ERAS Protocol for Obstructive Ventral Hernia
Critical Distinction: Emergency vs. Elective Management
For obstructive ventral hernias requiring emergency surgery, prioritize immediate source control and sepsis management before implementing full ERAS protocols, with surgery limited to essential procedures until the patient is adequately resuscitated and stabilized. 1
The key difference is that obstructive hernias often present with bowel compromise, inflammation, and sepsis—conditions that fundamentally alter the risk-benefit calculation and require modified ERAS implementation compared to elective ventral hernia repair.
Preoperative Phase
Immediate Assessment and Optimization (Emergency Setting)
- Rapid physiological assessment focusing on signs of sepsis (fever, leukocytosis, hypotension), bowel viability, and hemodynamic stability must occur within the first hours of presentation 1
- Aggressive fluid resuscitation using goal-directed therapy with cardiac output monitoring to optimize hemodynamics while avoiding fluid overload 1
- Early antimicrobial prophylaxis administered within 60 minutes of decision for surgery, with broader spectrum coverage than elective cases given potential bowel contamination 1, 2
- Thromboprophylaxis with well-fitting compression stockings and low molecular weight heparin should be initiated immediately despite emergency status 1, 2
Nutritional Considerations
- Avoid preoperative fasting beyond what is necessary for emergency surgery; if time permits, clear fluids up to 2 hours before induction 1, 2
- Do NOT perform mechanical bowel preparation in the emergency setting as it worsens dehydration and electrolyte disturbances 1, 2
- Screen for malnutrition even in emergency cases, as severely malnourished patients may exhibit adynamic sepsis with impaired wound healing and should have surgery limited to source control only 1
Preoperative Counseling (When Feasible)
- Provide structured information about the procedure, expected complications (higher than elective repair), and recovery timeline, acknowledging the emergency nature limits optimization 2, 3
Intraoperative Phase
Surgical Approach
- Initial diagnostic laparoscopy can be considered if the patient is hemodynamically stable and there is surgical expertise, as it may reduce overall morbidity compared to open approach 1
- However, maintain a low threshold for conversion to open given the higher complexity of obstructed hernias with potential bowel compromise 1
- Limit the extent of surgery in severely compromised patients—perform only essential source control (bowel resection if non-viable, hernia reduction) and defer definitive hernia repair with complex reconstruction to a later staged procedure 1
Anesthetic Management
- Standardized anesthetic protocol using short-acting agents (remifentanil) to allow rapid awakening and assessment 1, 3
- Maintain normothermia (>36°C) using active warming devices and warmed IV fluids, as hypothermia increases perioperative complications 1
- Multimodal PONV prophylaxis for patients with ≥2 risk factors using combination therapy 1, 2
Fluid and Hemodynamic Management
- Goal-directed fluid therapy using esophageal Doppler or cardiac output monitoring to target optimal cardiac output while avoiding overhydration 1
- Judicious vasopressor use for arterial hypotension rather than excessive fluid administration 1
Specific Intraoperative Decisions
- Avoid routine nasogastric tube placement; if placed for decompression, remove before reversal of anesthesia 1, 2
- Avoid routine intra-abdominal drain placement unless there is specific indication (contamination, concern for anastomotic leak) 1, 2
- High inspired oxygen concentration (FiO2 0.8) during surgery and immediate postoperative period 1
Postoperative Phase
Pain Management
- Multimodal analgesia combining regional techniques (thoracic epidural T7-10 for open cases), acetaminophen, and NSAIDs to minimize opioid requirements 1, 2, 3
- Recognize that adequate pain control is essential but opioid minimization reduces postoperative ileus 1, 2
Early Recovery Interventions
- Early mobilization with patients out of bed within 24 hours after surgery, targeting at least 6 hours per day of activity 2, 4, 3
- Early oral feeding initiated within 24 hours after surgery once bowel sounds present and patient tolerates clear liquids 1, 2, 4
- Early urinary catheter removal within 1-2 days postoperatively, even with epidural analgesia 1, 2, 3
Acceleration of Intestinal Recovery
- Alvimopan (if not on chronic opioids preoperatively) provides the greatest reduction in length of stay (36% decrease) and should be strongly considered 5
- This element has the highest impact on reducing hospital stay among all ERAS components for ventral hernia repair 5
Monitoring and Complications
- High-level postoperative monitoring is warranted given the emergency nature and higher complication risk 1
- Monitor for signs of ongoing sepsis, anastomotic leak (if bowel resection performed), wound complications, and respiratory compromise 1
- Transcutaneous oxygen saturation monitoring during the first 3 postoperative days helps identify respiratory complications early 6
Special Considerations for Obstructive Ventral Hernias
Risk Stratification
Patients with obstructive ventral hernias have significantly higher risk profiles than elective cases:
- CDC Wound Class III/IV (contaminated/infected) increases length of stay by 38% 5
- COPD increases length of stay by 35% 5
- Prior infected mesh increases length of stay by 21% 5
- Concomitant procedures (bowel resection) increase length of stay by 14% 5
Staged Approach
- For severely compromised patients with sepsis, perform only source control (bowel resection, hernia reduction without repair) and plan definitive hernia reconstruction at 7-10 days or longer once sepsis is adequately treated 1
- Avoid risky anastomoses and extensive dissections in the acute septic phase 1
Expected Outcomes
- Length of stay will be longer than elective ERAS protocols (which achieve 3-5 days) due to the emergency nature and complications 6, 7, 5
- Complication rates are higher than elective repair, but ERAS implementation still reduces complications by 29% compared to standard care 1
- Readmission rates are not increased with ERAS protocols 1
Implementation Priorities
Highest Impact Elements (Based on Evidence)
- Acceleration of intestinal recovery (alvimopan if eligible) - 36% reduction in length of stay 5
- Early mobilization - significant reduction in length of stay 5
- Multimodal pain management - significant reduction in length of stay 5
- Goal-directed fluid therapy - reduces complications 1
- Early oral feeding - promotes return of bowel function 1, 2
Common Pitfalls to Avoid
- Do not delay surgery >3 months in elective cases, but in obstructive hernias, do not rush to definitive repair if the patient is septic 1
- Do not perform mechanical bowel preparation even if planning bowel resection 1, 2
- Do not routinely place nasogastric tubes or drains unless specifically indicated 1, 2
- Do not use long-acting benzodiazepines for premedication, especially in elderly patients 1
- Do not perform complex hernia reconstruction in the setting of active sepsis or bowel compromise 1