Minimal access surgery during COVID-19 wave – Review of literature

General recommendations

1. All patients should undergo SARS-CoV-2 PCR testing 24 h prior to surgery. Patients who are SARS-CoV-2 PCR negative but positive for antibody do not require any further testing during the hospital stay days and patients who are PCR negative and antibody-negative for SARS-CoV-2 require testing to be done once a week during their hospital stay. Patients who are SARSCoV-2 positive should be treated according to national guidelines and surgery should be postponed if possible until recovery and viral shedding stop^[10]

2. Limiting health-care personnel and traffic in the OR room to reduce the amount of exposure and number of staff exposed

3. Dedicated OT and operating team for COVID-19-positive patients if feasible

4. The OR should be equipped with high-efficiency particulate air (HEPA) filter with ideally >25 air exchanges in the theatre

5. Positive pressure (laminar flow and air conditioners) to be switched off before intubation and extubation

6. Entry of surgeons and nurses into the operating room 20 min after intubation and leaving OT during extubation to keep exposure to a minimum

7. Regional anesthesia is favored over general anesthesia with endotracheal intubation since the latter is a high aerosol-producing procedure

8. Vaccination status of the patient should be kept in mind during the pre-operative period. If the patient is not vaccinated, consider the patient for vaccination unless the procedure is an emergency

9. All vaccines are now already proven to be practical, secure, and efficacious tools to prevent severe COVID-19, days of hospital stay, and death, but the quality of evidence greatly differs depending on the type, dose, and duration of vaccines considered.

Procedure-related considerations

1. There is very low authentication regarding the relative risk of transmission of SARS-CoV-2 of open, laparoscopic, or robotic surgery. Emerging evidence will determine the safest approach to surgery. Precautionary measures are to be strictly implemented for operation theater personals to reduce the chance of contamination, transmission, and to maintain the workforce. Strict use of PPE which includes N95 masks and face shields should be used by all OR staff regardless of known or suspected COVID-19 status^[11,12]

2. Although currently, there is very less evidence to indicate that laparoscopy leads to the dispersal of the virus as aerosol, devices to filter released CO₂ are strongly recommended. Minimal access surgery has proven benefits of decreased length of stay and complications and potential for filtration of aerosolized particles whereas it is difficult to filter aerosolized particles in open surgery.

Feasible measures for surgery

1. Patient’s consent for surgery should cover the possibility of COVID-19 exposure and possible consequences

2. If helpful surgical patients should be preoperatively tested for COVID-19 so that protective measures can be enacted as required. Personnel in the OT should Don adequate PPE according to PPE guidelines

3. Negative pressure room is to be used for procedures on the airway such as intubation and extubation. Operating theaters for COVID-19 suspected and confirmed patients should be different from others with adequate filtration and ventilation^[13,14]

4. Only the crucial staff should be participating in the surgery with the minimal exchange of room staff unless there is an emergency.^[15] Minimum 1 h interval/time gap should be maintained in between consecutive surgeries. Disinfection of OT tables and trolleys using 1% sodium hypochlorite

5. Minimizing duration of surgeries by avoiding multiple and complex procedures, surgical, and nursing training

6. The lowest possible settings should be used in electrosurgical units. The use of monopolar cautery devices, advanced bipolar devices, and ultrasonic dissectors which generate aerosols should be kept down or used with smoke evacuators. Surgical instruments used for COVID-19 patients should be cleaned separately. Bipolar is preferred over monopolar energy and pulses are kept short on tissue area^[16]

7. Minimal use and short burst usage are advised. Cold hemostasis is the choice method

8. Incisions for ports should be just adequate for passage of trocar to prevent leaks around the ports. Minimum number of incisions and minimum size for port sites. Avoidance of hand-assisted surgery

9. Minimizing the degree of Trendelenburg incision

10. Carbon dioxide insufflation should be done at the lowest possible flow rate. Pneumoperitoneum should be created with a closed technique and maintained at 10–12 mmHg and a smoke deportation system should be used. Pneumoperitoneum should be cleared through the system of filtration^[17,18]

11. Measures such as avoiding opening of trocar stopcocks, connection of trocars to filter for evacuation of smoke, minimal torque at trocar sites, airtightness around trocars, and port site closure after complete desufflation of pneumoperitoneum help to decrease the spread of aerosols^[16]

12. Insufflator port site should be closed before while removing tubing from the port site or switching off the insufflator

13. Specimens retrieval and fascia closure need to be done once all gas and smoke are evacuated.

Concerns in minimally invasive surgery

Aerosolization of a virus, leak from port sites, and chances of COVID-19 infection to operating time are the topmost concerns during every COVID-19 pandemic. There is no actual data on COVID-19 risk during conventional laparoscopy and robotic surgery.^[19]

The release of pneumoperitoneum is giving rise to most of the aerosol in the operation theater. SAGES and royal college of surgeons of England (RCS) have advised caution regarding minimally invasive surgery that minimally invasive surgery has a potential risk of transmission of infection although there is no evidence for the same.

The release of CO₂ cannot be eliminated as closed ports with valves leak when instruments are inserted. The CO₂ and plume need to be filtered to reduce the release of untreated aerosols in the air. Although there was no evidence that CO₂ and plumes have COVID-19 virus, previous studies have shown that hepatitis B viral RNA has been detected in surgical smoke. There are case reports on exposed surgeons getting infected with HPV after performing laser ablation on HPV-positive tumors.^[6,20]

The size of the COVID-19 virus is between 60 and 140 nm.^[21] Smoke evacuation and filtration systems such as AirSeal (0.01 micron size filter), SurgiQuest, and PneumoClear (0.08 micron size filter) removes CO₂ and pass them through ultra-low particulate air (ULPA) filter. Use of these systems further decreases the spread of the virus. Another concern is the suction devices that remove a considerable amount of CO₂ are also to be filtered by connecting to filtration systems like Neptune waste evacuation systems

Applying standard methods of filtration for smoke clearance during minimally invasive surgery, although escalate the cost, are mandatory for the safety of both patient and healthcare professionals. Thus, it will probably remain a normal practice in the future.^[22] The most recommended filters are HEPA filters, with a capability of almost 100% in filtering particles >0.03 µm diameter or ULPA filters, which can evacuate particles >0.05 µm in size. Various cost-effective filtration systems were developed, both having as the central piece a heat and moisture exchangers (HME) filter, with connection to a trocar which allows safe desufflation of carbon dioxide and other surgical gas. Because of having high resistance to flow along with bacterial and viral filtration efficiency of ≥99.999%, HME filters have come to light.^[22] Use of the different kinds of filters made its high cost.

This apprehension led to recommending the restrictions regarding minimally invasive surgery. However, the benefits of minimally invasive surgery on patient recovery cannot be left unaccounted.