analysis of 32 trials by Cecconi and
colleagues134 reported that patients with the highest risk of surgical mortality
benefited the most from goal-directed therapy, which seems to be supported by 1
prospective observational trial in patients undergoing laparotomies for gynecologic
cancer.132 RCTs are clearly lacking in the gynecologic surgery population with regards
to whether goal-directed fluid therapy confers benefits in these patients.

OTHER ENHANCED RECOVERY AFTER SURGERY PRINCIPLES FOR MAJOR

GYNECOLOGIC SURGERY

Other elements of ERAS for major gynecologic surgeries include the approach to pre-
operative preparation, bowel management, surgical approach, thromboprophylaxis,
and postoperative planning. A summary of the literature regarding those elements in
the gynecologic patient population is presented in Table 7.
 Evidence-Based Anesthesia for Gynecologic Surgery 197

Table 7
Summary of outcomes in major gynecologic surgery when comparing a traditional approach
with ERAS interventions

Traditional Approach ERAS Intervention Study Outcomes

Lack of focus Improve nutritional No known effective strategies identified
on preoperative status in patients with ovarian cancer 136
nutrition
Bowel preparations No bowel preparations Bowel preparations137–139
Do not:
Prevent infection
Improve surgical visualization
Do:
Reduce patient satisfaction
Routine NG tubes No routine NG tubes NG tubes140
Do not:
Reduce postoperative ileus
Reduce aspiration
Do:
Increase aspiration risk
Increase patient discomfort
Delayed feeding Early feeding Early feeding141,142
Does:
Promote early return of bowel function
Shorten HLOS
Increase nausea
Antibiotic Appropriate antibiotic Antibiotic prophylaxis143,144
prophylaxis prophylaxis Indicated: all open procedures
Unclear indication: some laparoscopic
procedures
Not indicated: minor or intrauterine
procedures
Open procedures Minimally invasive Hysterectomies1
procedures when VH vs AH: VH has less blood loss, fastest
feasible recovery, shortest HLOS, lowest
infection rate
VH vs LH: VH has less blood loss, lower
infection rate
Laparoscopic vs open for all gynecologic
surgeries1,145
Advantage:
Less pain
Less blood loss
Shorter HLOS
Disadvantage:
Increased urinary tract injuries
Robotic146:
No RCTs comparing robotic procedures
with laparoscopic or open
procedures
(continued on next page)
198 Bauchat & Habib

Table 7
(continued)

Traditional Approach ERAS Intervention Study Outcomes

No routine Routine Patients with ovarian cancer147:
thromboprophylaxis thromboprophylaxis Heparin SQ 3 times daily to prevent
thromboembolism
No increase in bleeding complications
Laparoscopic procedures148:
Unclear if needed in minor
laparoscopic procedures
More extensive surgeries increase the
risk of thromboembolism, so
prophylaxis warranted
Hysterectomy149:
Pharmaceutical prophylaxis highly
effective
Possible increased risk of postoperative
bleeding
Drains, tubes, No drains, tubes, Early removal of urinary catheters
catheters placed catheters reduces HLOS142
Discharge patient Preplanning discharge Scant literature on this topic in
when they are ready gynecology literature142

Abbreviations: AH, abdominal hysterectomy; HLOS, hospital length of stay; LH, laparoscopic hys-
terectomy; NG, nasogastric; SQ, subcutaneous; VH, vaginal hysterectomy.

SUMMARY
 Studies on ERAS after gynecologic surgery are limited and mainly extrapolate
several ERAS principles from colorectal surgery and apply them to gynecologic
surgery to a variable extent. Similar outcome benefits, namely a reduction in
hospital length of stay, have been reported in those studies.
 Despite recommendations for use of regional anesthesia for colorectal proce-
dures, an ideal, standardized anesthetic technique has not been identified, and
thus, it is important to evaluate the best evidence for regional techniques in gy-
necologic surgery when developing ERAS guidelines in this surgical population.
 Effective regional anesthetic techniques in gynecologic surgery include spinal
anesthesia, epidural analgesia, TAP blocks, local anesthetic instillation catheters,
and intraperitoneal local anesthetic instillation.
 Effective nonopioid analgesics include pregabalin, gabapentin, NSAIDs, COX-2
inhibitors, and paracetamol.
 Ketamine infusions may provide benefit for some patients after major gynecologic
surgery but should not be used routinely. Lidocaine infusions, although effective in
other abdominal surgeries, provide no benefit for gynecologic surgery.
 A multimodal antiemetic strategy must be used, including strategies to reduce
the baseline risk of PONV in conjunction with combination antiemetic therapy.
 RCTs exploring fluid management strategies on ERAS outcomes in the major
gynecologic surgery population are lacking.
 Anesthesiologists should be aware of all ERAS principles from colorectal surgery
that are also beneficial in major gynecologic surgery, such as bowel manage-
ment, goal-directed fluid management strategies, timely administration of
appropriate antibiotics, and thromboprophylaxis, because many of these may
become quality measures for anesthesiologists in the future.
 Evidence-Based Anesthesia for Gynecologic Surgery 199

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