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Kumar et al. Mini-invasive Surg 2018;2:41 I http://dx.doi.org/10.20517/2574-1225.2018.49 Page 9 of 12

CONCLUSION
ERAS programs represent a standardized and evidence-based multimodal perioperative pathway founded
on a series of measures aiming to attenuate the physical and psychological stress responses to surgical in-
sults, potentiating postoperative rehabilitation of patients. Increasing evidence demonstrates that the appli-
cation of ERAS in the field of liver surgery leads to an improvement in LOS, morbidity, patient satisfaction
and a trend towards less hospital costs compared to traditional care. These benefits are leading to an in-
crease adoption of various elements of ERAS protocols as part of modern surgical practice in liver surgery
referral centers worldwide, including our institute [Figure 1]. Core elements of this multidisciplinary effort
include adequate pre-operative patient education and counselling, shortened preoperative fasting with
carbohydrate loading, judicious use of pre-anesthetic medication, prophylaxis against venous thromboem-
bolism, targeted antimicrobial prophylaxis and early withdrawal, preventing and treating of PONV, mini-
mally invasive approach, avoidance of postoperative nasogastric decompression, preventing hypothermia,
optimal perioperative fluid management, selective use of abdominal drains, early urinary catheter removal,
optimal pain control, early oral feeding and mobilization. Given the strong evidence suggesting that strict
adherence to ERAS protocols is paramount for their successful implementation, continuous local audit
[2,5]
of compliance has also become a key element of the approach . Even though there is a growing body of
evidence in favor of ERAS application in liver surgery, further studies are required to determine the most
effective ERAS protocol for this particular field.

DECLARATION
Authors’ contributions
Contributed significantly to the work, read the manuscript, attest to the validity and legitimacy of the data
and its interpretation: Kumar N
Contributed significantly to the work, read the manuscript, revised the manuscript, attest to the validity
and legitimacy of the data and its interpretation: Jha SK
Conceptualised the review, contributed significantly to the work, read the manuscript, attest to the validity
and legitimacy of the data and its interpretation: Negi SS

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2018.

REFERENCES
1. Kehlet H. Manipulation of the metabolic response in clinical practice. World J Surg 2000;24:690-5.
2. Page AJ, Ejaz A, Spolverato G, Zavadsky T, Grant MC, et al. Enhanced recovery after surgery protocols for open hepatectomy--physiol-