Background: Enhanced Recovery After Surgery (ERAS) pathways improve postoperative outcomes across surgical specialties; however, implementation in gynecologic surgery remains inconsistent. This study assessed national ERAS implementation in Austrian gynecologic departments and compared reported practices between departmental leadership and frontline clinicians.

Methods: A national cross-sectional survey was conducted using two structured online questionnaires targeting Heads of Department (HoDs) and residents and non-leadership specialists (“clinicians”). Survey items were derived from American College of Obstetricians and Gynecologists and ERAS Society recommendations. ERAS awareness and self-reported implementation were analyzed separately. Group comparisons were performed using Fisher’s exact test and Kruskal–Wallis testing; concordance between leadership and clinician response patterns was assessed using Kendall’s Tau-b correlation.

Results: Fifty of sixty one HoDs (82%) participated, representing university (16%), large non-university (59%), and small non-university hospitals (25%). Fifty–eight clinicians completed the survey. HoDs reported high adherence to several intraoperative and postoperative ERAS elements, including comorbidity assessment, antibiotic prophylaxis, and preference for minimally invasive surgery. In contrast, preoperative optimization measures showed consistently low adherence. Preoperative carbohydrate loading was reported as not implemented by 62% of HoDs and 60% of clinicians. No significant differences in ERAS adherence were observed between university and non-university hospitals for any key ERAS element. Preoperative nutritional screening (36% vs. 14%; p < 0.001) and nutritional supplementation in malnourished patients (66% vs. 14%; p<0.001) were reported significantly more often by HoDs than by clinicians. Overall concordance between HoD and clinician response patterns was strong (Kendall’s τ = 0.65; p<0.001). Nearly all clinicians (98%) expressed interest in structured ERAS education.

Conclusion: ERAS implementation in Austrian gynecologic surgery remains heterogeneous, with consistent adoption of several intraoperative and postoperative elements but persistently low adherence to key preoperative optimization measures. Academic affiliation does not confer superior ERAS implementation. These findings highlight the need for structured education, standardized pathways, and coordinated national implementation strategies to improve guideline-consistent perioperative care.

Enhanced recovery after surgery, Gynecologic surgery, Gynecology, Health education, Perioperative care