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Laparoscopy in the era of enhanced recovery

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Abstract

Laparoscopy is one of the cornerstones in the surgical revolution and transformed outcome and recovery for various surgical procedures. Even if these changes were widely accepted for basic interventions, like appendectomies and cholecystectomies, laparoscopy still remains challenged for more advanced operations in many aspects. Despite these discussion, there is an overwhelming acceptance in the surgical community that laparoscopy did transform the recovery for several abdominal procedures. The importance of improved peri-operative patient management and its influence on outcome started to become a focus of attention 20 years ago and is now increasingly spreading, as shown by the incoming volume of data on this topic. The enhanced recovery after surgery (ERAS) concept incorporates simple measures of general management, and requires multidisciplinary collaboration from hospital staff as well as the patient and the relatives.

Several studies have demonstrated a significant decrease in postoperative complication rate, length of hospital stay and reduced overall cost. The key elements of success are fluid restriction, a functioning epidural and preoperative carbohydrate intake.

With the expansion of laparoscopic techniques, ERAS increasingly incorporates laparoscopic patients, especially in colorectal surgery. However, the precise impact of laparoscopy on ERAS is still not clearly defined. Increasing evidence suggests that laparoscopy itself is an additional ERAS item that should be considered as routine where feasible in order to obtain the best surgical outcomes.

Section snippets

Background to laparoscopy – evidence of impact on recovery

The widespread introduction of laparoscopy into surgery has been the only real revolutionary change in surgical technique in the last 100 years. It has transformed the way we operate and has transformed outcome and recovery for many common surgical operations. Although to many the improvements were immediately both dramatic and obvious it did not prevent an abundance of scepticism for nearly every operation into which the technology was introduced. This prompted research including randomized

Background to enhanced recovery – evidence of impact on recovery

Good surgical technique, the use of new technology and the application of multimodal therapy in cancer surgery can all improve outcome and reduce complications. The more general management of patients pre, intra and post-operatively has been relatively neglected. The concept of enhanced recovery after surgery had not received adequate attention for many years when compared to surgical technique and technology.

The importance of improved peri-operative patient management and its influence on

Relative impact of enhanced recovery and laparoscopic surgery

The preceding sections have dealt with the evidence in support of both minimally invasive surgery (MIS) and enhanced recovery programs (ERP) on recovery after surgery. The question of the relative impact of each has also been addressed. This is an important issue as there is considerable overlap in some aspects of care. The enabling effect of MIS has naturally assimilated many of the components of what was later to become enhanced recovery and so a sceptical view might be that it is the

Conclusions

Laparoscopic surgery and Enhanced Recovery Programs share the same goals: improving outcome and decreasing surgical stress and complications.

The main difference however, is that laparoscopy involves the surgeons and is based on skills, new techniques and new technology. ERP on the other hand incorporates relatively simple measures of general patient management, and requires successful collaboration between surgeons, anaesthesiologists and nursing staff as well as the patient and the relatives.

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