COVID 19 and laparoscopic surgeons, the Indian scenario - Perspective

Measurement and Control of Surgical Smoke to Enhance Surgical Team Safety

Amid the coronavirus disease 2019 era, concern about the safety of surgical teams related to surgical smoke (SS) is rising. As simple ventilation improvement methods (SVIMs), we replaced 4 of the 8 supply diffusers with a direction-adjustable louver-type, closed 2 of the 4 exhaust grills, and strengthened the sealing of the doorway. Dynamic changes in the concentration of particulate matter (PM) with sizes of < 1.0 μm (PM1.0) were measured using low-cost PM meters (LCPMs) at eight locations in the operating room (OR). SS concentration up to 4 minutes at the location of the surgeon, first assistant, and scrub nurse before and after SVIMs application decreased from 65.4, 38.2, 35.7 µg/m³ to 9.5, 0.1 and 0.7 µg/m³ respectively. A similar decrease was observed in the other 5 locations. SVIMs could effectively control SS and the LCPM was also effective in measuring SS in the OR or other spaces of the hospital.

Control of airborne particles in surgical procedures during the Covid-19 pandemic: scoping review

OBJECTIVE

To map the technical and managerial strategies for the management and reduction of airborne particles production in surgical procedures settings during the Covid-19 pandemic.

METHOD

Scoping review, according to the Joana Briggs Institute methodology, based on documents indexed in MEDLINE, VHL, CINAHL Cochrane, Embase, Scopus, Web of Science, and gray literature, published in Portuguese, English, or Spanish. All studies from indexed scientific journals and recommendations published by international agencies or academic associations from 2019 to January 2022 were considered. Findings were summarized and analyzed using descriptive statistics and narrative synthesis.

RESULTS

Twenty-two studies were selected, 19 of which were published in English, two in Spanish, one in Portuguese, with a predominance of literature reviews. Findings were categorized into recommendations for the environment, the team, and the surgical technique.

CONCLUSION

The review mapped the technical and managerial strategies for the management and reduction of the airborne particles production in surgical procedures settings. They involve from the use of personal protective equipment, training, anesthetic modality, airway manipulation, to the execution of the surgical technique.

Controle de partículas aéreas nos procedimentos cirúrgicos durante a pandemia da Covid-19: revisão de escopo

RESUMO Objetivo: Mapear as estratégias técnicas e gerenciais para o manejo e a redução da produção de partículas aéreas em ambientes de procedimentos cirúrgicos durante a pandemia da Covid-19. Método: Revisão de escopo, de acordo com metodologia do Joana Briggs Institute, a partir de documentos indexados nas bases MEDLINE, BVS, CINAHL Cochrane, Embase, Scopus, Web of Science e literatura cinza, publicados em português, inglês ou espanhol. Foram considerados todos os estudos provenientes de periódicos científicos indexados e recomendações publicadas por órgãos internacionais ou associações acadêmicas, de 2019 a janeiro de 2022. Os achados foram sumarizados e analisados por estatística descritiva e síntese narrativa. Resultados: Foram selecionados 22 estudos, sendo 19 publicados em inglês, dois em espanhol, um em português, com predominância de revisões da literatura. Os achados foram categorizados em recomendações para o ambiente, a equipe e a técnica cirúrgica. Conclusão: a revisão mapeou as estratégias técnicas e gerenciais para o manejo e a redução da produção de partículas aéreas nos ambientes de procedimentos cirúrgicos. Envolvem desde o uso de equipamentos de proteção individual, treinamentos, modalidade anestésica, manipulação de vias aéreas, até a execução da técnica cirúrgica.

Removal of a Giant Cyst of the Left Ovary from a Pregnant Woman in the First Trimester by Laparoscopic Surgery under Spinal Anesthesia during the COVID-19 Pandemic

This paper reports a case of a 21 year old primigravida at 6 weeks gestation, suffering from important abdominal pain, who was admitted into the medical center with a giant cyst of 28 × 20 cm on her left ovary. A torsion of the ovarian cyst was suspected. Her COVID-19 status was unknown. In view of the emergency of the situation and the COVID-19 pandemic, laparoscopy in spinal anesthesia was performed. The patient remained conscious during the surgical intervention and tolerated it well apart from a slight dyspnea, which was easily eliminated by changing her body position and decreasing the pneumoperitoneum pressure. The ovarian cyst was removed by enlarging the trocar incision. The patient recovered with neither incident nor pregnancy loss. COVID-19-related complications can induce adverse pregnancy outcomes. Under general anesthesia, patients with COVID-19 are at risk of severe pneumonia and of passing their infection to the medical personnel. To avoid such complications in non-specialized centers, laparoscopy should be performed in regional anesthesia. Laparoscopy in spinal anesthesia can be performed safely on pregnant patients by placing them in the proper position, using a low pneumoperitoneum, and monitoring the hemodynamics. During early pregnancy, general anesthesia induces a higher risk of teratogenic effects and of miscarriage.

Laparoscopy in Gynecologic and Abdominal Surgery in Regional (Spinal, Peridural) Anesthesia, the Utility of the Technique during COVID-19 Pandemic

BACKGROUND

laparoscopic surgery is mainly performed in general anesthesia. Symptomatic patients infected with COVID-19 needing surgery are however at higher risk for COVID-19 complications in general anesthesia than in regional anesthesia. Even so, Covid transfection is a hazard to medical personnel during the intubation procedure and treatment drugs may be in shortage during a pandemic. Recovery and hospital stay are also shorter after laparoscopy. Laparoscopy performed in regional anesthesia may have several advantages in limiting Covid.

METHODS

international literature on the risk of COVID-19 complications development was searched. 3 topics concerning laparoscopic surgery were reviewed: (1) Achievements in laparoscopy; (2) Advantages of regional anesthesia compared to general anesthesia; (3) Feasibility to perform laparoscopy in regional anesthesia in COVID-19 pandemic. The authors reviewed abstracts and full-text articles concerning laparoscopic surgery, gynecology, anesthesia and COVID-19. Studies published in PubMed, Embase, Cochrane Library and found in Google Scholar before 1st FEB, 2021 were retrieved and analyzed.

RESULTS

a total of 83 studies were found, all of them written in English. 17 studies could be found in gynecology and in general surgery about laparoscopy with regional anesthesia. In Covid time only one study compared laparoscopic surgery in general anesthesia to laparotomy and another study laparotomy in general anesthesia to regional anesthesia. Laparoscopy showed no disadvantage compared to laparotomy in Covid pandemic and in another study laparotomy in general anesthesia was associated with higher mortality and more pulmonary complications. Trendelenburg position can be a threat if used by inexperienced personnel and can induce unintended anesthesia of breathing organs. On the other hand Trendelenburg position has advantages for cardiovascular and pulmonary functions. Pneumoperitoneum of low CO2 pressure is well tolerated by patients.

CONCLUSIONS

elective surgery should be postponed in symptomatic Covid patients. In inevitable emergency surgery intubation anesthesia in COVID-19 pandemic is as far as possible to be avoided. In COVID-19 pandemic, regional anesthesia is the preferred choice. The optimum may be the combination of laparoscopic surgery with regional anesthesia. Reducing the pneumoperitoneum is a good compromise for the comfort of patients and surgeons. A special case is gynecology, which needs to be performed in Trendelenburg position to free pelvic organs.

Surgical Diseases Management during COVID-19 Crisis at a Tertiary Care Hospital of India: Our Institutional Strategy

Introduction  In response to the national coronavirus disease 2019 (COVID-19) pandemic, all hospitals and medical institutes gave priority to COVID-19 screening and to the management of patients who required hospitalization for COVID-19 infection. Surgical departments postponed all elective operative procedures and provided only essential surgical care to patients who presented with acute surgical conditions or suspected malignancy. Ample literature has emerged during this pandemic regarding the guidelines for safe surgical care. We report our experience during the lockdown period including the surgical procedures performed, the perioperative care provided, and the specific precautions implemented in response to the COVID-19 crisis. Materials and Methods  We extracted patient clinical data from the medical records of all surgical patients admitted to our tertiary care hospital between the March 24th, 2020 and May 31st, 2020. Data collected included: patient demographics, surgical diagnoses, surgical procedures, nonoperative management, and patient outcomes. Results  Seventy-seven patients were included in this report: 23 patients were managed medically, 28 patients underwent a radiologic intervention, and 23 patients required an operative procedure. In total eight of the 77 patients died due to ongoing sepsis, multiorgan failure, or advanced malignancy. Conclusion  During the COVID-19 lockdown period, our surgical team performed many lifesaving surgical procedures and appropriately selected cancer operations. We implemented and standardized essential perioperative measures to reduce the spread of COVID-19 infection. When the lockdown measures were phased out a large number of patients remained in need of delayed elective and semi-elective operative treatment. Hospitals, medical institutes, and surgical leadership must adjust their priorities, foster stewardship of limited surgical care resources, and rapidly implement effective strategies to assure perioperative safety for both patients and operating room staff during periods of crisis.

Laparoscopic surgery during the COVID-19 pandemic: detection of SARS-COV-2 in abdominal tissues, fluids, and surgical smoke

Background

There are still concerns over the safety of laparoscopic surgery in coronavirus disease 2019 (COVID-19) patients due to the potential risk of viral transmission through surgical smoke/laparoscopic pneumoperitoneum.

Methods

We performed a systematic review of currently available literature to determine the presence of severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) in abdominal tissues or fluids and in surgical smoke.

Results

A total of 19 studies (15 case reports and 4 case series) comprising 29 COVID-19 patients were included. The viral RNA was positively identified in 11 patients (37.9%). The samples that tested positive include the peritoneal fluid, bile, ascitic fluid, peritoneal dialysate, duodenal wall, and appendix. Similar samples, together with the omentum and abdominal subcutaneous fat, tested negative in the other patients. Only one study investigated SARS-COV-2 RNA in surgical smoke generated during laparoscopy, reporting negative findings.

Conclusions

There are conflicting results regarding the presence of SARS-COV-2 in abdominal tissues and fluids. No currently available evidence supports the hypothesis that SARS-COV-2 can be aerosolized and transmitted through surgical smoke. Larger studies are urgently needed to corroborate these findings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-021-02142-8.

Pharmacological Prophylaxis and Personal Protective Equipment (PPE) Practices in Gynecological Cancer Surgery During COVID-19 Pandemic

Purpose

In the absence of vaccine, proper use of personal protective equipment (PPE) is the most important strategy to protect healthcare workers against COVID-19 infection. The recommendations on pharmacological prophylaxis against COVID-19 infection are controversial. The aim of current study was to assess PPE practices during surgery on COVID-19 negative gynecological cancer patients and use of pharmacologic prophylaxis by clinicians practicing gynecologic oncology.

Methods

We disbursed a survey questionnaire through various social media platforms among clinicians practicing gynecologic oncology. The survey consisted of 37 questions divided into five subgroups evaluating demographic details, use of pharmacological prophylaxis against COVID-19, preoperative COVID-19 screening protocol, details on PPE usage and associated discomfort, if any.

Results

Two hundred twenty oncologists from 13 countries responded to the survey. Pharmacological prophylaxis was being used by 85 (38.6%) respondents; most common agent was hydroxychloroquin (HCQ) by 24.5% respondents. Routine preoperative screening for COVID-19 was performed by 214 (97.3%) respondents. Some degree of discomfort during surgery due to PPE use was reported by 170 (77.3%) respondents, which was moderate to severe in 73 (33.2%) respondents. Most common difficulties associated with face mask/shield were problems in communication (69.5%) and breathing (58.1%). Eye protection was associated with poor visibility, fogging and headache. Unusual fatigue attributed to PPE use was experienced by 143(65%) respondents.

Conclusion

Use of pharmacological prophylaxis against COVID-19 is controversial and the same is reflected in our survey. Most respondents adhered to PPE use despite experiencing some physical discomfort.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40944-021-00500-4.

Comparison of acute appendicitis before and within lockdown period in COVID-19 era: A retrospective study from rural Nepal

INTRODUCTION

The world has been engulfed with the pandemic of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which have created significant impact in the emergency surgical health delivery including acute appendicitis. The main aim of this study was to compare the demographic and clinical parameters between two cohorts before the onset of lockdown and within the pandemic.

METHODS

A retrospective analysis was performed between two groups A and B, who presented with acute appendicitis three months prior to and after initiation of lockdown on March 24 2020 respectively in one of the tertiary centers of Nepal. These two cohorts were compared in demographics, clinicopathological characteristics and surgical aspects of acute appendicitis.

RESULTS

There were 42 patients in group A and 50 patients in group B. Mean age of the patients was 31.32±17.18 years with male preponderance in group B (N = 29). Mean duration of pain increased significantly in group B [57.8±25.9(B) vs 42.3±25.0(A) hours, P = 0.004] along with mean duration of surgery [51.06±9.4(B) vs 45.27±11.8(A) minutes, P = 0.015]. There was significant decrease in post-operative hospital stay among group B patients [3.04±1.1(B) vs 3.86±0.67(A) days, P = 0.0001]. Complicated cases increased in group B including appendicular perforation in 10 cases. Similarly, mean duration of presentation to hospital significantly increased in group B patients with perforation [69.6±21.01 vs 51.57±17.63 hours, P = 0.008].

CONCLUSION

During the adversity of the current pandemic, increased number of cases of acute appendicitis can be dealt with surgery as the chances of late presentation and complexity of the lesion exists.

Laparoscopic Surgery in COVID-19 Era-Safety and Ethical Issues

(1) Background: The paper aims to review the available evidence regarding the health risk of the aerosolization induced by laparoscopy induced and impact of the COVID-19 pandemic upon minimally invasive surgery. (2) Materials and methods: A systematic review of the literature was performed on PubMed, Medline and Scopus until 10 July. (3) Results: Chemicals, carcinogens and biologically active materials, such as bacteria and viruses, have been isolated in surgical smoke. However, the only evidence of viral transmission through surgical smoke to medical staff is post-laser ablation of HPV-positive genital warts. The reports of SARS-CoV-2 infected patients who underwent laparoscopic surgery revealed the presence of the virus, when tested, in digestive wall and stools in 50% of cases but not in bile or peritoneal fluid. All surgeries did not result in contamination of the personnel, when protective measures were applied, including personal protective equipment (PPE) and filtration of the pneumoperitoneum. There are no comparative studies between classical and laparoscopic surgery. (4) Conclusions: Previously published data showed there is a possible infectious and toxic risk related to surgical smoke but not particularly proven for SARS-CoV-2. Implementing standardized filtration systems for smoke evacuation during laparoscopy, although increases costs, is necessary to increase the safety and it will probably remain a routine also in the future.