Enhanced Recovery after Surgery Pathway for Abdominal Wall Reconstruction

SUMMARY: Enhanced recovery after surgery (ERAS) pathways represent a multimodal approach to improve the quality of postoperative care by diminishing the stress response to the trauma of an operation, thereby minimizing hospital length of stay and potentially complications. At a time when healthcare costs are being intensely scrutinized, efforts to reduce patient morbidity and hospital stay are imperative and timely. The success of ERAS fast-track surgery pathways-thoroughly studied in the colorectal literature-has led to their application in other fields. Herein, we present our ERAS pathway for patients undergoing abdominal wall repairs, including the rationale and supporting evidence behind each of its components and our early clinical results after implementation. Although hastened patient recovery is clearly multifactorial, our pathway, incorporating alvimopan, early feeding strategies, and multimodal pain therapy with an emphasis on the reduction of opiate usage as well as precise intraoperative nerve block with novel longer-acting local anesthetic Exparel, appears to provide significant improvement in postoperative pain, bowel function recovery, and shorter hospital stay. Although a prospective evaluation of the entire ERAS pathway as well as contribution of its various components is currently ongoing at our Hernia Center, we believe ours or similar ERAS pathways will soon become standard for the vast majority of patients undergoing abdominal wall surgery.