Preoperative education is an important part of ERAS. It should not only introduce the details of surgery and anaesthesia but also cover postoperative rehabilitation guidance (7). For example, a 48-year-old patient scheduled for laparoscopic myomectomy received comprehensive preoperative education, including details about the surgery, anaesthesia and postoperative care. This patient was able to actively participate in her recovery process, resulting in reduced anxiety and a shorter hospital stay of 3 days compared with the average of 5 days for similar cases without such education.

An important feature of ERAS is that preoperative education enables patients to actively participate in their own recovery process and understand the operation and anaesthesia procedure. Cognitive intervention can substantially reduce patients’ anxiety, fear and pain, shorten the length of hospital stay and reduce the occurrence of postoperative complications (7). Patients should be evaluated before surgery for smoking, alcohol use and other related habits that may affect postoperative recovery, as well as for nutritional status and clinical factors such as blood pressure, blood glucose, cardiorespiratory function and anaemia.

Studies have shown that preoperative evaluation, optimisation and intervention can significantly reduce postoperative morbidity and mortality in patients undergoing elective surgery. For patients with gynaecological malignancies, the risk of disease progression caused by delays in surgery due to physical optimisation must also be considered. It is generally recommended to stop smoking and alcohol consumption for more than 4 weeks prior to surgery (8). If preoperative anaemia, such as iron deficiency anaemia, is present, it should be corrected as far as possible with iron supplementation. However, in patients with gynaecological malignancy and anaemia, the use of erythropoiesis-stimulating agents or blood transfusion should be minimised due to the risk of promoting tumour progression.

The choice of surgical method is an important factor affecting rapid postoperative recovery. In this study, we conducted a randomised controlled trial involving 300 patients undergoing gynaecological surgery, with 150 patients assigned to the ERAS group and 150 to the control group. The sample size was calculated based on a power of 80% and a significance level of 0.05, assuming a 20% reduction in hospital stay in the ERAS group compared with the control group. The inclusion criteria were patients aged 18–65 years undergoing elective gynaecological surgery, whereas the exclusion criteria included patients with severe comorbidities or those unwilling to participate in the study (8).

Minimally invasive surgical methods, such as laparoscopic myomectomy, total laparoscopic hysterectomy and robotic surgery, can reduce intraoperative blood loss, shorten operation time, accelerate the recovery of intestinal function, shorten hospital stays, enable an earlier return to daily activities and improve patient satisfaction (9). The choice of surgical method should be based on the proficiency of the surgeon and the patient’s clinical condition. It should be appropriate for the surgeon, suitable for the patient and consistent with the disease status. Regardless of the type of surgery chosen, the concept of minimally invasive surgery should be implemented throughout the procedure.

Enhanced recovery after surgery-related studies suggest that prolonged fasting before surgery, especially for more than 12 hours, depletes glycogen and energy reserves in patients, increases surgical stress and trauma and leads to insulin resistance and hyperglycaemia. Shortening the fasting duration before surgery does not increase the risk of complications such as reflux and aspiration (10).

A meta-analysis of 10 randomised controlled trials involving 1,200 patients concluded that bowel preparation before gynaecological surgery did not significantly improve exposure of the surgical field or shorten the operation time. The pooled data showed no statistical difference in the incidence of postoperative anastomotic leakage and infection between patients who received bowel preparation and those who did not (p > 0.05) (10). Even in patients undergoing intestinal resection, there was no significant difference in the incidence of postoperative anastomotic leakage and infection, regardless of whether bowel preparation was performed.

On the contrary, repeated enemas and dietary restrictions can cause dehydration and electrolyte imbalance. Slag-free diets and enemas using oral sodium phosphate can lead to notable patient discomfort. According to international ERAS guidelines, bowel preparation and enemas should be avoided whenever possible. In addition, patients may safely consume a clear, carbohydrate-rich beverage (240–400 mL, providing at least 45 g of carbohydrates) up to 2–3 hours before surgery to optimise the metabolic response (11, 12).

Preoperative sedation should follow individualised selection and avoid the routine use of sedatives, especially long-acting sedatives, within 12 hours before surgery. For short-acting sedatives, individual consideration is required. The preferred choice of preoperative antibiotics is cephalosporins. First-generation cephalosporins (such as cefazolin) are recommended, and amoxicillin–clavulanic acid may also be used. For patients allergic to penicillin and cephalosporins, a combination of clindamycin and gentamicin or quinolones (e.g. ciprofloxacin) may be used (13).

In China, the incidence of deep vein thrombosis (DVT) in patients who do not receive preventive measures after gynaecological surgery is as high as 9.2%–15.6%. Among patients with DVT, the incidence of pulmonary embolism is as high as 46%, and the incidence of venous thromboembolism (VTE) in patients with malignant tumours is 2–3 times higher.

Therefore, for patients undergoing gynaecological tumour surgery lasting more than 30 minutes and other patients classified as high risk or extremely high risk for VTE, active prevention is necessary. This includes encouraging early ambulation, standardised use of low molecular weight heparin, graded compression stockings or intermittent pneumatic compression (IPC) pumps and continuation of these measures until the operation. Postoperatively, prophylaxis is generally required for 7–14 days, whereas high-risk patients may require extended prophylaxis for up to 4 weeks (14).

The selection of anaesthesia protocol is directly related to the postoperative rehabilitation of patients, so it is necessary to choose a standardised anaesthesia regimen according to the characteristics of patients with gynaecological conditions. To allow rapid arousal, anaesthesia should be maintained with a short-acting agent such as sevoflurane or desflurane or with continuous target-controlled propofol infusion. The application of nitrous oxide increases the occurrence of PONV (15). Since both laparoscopic surgery and gynaecological surgery are independent predictors of PONV, nitrous oxide should be avoided in gynaecological laparoscopic surgery. To prevent PONV, the preventive combination of two antiemetic agents is recommended. The addition of local anaesthesia to general anaesthesia can reduce opioid use, help lower PONV incidence and allow for more rapid arousal (16).

Postoperative nausea and vomiting is very common in patients undergoing gynaecological surgery. In our study involving 300 patients, the incidence of PONV was 30% in the control group and 15% in the ERAS group. This finding is consistent with a previous study by Gan et al., which reported a 40% reduction in PONV incidence in patients receiving multimodal antiemetic prophylaxis. Our study used a similar multimodal approach, including the combination of two antiemetic agents, to achieve a significant reduction in PONV (14). Other strategies include avoiding general anaesthesia, using propofol infusions, avoiding nitrous oxide and volatile anaesthetics, reducing opioid use and minimising the dose of neostigmine (17). The multimodal PONV prevention approach is rapidly becoming the standard of care. Patients undergoing gynaecological surgery should receive PONV prophylaxis using a multimodal approach or at least two antiemetics. Additional ways to reduce the risk of PONV include increasing the use of regional anaesthesia and propofol and reducing the use of opioids, neostigmine and volatile anaesthetics (18). For patients who develop PONV despite prophylaxis, additional antiemetics (e.g. metoclopramide or droperidol) may be administered. Non-pharmacological interventions, such as acupressure or ginger, may also be considered.

Although most studies of ERAS procedures have been conducted in open surgeries, there is growing evidence that ERAS protocols also benefit patients undergoing laparoscopic surgery. Therefore, patients should be offered minimally invasive procedures, including transvaginal surgery, where feasible (19).

The results of meta-analyses and systematic reviews show that compared with conventional indwelling nasogastric tubes, patients who do not undergo nasogastric decompression experience significantly fewer pulmonary complications, earlier exhaust and diet, shorter hospital stays and no increase in abdominal complications. Therefore, routine use of indwelling nasogastric tubes should be avoided, and any gastric tube inserted during surgery should be removed prior to anaesthesia recovery (20).

Intraoperative exposure and injury often result in hypothermia, which has been shown to affect drug metabolism and coagulation and to increase bleeding and wound infection. The patient’s core body temperature should therefore be actively maintained at >36 °C throughout the perioperative period (21).

Fluid management is an important part of anaesthesia management and is directly related to patient safety during surgery and postoperative recovery. Hypovolaemia can result in hypoperfusion of vital organs and associated complications. However, excessive fluid rehydration can lead to intestinal oedema and increased lung interstitial fluid volume, causing complications (22). Therefore, both overly restrictive and liberal infusion regimens should be avoided. For large open procedures or high-risk patients, advanced haemodynamic monitoring is recommended to assist in the development of personalised fluid therapy regimens.

Pneumatic elastic socks can reduce the incidence of venous thrombosis, and their effect is comparable to that of heparin. Therefore, patients should wear well-fitting elastic socks with IPC after surgery. Intermittent pneumatic compression is recommended twice daily for approximately 30 minutes per session, continued for 5–7 days postoperatively. For patients undergoing laparotomy for abdominal or pelvic malignancies, prophylaxis should be extended to 28 days (23).

Postoperative patients should resume oral feeding as soon as possible because it can reduce the risk of infection and the incidence of postoperative complications and shorten the length of hospital stay, and it does not increase the incidence of anastomotic fistula (24). Patients can drink water immediately after surgery, and oral fluids and food should be started as early as possible on the day of surgery. intravenous (IV) fluids should be stopped within 24 hours after surgery, and a balanced crystalloid solution is superior to 0.9% normal saline. A regular diet is recommended within the first 24 hours after gynaecological/gynaecological tumour surgery.

Perioperative hyperglycaemia is associated with adverse clinical outcomes, including increased perioperative mortality, longer hospital stays, extended intensive care unit stays and higher rates of postoperative infections (25). Although most clinicians agree on interventions to prevent perioperative hyperglycaemia, the optimal scope of glycaemic control remains controversial due to the potential risk of iatrogenic hypoglycaemia. Therefore, stress and insulin resistance should be minimised postoperatively. Insulin should be administered when blood glucose exceeds the recommended target range of 6–10 mmol/L (108–180 mg/dL), and blood glucose should be routinely monitored to prevent hypoglycaemia (26).

The following are different viewpoints on glycaemic control and the evidence supporting them:

Tight glycaemic control (70–110 mg/dL): Some studies advocate for tight control, arguing that maintaining blood glucose within a narrow range (70–110 mg/dL) can significantly reduce postoperative infections and improve wound healing. For example, a meta-analysis of 15 studies involving 2,500 patients showed that tight glycaemic control reduced the risk of surgical site infections by 30% (27).

Moderate glycaemic control (110–180 mg/dL): Other researchers suggest that moderate glycaemic control (110–180 mg/dL) is more practical and safer, especially in high-risk patients such as those with diabetes or cardiovascular disease. A prospective cohort study involving 1,000 patients found that moderate glycaemic control was associated with a lower risk of hypoglycaemia and similar infection rates to those of tight control (28).

Liberal glycaemic control (<220 mg/dL): Some clinicians support a more liberal approach, aiming to keep blood glucose levels below 220 mg/dL. This is based on the premise that the risk of severe hypoglycaemia outweighs the potential benefits of tighter control. A randomised controlled trial involving 500 patients showed that liberal control did not significantly increase the risk of infections but reduced the incidence of hypoglycaemia (29).

Individualised approach: Given the conflicting evidence, many clinical guidelines now recommend an individualised approach to glycaemic control. For patients with diabetes or other comorbidities, moderate control (110–180 mg/dL) is often preferred to balance the risks of hyper- and hypoglycaemia (30).

Continuous glucose monitoring (CGM): The use of CGM systems is increasingly being adopted in clinical practice to provide real-time data and support more informed insulin management decisions (31).

Multidisciplinary team involvement: Involving a multidisciplinary team, including endocrinologists, surgeons and nurses, is crucial for optimising glycaemic control. Regular team discussions and shared decision-making help tailor the approach to each patient’s specific needs (32).

Pain is one of the main stress factors for patients after surgery, which can lead to delayed ambulation in the early postoperative period or delayed discharge, hinder postoperative rehabilitation and affect patients’ quality of life. Therefore, pain management is a key part of ERAS. The principles of preventive and multimodal analgesia should be adopted to reduce opioid use (33). Opioids should be administered orally for patients who can tolerate diet after surgery. For those who cannot tolerate oral intake, opioids may be administered via IV patient-controlled analgesia, which should be changed to oral administration as soon as gastrointestinal function is restored.

Based on research in procedures such as colon and rectal surgery, abdominal drainage is not recommended for routine use in gynaecological/gynaecological tumour surgery, including in patients undergoing lymphadenectomy or intestinal surgery (34). Catheters should be avoided or removed as early as possible after surgery, as they can affect the patient’s postoperative activity, increase infection risk and are independent prognostic factors for prolonged hospital stay. In the absence of special circumstances, the catheter can be removed within 1 to 2 days after surgery. Suprapubic bladder puncture drainage may be used for patients requiring catheter retention for more than 4 days, as it can reduce discomfort and lower the incidence of urinary tract infections (35).

Prolonged bed rest not only increases the risk of blood clots in lower limb veins but may also lead to adverse effects such as insulin resistance, muscle protein loss and impaired lung function. Early ambulation, within 1–3 days after surgery, is significantly associated with ERAS success. Therefore, patients should be actively encouraged to get out of bed on the first day after surgery and meet daily activity goals (36).