What is the role of minimal-access surgery (MAS) in enhanced recovery after surgery (ERAS) programs for emergency GI surgical procedures?

Updated: Jan 20, 2021
  • Author: Vikram Kate, FRCS, MS, MBBS, PhD, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS, FFST(Ed); Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Answer

Answer

MAS is an important determinant of an ERAS protocol, in that it leads to enhanced recovery and an optimal postoperative outcome. Any surgical procedure causes two types of injury, direct and indirect. [11] Direct injury is due to incision and tissue damage from mobilization of tissues and organs; indirect injury sets in with hemorrhage, anesthetic techniques, patient positioning, and creation of pneumoperitoneum with CO2.

In open surgical procedures, reducing the surgical wound by performing a smaller incision involving few dermatomes and myotomes decreases the surgical trauma. [11] Intraoperative bleeding may be controlled by using ultrasonic technology or electrocoagulation.

A much better approach is to perform a laparoscopic procedure whenever feasible. Laparoscopic surgery has the advantage of requiring only small incisions that cause less tissue damage. It is targeted to reduce the stress and injury caused by the surgery to the body. [31] However, the creation of a pneumoperitoneum may have a detrimental effect, particularly when the operation is prolonged. This effect can be counteracted with the help of special ports and neuromuscular blocks. [11]

Lack of infrastructure, unavailability of an appropriately trained surgeon, and a busy emergency operation theater schedule are all potential hindrances to performing emergency laparoscopic surgery on a routine basis. Nevertheless, whenever possible, use of a MAS approach is preferable in an ERAS protocol. The pioneering study on emergency ERAS by Gonenc et al reported successful use of MAS in the management of patients with perforated peptic ulcers. [5] Drain usage should be limited because it impedes early mobilization, thereby prolonging recovery.

A coordinated effort by the surgeon, the anesthesiologist, and the other caregivers in the intraoperative phase of the ERAS protocol is important for successfully translating the benefits of this phase into the postoperative phase.


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