Abstract
The unprecedented pandemic of COVID-19 has impacted many lives and affects the whole healthcare systems globally. In addition to the considerable workload challenges, surgeons are faced with a number of uncertainties regarding their own safety, practice, and overall patient care. This guide has been drafted at short notice to advise on specific issues related to surgical service provision and the safety of minimally invasive surgery during the COVID-19 pandemic. Although laparoscopy can theoretically lead to aerosolization of blood borne viruses, there is no evidence available to confirm this is the case with COVID-19. The ultimate decision on the approach should be made after considering the proven benefits of laparoscopic techniques versus the potential theoretical risks of aerosolization. Nevertheless, erring on the side of safety would warrant treating the coronavirus as exhibiting similar aerosolization properties and all members of the OR staff should use personal protective equipment (PPE) in all surgical procedures during the pandemic regardless of known or suspected COVID status. Pneumoperitoneum should be safely evacuated via a filtration system before closure, trocar removal, specimen extraction, or conversion to open. All emergent endoscopic procedures performed during the pandemic should be considered as high risk and PPE must be used by all endoscopy staff.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
COVID-19 has demonstrated a propensity to spread at an exponential rate in several countries, significantly impacting many lives and significantly affecting the healthcare practice and healthcare professionals. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and The European Association for Endoscopic Surgeons (EAES) are committed to the protection and care of patients, supporting their members surgeons and staff, and all who are served by the medical community at large.
These joint recommendations draw on a number of sources including the limited available literature on the topic but more immediately from practicing surgeons across Europe, Asia, North America, and beyond. This guide is subject to update and we will continue to monitor emerging evidence and support novel research to address clinical and scientific gaps in this topic.
Through this prism, the following recommendations are being made with the aim that they can be of support to the surgical community in general and Minimally invasive Surgery (MIS) in particular, by addressing a number of uncertainties regarding the surgical practice, staff safety, and overall patient care. The recommendations are summarized in Table 1 and depicted in an infographic diagram (Fig. 1).
Rationalization of service
-
All elective surgical and endoscopic cases should be postponed at the current time. These decisions however should be made locally, based on COVID-19 burden and in the context of medical, logistical, and organizational considerations. There are different levels of urgency related to patient needs, and judgment is required to discern between them. However, as the numbers of COVID-19 patients requiring care is expected to escalate over the next few weeks, the surgical care of patients should be limited to those whose needs are imminently life threatening. These may include patients with malignancy that could progress or with active symptoms that require urgent care. All others should be delayed until after the peak of the pandemic is seen. This minimizes the risk to both patient and health care team, as well as minimizes utilization of necessary resources, such as beds, ventilators, and personal protective equipment (PPE).
-
All non-essential hospital or office staff should be allowed to stay home and telework. All in-person educational sessions should be cancelled and could be replaced by online resources. The minimum number of necessary providers should attend patients during rounds and other encounters. Adherence to hand washing, antiseptic foaming, and appropriate use of PPE should be strictly enforced. When necessary, in-person surgical consultation should be performed by decision makers only.
-
All non-urgent in-person clinic/office visits should be cancelled or postponed, unless needed to triage active symptoms or manage wound care. All patient visits should be handled remotely when possible, and in person only when absolutely necessary. Access to clinics should be maintained for those special circumstances to avoid patients seeking care in the Emergency Department (ED). Only a minimum of required support personnel should be present for these visits, and PPE should again be appropriately utilized. When in critical need, consideration should be given to redeploying OR resources for intensive care needs.
-
Multidisciplinary team (MDT) meetings should be held virtually as possible and/or limited to core team members only, including surgeon, pathologist, Clinical Nurse Specialist, radiologist, oncologist, and coordinator. The MDT is responsible for the decision making and classifying the patient’s priority level of need for surgery.
Procedural considerations
-
1.
There is very little evidence regarding the relative risks of minimally invasive surgery (MIS) versus the conventional open approach, specific to COVID-19. We will therefore continue to monitor emerging evidence and support novel research to address these issues.
-
2.
It is strongly recommended, however, that consideration be given to the possibility of viral contamination to staff during open, laparoscopic, or robotic surgery and that protective measures are strictly employed for OR staff safety and to maintain a functioning workforce.
-
3.
Although previous research has shown that laparoscopy can lead to aerosolization of blood borne viruses, [1,2,3] there is no evidence to indicate that this effect is seen with COVID-19, nor that it would be isolated to MIS procedures. Nevertheless, erring on the side of safety would warrant treating the coronavirus as exhibiting similar aerosolization properties. For MIS procedures, use of devices to filter released CO2 for aerosolized particles should be strongly considered.
-
4.
Proven benefits of MIS of reduced length of stay and complications [4,5,6,7] should be strongly considered in these patients, in addition to the potential for ultrafiltration of the majority of aerosolized particles. Filtration of aerosolized particles may be more difficult during open surgery [8, 9].
-
5.
There may also be enhanced risk of viral exposure to proceduralists/endoscopists from endoscopy and airway procedures. When these procedures are necessary, strict use of PPE should be considered for the whole team, following Centers for Disease Control (CDC, https://www.cdc.gov) or WHO (https://www.who.int) guidelines for droplet or airborne precautions. The PPE should include, at a minimum, N95 masks and face shields [10, 11].
Practical measures for surgery
-
1.
Consent discussion with patients must cover the risk of COVID-19 exposure and the potential consequences.
-
2.
If readily available and practical, surgical patients should be tested pre-operatively for COVID-19 and delay of surgery or additional protective measures enacted as appropriate for COVID-positive patients.
-
3.
If needed and possible, intubation and extubation should take place within a negative pressure room (https://www.asahq.org/in-the-spotlight/coronavirus-covid-19-information, https://icmanaesthesiacovid-19.org; [12, 13]).
-
4.
Operating rooms for presumed, suspected, or confirmed COVID-19-positive patients should be appropriately filtered and ventilated and, if possible, should be different than rooms used for other emergent surgical patients.
-
5.
Only those considered essential staff should be participating in the surgical case and unless there is an emergency, there should be minimal exchange of room staff [14].
-
6.
All members of the OR staff should use PPE as recommended by national or international organizations, including the WHO or CDC. These recommendations may be modified by local hospital policy, as necessary. Appropriate gowns and face shields should be utilized. These measures should be used in all surgical procedures during the pandemic regardless of known or suspected COVID status. Placement and removal of PPE in should be done according to CDC guidelines (link to CDC https://www.cdc.gov [15])
-
7.
Electrosurgery units should be set to the lowest possible settings for the desired effect. Use of monopolar electrosurgery, ultrasonic dissectors, and advanced bipolar devices should be minimized, as these can lead to particle aerosolization [16,17,18,19,20,21,22], and if available, monopolar diathermy pencils with attached smoke evacuators should be used.
-
8.
Surgical equipment used during procedures with COVID-19-positive or person under investigation (PUI)/suspected COVID patients should be cleaned separately from other surgical equipment.
Practical measures for laparoscopy
-
1.
Incisions for ports should be as small as possible to allow for the passage of ports but not allow for leakage around ports.
-
2.
CO2 insufflation pressure should be kept to a minimum and an ultrafiltration (smoke evacuation system or filtration) should be used, if available.
-
3.
At the end of surgery or before converting to open surgery or removal of trocars, the pneumoperitoneum should be carefully released [23] and should be safely evacuated via a filtration system in case of aerosol formed during the operation [9, 24, 25].
Practical measures for endoscopy
-
1.
The ability to control aerosolized virus during endoscopic procedures is lacking, so all members in the endoscopy suite or operating room should wear appropriate PPE, including gowns and face shields. Placement and removal of PPE should be done according to CDC guidelines [15, 26, 27].
-
2.
Since patients can present with gastrointestinal manifestations of COVID-19, all emergent endoscopic procedures performed in the current environment should be considered as high risk [10, 26,27,28].
-
3.
Since the virus has been found in multiple cells in the gastrointestinal tract and all fluids including saliva, enteric contents, stool, and blood, surgical energy should be minimized [29, 30].
-
4.
Endoscopic procedures that require additional insufflation of CO2 or room air by additional sources should be avoided if possible until we have better knowledge about the aerosolization properties of the virus. This would include many of the endoscopic mucosal resection (EMR) and endoluminal procedures.
-
5.
Removal of caps on endoscopes could release fluid and/or air and should be avoided.
-
6.
Endoscopic equipment used during procedures with COVID-19-positive or PUI patients should be cleaned separately from other endoscopic equipment.
Conclusions
The surgical management of patients with suspected or known or COVID‐19 requires specific considerations for theater staff and patient safety. Although specific evidence to COVID-19 and the risk for aerosol transmission during laparoscopy is lacking, every effort must be made to minimize this potential risk during surgery to protect staff and maintain a functioning workforce that can continue to care for our patients.
References
Alp E, Bijl D, Bleichrodt RP, Hansson B, Voss A (2006) Surgical smoke and infection control. J Hosp Infect 62(1):1–5
Eubanks S, Newman L, Lucas G (1993) Reduction of HIV transmission during laparoscopic procedures. Surg Laparosc 3(1):2–5
Kwak HD, Kim SH, Seo YS et al (2016) Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery. Occup Environ Med 73:857–863
COST Study Group (2004) A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 350:2050–2059
Lacy AM, Garcia-Valdecasas JC, Delgado S, Castells A, Taura P, Pique JM et al (2002) Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet 359:2224–2229
Veldkamp R, Kuhry E, Hop WC, Jeekel J, Kazemier G, Bonjer HJ et al (2005) Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol 6:477–484
Bonjer HJ, Deijen CL, Abis GA, Cuesta MA, van der Pas MH, de Lange-de Klerk ES et al (2015) A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med 372:1324–1332
Choi SH, Kwon TG, Chung SK, Kim TH (2014) Surgical smoke may be a biohazard to surgeons performing laparoscopic surgery. Surg Endosc 28(8):2374–2380
Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) https://www.sages.org/resources-smoke-gas-evacuation-during-open-laparoscopic-endoscopic-procedures.
Repici A, Maselli R, Colombo M, Gabbiadini R, Spadaccini M, Anderloni A, Carrara S, Fugazza A, Di Leo M, Galtieri PA, Pellegatta G, Ferrara EC, Azzolini E, Lagioia M (2020) Coronavirus (COVID-19) outbreak: what the department of endoscopy should know. Gastrointest Endosc. https://doi.org/10.1016/j.gie.2020.03.019
Lie SA, Wong SW, Wong LT, Wong TGL, Chong SY (2020) Practical considerations for performing regional anesthesia: lessons learned from the COVID-19 pandemic. Can J Anaesth. https://doi.org/10.1007/s12630-020-01637-0
Wax RS, Christian MD (2020) Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anaesth. https://doi.org/10.1007/s12630-020-01591-x
Zucco L, Levy N, Ketchandji D, Aziz M, Ramachandran SK. Anesthesia Patient Safety Foundation. https://www.apsf.org/news-updates/perioperative-considerations-for-the-2019-novel-coronavirus-covid-19/. Accessed 12 Feb 2020
Park J, Yoo SY, Ko JH, Lee SM, Chung YJ, Lee JH et al (2020) Infection prevention measures for surgical procedures during a middle east respiratory syndrome outbreak in a Tertiary Care Hospital in South Korea. Sci Rep 10(1):325. https://doi.org/10.1038/s41598-019-57216
Centers for Disease Control (CDC) and Prevention. https://www.cdc.gov. Accessed 6 Apr 2020
Parsa RS, Dirig NF, Eck IN, Payne WK III (2015) Surgical smoke and the orthopedic implications. Internet J Orthopedic Surg. https://doi.org/10.5580/IJOS.31497
Gloster HM Jr, Roenigk RK (1995) Risk of acquiring human papilloma-virus from the plume produced by the carbon dioxide laser in the treatment of warts. J Am Acad Dermatol 32:436–441
Garden JM, O‘Banion MK, Shelnitz LS et al (1988) Papillomavirus in the vapor of carbon dioxide laser-treated verrucae. JAMA 259:1199–1202
Ferenczy A, Bergeron C, Richart RM (1990) Human papillomavirus DNA in CO2 laser-generated plume of smoke and its consequences to the surgeon. Obstet Gynecol 75:114–118
Baggish MS, Poiesz BJ, Joret D, Williamson P, Refai A (1991) Presence of human immunodeficiency virus DNA in laser smoke. Lasers Surg Med 11:197–203
In SM, Park DY, Sohn IK et al (2015) Experimental study of the potential hazards of surgical smoke from powered instruments. Br J Surg 102:1581–1586
Wisniewski PM, Warhol MJ, Rando RF, Sedlacek TV, Kemp JE, Fisher JC (1990) Studies on the transmission of viral disease via the CO2 laser plume and ejecta. J Reprod Med 35:1117–1123
Royal Surgical Colleges, Association of Surgeon of Great Britain & Ireland, Association of Coloproctology of Great Britain & Ireland, & Association of Upper Gastrointestinal Surgeons. (2020) Intercollegiate General Surgery Guidance on COVID-19
Okoshi K, Kobayashi K, Kinoshita K, Tomizawa Y, Hasegawa S, Sakai Y (2015) Health risks associated with exposure to surgical smoke for surgeons and operation room personnel. Surg Today 45(8):957–965
Zheng MH, Boni L, Fingerhut A (2020) Minimally invasive surgery and the novel coronavirus outbreak: lessons learned from Italy. Ann Surg. https://doi.org/10.1097/SLA.0000000000003924
JOINT GI SOCIETY MESSAGE: COVID-19 Clinical Insights for Our Community of Gastroenterologists and Gastroenterology Care Providers. https://www.asge.org/home/joint-gi-society-message-covid-19. Accessed 6 Apr 2020
The British Society of Gastroentrology (BSG). https://www.bsg.org.uk. Accessed 6 Apr 2020
Chiu PWY, Ng SC, Inoue H, Reddy DN, Ling HuE, Cho JY, Ho LK, Hewett DG, Chiu HM, Rerknimitr R, Wang HP, Ho SH, Seo DW, Goh KL, Tajiri H, Kitano S, Chan FKL (2020) Practice of endoscopy during COVID-19 pandemic: position statements of the Asian Pacific Society for Digestive Endoscopy (APSDE-COVID statements). Gut. https://doi.org/10.1136/gutjnl-2020-321185
Gu J, Han B, Wang J (2020) COVID-19: gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology. https://doi.org/10.1053/j.gastro.2020.02.054
ASGE | JOINT GI SOCIETY MESSAGE- COVID-19 Clinical insights for our community of gastroenterologists and gastroenterology care providers. https://www.asge.org/home/joint-gi-society-message-covid-19.
Acknowledgements
This manuscript was reviewed by the Executive Boards of both SAGES and EAES, and we are grateful for their input and support. Useful website information: SAGES Telehealth Primer: https://www.sages.org/telehealth-primer-covid-19-pandemic/. SAGES Resources for Smoke and Gas Evacuation during Open, Laparoscopic, and Endoscopic Procedures: https://www.sages.org/resources-smoke-gas-evacuation-during-open-laparoscopic-endoscopic-procedures/. SAGES Summary of Commercially Available Pneumoperitoneum Smoke Evacuation Systems: https://www.sages.org/wp-content/uploads/2020/03/Summary-of-Commercially-Available-Pneumoperitoneum-Smoke-Evacuation-Systems.pdf
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Disclosures
Nader Francis, Jonathan Dort, Eugene Cho, Liane Feldman, Deborah Keller, Rob Lim, Dean Mikami, Edward Phillips, Konstantinos Spaniolas, Shawn Tsuda, Kevin Wasco, Tan Arulampalam, Markar Sheraz, Salvador Morales, Andrea Pietrabissa, Horacio Asbun, and Aurora Pryor have no conflicts of interest or financial ties to disclose.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Francis, N., Dort, J., Cho, E. et al. SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic. Surg Endosc 34, 2327–2331 (2020). https://doi.org/10.1007/s00464-020-07565-w
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-020-07565-w