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Benaim EH, Jaspers I. Surgical smoke and its components, effects, and mitigation: a contemporary review. Toxicol Sci 2024; 198:157-168. [PMID: 38243717 DOI: 10.1093/toxsci/kfae005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024] Open
Abstract
Energy-based surgical instruments produce surgical smoke, which contains harmful byproducts, such as polycyclic aromatic hydrocarbons, volatile organic compounds, particulate matter, and viable microorganisms. The research setting has shifted from the laboratory to the operating room. However, significant heterogeneity in the methods of detection and placement of samplers, diversity in the tissue operated on, and types of surgeries tested has resulted in variability in detected levels and composition of surgical smoke. State regulation limiting surgical smoke exposure through local evacuators is expanding but has yet to reach the national regulatory level. However, most studies have not shown levels above standard established limits but relatively short bursts of high concentrations of these harmful by-products. This review highlights the limitations of the current research and unsupported conclusions while also suggesting further areas of interest that need more focus to improve Occupational Safety and Health Administration guidelines.
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Affiliation(s)
- Ezer H Benaim
- Center for Environmental Medicine, Asthma and Lung Biology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA
| | - Ilona Jaspers
- Center for Environmental Medicine, Asthma and Lung Biology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA
- Curriculum in Toxicology & Environmental Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA
- Center for Environmental Medicine, Asthma, and Lung Biology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA
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Kahramansoy N. Surgical smoke: a matter of hygiene, toxicology, and occupational health. GMS HYGIENE AND INFECTION CONTROL 2024; 19:Doc14. [PMID: 38655124 PMCID: PMC11035985 DOI: 10.3205/dgkh000469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
The use of devices for tissue dissection and hemostasis during surgery is almost unavoidable. Electrically powered devices such as electrocautery, ultrasonic and laser units produce surgical smoke containing more than a thousand different products of combustion. These include large amounts of carcinogenic, mutagenic and potentially teratogenic noxae. The smoke contains particles that range widely in size, even as small as 0.007 µm. Most of the particles (90%) in electrocautery smoke are ≤6.27 µm in size, but surgical masks cannot filter particles smaller than 5 µm. In this situation, 95% of the smoke particles which pass through the mask reach deep into the respiratory tract and frequently cause various symptoms, such as headache, dizziness, nausea, eye and respiratory tract irritation, weakness, and abdominal pain in the acute period. The smoke can transport bacteria and viruses that are mostly between 0.02 µm and 3 µm in size and there is a risk of contamination. Among these viruses, SARS-CoV-2, influenza virus, HIV, HPV, HBV must be considered. The smoke may also carry malignant cells. The long-term effects of the surgical smoke are always ignored, because causality can hardly be clarified in individual cases. The quantity of the smoke changes with the technique of the surgeon, the room ventilation system, the characteristics of the power device used, the energy level at which it is set, and the characteristics of the tissue processed. The surgical team is highly exposed to the smoke, with the surgeon experiencing the highest exposure. However, the severity of exposure differs according to certain factors, e.g., ventilation by laminar or turbulent mixed airflow or smoke evacuation system. In any case, the surgical smoke must be removed from the operation area. The most effective method is to collect the smoke from the source through an aspiration system and to evacuate it outside. Awareness and legal regulations in terms of hygiene, toxicology, as well as occupational health and safety should increase.
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Affiliation(s)
- Nurettin Kahramansoy
- Department of Surgery, İzmir Bozyaka Education and Research Hospital, İzmir, Turkiye
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Steel BJ, Horridge C, Awni S, Adams JR. Chemical constituents, viable micro-organism and malignant cell content in ultrasonic scalpel plume: A literature review. J Perioper Pract 2024; 34:47-56. [PMID: 36635896 DOI: 10.1177/17504589221140990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE To identify all published data on the chemical, micro-organism and malignant cell contents of ultrasonic scalpel plume, if any, and on any clinical implications of the contents on patients and operating staff. METHODS Searches were conducted aiming to identify all published evidence on the chemical constituents, presence/absence of viable micro-organisms and malignant cells in ultrasonic scalpel plume. Attempts were made to source unpublished industry data. RESULTS There is evidence from human and in vitro studies of the presence of a range of harmful, and some human carcinogenic, chemicals within ultrasonic plume, mostly at very low concentrations. Any clinical relevance of this has not been studied. There is evidence from experimental studies of the presence of hepatitis virus, human coronavirus and human papillomavirus material within ultrasonic plume. Any clinical effect of this has not been studied. There is conflicting evidence from combined in vitro and mouse model studies of the presence of viable malignant cells within ultrasonic plume. Any clinical relevance of this has also not been studied. CONCLUSION Overall, relatively little research into the plume has been published, and further study is required to more clearly delineate any potential risk to patients, surgeons and other theatre staff. Current safety recommendations are discussed.
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Affiliation(s)
- Ben J Steel
- Department of Oral and Maxillofacial Surgery, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Catherine Horridge
- Department of Oral and Maxillofacial Surgery, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Sarah Awni
- Department of Oral and Maxillofacial Surgery, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - James R Adams
- Department of Oral and Maxillofacial Surgery, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
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Cizmic A, Eichel VM, Weidner NM, Wise PA, Müller F, Rompen IF, Bartenschlager R, Schnitzler P, Nickel F, Müller-Stich BP. Viral load of SARS-CoV-2 in surgical smoke in minimally invasive and open surgery: a single-center prospective clinical trial. Sci Rep 2023; 13:20299. [PMID: 37985848 PMCID: PMC10662446 DOI: 10.1038/s41598-023-47058-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/08/2023] [Indexed: 11/22/2023] Open
Abstract
At the beginning of the COVID-19 pandemic, it was assumed that SARS-CoV-2 could be transmitted through surgical smoke generated by electrocauterization. Minimally invasive surgery (MIS) was targeted due to potentially higher concentrations of the SARS-CoV-2 particles in the pneumoperitoneum. Some surgical societies even recommended open surgery instead of MIS to prevent the potential spread of SARS-CoV-2 from the pneumoperitoneum. This study aimed to detect SARS-CoV-2 in surgical smoke during open and MIS. Patients with SARS-CoV-2 infection who underwent open surgery or MIS at Heidelberg University Hospital were included in the study. A control group of patients without SARS-CoV-2 infection undergoing MIS or open surgery was included for comparison. The trial was approved by the Ethics Committee of Heidelberg University Medical School (S-098/2021). The following samples were collected: nasopharyngeal and intraabdominal swabs, blood, urine, surgical smoke, and air samples from the operating room. An SKC BioSampler was used to sample the surgical smoke from the pneumoperitoneum during MIS and the approximate surgical field during open surgery in 15 ml of sterilized phosphate-buffered saline. An RT-PCR test was performed on all collected samples to detect SARS-CoV-2 viral particles. Twelve patients with proven SARS-CoV-2 infection underwent open abdominal surgery. Two SARS-CoV-2-positive patients underwent an MIS procedure. The control group included 24 patients: 12 underwent open surgery and 12 MIS. One intraabdominal swab in a patient with SARS-CoV-2 infection was positive for SARS-CoV-2. However, during both open surgery and MIS, none of the surgical smoke samples showed any detectable viral particles of SARS-CoV-2. The air samples collected at the end of the surgical procedure showed no viral particles of SARS-CoV-2. Major complications (CD ≥ IIIa) were more often observed in SARS-CoV-2 positive patients (10 vs. 4, p = 0.001). This study showed no detectable viral particles of SARS-CoV-2 in surgical smoke sampled during MIS and open surgery. Thus, the discussed risk of transmission of SARS-CoV-2 via surgical smoke could not be confirmed in the present study.
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Affiliation(s)
- Amila Cizmic
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Vanessa M Eichel
- Department of Infectious Diseases, Section Infection Control University Hospital Heidelberg, Heidelberg, Germany
| | - Niklas M Weidner
- Department of Infectious Diseases, Virology, Heidelberg University, Heidelberg, Germany
- Department of Infectious Diseases, Medical Microbiology and Hygiene, University Hospital Heidelberg, Heidelberg, Germany
| | - Philipp A Wise
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Felix Müller
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ingmar F Rompen
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ralf Bartenschlager
- Department of Infectious Diseases, Molecular Virology, University Hospital Heidelberg, Heidelberg, Germany
| | - Paul Schnitzler
- Department of Infectious Diseases, Virology, Heidelberg University, Heidelberg, Germany
| | - Felix Nickel
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Beat P Müller-Stich
- Department of Digestive Surgery, University Digestive Healthcare Center Basel, Kleinriehenstrasse 30, 4058, Basel, Switzerland.
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Zhou YZ, Wang CQ, Zhou MH, Li ZY, Chen D, Lian AL, Ma Y. Surgical smoke: A hidden killer in the operating room. Asian J Surg 2023; 46:3447-3454. [PMID: 37002044 DOI: 10.1016/j.asjsur.2023.03.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/12/2023] [Accepted: 03/15/2023] [Indexed: 03/31/2023] Open
Abstract
Surgical smoke is a byproduct of aerosols containing several components produced by energy equipment. The characteristics of surgical smoke components produced by different types of tissues or using different kinds of energy devices vary. For example, the average diameter of smoke particles produced by electrocautery is smaller, and the possibility of viable cells and pathogens in surgical smoke produced by an ultrasonic knife is higher. According to the characteristics of its composition, surgical smoke may be an important risk factor affecting the health and safety of operating room staff and patients. The use of surgical masks, suction devices and portable smoke evacuation systems can reduce this risk to some extent. However, most operating room staff members do not implement corresponding measures to protect themselves. In this paper, the characteristics of surgical smoke and the research progress in protective measures are briefly reviewed.
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Affiliation(s)
- Yong-Zhi Zhou
- Department of Minimal Invasive Hepatic Surgery of the First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China; Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, 150001, China
| | - Chao-Qun Wang
- Department of Minimal Invasive Hepatic Surgery of the First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China; Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, 150001, China
| | - Meng-Hua Zhou
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, 150001, China; Department of Hepatic Surgery, The First Affliated Hospital of Harbin Medical University, Harbin, 150001, China
| | - Zhong-Yu Li
- Department of Minimal Invasive Hepatic Surgery of the First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China; Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, 150001, China
| | - Dong Chen
- Department of Minimal Invasive Hepatic Surgery of the First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China; Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, 150001, China
| | - Ai-Ling Lian
- Operating Room, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China.
| | - Yong Ma
- Department of Minimal Invasive Hepatic Surgery of the First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China; Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, 150001, China.
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Chene G. [Surgical smoke management in the operating room]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2023; 51:1-2. [PMID: 36462713 DOI: 10.1016/j.gofs.2022.11.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 11/25/2022] [Indexed: 12/05/2022]
Affiliation(s)
- G Chene
- Département de chirurgie gynécologique, hôpital Femme-Mère-Enfant HFME, university hospital of Lyon, 59, boulevard Pinel, hospices civils de Lyon, 69500 Bron, France; Université Claude-Bernard Lyon 1, EMR 3738 CICLY, 69000 Lyon, France.
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Hany M, Zidan A, Gaballa M, Ibrahim M, Agayby ASS, Abouelnasr AA, Sheta E, Torensma B. Lingering SARS-CoV-2 in Gastric and Gallbladder Tissues of Patients with Previous COVID-19 Infection Undergoing Bariatric Surgery. Obes Surg 2023; 33:139-148. [PMID: 36316598 PMCID: PMC9628579 DOI: 10.1007/s11695-022-06338-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Lingering severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in gut tissue might be a source of infection during bariatric surgery. This study aimed to confirm the presence of SARS-CoV-2 nucleocapsid in gastric and gallbladder tissues removed during bariatric surgery in individuals previously infected with coronavirus disease 2019 (COVID-19) who had negative polymerase chain reaction results prior to the surgery. METHODS Gastric and gallbladder specimens from 80 patients who underwent bariatric surgery between November 2021 and May 2022 and had a history of COVID-19 infection with gastrointestinal symptoms were examined for the presence of lingering SARS-CoV-2 nucleocapsid proteins using immunohistochemistry. RESULTS Gastric specimens from 26 (32.5%) patients and 4 (100%) cholecystectomy specimens showed positive cytoplasmic staining for the anti-SARS-CoV-2 nucleocapsid protein in surface mucosal epithelial cells. The mean age was 37.8 ± 10.3 years. The average body mass index was 44.2 ± 7.0 kg/m2; most of the patients were females (71.3%). The positive staining group was significantly younger than the negative staining group (p = 0.007). The full-dose vaccination rate was 58.8%, with a median of 91 days after the last vaccine dose. A positive serological anti-spike IgG response was observed in 99% of the patients. The median time between initial COVID-19 infection and surgery was 274 and 380 days in the positive and negative staining groups, respectively (p = 0.371). CONCLUSION Gastric and gallbladder tissues can retain SARS-CoV-2 particles for a long time after COVID-19 infection, handling stomach specimens from patients during an operation must be done with care, as we usually do, but now with the knowledge that in 1/3 of patients they can be present. Performing LSG on post-COVID patients did not seem to increase perioperative morbidity.
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Affiliation(s)
- Mohamed Hany
- grid.7155.60000 0001 2260 6941Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, 21561 Alexandria Egypt ,Madina Women’s Hospital, Alexandria, Egypt
| | - Ahmed Zidan
- grid.7155.60000 0001 2260 6941Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, 21561 Alexandria Egypt
| | - Muhammad Gaballa
- grid.7155.60000 0001 2260 6941Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, 21561 Alexandria Egypt
| | - Mohamed Ibrahim
- grid.7155.60000 0001 2260 6941Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, 21561 Alexandria Egypt
| | - Ann Samy Shafiq Agayby
- grid.7155.60000 0001 2260 6941Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, 21561 Alexandria Egypt
| | - Anwar Ashraf Abouelnasr
- grid.7155.60000 0001 2260 6941Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, 21561 Alexandria Egypt
| | - Eman Sheta
- grid.7155.60000 0001 2260 6941Pathology Department, Alexandria University, Alexandria, Egypt
| | - Bart Torensma
- grid.10419.3d0000000089452978Leiden University Medical Center (LUMC), Leiden, The Netherlands
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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. Med Sci (Basel) 2021; 9:medsci9040070. [PMID: 34842760 PMCID: PMC8628878 DOI: 10.3390/medsci9040070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 10/14/2021] [Accepted: 10/27/2021] [Indexed: 11/25/2022] Open
Abstract
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.
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Major AL, Jumaniyazov K, Yusupova S, Jabbarov R, Saidmamatov O, Mayboroda-Major I. Laparoscopy in Gynecologic and Abdominal Surgery in Regional (Spinal, Peridural) Anesthesia, the Utility of the Technique during COVID-19 Pandemic. MEDICINES (BASEL, SWITZERLAND) 2021; 8:60. [PMID: 34677489 PMCID: PMC8541053 DOI: 10.3390/medicines8100060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/07/2021] [Accepted: 10/12/2021] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Attila Louis Major
- Femina Gynecology Centre, CH-1205 Geneva, Switzerland
- Department of Obstetrics & Gynecology, University of Fribourg, CH-1700 Fribourg, Switzerland
| | - Kudrat Jumaniyazov
- Department of Obstetrics and Gynecology, Urgench Branch of Tashkent Medical Academy, Urgench 220100, Uzbekistan; (K.J.); (S.Y.); (R.J.)
| | - Shahnoza Yusupova
- Department of Obstetrics and Gynecology, Urgench Branch of Tashkent Medical Academy, Urgench 220100, Uzbekistan; (K.J.); (S.Y.); (R.J.)
| | - Ruslan Jabbarov
- Department of Obstetrics and Gynecology, Urgench Branch of Tashkent Medical Academy, Urgench 220100, Uzbekistan; (K.J.); (S.Y.); (R.J.)
| | - Olimjon Saidmamatov
- Faculty of Tourism and Economics, Urgench State University, Urgench 220100, Uzbekistan
| | - Ivanna Mayboroda-Major
- Department of Gynecology and Obstetrics, University Hospital of Geneva, CH-1205 Geneva, Switzerland
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