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Enhanced Recovery After Surgery (ERAS®)

What is ERAS^®?

ERAS^® stands for Enhanced Recovery After Surgery.

Implemented in Singapore at Tan Tock Seng Hospital in 2016, ERAS^® is a surgical care program that improves recovery through an evidence-based, multidisciplinary approach.

ERAS^® aims to reduce stress on the body from surgery and to maintain reserves. This is done through strategies before, during and after surgery.

ERAS^® Goals

ERAS^® guidelines are in place to standardise care to achieve better outcomes.

Aims of ERAS for patients


Faster functional recovery	Decrease post-surgical complications	Decrease hospital length of stay	Decrease in readmission rates

TTSH programme helps speed up post-op recovery. Read more.

New system offers better outcomes after surgery. Read more.

Key ERAS^® Strategies

Immediately after surgery, patient’s function declines. Hence with the ERAS^® strategies introduced, physiological reserves prior to surgery are increased by measures such as nutrition and exercise. The impact of surgery is also mitigated.

ERAS^® interventions during patient's perioperative journey include:

Step 1: Before Surgery
Step 2: During Surgery
Step 3: After Surgery

Before Surgery

1.Before.jpg

Empowerment of patient through education
Pre-operative optimisation of medical conditions, nutrition and muscle strength

During Surgery After Surgery

ERAS^® Patient’s Journey

The journey begins when surgery has been decided at the clinic. The team provides support through education, allaying anxiety and encouraging patients in proactively preparing for surgery.

Workflow for patients under the TTSH ERAS® Programme

1. Listing for Surgery

Identification for ERAS^® programme
Screening Questionnaire for further dietician and Physiotherapist evaluation
Selective prescription of bowel preparation
Prescription of immuno-nutrition and carbohydrate loading

2. Prior to Surgery

Pre-operative ERAS^® Nurse consultation
Dietician and Physiotherapist consultation for selected individuals

3. Day of Surgery

Minimal invasive surgical
techniques where applicable
Use of patient warming devices and warm intra veneous fluids to prevent hyphothermia
Balanced intravenous fluid regime to maintain optimum hydration
Analgesia strategies involving multiple modalities to minimise opiods. This may include injections of local anaesthetics, oral and intravenous medications

4. After Surgery

Resumption of oral intake as soon as possible
Early mobilisation progressively from sitting out of bed to walking
Provision of a supportive and encouraging environment for optimal recovery

5. After Discharge

Follow-up with patient through telephone and clinic visit
Obtain patient-reported outcomes and experience

Preparation Before Surgery

Patients play an important role in preparing before surgery.

Lifestyle Modifications

Stop smoking and alcohol consumption
Smoking and alcohol consumption can increase the risk of post-operative complications.
Stop smoking and alcohol intake at least two weeks before your surgery.
Well-balanced diet
Your body needs to be in optimal condition to recover from a major surgery.
You may be prescribed supplemental nutrition drinks by your doctor to be taken several days leading up to your surgey.
Maintain Active Lifestyle
Condition your body by exercising regularly. If you are not doing so, start by introducing simple exercises into your daily routine.
Simple exercises like a 30 minute walk is better than being physically inactive. Staying fit helps your body recover faster from the stress of surgery.

Deep Breathing Exercises with Spirometer

Sometimes, patients may be prescribed with a simple breathing exercise tool called the Incentive Spirometer (image, right). Use it when performing deep breathing exercises.

Sit upright in bed or on a chair
Hold the Incentive Spirometer in an upright position.

Breathe out normally, then do the following:

Put the mouthpiece in your mouth and close your lips tightly around it.
Inhale slowly through your mouth as deeply as you can. The yellow piston will rise inside the large column on the left.
As the piston rises, the indicator on the right should move upwards.
Aim to keep this indicator within the “smiley face” for up to three seconds.
Breathe out gradually.

The ERAS^® Team

Collaboration among the multiple disciplines working towards the common goal of patient-centred care is essential in ERAS^®. This is vastly different from conventional care carried out by segregated groups in the past.

The ERAS^® team includes committed staff from the departments of Anaesthesia, Dietetics, Nursing, Operations, Physiotherapy and Surgery working together to see you through the entire journey.

The ERAS® Journey

In 2016, ERAS^® was piloted for Colorectal Surgery patients and the outcomes of the study showed positive results. This led to 2018 ERAS^® principles being adopted by Pancreatic Surgery and Upper GI and in 2019, by Breast Reconstruction, Head and Neck Surgery as well as for Total Knee Replacement.