Patient education and counseling should include information to enlighten the patient about the operation and the recovery process. Components of effective patient education should be informed consent forms, including online models, and patient interviews with the surgical team. Although its benefit is not much in the studies, certainly, the consultancy service does not cause any harm; for this reason, pre-surgery patient education and counseling are recommended [10].

Pre-operative health optimization includes medical comorbidities such as anemia and hyperglycemia. In addition, tobacco and alcohol use should be routinely evaluated before surgery. Population studies have shown that; 25% of women have anemia before elective hysterectomy or myomectomy [11, 12, 13]. Anemia is a factor associated with the high probability of blood transfusion during surgery and clinical adverse outcomes [12]. In a study on gynecological surgery, it was reported that anemia was associated with one-month mortality and morbidity [14]. Blood transfusion did not appear to improve these risks. Women with pre-operative hemoglobin (Hgb) level 12 g/dL are more likely to be subjected to perioperative blood transfusions and their hospitalization time is also prolonged [15]. There are three goals in patient blood management, to keep the patient’s pre-operative Hgb value of 12 and above, to reduce the amount of bleeding during surgery, and to be able to apply it correctly when blood transfusion is required [16]. Blood transfusion should be planned when the perioperative Hgb level falls below 7 [17]. Oral iron should be preferred over pre-operative blood transfusion [12]. There is evidence that interventions addressing these factors before elective surgery reduce perioperative morbidity and mortality [9].

Smoking and alcohol use are common lifestyle risk factors that can affect the outcome of the surgery, and they affect human physiology in different ways. Smoking mostly affects lung function, cardiovascular system, immune response, and tissue healing [18]. Alcohol negatively affects the liver, pancreas, and nervous system, heart function, immune capacity, hemostasis, metabolic stress response [19]. Smoking and alcohol are associated with increased postoperative morbidity and should be stopped at least four weeks before the procedure.

Surgery is metabolic stress and therefore causes peripheral insulin resistance, resulting in hyperglycemia and postoperative complications, and prolonged recovery time [20]. In studies conducted in the light of this information, it has been shown that postoperative insulin resistance is reduced by half as a result of pre-operative carbohydrate loading sufficient for rapid insulin response [21]. Compared with fasting before the operation, it has been shown that patients who received carbohydrates were discharged earlier [21]. Oral carbohydrate loading reduces postoperative insulin resistance, improves preoperative health, and is routinely recommended [22].

ERAS protocols for gynecological surgery allow up to 2 hours of clear fluids and up to 6 hours of solids before induction of anesthesia, and carbohydrate loading is recommended [23]. Mechanical bowel preparation is not routinely recommended, even when bowel resection is planned; because mechanical bowel preparation can often cause dehydration and there is insufficient evidence that it will benefit the patient [24]. Studies have shown that the liquid taken up to 2 hours before surgery does not decrease the pH of gastric fluid, does not increase complications, and does not increase stomach content [25].

Routine sedatives should be avoided to reduce preoperative anxiety to speed up postoperative recovery [26]. Between the medications used in elective surgeries to be performed with general anesthesia and placebo, it has been shown that the postoperative experience of the patient does not improve and the duration of anesthesia is increased with these medications [27].

Patients at risk of venous thromboembolism (VTE) should receive prophylaxis with low-molecular-weight heparin (LMWH) or heparin initiated before surgery in combination with mechanical methods. Patients should discontinue oral contraception and switch to another form before surgery. Because in women using combined oral contraceptives thrombotic coagulation factor changes, it continues until 4–6 weeks after cessation of treatment [9, 26]. Therefore, it is recommended that the oral contraceptive method should be discontinued one month before the surgery, but this situation should be evaluated carefully with the possibility of unwanted pregnancy [26].

Most pelvic surgeries include operations that belong to the clean-contaminated wound class. In gynecology, pathogens in surgical site infections often include skin flora, vaginal flora, or enteric bacteria. Intravenous antibiotics (1st generation cephalosporin or amoxicillin-clavulanic acid) should be routinely administered within 60 minutes before skin incision [9]; additional doses should be given in case of prolonged operations, severe blood loss, and during the operation of obese patients [28]. For patients with penicillin/cephalosporin allergy, a combination of clindamycin and gentamicin or quinolone can be used [26]. Laparoscopic operations that are not contaminated with genitourinary or digestive tracts do not require antimicrobial prophylaxis. Before surgery, skin preparation is traditionally done with a shower, epilation, or skin antiseptic solution. However, there is no clear evidence that epilation reduces wound infection, regardless of the method chosen (shaving, haircutting, or depilatory cream) [28]. For this reason, epilation should be avoided and if necessary, a haircut is preferred. For skin cleansing, chlorhexidine-alcohol should be preferred over aqueous povidone-iodine solution [29].

Short-acting anesthetic agents are preferable during surgery to ensure rapid reanimation [9]. With the addition of regional anesthesia to general anesthesia, postoperative nausea and vomiting are reduced and a faster awakening is provided. Since tidal volume (TV) can cause ventilator-induced lung damage, no systematic advice can be provided, therefore no comment will be made on this issue [8].

Although minimally invasive surgery is an important factor in reducing hospital stay and accelerating patient recovery on its own, it is not seen as an integral part of ERAS. In the ERAS protocol, it is recommended that efforts be made to minimize surgical trauma by using the smallest incision possible, making a transverse incision instead of the sub-umbilical median [9].

While planning the operation within the scope of ERAS, the surgical team should pay attention to choosing the least invasive surgical method, determining the necessity and duration of bladder catheterization, avoiding nasogastric tubes, and minimizing the use of other drainage tubes [8, 30].

Anesthesia models performed with the ERAS protocol also aim to maintain normothermia and perioperative euvolemia. Intraoperative hypothermia prolongs the recovery time after anesthesia. Maintaining normothermia can shorten the time in the post-anesthesia care unit and lower maintenance costs [31].

While the idea of ​​replacing the losses in the body due to reduced urine output and unnoticeable sweating has traditionally been adopted, new studies have shown that these losses are not as high as thought [32]. Excess fluid therapy has also been shown to increase intravascular pressure and increase the atrial natriuretic peptide and cause deterioration in the vascular endothelium [33]. Consequently, the purpose of intraoperative fluid balance should be to maintain body weight before surgery, and fluid therapy with zero balance should be applied to ensure euvolemia [34].

Patients should be encouraged to mobilize within 24 hours of surgery.

Recommendations for postoperative venous thromboembolism prophylaxis are for patients to wear appropriate pressure stockings and apply intermittent pneumatic compression. Expanded prophylaxis for patients after laparotomy for abdominal or pelvic malignancies, that is, should be arranged as 28 days [35].

Intravenous fluids should be stopped within 24 hours after surgery and balanced crystalloid solutions should be preferred [35].

A standard diet is recommended within the first 24 hours after surgery.

With the use of postoperative laxatives and chewing gum, rapid recovery of the intestines can be achieved [35]. In addition, by keeping blood glucose levels between 180–200 mg/dL before, during, and after the operation to reduce insulin resistance, metabolic stress can be reduced, and ultimately perioperative results can be improved [35].

A multimodal analgesia strategy should be applied to reduce the need for opioids after surgery and to cope with pain. Post-operatively, opioids should be given orally to patients as soon as possible [35]. Postoperative nausea and vomiting (PONV) is a common problem that delays recovery and prolongs hospital stay [36]. Women who have undergone laparoscopic and gynecological surgery, It has a high risk of PONV, especially in long-term operations [36]. As a pain reliever, acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) in combination or dexamethasone can be applied to all patients as long as there are no contraindications to reduce postoperative nausea and vomiting [35].

Urine catheters should be removed as soon as possible postoperatively and within a maximum of 24 hours. Patients should be encouraged to act within 24 hours after surgery [35].

Peritoneal drainage has traditionally been used to prevent fluid accumulation in the dissection bed, reduce blood, serous collections, or the rate of infection [35]. It has also been thought to be effective in preventing anastomotic leakage in colorectal surgery [37]. However, drainage is not routinely recommended after colon and rectal surgery [38, 39]. In the field of gynecology, there is very little data on drains and anastomotic leaks [40]. It is not very appropriate to comment on the data obtained from colorectal surgery in gynecological surgery [35]. In a Cochrane systematic review four studies with 571 participants were included [41]. Lymphocysts of drains after pelvic lymphadenectomy has been shown to inhibit [41]. Drains have even been associated with higher cyst rates after pelvic lymphadenectomy [41]. There are few studies on para-aortic lymphadenectomy, but no evidence to suggest drainage [42].