Enhanced recovery protocol in laparoscopic liver surgery

Abstract

Introduction: Enhanced recovery protocols (ERP) accelerate recovery and shorten postoperative hospital stay. This increased knowledge of ERPs has also gradually implemented into liver surgery. However, in laparoscopic liver surgery (LLS), the experience of optimized perioperative care protocols is still limited.

Methods: We prospectively studied the implementation of multimodal ERP principles to LLS in the first 100 consecutive patients. Opioid-sparing multimodal pain management was applied together with early mobilization already in the postoperative care unit (PACU). Drains and catheters were avoided and per oral intake was initiated promptly. Primary pain control was achieved with iv NSAIDS, low-dose opioid and corticosteroids. Combination of per oral ibuprofen and long-acting tramadol was routinely administered shortly after operation. The multiprofessional adherence to the protocol was also evaluated.

Results: Investigated LLS was performed during Aug 2016-Apr 2019. Operations were done due to malignancy in 83 (83%) of cases, mostly for colorectal liver metastases (n = 52, 52%). Forty-eight (48%) of the operated patients were female. Median age was 65 years (range 17-91). The American Society of Anaesthesiologists Physical Status (ASA) classification median was three. Median postoperative hospital stay was 2 days (range 1-8 days). More than seventy percent of patients were discharged by the second postoperative day and nearly ninety percent by the third postoperative day. Complications after surgery were few. The new ERP elements were adopted in most of the cases.

Conclusions: ERP was introduced safely and effectively after LLS. The adherence to the ERP was good. Routine discharge 1-2 days after LLS is realistic and achievable.

Keywords: Enhanced recovery; Laparoscopic liver surgery; Opioid-sparing pain management.

Fig. 1

Postoperative length of hospital stay is shown here. Eighty-eight (88%) patients were discharged by the 3rd postoperative day. Most of the patients were discharged at the 2nd postoperative day

Fig. 2

Pain level and pain medication sufficiency three days after discharge are presented here. The majority of the patients experienced moderate pain (A), which is common after abdominal surgery. However, most of the patients felt that their pain medication was at a sufficient level (B)

Fig. 3

Patient satisfaction 3 days after discharge is shown here. Most of the patients described their experience either as “Excellent” or “Good”