Enhanced Recovery After Surgery Program in a Low and Middle-income Country: Feasibility, Safety, Patient's Acceptance, Reduction of the Length of Hospital Stay, Bed Turnover and Cost Benefits for Laparoscopic Cholecystectomy at CHUK
Phase: NA
Conditions: ERAS, Gall Bladder Disease
Sponsor: Olivier Detry MD PhD

 
1
 
 
 
RESEARCH PROTOCOL 
 
ID: EC/CHUK/074/2021 
 
 
 
 
 
 
 
 
 
 
Enhanced recovery after surgery program in a low and 
middle-income country: 
 
Feasibility, safety, patient’s acceptance, reduction of the 
length of hospital stay, bed turnover and cost benefits for 
laparoscopic cholecystectomy at CHUK  
 
 
 
 
By  
 
NYUNDO Martin. MD 
 
Clinical Associate Professor of Surgery  
Senior Consultant General Surgeon 
 
 
 
 
 
 
 

 
2
June 2021 
 
 
Research proposal 
 
Title: Enhanced recovery after surgery program in a low and middle-income 
country: Feasibility, safety, patient’s acceptance, reduction of the length of hospital 
stay, bed turnover and cost benefits for laparoscopic cholecystectomy at CHUK 
This research proposal concerns a research project on minimally invasive surgery as 
new surgical techniques in Rwanda, which will include different studies to conclude 
into a PhD project in clinical research and public health at the college of medicine and 
Health Sciences. 
This project is part of a laparoscopic surgery program in the Rwandan referral and 
teaching hospitals to improve the recovery of the patients after surgery especially after 
laparoscopic cholecystectomy, which will lead to a reduction of hospital of stay and a 
good bed turnover in surgical department. 
1. Principal Investigator: Martin Nyundo, MD, MMed, FCS (Ecsa) 
 
Clinical Associate Professor of Surgery 
Senior Consultant General Surgeon 
University Teaching Hospital of Kigali (CHUK) 
Email: nyundomartin@gmail.com;  
Phone: +250 788418727 or +250739952730 
2. Research team 
 
- Prof Detry Olivier, General, Hepatobiliary & Laparoscopic Surgeon, University of 
Liège, Belgium 
- Dr. Nifasha Antoine, General and laparoscopic surgeon, CHUK 
- Dr. Limgba Augustin, General, Thoracic and Laparoscopic surgeon, KFH/CHUK 
- Dr. Urimubabo Christian, General Surgeon, CHUK 
- Dr. Gasakure Miguel, General Surgeon, CHUK 
- Dr. Nizeyimana Francoise, Head Anesthesiologist, CHUK 

 
3
- Mr Gasana Magnius, Clinical Psychologist, CHUK 
 
1. Backgroud 
Enhanced Recovery After Surgery (ERAS) was started by a group of surgeons from 
Northern Europe who formed a research group with the aim to explore the ultimate care 
pathway for patients undergoing colonic resections. In the 1990s Henrik Kehlet had 
initiated this work with his innovative work on fast track surgery (1) (2), showing that 
most patients had recovered enough to be discharged 2 days after open sigmoid 
resections (3), when the length of stay for these operations was 10 days or more in most 
countries. The ERAS implementation program is a structured systematic 
implementation program successfully employed internationally in >25 countries. The 
ambition of the ERAS Society is to disseminate evidence- based principles for 
perioperative care and to support the development of new knowledge in perioperative 
medicine and surgical pathophysiology (4). 
No single technique or therapy can eliminate postoperative morbidity and mortality. 
Therefore, it is necessary to resort to multimodal management where several treatments 
and clinical approaches are combined to reduce in a clinically relevant way the 
undesirable consequences of surgical aggression, improve patient rehabilitation and 
reduce postoperative morbidity and overall costs (1)(5)(6)(2).  
An enhanced recovery program (ERP) after surgery consists of multimodal and 
multidisciplinary management to mitigate the surgical stress and the inflammatory 
response, and their consequences. Postoperative recovery is thereby improved and 
accelerated. The preoperative period is used to optimize the patient’s medical condition 
(2). Patient education, perioperative instructions and setting achievable expectation, 
incorporating the patient as a vital component in his/her own wellbeing, and recovery 
are of utmost importance. Patients need to understand that unless they contribute to the 
care path presented to them by the ERAS team, optimal surgical outcome and recovery 
will not be achievable. The patient needs to understand that they have ‘‘skin in the 
game’’(7) (8) (9) (10) (11). 
Laparoscopic surgery has helped to minimize surgical trauma in an increasing number 
of surgical procedures and avoids drains. The anesthetist makes preferential use of loco-
regional techniques, avoids perioperative fluid overload, and prevents postoperative 
nausea and vomiting. After surgery, early feeding and mobilization are encouraged and 
facilitated by a multimodal analgesia strategy that spares opioids and limits their side 
effects.  

 
4
ERPs reduce the incidence of medical complications by 50 %, including fewer 
infectious complications and a possible positive impact on survival after oncologic 
surgery. Hospital length of stay is shortened (2)  (12) (13) (14) (7) (10).  
ERAS has been shown to have important clinical and economic benefits and significant 
reductions in length of hospital stay and the implementation of ERAS pathways 
improves clinical outcomes and induces substantial economic gains. ERAS is the 
current surgical revolution (15) (16).  
Cholecystectomy is one of the commonest general surgical operations. Laparoscopic 
cholecystectomy is currently the most favored approach. As it is associated with less 
postoperative pain and ileus, it allows early discharge of patients from the hospital (17) 
(18). Studies from the West have reported that 'day case laparoscopic cholecystectomy' 
is feasible and safe with success rate of between 69-92 percent (18) (19). 
In two randomized groups comparing ambulatory care and overnight stay, the average 
hospital stay was 3.1 for overnight stay versus 1.7 for ambulatory care (Dirksen) and 
the ambulatory treatment was less expensive (20) (17). However, careful patient 
selection is essential in ensuring a high success rate (18).  
ERAS is not known in Rwanda and there is no report from any sub African country 
describing laparoscopic cholecystectomy in ERP. We will conduct a prospective study 
to assess the feasibility; safety, patients' acceptance, LOS and bed turnover of 
laparoscopic cholecystectomy in a tertiary care hospital in the ERP. 
2. Problem statement  
All surgeries, including laparoscopic surgery, represent a major stressor to the patient 
with possible sequelae for post-operative well being, including decline in functional 
capacity, cognitive ability, and even cancer spread. Comorbidities such as diabetes, 
ischemic heart and vascular disease, stroke, and others have a larger impact on 
postoperative morbidity and mortality than age (21) (10).  
ERAS pathways have been successfully implemented in many surgical specialties, 
including gastrointestinal, hepato-biliary, pancreatic, urologic, gynecologic, and 
urologic surgery (22) (23) (24).  
The strongest evidence so far has been described in patients undergoing open colorectal 
procedures (6) (25) (26). Combining minimally invasive laparoscopic surgery and 
ERAS has been shown to have important clinical and economic benefits and significant 
reductions in length of hospital stay, but its spread remains slow worldwide. 

 
5
Implementation of ERAS pathways improves clinical outcomes and induces substantial 
economic gains (15) (16) (2), and is becoming the optimal strategy for many surgeries 
when technically feasible (27) (28) (10).  
Laparoscopic cholecystectomy can be performed as a day-case procedure with a low 
rate of complications and admissions/readmissions. Patient acceptance in terms of 
quality of life variables is similar to that for cholecystectomy with an overnight stay. 
The day care strategy is associated with a reduction in cost (29).  
Laparoscopic cholecystectomy in ERAS program should optimize the surgical outcome 
and improve a quick recovery and decrease the length of hospital stay. At the University 
Teaching of Kigali, the current practice is to admit patients for laparoscopic 
cholecystectomy 24 hours prior to surgery and to discharge most patients within two to 
three days of surgery with a rate of complications around 5%.  
Patients overcrowd CHUK and the hospital bed management is a serious challenge. 
Patients coming far from their homes and with limited financial resources are suffering 
to get admitted in hospital for elective and none urgent surgeries like cholecystectomy, 
We believe that ERP can benefit the hospital with a rapid bed turnover rate, and reduces 
cost for surgery and hospitalization while providing to the patients with quality care 
and the same time increasing the comfort of the patient in the post-operative period and 
minimizing the postoperative complications. 
The aim of our study is to assess the feasibility and safety of laparoscopic 
cholecystectomy in the ERP by decreasing the length of stay from 72 hours to 36 hours, 
hospital bed turnover and evaluate the adverse events and cost related in a tertiary care 
hospital in Rwanda 
3. Research Questions 
- 
Is ERAS protocol implementable in Rwanda Tertiary Hospital? 
- 
Is laparoscopic cholecystectomy feasible, safe and cost-effectiveness in the 
context of ERP in our settings? 
- 
Is possible to discharge laparoscopic cholecystectomy patients within 36 hours 
postoperative? 
 
 

 
6
4. Objectives of the study 
4.1. 
General Objective 
The general objective of this study is to test the implementation of ERAS protocol in 
laparoscopic cholecystectomy with the aim of decreasing of the length of hospital stay 
to 36 hours and assess its safety and patients' acceptance.  
 
4.2. 
Specific Objectives 
1. To assess the level of knowledge and practice of Health care professional about 
Enhanced recovery after surgery program. 
2. To determine the frequency of postoperative adverse events and complications after 
laparoscopic cholecystectomy (tress, fatigue, nausea and vomiting)  
3. To determine the average length of hospital stay and bed turn over after laparoscopic 
cholecystectomy 
4. To determine the rate and reason of overnight and re-admissions 
5. To assess the patients’ acceptance of ERAS program and the overall satisfaction 
6. To determine the patient cost benefit when ERAS is implemented correctly. 
 
5. Research Methodology  
 
5.1. 
Methods and Settings 
This is a prospective and cross sectional study. The study will be conducted in Rwanda 
at the University Teaching Hospital of Kigali from January to December 2021.  
Rwanda is a country of 11.9 million in East Africa. There are approximately 80,000 
surgical procedures performed annually in Rwanda, 510 major operations per 100,000 
populations (30). Rwanda has 4 main referral hospitals performing surgical operations 
including laparoscopic procedures. The referral hospitals include: University Teaching 
Hospital (CHUK), University Teaching Hospital of Butare (CHUB), Rwanda Military 
Hospital (RMH) and King Faisal Hospital, Kigali (KFH, K) 

 
7
The University Teaching Hospital of Kigali (CHUK) is the major public, tertiary 
referral and teaching hospital in Rwanda and it is located in the capital in Kigali. It has 
565 beds and 11 operating theaters shared among all surgical services. It provides 
approximately up to 1600 major operative cases in general surgical services every year 
including 140 cases of laparoscopic surgeries with 75 cases of laparoscopic 
cholecystectomies. The CHUK started performing laparoscopic surgery routinely long 
time before others and currently it performs more than 60% of laparoscopic surgeries 
performed in the Country in different specialties including general surgery, Urology 
and Genecology.  Considering the above reason, we selected this hospital to represent 
others and be the site of our research interest. 
This study will be conducted in general surgical unit at the University Teaching 
Hospital of Kigali (CHUK), it has a capacity of 2 operating rooms with 2 lap towers 
with complete sets of laparoscopic material and around 40 in patient beds.  
The population proportion of laparoscopic cholecystectomy is 5% within a total general 
surgical population size of 1600 patients per year. A range of 50 to 70 patients will 
allows to have a confidence level of 95% that the real value is within ±5% of the 
measured value and have relevant conclusions. 
 
5.2. 
ERAS pathways 
Enhanced recovery after surgery is multimodal and multidisciplinary patient centered 
care; the patient becomes a true actor of his care. The surgeon, the anesthesiologist and 
the nurses constitute the trinomial leader. Other specialists are also concerned: 
physiotherapist, nutritionist, gastroenterologist, etc. (2). This partnership explains the 
importance of education and enhanced preoperative information during hospitalization 
(2). The success of this true teamwork requires the concerted writing of protocols, 
interdisciplinary communication, continuous evaluation of one's practice, and the 
existence of leadership (31). The team spirit is strengthened (2) (10) (32).  
 
 

 
8
5.2.1. Principal measures (elements) contained in the ERP, irrespective of the specialty 
(32) 
Pre-operative 
Pre-admission 
Intra-operative 
Post operative 
Post Discharge 
1. Patient information 
and education:  Patient 
optimization 
(Counseling, smoking, 
alcohol, pain 
management plan, pre-
habilitation of select 
patients (e.g., diabetic, 
hypertensive)  
2. No bowel 
preparation 
3. No premedication 
4. Initial multimodal 
medications  
5. Limited fasting 
(light meal up to 6 
hours preoperative)  
5. Carbohydrate 
loading (up to 2 hours 
preoperative) and 
Glucose control  
6. Discharge planning, 
education and home 
medication plan 
 
1. Limited fluid 
intake 
(Normovolemia) 
2. Normoglycemia 
3. Corticosteroids  
4. Prevention of 
hypothermia 
(Normothermia)   
4. Antibiotic 
prophylaxis   
6. Prevention of 
PONV  
7. Minimal 
invasive access  
8. Multimodal 
analgesia and 
Limitation of 
opioid use,  
 8. No drain or 
nasogastric tube 
1. Multimodal 
analgesia  
2. Katamine , IV 
lidocaine 
3. NSAIDs for 48 h  
4. Nausea and 
vomiting management 
5. Early mobilization 
6. No or judicious IV 
fluid management  
7. Early re-feeding  
8. No or rapid removal 
of the bladder catheter 
9. Patient/family 
education (Delirium 
prevention) 
 
 
1. Risk 
management 
(Monitor for 
symptoms or 
changes in health 
to seek assistance) 
2. Telephone calls 
and SMS (Follow-
up with surgeon)  
3. Continue 
therapy and other 
activities for 
recovery as 
planned  
 
 
Source: How to implement an enhanced recovery program? Proposals from the Francophone 
Group for enhanced recovery after surgery (GRACE):  

 
9
5.2.2. Preoperative evaluation  
All the patients include in the ERAS protocol will undergo a preoperative 
multidisciplinary evaluation performed by the ERAS team. During this evaluation, all 
information regarding all the step of the ERAS protocol will be given to the patients 
and all the information regarding the preoperative step to follow, such as smoking quit 
or alcohol use. Moreover, information about the entire postoperative ERAS step that 
the patients needed to follow during the hospitalization will be given. Education and 
discharge plan will be discussed. 
5.2.3. Preoperative fasting 
All patients will be allowed to take a regular diet until 6 h and Carbohydrate loading or 
clear fluids until 2 h before surgery. Thromboembolism prophylaxis with low molecular 
weight heparins will be administered according to patient’s comorbidities.  
5.2.3. Anaesthesiologic protocol  
No premedication will be administered. Two different types of anesthesiology 
technique will be used: general anesthesia with local infiltration of the surgical incision. 
In all cases restricted intraoperative fluid administration (6–8 ml/kg/h) and prevention 
of hypothermia during surgery will be used. Moreover, no opioids will be used during 
all the perioperative period. Antibiotic prophylaxis will be given in agreement with the 
hospital protocol. Analgesia and Prevention of PONV will be given. Immediate 
postoperative monitoring will be performed in the recovery room where the pain 
numeric rating scale (NRS) will be routinely evaluated by the anesthesiologist or the 
NPA.  
5.2.4. Surgical technique  
Laparoscopic approach with a 4-trocar technique will be the first choice when not 
contraindicated. No Abdominal drainage, no nasogastric tube, when necessary it will 
be placed immediately after anesthesia and removed upon awakening. A bladder 
catheter will be placed if indication and be removed immediately after surgery.  
5.2.5. Postoperative care  
- Analgesia: IV Paracetamol or Katamine administration when necessary.  
- No opioids 
- Treatment of Nausea and vomiting when necessary  

 
10
- Pain assessment every 4 hours using pain NRS scale by nursing staff 
- If pain not severe: Paracetamol + Ibuprofen or Diclofenac 
- Re-feeding 
- Two to 4H after surgery: Liquid diet and mobilization. 
- Withdrawal of intravenous infusions (0.7–1 ml/ kg/h) was obtained during  
- From 8H:  light semiliquid meal  
- From the 12H after surgery: a free diet and patient mobilization was further 
encouraged and increased gradually. All the meals had to be consumed sitting 
at the table.  
- From 24h after surgery: Blood works (FBC and CRP) and Discharge  
5.2.6. Discharge & Post discharge 
The important criteria for the patient's discharge from the hospital are: Normal vital 
signs and blood works, absence of complications or symptoms, a digestive function 
enabling the patient to eat without nausea or vomiting, return of intestinal transit with 
emission of gas (stool not required), autonomy to move and post-operative pain relief 
with oral analgesics (2).  
After the discharge for all the patients, the surgeon will make follow up on phone on 
day 3, 5 day and day 7 to detect any signs of complications during the first week. If no 
complaints the out patient clinic evaluation will be planned at 15 and 30 days from the 
operation. The patient will be given oral analgesia for at least 48 hours. 
5.3. 
Data collection and analysis  
A baseline survey will be conducted to assess the awareness and knowledge of health 
care professional in charge of perioperative care. From November 2021, we will put in 
place an ERAS protocol for laparoscopic cholecystectomies. Patients living in Kigali 
and near Kigali having an easy communication means will be sensitized to adhere to 
the program. 
A multidisciplinary team (Surgeons, Anesthesiologists, nurses, anesthetists and 
psychologists) will be mobilized to participate in the team. A google sheet 
questionnaire will be designed to collect information about the awareness and 
knowledge of perioperative health care professional about ERAS programme and then 

 
11
a modified ERAS protocol will be put in place and data collection will be done using a 
coded checklist form and consecutive selection of patients will be done during the study 
period until we reach at least 50 patients. The operative procedures and instrumentation 
will be standardized for laparoscopic cholecystectomy, and surgeons who will perform 
the procedures will be having expertise in laparoscopic cholecystectomy. Reasons for 
conversion from laparoscopic to open cholecystectomy will be recorded and 
documented. Emergency patients and patients defined as ASA IV and pediatric 
patients aged below 16 years will be excluded. 
Data will be collected for age, gender, indications for surgery, American Society of 
Anesthesiology (ASA) class, operative time, adverse events (pain, nausea and 
vomiting), length of hospitalization, and intra- and post-operative complications. The 
expenses of surgery and in-hospital care will be calculated and analyzed. On discharge, 
on day 3 of discharge, day 10, day 15 and day 30 of discharge patient will report 
outcomes and will be recorded by Surgical Recovery Scale. After discharge, the 
patients will be called or texted on phone to know about their status and collect 
information. Data will be recorded using EXCEL. Statistical analysis will be done using 
SPSS software and the one-way analysis of variance (ANOVA) test, the Chi-square 
test, and the t Student’s test will be used when appropriate for comparisons.  
A Univariate analysis will be done to determine variables associated with the length of 
hospital stay. Pearson’s chi square will be calculated to compare variables and.. 
Continuous variables were presented as mean ± standard deviation or median (range) 
when appropriate and categorical variables will be presented as frequency (percentage). 
A Univariate analysis will be performed through a stepwise linear regression model 
using length of hospital stay as dependent variable and age, BMI, gender, ASA score, 
intraoperative infusions, pain, analgesia, nausea, vomiting, 30 days-readmission rates, 
presence of complications and mortality as independent factors. Variables with 
significant link will be crossed with outcome variables to draw their correlation 
overnight, using Multivariate logistic regression A p value < 0.05 will be considered 
statistically significant.  
 
6. Expected Results  
Table 1: Level of awareness and knowledge of ERAS among perioperative care health 
professionals 
Table 2: Baseline characteristics of patients  

 
12
Table 2: Acceptance rate of patients in ERP 
Table 3: Rate of adverse events (Stress, fatigue, pain, nausea and Vomiting) 
Table 4: Complications of laparoscopic cholecystectomy 
Table 5: The average length of hospital stay 
Tableau 6: Cost of laparoscopic cholecystectomy 
Table 7: Rate of overnight and readmission  
Table 8: Overall satisfaction of patients after laparoscopic cholecystectomy in ERP 
Table 9: Comparative analysis of length and independents variables  
 
7.  Significance of the study 
The results from this study will determine if ERP can be implemented in our settings 
and laparoscopic cholecystectomy patients are safe to be discharged on one-day post-
operative period in a teaching hospital in Rwanda to increase bed turnover and decrease 
patients hospital costs.  
Recommendations will be formulated to encourage surgeons and hospitals in Rwanda 
to put in place the ERAS protocols and test it for other surgeries. Finally, this study 
may posit a direction for related future researches 
 
8. Ethical consideration 
 
8.1. 
Confidentiality 
Confidentiality and ethics in this research will be highly considered. The names, 
identity numbers and identification contact of the patients will be removed from the 
database and replaced with dummy values (codes). 
 
8.2. 
Risks of participants 

 
13
The patients will be closely monitored and any adverse events will be treated using 
standard approaches. All patients will be discharged using standardized criteria of safe 
discharge. The patient’s privacy or confidentiality will be respected and reasonable 
effort will be made to protect the patient’s information while their data will be used for 
the purpose of this research. Participation will be voluntary and there will be no direct 
compensation. 
 
8.3. 
 Informed consent 
All participants will sign an informed consent during the preoperative evaluation 
regarding the type of operation and the ERAS protocol application 
 
8.4. 
Ethical approval  
This research proposal will be presented in the UR/IRB and CHUK ethic committee for 
review and approval.  
9. Timeframe of Activity 
Activities
/Months 
Fe 
20 
M
2
1 
Ap 
21 
May 
21 
Jun 
21 
Jul 
21 
Aug 
21 
Sept 
21 
Oct 
21 
No 
21 
De 
21 
Jan 
22 
Fe
22 
Ma 
22 
Ap 
22 
Research 
proposal 
X 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
Ethics 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
Data 
collection 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
 
 
 
 
Data 
encoding 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
Data 
analysis 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
 
 
Report 
writing 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Manuscri
pt writing 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
Submissi
on 
for 
Publicati
on 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 

 
14
 
10. Approximated Budget 
 
Item 
Description 
Cost/unit 
(FRw) 
Qtity 
No days 
Total Cost 
(FRw) 
Access to Journal 
Papers that are not 
open access 
80,000 
6 
- 
480,000 
Ethical clearance 
Ethical fees 
150,000 
1 
- 
150,000 
Data collection 
Incentive for 
research assistants 
(Residents) 
100,000/
moth 
5 
6 
mont
hs 
3,000,000 
Data encoding 
Incentive for data 
entree  (Medical 
students) 
25,000 
2 
7 
350,000 
Data analysis 
Data clearing and 
analysis by 
statistician 
50,000 
1 
7 
350,000 
PI allowances 
Coordination fees 
for general 
coordination of the 
study and cross 
checking of 
information 
150,000/
Month 
6 
- 
900,000 
Communication 
fees 
Call patients for 
post operative 
follow up by 
Research assistants 
100,000/
month 
6 
- 
600,000 
Report and 
manuscript 
Reporting, IT and 
printing 
500,000 
- 
- 
500,000 
Publications 
High indexed and 
per reviewed 
journal 
400,000 
2 
- 
800,000 
Total 
 
 
 
 
7,130,000 
 
 
 

 
15
11. Planning of Activities and related funds 
 
 
 
Activities 
Q1 
June-
September 
2021 
Q2 
October – 
December 
2021 
Q3 
January – 
March 
2022 
Q4 
April- June 
2022 
Total 
General 
coordination  
450,000 
450,000 
0 
0 
900,000 
Ethical 
clearance 
150,000 
0 
0 
0 
150,000 
Data collection 
(Medical files 
records and post 
operative follow 
up by phone 
calls 
1,800,000 
1,800,000 
0 
0 
3,600,000 
Data Encoding 
0 
0 
350,000 
0 
350,000 
Data analysis 
0 
0 
350,000 
0 
350,000 
Report and 
Manuscript 
writing 
0 
0 
500,000 
0 
500,000 
Literature 
review 
0 
0 
0 
480,000 
480,000 
Submission for 
Publication 
0 
0 
0 
800,000 
800,000 
Total  
2,400,000 
2,250,000 
1,200,000 
1,280,000 
7,130,000 

 
16
12. Conclusion 
The minimally invasive surgical procedures proceed towards patient safety without 
increased fatal complications  
The quality of recovery and patient satisfaction are among clinical outcomes should 
interest the surgeons as indicator of quality of care to patients. 
Laparoscopic cholecystectomy combined with ERAS can effectively treat a variety of 
benign, non-acute gallbladder diseases with shortened waiting time and postoperative 
hospital stay. ERAS benefits the hospital with a rapid bed turnover rate, and reduces 
cost for surgery and hospitalization 
My study will determine if the ERP is feasible is our context and proposes 
recommendations in order to improve the quality of recovery of surgical patients and 
improve the bed turnover in different referral hospitals in Rwanda using enhanced 
recovery protocols. 
 
 

 
17
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14.  
 
Done at Kigali, on 16th June 2021 
 
NYUNDO Martin, MD