Although there are institutional differences, the core of ERP remains the use of multimodal approach to reduce surgical stress, organ dysfunction, and postoperative morbidity. ERPs can be broken down into preoperative, intraoperative, and postoperative goals of care (Table 21.1). A key component of the preoperative phase is selection of patients. Those patients who are well nourished, relatively healthy, assigned ASA class 1 or 2 may benefit the most, although ERPs have been applied across the spectrum of patients and procedure complexity. More important than patient selection is the education of the individual regarding the treatment plan and postoperative expectations. Certainly, early mobilization and enteral nutrition goes against the traditional expectations of recovery from surgery. Providers and hospitals often also have a more conservative view of optimal postoperative care. In order for an ERP to be successful, it requires full “buy in” from the entire treatment team, including dieticians, nurses, surgeons, anesthesiologists, and other ancillary providers as well as hospital leadership. The other major elements of ERP are minimizing IV fluids, minimizing narcotics use, early removal of drains and tubes, early mobilization, and early enteral nutrition. Since its introduction in the mid-1990s by Kehlet, there have been multiple randomized control studies in colorectal patients reporting shorter lengths of stay, faster return of bowel function, and decrease in complication rates for ERPs compared to traditional perioperative care. A recent meta-analysis of 14 randomized controlled trials of colorectal operations showed that ERP shortened hospital stay (−2.28 days [95 % CI −3.09 to −1.47]), without increasing readmission rate. Additionally, ERPs were associated with a reduction in overall morbidity [relative ratio (RR) = 0.60, (95 % CI 0.46–0.76)], particularly with respect to nonsurgical complications, i.e., respiratory and cardiovascular complications [RR = 0.40, (95 % CI 0.27–0.61)] [2].

In a similar vein, since the early 1990s laparoscopy has been widely recognized to be associated with less pain, shorter postoperative ileus, improved pulmonary function, and shorter length of stay. Compared to other procedures, adoption was relatively slow for colorectal surgery due to oncologic concerns and issues associated with the learning curve such as bowel injury, conversion to open surgery, and longer operative times. Although the oncologic concerns have been put to rest, uptake of laparoscopic colectomy remains relatively low, with wide geographic variability. Similar to ERPs, systematic reviews and population datasets conclude that laparoscopy is associated with decreases length of stay, pain, ileus and overall complications compared to open surgery.

Since both laparoscopy and ERPs are associated with less surgical stress, better postoperative pain profiles, less postoperative ileus, and shorter length of stay, some practitioners advocated for the integration of laparoscopic colon resections within an enhanced recovery program. The benefits of this approach were not obvious to all. Some suggested that since laparoscopic colon resection already decreased postoperative pain and length of stay, the addition of an ERP would incur additional cost and complexity without significant return. Over the past decade, several randomized controlled trials have investigated the impact of the combination of an ERP with laparoscopy in colorectal surgeries.

In 2005, Basse et al. reported a small trial in Denmark comparing laparoscopic and open colectomies [3]. There were 30 patients in each arm undergoing either sigmoid colectomy or right colectomy for cancer or benign disease. A well-defined multimodal rehabilitation program was followed that included continuous epidural analgesia for 48 h, early oral feeding including protein drinks, active mobilization, and planned discharge on the second postoperative day. The type of surgery was blinded to the patient, the ward nurses, and the observer from the research team with use of a large opaque abdominal dressing. The dressing was not removed until a decision about discharge had been taken. The characteristics of the patients were comparable. However, the duration of surgery was significantly longer in the laparoscopic group: median 215 min versus 131 min. The measured outcomes included LOS, complications, postoperative fatigue and pain, reoperation, readmission, and some physiological measurements like pulmonary function tests and CRP. The trial showed no differences in any of the measured outcomes. The study asserted that with appropriate blinding and strict adherence to ERP, there appears no additional benefit to laparoscopy. They concluded, “Functional recovery of a large variety of organ functions is fast but similar between laparoscopic and open procedures” [3].