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Page 8 of 18 Tebala et al. Mini-invasive Surg 2018;2:32 I http://dx.doi.org/10.20517/2574-1225.2018.37

laparoscopic surgery of the pelvis - much more than in open surgery - to allow a complete distension of the
[23]
abdomen without contrasting the CO insufflation and to facilitate the pelvic dissection .
2
Prevention of hypothermia
It is well known that hypothermia is one of the killers of the surgical and trauma patient, also due to its
negative effect on coagulation. It has been demonstrated, and is considered best practice, that prevention
of hypothermia through the administration of warm fluids and the use of a thermic blanket can reduce
bleeding, surgical site infection and cardiac complications.

Hypothermia can also be detrimental in terms of prolonging the admission and delaying oral feeding, but
[58]
its direct relation with postoperative ileus has not been proved . It has been suggested to monitor body
[18]
temperature during and after surgery .
Surgical technique
The ERAS being mostly a perioperative policy, the surgical technique is pretty much unchanged with re-
spect to the traditional protocols. However, if we want to get the whole range of benefits of ERAS, it is clear
that the surgical technique must be as less invasive as possible. Therefore, the higher benefits of ERAS can
[2,5]
be obtained in patients operated by laparoscopy . Although pelvic dissection is always traumatic, in par-
ticular when coupled with perineal dissection, the laparoscopic approach associated with ERAS would re-
[18]
duce postoperative ileus and overall physiologic recovery . Numerous and strong evidence [59,60] confirmed
that laparoscopic surgery for rectal cancer is feasible, safe and effective and adds the benefits of the mini-
invasive approach to the care of patients with rectal malignancies. The combination of laparoscopic surgery
with the ERAS approach improves the already outstanding results of each of the two taken singularly;
therefore we strongly believe that laparoscopic surgery must be considered one of the core items of ERAS
also in pelvic benign and malignant conditions.

Use of drains
If one of the principles of the surgical technique under an ERAS protocol is to be respectful of the par-
ticular pathophysiology of the patient, it necessarily follows that all those items that can delay his or her
recovery should be avoided. The presence of one or more drains in the pelvis can impair the patient’s early
mobilization, without reducing the incidence or the severity of anastomotic leaks [61,62] . A large retrospec-
tive study from Holland and a meta-analysis from Italy showed that in patients who had total mesorectal
excision the use of drain can be beneficial [63,64] , but this finding was not confirmed by the GRECCAR 5
[65]
randomized controlled trial .

Nasogastric tube
The traditional use of a nasogastric (NG) tube to prevent postoperative vomiting and gastric distension has
been demonstrated to be detrimental to an expedited recovery as it may be one of the causes of respiratory
complications. A Cochrane meta-analysis demonstrated that bowel motility recovers quickly without a NG
[66]
tube, with no increased risk of inhalation . NG tubes should be reserved to those patients who develop
[23]
postoperative ileus .
Bladder catheter
The use of a bladder catheter (either transurethral or suprapubic) has been part of the traditional periop-
erative management for decades, as it allows to monitor the urinary output and to deflate the bladder to
improve the visualization of the pelvis, either by open or laparoscopic surgery. Moreover, it can be useful if
the patient is not yet fully mobile. In rectal surgery, bladder catheter is standard practice due to the risk of
urinary function impairment. However, there is no evident advantage in maintaining the catheter beyond