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This paper summarizes debates from the 2025 ERAS World Congress regarding implementation of ERAS protocols in gynecologic surgery. Key topics included targeted glycemic control screening (HbA1c), regional analgesia (TAP blocks vs. wound infiltration), VTE prophylaxis for laparotomy of adnexal masses, and normothermia protocols. The debates emphasized refining and implementing existing evidence, and individualizing ERAS protocols based on patient and resource variability.
Individualized standardization of ERAS protocols, adapting to patient and resource variability, remains the cornerstone of enhanced recovery progress in gynecologic surgery.
INTRODUCTION The Enhanced Recovery After Surgery pathway has transformed peri-operative care in gynecologic surgery through multi-disciplinary, evidence-based protocols. However, real-world adherence to and interpretation of specific Enhanced Recovery After Surgery elements remain heterogeneous, with ongoing discussion about their feasibility and clinical relevance. During the 2025 Enhanced Recovery After Surgery World Congress in Turin, Italy, a rapid-fire debate session addressed 4 "hot topics" in gynecologic Enhanced Recovery After Surgery implementation. GLYCEMIC CONTROL Peri-operative dysglycemia is associated with worse surgical outcomes, although the evidence favors a targeted rather than universal screening strategy. Universal hemoglobin A1c testing was considered impractical, with screening recommended for patients with diabetes, obesity, or cardiovascular disease to balance safety and oncologic timeliness. REGIONAL ANALGESIA Although transversus abdominis plane blocks reduce opioid use and prolong analgesia, multi-layer wound infiltration remains a pragmatic and cost-effective alternative, especially in low-resource settings where expertise or ultrasound guidance is limited. VENOUS THROMBOEMBOLISM PROPHYLAXIS In light of the overall risk profile and low bleeding rates, many patients undergoing laparotomy for adnexal masses are likely to benefit from pharmacologic prophylaxis. Development of gynecology-specific risk models remains an unmet research priority. NORMOTHERMIA Structured multi-disciplinary warming bundles can significantly reduce peri-operative hypothermia, but implementation must remain flexible to accommodate different institutional resources and thresholds. CONCLUSIONS The 2025 Enhanced Recovery After Surgery World Congress debates reinforced that the evolution of Enhanced Recovery After Surgery in gynecologic surgery depends less on discovering new interventions than on refining, validating, and implementing existing evidence. Individualized standardization-adapting Enhanced Recovery After Surgery principles to patient and resource variability-remains the cornerstone of enhanced recovery progress.
