ERAS protocols in abdominoplasty

What ERAS means

Enhanced Recovery After Surgery (ERAS) is a multimodal perioperative protocol developed initially for colorectal surgery and now adapted across surgical disciplines. Its core principle: evidence-based optimisation at every perioperative step rather than reliance on traditional habits. Adapted for abdominoplasty over the last several years, ERAS protocols produce faster recovery, reduced complications, lower opioid consumption, and shorter length of stay.

The three phases of ERAS

Phase 1 — Pre-operative optimisation

Patient education and expectations

• Detailed pre-operative consultation explaining the procedure, recovery timeline, what to expect at each stage.
• Patient takes active role in their own preparation and recovery.
• Setting realistic expectations reduces post-op anxiety and pain perception.

Pre-habilitation

• Smoking cessation — 4-6 weeks minimum, ideally 8-12 weeks.
• Nutritional optimisation — adequate protein intake, vitamin D supplementation if deficient, iron correction if anaemic.
• Weight stability — particularly important in post-bariatric patients.
• Exercise capacity — pre-operative cardiopulmonary fitness predicts recovery quality.

Carbohydrate loading

• Replaces traditional "nothing after midnight" with a metabolically optimised pre-op state.
• Clear sugar drink 2-3 hours before surgery.
• Reduces post-operative insulin resistance, nausea, and catabolic stress.

Avoiding prolonged fasting

• Solids cleared 6-8 hours pre-op (vs 12+ hours traditionally).
• Clear liquids permitted up to 2 hours pre-op.
• Less metabolic disruption and better patient experience.

Pre-emptive analgesia

• Pain medication started before pain begins — typically paracetamol + an NSAID 1 hour pre-op.
• Anxiolytic preparation as needed (modest dose, not heavy sedation).

Phase 2 — Intra-operative optimisation

Multimodal analgesia

• Paracetamol IV intra-operatively.
• NSAID (ketorolac, diclofenac) when not contraindicated.
• Regional blocks — TAP block primarily.
• Opioid as the smallest necessary dose, not the primary analgesic.

TAP block (transversus abdominis plane)

• Local anaesthetic injected under ultrasound guidance in the plane between internal oblique and transversus abdominis muscles.
• Bilateral injection covers most of the abdominal wall sensory innervation.
• Single-shot provides 12-18 hours of significant pain relief.
• Catheter-based for prolonged blockade in complex cases.
• Outcome: 50-70% reduction in post-operative opioid requirements.

Goal-directed fluid therapy

• Appropriate fluids without over-resuscitation that swells tissues and prolongs recovery.
• Cardiac output / stroke volume monitoring in higher-risk patients.
• Most uncomplicated abdominoplasty patients require modest crystalloid maintenance.

Active warming

• Forced-air warming throughout the procedure prevents hypothermia.
• Hypothermia delays recovery, impairs coagulation, and worsens immune function.

Antiemetic prophylaxis

• Multimodal — typically combination of dexamethasone, ondansetron, and droperidol.
• Major recovery accelerator — post-operative nausea and vomiting is one of the largest barriers to early ambulation and oral intake.

Surgical technique adaptations

• Minimally traumatic dissection.
• Careful haemostasis (less bleeding = less inflammation).
• Modern closure techniques (PTS, drainless when appropriate).

Phase 3 — Post-operative optimisation

Early ambulation

• First walk within 4-6 hours of surgery (with assistance, briefly, but ambulation begins).
• Reduces VTE risk, accelerates bowel function recovery, improves pulmonary function.
• Expectation set pre-operatively that early walking is part of recovery, not optional.

Multimodal pain management continues

• Scheduled paracetamol + NSAID every 6-8 hours for first 7-10 days.
• Opioid as rescue only — typically used Day 1-3, then tapered.
• Most ERAS abdominoplasty patients use under 10-15 doses of opioid total (vs 30-50+ in traditional protocols).

Early oral intake

• Water within hours of surgery, light food the same evening as tolerated.
• Standard diet typically resumed Day 1.
• Reduces ileus risk, accelerates return to normal function.

Reduced opioid use

• Multimodal pain management substantially reduces opioid requirements.
• Less opioid means less nausea, less constipation, less sedation, less urinary retention.
• Lower opioid use also reduces risk of post-operative opioid dependence.

Active early VTE prophylaxis

• Sequential compression devices in recovery.
• Enoxaparin 6-12 hours post-op when chemical prophylaxis indicated.
• Early ambulation as primary mechanical prophylaxis.

Discharge criteria-based

• Discharge based on functional criteria (eating, drinking, walking, pain controlled, no concerns) rather than fixed time.
• Many ERAS abdominoplasty patients home in 1 night vs 2 traditionally.

Outcomes — what the evidence shows

What this means for the patient

An ERAS-aligned abdominoplasty experience is meaningfully different from traditional. Pre-operatively: clear expectations, smoking cessation verification, carbohydrate drink 2-3 hours before surgery, paracetamol and NSAID an hour before. Intra-operatively: TAP block plus multimodal analgesia, active warming, structured antiemetic prophylaxis. Post-operatively: walking within 4-6 hours, water and light food the evening of surgery, off the strong opioid by Day 3-4, home in 1 night.

Patients should ask whether their planned procedure follows ERAS principles. A surgeon and anaesthesia team familiar with the protocol can describe their approach in terms of the specific components above. Generic answers ("we use modern techniques") without component specifics suggest the protocol is not formally implemented.

Frequently asked questions