الفهرس 
Introduction & Aim of the workOnly 14 pages are availabe for public view
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Abstract
Several recent studies have identified many of the key patient and provider determinants of the underutilization of minimally invasive surgery (MIS) by gynecologic surgeons .
While both the American Congress of Obstetrics and Gynecology (ACOG) and the American Association of Gynecologic Laparoscopists (AAGL) recognize minimally invasive hysterectomy as the standard of care, the best approach to transforming this recommendation into practice remains unresolved. Implementation of standardized care pathways centered around MIS, such as Enhanced Recovery After Surgery (ERAS) pathways, may be one particularly effective solution. ERAS pathways are multidisciplinary, multimodal, and evidence-based care protocols that are improving perioperative outcomes across a wide spectrum of surgical fields. ).Specifically, the components of an ERAS pathway interact to minimize the neuroendocrine response to surgical insult (i.e. surgical stress response) which, in turn, translates into fewer postoperative complications, a decreased length of stay (LOS), and other adverse effects such as physical/cognitive decline. Various interdisciplinary care teams, including surgery, anesthesia, nursing, nutrition, pharmacy, and physical therapy, interface with the pathway making collaboration essential for success.
All surgeries, including MIS, are followed by a spectrum of impaired functional capacity and cognitive ability that extends beyond the immediate postoperative period. Enhanced recovery programs are principle-based, rather than ritual-based, perioperative care protocols designed to minimize surgical stress and its negative sequelae.
Over the past decade, ERAS programs for open abdomino-pelvic surgery have been formalized. Their core components include patient education, preoperative oral hydration and carbohydrate loading, multi-modal pain control, and goal-directed fluid therapy. Given that these interventions target the basic physiologic alterations that occur with elective surgery, their global impact is likely independent of surgical approach. However, a more nuanced understanding of the relative contributions of individual ERAS pathway components to recovery following open versus minimally invasive surgery is lacking. ERAS in major open abdomino-pelvic surgery has been shown to decrease complications, LOS, analgesic requirements, and cost of care .Whether similar or other gains are possible with ERAS following gynecologic MIS remains to be seen.
Certainly, the synthesis and standardization of a subspecialty-specific ERAmiS protocol must be the first step. Thereafter, work to-wards leveraging the protocol to improve MIS rates at the institutional level and beyond, to minimize postoperative opioid prescribing, and to proactively involve patients in managing their own recoveries, will follow. Institutions with a surgical enterprise committed to making value-based improvements in patient care that are driven by scientific method, such as ERAS and ERAmiS, should set the new standards for surgical care.
Blikkendaal et al. performed a meta-analysis of minimally invasive surgery (MIS) hysterectomy (laparoscopic, robotic, vaginal) versus open hysterectomy in patients with Class II or III obesity.
This meta-analysis included both randomized trials and observational studies. The authors found laparoscopic hysterectomy (including robotic) to be superior to open hysterectomy, with the latter demonstrating higher rates of wound dehiscence and wound infections and greater lengths of hospital admissions.
There has been 1 comparative study of laparoscopic hysterectomy versus vaginal hysterectomy for benign conditions in patients with at least Class I obesity (Bogani et al., 2015) .Although it was a non-randomized study, through a multivariable analysis, the authors found that laparoscopic hysterectomy was associated with shorter hospital stay and fewer complications than vaginal hysterectomy.
In a large study involving minimally invasive hysterectomy in the American College of Surgeons National Safety and Quality Improvement Project (NISQIP) registry, vaginal hysterectomy had the shortest operating times, but total laparoscopic hysterectomy (TLH) had less blood transfusion and less postoperative stay compared with vaginal hysterectomy, across BMI categories (i.e., including in patients with obesity). TLH was also associated with less blood transfusion compared with laparoscopic-assisted vaginal hysterectomy (LAVH). In women undergoing vaginal hysterectomy, operating time increased with increasing BMI, especially with enlarged uteri (>250 g).
This study had been conducted in the Obstetrics and Gynecology Department, Minia University Hospital during the period from July 2018 to June 2020.
Patients were classified into 3 groups ; first group includes patients undergoing laparoscopic hysterectomy were managed with enhanced recovery perioperative protocol ; second group includes patients undergoing abdominal hysterectomy managed with enhanced recovery perioperative protocol ; third group includes patients undergoing abdominal hysterectomy managed with conventional protocol .
Our findings revealed that ERAS protocol was associated with shorter length of hospital stay without any signs of increasing complications. Length of hospital stay was shorter in group 1 than in group 2 and this is statistically significant (p-value 0.001) , also it was shorter in group 2 than in group 3 and this is statistically significant (p-value 0.001).
In this study patients in group 1 had less postoperative pain than patients group 3 and this is statistically significant (p-value 0.001).
In current study only 6 patients in group 1 needed opioid; however 24 cases in group 3 needed opioid indicating that ERAmiS is associated with decreased pain despite reduced opioid use.