Laparoscopic surgery for COVID-19 positive patients: A Dilemma

COVID-19 positivity is not an obstacle to laparoscopic surgery

Key Points

Highlights:

• Regarding surgical interventions in COVID-19 positive patients, there is a great concern for the contamination of health care providers (HCP).
• There seems to be no reason for discarding urgent laparoscopy, but HCP should be alert on recent studies and perform laparoscopy only when it is necessary due to the possible risks of surgery in COVID-19 positive patients.

Aims of the research:

• Delineating potential contamination routes, possible risks for HCPs via research questions based on current publications, and expertise on laparoscopic surgery of  COVID-19 positive patients.

What's done here:

• A scoping narrative review with five additional questions concerning possible contamination was made from medical databases.
• This search was done not only for COVID-19 but also for possible virus contaminations in general.

Key results:

• Out of 267 papers, 84 manuscripts 14 of which discussing SARS-CoV-2 were finally reviewed, concluded that significant evidence exists for in- and extubation procedures.
• These procedures definitely result in high-risk aerosol productions.
• However, no papers were found on the risk of SARS-CoV-2 and surgical smoke. However, 25 papers had evidence on the risks of infections and contamination with HPV, hepatitis B, polio, and rabies operations.
• There were no publications discussing the risks of tissue extraction or the deflation of pneumoperitoneum after laparoscopic surgery.
• Final advice:
  • Either turn off the high pressure or create low pressures ORs and create specific ORs only for the purpose of emergency surgery on COVID-19 patients if possible;
  • Consider evacuating the smoke to prevent it to be free in the OR, and use devices for filtration of released CO2 along with aerosolized particles;
  • Think logical about tissue extraction, protect yourself along with the OR staff,
  • First de-sufflate the abdomen and do not hesitate to increase the incision rather than increasing the risk on the spread of aerosols and using a filter (maybe the same system as the smoke evacuation).

Lay Summary

COVID-19 pandemic is the most important issue of our days. In this regard, it is crucial to keep health care providers (HCPs) safe and away from contamination. Doctors Without Borders reported that regardless of all preventive measurements, nearly eight percent of the total COVID-19 cases in Italy are HCPs making HCP the highest risk group, and the importance of protecting this group is clear.

All HCP who are in direct contact with infectious secretions from a patient with COVID-19 at risk according to the American Center for Disease Control, as sputum, serum, blood, feces, and respiratory droplets are the cause of viral transmission necessitate wearing personal protective equipment. It seems that aerosol-generating procedures such as intubation, extubation, noninvasive ventilation, and exposure to aerosols are associated with further high risk. Specifically, anesthesiologists, intervention radiologists, obstetricians, and cardiothoracic surgeons need to continue acute surgical interventions which are performed by laparoscopy, but the risks for the HCP of laparoscopic surgery in a COVID-19 positive patient is not well-known.

An international collaborative study regarding the safety of laparoscopic surgery in COVID-19 positive patients has been recently published online in "JMIR Public Health and Surveillance", to provide a narrative overview about contamination routes, and by summarizing the literature about viral infectious risks in laparoscopy, the study aims to construct guidelines for acute laparoscopic surgery in COVID-19 patients.

267 full-text papers were considered, at the end 84 publications of which 14 were discussing SARS-CoV-2 were finally evaluated. Based on the theoretical contamination routes, the following questions were answered: i) the effect of operating room (OR) pressure on the contamination risk, ii) the additional risk during intubation and extubation, iii) whether smoke evacuation increase the risk of spread of COVID-19 in laparoscopic surgery, iv) the harm of tissue extraction from a COVID- 19 positive patients and v) the formation of harmful airborne aerosols during abdomen de-sufflation.

Either to turn off the high pressure or create low pressures ORs; to create specific ORs only for the purpose of emergency surgery on COVID-19 patients; to consider about evacuating the smoke to prevent it to be free in the OR; to use devices for filtration of released CO2 along with aerosolized particles; logical thinking about tissue extraction and protecting yourself along with the OR staff, first de-sufflation of the abdomen and not to hesitate to increase the incision rather than increasing the risk on the spread of aerosols and using a filter or use the same system as the smoke evacuation are important issues.

"There seems to be no reason for discarding urgent laparoscopy, however, we should be alert on most recent studies, and perform laparoscopy only when it is necessary due to the possible risks of surgery in COVID-19 positive patients. A global effort is taken to report on the experience and outcomes of COVID-19 surgical patients can be found at globalsurg.org/covidsurg/" concluded the authors.

Research Source: https://pubmed.ncbi.nlm.nih.gov/32406853