As elective operations are being cancelled, and surgeons are called upon to perform
only emergency or carcinological surgery, the precautions to take when operating on
patients who are potentially or proven COVID-19 positive are of utmost importance.
The novel coronavirus (2019-nCoV) outbreak hit China in the beginning of December
2019, and ignited the headlines a few days later. Unexpected, unprecedented, and radical
modifications have profoundly shaken the world since then. The economic shutdown in
China cleared the map of China viewed from the sky, the halt in travel, counseled
first within the country, then internationally, was too late to stop the diffusion
outside of China, and meanwhile has destroyed enterprises such as Flybe, while changing
the economy of airlines and airports the world over. Hospitals and medical structures,
in China, then Korea, and now Italy and France, abound with people either infected,
or afraid of being so. The stock of respiratory machines has never been used so prominently,
while facial masks, visors of all sorts and handkerchiefs, wipes and tissues have
never been expended more often, and are even depleted in certain regions.
First in China, then in Europe, and in particular, in Italy, the sudden and rapidly
exponential afflux of patients in need of management, simple or intensive care, or
simply advice to stay where they were, became the omnipresent and urgent preoccupation
of health care workers, essentially those based in hospitals. In China, make-shift
neo-hospitals were built in unparalleled record-braking time spans, and in Europe,
external triage tents, internal reshuffling of beds and usage radically modified the
architecture of existing health facilities.
Surgery has also evolved and changed radically, but over a 30-year span. How has the
novel coronavirus (2019-nCoV) outbreak affected surgery in China and Italy and will
affect the future of surgery tomorrow is the question of today.
The Centers for Disease Control and Prevention recently published recommendations
that were upgraded by the American College of Surgeons.
1
Both recommended to stop elective surgery and to take general precautions, but there
was little on the pragmatic aspects of surgery.
In laparoscopic surgery, an essential part of the technique is the establishment and
maintenance of an artificial pneumoperitoneum; with this comes the risk of aerosol
exposure for the operation team. Ultrasonic scalpels or electrical equipment commonly
used in laparoscopic surgery can easily produce large amounts of surgical smoke, and
in particular, the low-temperature aerosol from ultrasonic scalpels cannot effectively
deactivate the cellular components of virus in patients. In previous studies, activated
corynebacterium, papillomavirus, and HIV have been detected in surgical smoke
2–4
and several doctors contracted a rare papillomavirus
5
suspected to be connected to surgical smoke exposure. The risk of 2019-ncov infection
aerosol should not be any exception. One study found that after using electrical or
ultrasonic equipment for 10 minutes, the particle concentration of the smoke in laparoscopic
surgery was significantly higher than that in traditional open surgery.
6
The reason may be that due to the low gas mobility in the pneumoperitoneum, the aerosol
formed during the operation tends to concentrate in the abdominal cavity. Sudden release
of trocar valves, non-air-tight exchange of instruments, or even small abdominal extraction
incisions can potentially expose the health care team to the pneumoperitoneum aerosol;
the risk is definitely higher in laparoscopic than in traditional open surgery. This
outbreak thus poses a great challenge to the clinical work of surgeons who practice
MIS.
As the epidemic spreads and pandemics, we surgeons have the responsibility of raising
the level of awareness, prevention, and control of transmission, not only for the
current epidemic, but also, in general, as a principal for all surgeries.
7
Even if all elective surgery has been curtailed if not stopped in countries of the
current pandemic, the risk is present for patients who require emergency surgery or
operations for malignancy, and above all, for the surgeons and operating room staff
who undertake these operations.
We would like to share the following, based on our recent experience in Shanghai and
Milan.
1)
General protection: all surgery patients must complete preoperative health screening,
whether they are symptomatic or not. As operating staffs might become infected, and
therefore reduced in number, all medical personnel have to comply with the tertiary
protection regulations.
8,9
2)
Prevention and management of aerosol dispersal: during operations, whether laparoscopic
or via laparotomy, instruments should be kept clean of blood and other body fluids.
Special attention should be paid to the establishment of pneumoperitoneum, hemostasis,
and cleaning at trocar sites or incisions to prevent any gush of body fluid caused
by air leakage or uncontained laparotomy incisions. Liberal use of suction devices
to remove smoke and aerosol during operations, and especially, before converting from
laparoscopy to open surgery or any extra-peritoneal maneuver. Avoid using 2-way pneumoperitoneum
insufflators to prevent pathogens colonization of circulating aerosol in pneumoperitoneum
circuit or the insufflator.
3)
Management of artificial pneumoperitoneum: keep intraoperative pneumoperitoneum pressure
and CO2 ventilation at the lowest possible levels without compromising the surgical
field exposure. Reduce the Trendelenburg position time as much as possible. This minimizes
the effect of pneumoperitoneum on lung function and circulation, in an effort to reduce
pathogen susceptibility.
4)
Operation techniques: The power settings of electrocautery should be as low as possible.
Avoid long dissecting times on the same spot by electrocautery or ultrasonic scalpels
to reduce the surgical smoke. Special attention is warranted to avoid sharp injury
or damage of protective equipment, in particular gloves and body protection.
5)
Postoperative operating room and equipment management: all protocols involving postoperative
cleaning and disinfection should comply with governmental and learned society instructions.
1,8,9
Devices used on infection-suspected or proven patients should undergo separate disinfection
followed by proper labeling. It is mandatory to specifically label and dispose clinical
wastes separately.
6)
Ideally, hospitals should be immediately divided into 2 main categories: dedicated
hubs for positive COVID-19 patients (with limited surgical staff and ORs, for those
infected patients requiring surgery) and other both for emergency surgery and urgent
oncological procedures in negative COVID 19 patients. Health authorities should allow
surgical teams to move from one hospital to another.
7)
Teaching and future recommendations: strengthen the awareness on the hazards caused
by surgical smoke and the management of intraoperative aerosol. Strict protocols must
be established for the creation and maintenance of laparoscopic pneumoperitoneum to
reduce the occupation hazard caused by aerosol exposure.
8)
Operating staff protection: efforts must be made to raise awareness of the occupation
protection on operating staffs, including surgeons, anesthetists, and nurses and all
possible transiting persons in the OR. Correct 2-way protective apparel (goggles,
visor, mask, and body protective garb) should be routine. When engaging a suspected
or diagnosed patient, tertiary dress code should be applied according to the protocols
which also include strengthening OR ventilation and installing air purification equipment.
9)
Preoperative health screening: to effectively battle against the possibility of prolonged
2019-nCOV outbreak, it is imperative to establish new standards of practice for admitting
patients in the future. This should range from preoperative health screening to final
differential diagnosis, including epidemiology investigation and adequate imaging.
This outbreak not only raises challenges to MIS in terms of disease control today
but also should remind surgeons that we need stronger occupational protection in the
future. We must raise the level of awareness and protection measures for the risk
of occupational exposure in laparoscopic but also traditional open surgery. There
is an urgent need of a strict protocol to accurately manage the artificial pneumoperitoneum
and the hazards of aerosol diffusion for surgeons.