Abstract
Enhanced Recovery After Surgery (ERAS) pathways are frequently introduced as collections of individual tasks, yet their clinical value depends on whether those tasks form a reliable perioperative sequence. This focused therapeutic and implementation review examined evidence relevant to adult benign and oncologic gynecologic surgery, emphasizing patient readiness, preservation of physiology during surgery, early functional recovery, and protocol fidelity. The most recent ERAS Society guidance maintains a multimodal pathway model, while comparative evidence consistently associates ERAS care with shorter hospitalization and no penalty in readmission or major morbidity. In a 2023 meta-analysis of 40 studies and 7,885 patients, ERAS reduced length of stay by 1.22 days (95% CI, 0.86–1.59 days), reduced readmission odds by 20%, and reduced ileus by 47%. A gynecologic oncology meta-analysis reported a 1.6-day reduction in length of stay, lower complications (OR 0.68), and lower readmission (OR 0.80). However, benefit is not attributable to indiscriminate acceleration: randomized evidence shows that multimodal analgesia can reduce opioid exposure and hasten ambulation without necessarily improving a global recovery score. The strongest practical model therefore links correction of anemia and modifiable risk, avoidance of unnecessary fasting and bowel preparation, minimally invasive access when appropriate, normothermia and euvolemia, opioid-sparing analgesia, early nutrition and mobilization, risk-adjusted thromboprophylaxis, and continuous audit. The clinical target is a stable return of function rather than discharge at the earliest possible clock time.