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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 1-8

Surgery during the COVID-19 pandemic


1 Department of Minimal Access Surgery, P. D. Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
2 Department of Respiratory Medicine, P. D. Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India

Date of Submission24-Jul-2020
Date of Decision29-Aug-2020
Date of Acceptance09-Dec-2020
Date of Web Publication19-Jan-2021

Correspondence Address:
Dr. Deepraj Bhandarkar
Department of Minimal Access Surgery, Room No. 2103, OPD Building, Hinduja Hospital, Veer Savarkar Road, Mahim, Mumbai - 400 016, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_29_20

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  Abstract 

The COVID-19 pandemic has impacted health-care systems worldwide, mandating novel measures to protect patients and health-care workers. In addition to the stratification of risks in terms of patient, anesthesia, and surgery, surgeons will now have to consider infectious risks associated with the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus in their preoperative assessment. It is imperative that surgeons adapt to this new challenge, which is likely to be a part of the foreseeable future. This review aims to guide the operating surgeon to make informed decisions regarding risks associated with the virus, and how to best prepare for the same. It is a collation of the current knowledge in the field and covers (a) SARS-CoV-2 epidemiology, clinical characteristics, and testing; (b) strategies for stratification of surgeries; (c) preoperative testing; (d) preoperative considerations; (e) intraoperative concerns; (f) precautions to be followed in the performance of open as well as laparoscopic surgery; and (e) issues related to resumption of elective surgery.

Keywords: COVID-19, laparoscopic surgery, severe acute respiratory syndrome-coronavirus-2, surgery


How to cite this article:
Bhandarkar D, Pinto L. Surgery during the COVID-19 pandemic. Saudi Surg J 2020;8:1-8

How to cite this URL:
Bhandarkar D, Pinto L. Surgery during the COVID-19 pandemic. Saudi Surg J [serial online] 2020 [cited 2021 Jul 30];8:1-8. Available from: https://www.saudisurgj.org/text.asp?2020/8/1/1/307417


  Introduction Top


As of late April 2020, most of the humanity is in various states of lockdown due to the COVID-19 pandemic. In these challenging times, surgeons need to stay focused on (a) keeping themselves, their families, and the communities they live in safe; (b) learning information that is of relevance to their functioning as surgeons during the pandemic; and (c) preparing themselves for the likely challenges when the pandemic is over. There is good-quality information available online and the recommendations related to the practice of surgery in the COVID-19 era are constantly evolving. This review collates, compiles, and crystallizes the current knowledge in this field.


  Severe Acute Respiratory Syndrome-Coronavirus-2: Epidemiology and Clinical Characteristics Top


COVID-19 is caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). It is likely that the virus originated in horseshoe bats, and was transmitted to humans through an unidentified intermediate mammalian host.[1] The presence of virus has been documented on surfaces (fomites)[2] and in blood, body fluids, and feces.[3] Once infected, a person can remain asymptomatic or develop symptoms after an incubation period varying between 0 and 24 days, with a mean of 3–9 days. Common symptoms include fever, cough, fatigue, and dyspnea; uncommon ones are myalgia, anorexia, anosmia, nausea, diarrhea, headache, and abdominal pain.[4],[5] Even before the symptomatic phase, nasopharyngeal shedding in close contacts of patients has been demonstrated,[6],[7] and it is this feature that makes screening of asymptomatic individuals crucial in a health-care setting. A proportion of infections in China were acquired from health-care workers (HCWs),[8] and surgeons must do their utmost to prevent this from occurring. Once asymptomatic, most individuals stop shedding the virus after 15 days, although some continue to do so for a longer period.[9]


  Severe Acute Respiratory Syndrome-Coronavirus-2: Testing Top


Detecting the presence of virus

The reference or “gold” standard for detecting the presence of the virus is the demonstration of viral ribonucleic acid (RNA) in a specimen collected from an individual. This is achieved through nucleic acid amplification by reverse transcription-polymerase chain reaction (RT-PCR). The preferred specimen is a nasopharyngeal swab, which has a higher sensitivity (70%) than that of a pharyngeal/throat swab (32%).[3],[10],[11]

Rapid antigen tests, which are chromatographic immunoassays, have now been developed to detect the presence of the virus in the nasopharynx. These tests have a high specificity but variable sensitivity, thereby mandating a confirmatory test if the virus is not detected in a setting of a high pretest probability. While rapid tests are very useful in a high-prevalence setting, that is, in symptomatic patients, we do not recommend them for screening, as the predictive value is likely to low in a low-prevalence setting.[12]

Detecting the presence of antibodies in the virus

Serological tests can be used to detect an antibody response to the virus. However, the antibody response is not immediate, and there is an early window period during which an infected person does not demonstrate the presence of antibodies. Patients infected with SARS-CoV-2 typically develop detectable antibodies 7–11 days post infection.[13] The IgM antibodies appear first, and are the first to wane, whereas the IgG antibodies appear later, and have a sustained presence. As the antibody tests get standardized, it may be possible to fine-tune the interpretation of the results in terms of the temporality of infection and the degree of immunity conferred.[14] Presently, caution needs to be exercised in the use and interpretation of the multitude of available assays, as not all have been validated.[14]

Detecting the morphological changes caused by the virus on chest tomography

Computed tomography (CT) of the chest may have a role in the diagnostic algorithm. A study of 1014 patients from China, in whom 59% had positive RT-PCR results for SARS-CoV-2, found CT scans of the chest to have a sensitivity of 97%, with a poor specificity of 25%.[15] A later study conducted with radiologists from China and the USA reported high specificities in distinguishing COVID from non-COVID viral pneumonias.[16] The findings of peripheral distribution, ground-glass opacity, and vascular thickening were found to be specific for COVID pneumonias. CT scans are expensive, and their interpretation is a function of the expertise available.


  Stratification of Surgeries Top


It is impossible to predict the magnitude of the COVID-19 pandemic for a country. Health-care systems around the world have struggled to cope with the patient load when the incidence of cases peaks.

The rationale for stratifying surgeries and undertaking only those which are absolutely necessary is to: (a) reduce the risk of the patients getting exposed to the viral infection in the hospital; (b) help preserve resources for better management of the patients in the eventuality of a sudden surge; (c) safeguard HCWs; (d) prevent the shutting down of hospitals due to HCWs being quarantined; and (e) make surgeons, anesthetists, and the operation theater (OT) teams available for supporting wider emergency care, if needed.

The guidance issued by the Royal Colleges in the UK along with the National Health Service (NHS)[17] categorizes patients requiring surgery into the following five priority levels: level 1 are emergencies which require surgery within 24 h, Level 1b are urgent surgeries which should be undertaken within 72 h, Level 2 are surgeries which can be deferred for up to 4 weeks, Level 3 are surgeries that can be delayed for up to 3 months, and Level 4 are surgeries which can be delayed for more than 3 months [Table 1].
Table 1: Examples of surgeries stratified by indication and surgery

Click here to view



  Preoperative Testing of Patients Top


Emergency and urgent cases

Ideally, if the local policies and availability of the test kits permit it, SARS-CoV-2 RT-PCR testing (from a nasopharyngeal swab) should be used for all patients. The American College of surgeons (ACS) endorsed this view in March 2020, and despite the progress we have made since, the inability to predict infection based on biomarkers, especially in asymptomatic individuals, has resulted in later guidelines from various other professional bodies recommending the same.[18],[19] The ACS, in a recent joint statement with the American Society of Anesthesiologists, Association of Perioperative Registered Nurses, and American Hospital Association, does not deviate from the original recommendations.[20]

If universal testing is not feasible, it is better to assume that these patients may be carriers of the virus and take due precautions. Where it is not feasible to wait for the results of the RT-PCR, a combination of a rapid antibody test and chest CT would offer the highest accuracy. If, however, the turnaround time for a RT-PCR is a few hours, and if such delay is acceptable for a patient, a combination of RT-PCR and a rapid antibody test would possibly be the preferred modality. A positive antibody test in the absence of detectable viral RNA in a nasopharyngeal swab should prompt a second swab.

Elective surgery

All patients must undergo RT-PCR and a rapid antibody test before being admitted to the hospital. A person with both tests negative could either be uninfected, or in the window period, and a repeat RT-PCR test should be done after a minimum period of 24 h. A positive RT-PCR is considered as being evidence of active infection, and one would proceed with surgery only if the institution has the capabilities that the admission of such a patient would entail. A positive antibody test in the absence of detectable viral RNA in a nasopharyngeal swab should prompt a waiting period of a week without symptoms followed by a repeat nasopharyngeal swab before proceeding with elective surgery. The only exception to this would be if the IgG antibody is positive, the IgM antibody is negative, and there is no detectable viral RNA in the nasopharyngeal swab. This would suggest past infection that has resolved, in which case the patient could be taken up for surgery without further testing. Our suggested algorithm is presented in [Figure 1].
Figure 1: Suggested algorithm for preoperative testing

Click here to view



  Considerations to Be Cognizant of Before Operating Top


Risk of developing COVID-19 infection for health-care workers

HCWs are at a high risk of acquiring the SARS-CoV-2 infection. A study from Wuhan province found that those working in high-risk departments including the OT were over at a 2.13 times higher risk of getting infected.[21] The risk was higher with longer duty hours and reduced with strict hand hygiene measures. In Italy too, 20% of HCWs have become infected and some have died.[22]

Patient counseling and consent

It is important to adequately counsel the patient and the family about the diagnosis, the prognosis, the treatment options, the reasons for recommending an emergency or urgent surgery, and the risk of exposure to SARS-CoV-2. A model consent form for use in COVID-19 era has been proposed.[23]

Thrombo-embolic prophylaxis

It has been observed that patients with COVID-19 infection may predispose patients to thrombotic events.[24] It is unknown whether this is as a result of SARS-CoV-2 or the consequence of a “cytokine storm” that precipitates the onset of systemic inflammatory response syndrome. There may be an increased incidence of venous thrombo-embolism in patients receiving intensive care for COVID-19 infection. In a recent publication, Grillet et al. identified CT angiographic findings of acute pulmonary embolism in 23% of the patients with features of severe COVID-19 infection.[25] All patients undergoing emergency surgery, irrespective of their COVID-19 status, should be considered for thrombo-embolic prophylaxis.


  Intraoperative Concerns Top


Presence of virus in peritoneal fluid

SARS-CoV-2 was found in the peritoneal fluid in a patient undergoing laparotomy for bowel obstruction.[26] Whether this was a result of transmigration across the wall, as is known to happen in patients with obstruction, is unknown. On the other hand, in a patient with COVID-19 disease undergoing laparoscopic appendectomy, peritoneal fluid samples obtained at the beginning and end of the surgery both tested negative for the virus.[27] Though the findings are conflicting, it is prudent for the HCWs to take precautions when performing abdominal surgery.

Risk of viral transmission in surgical smoke in open and laparoscopic surgeries

Since the beginning of the pandemic, there has been considerable debate over the risk of viral transmission in smoke produced during open and laparoscopic surgeries. Mintz et al. recently published an extensive review after analyzing fifty articles on the subject.[28] They concluded that (a) there is no difference in the generation of smoke or the cumulative concentration of particles in it during open and laparoscopic surgeries. In fact, during open surgery, the smoke spreads throughout the OT, whereas in laparoscopy, it remains contained within the abdomen, until released; (b) previous publications that point to the presence of viruses in the surgical smoke relate to the use of laser or oscillating bone-cutting tools. Few recent experimental studies have shown stability of SARS-CoV-2 in aerosols but not its viability. SARS-CoV-2 has not been documented in the surgical smoke, and there is no data to suggest that it can spread in this manner; and (c) laparoscopic surgery may in fact be safer than laparotomy as during the former, the aerosol remains contained within the abdomen until it is evacuated via filters in the safe environment of the OT with rapid air exchanges. Though the potential for SARS-CoV-2 to infect HCWs via surgical smoke appears theoretical, more research is warranted in this area and in the interim, it is prudent to take adequate precautions while performing all surgeries.


  Performance of Surgery in the Times of the COVID-19 Pandemic Top


Due to constraints on the availability of routine testing as well as the possibility of false-negative tests, it is advisable to take certain precautions during all surgeries. These become even more pertinent when operating on a patient known to be COVID-19 positive or during emergency surgery where the testing may not have been possible.


  General Considerations Top


  • The surgery should be performed by experienced surgeons in order to minimize the operative time
  • Until induction of anesthesia and intubation are completed, the surgical team should remain outside the OT
  • Surgery should be performed with minimum number of personnel present in the OT
  • No personnel should leave the OT till the surgery is completed
  • Training should be temporarily suspended
  • The virus has also been demonstrated in the stool, and precautions should be taken in handling of the bowel and creation of enterotomy or stoma
  • Usage of intraoperative drains should be minimized.


Operation theater

  • Ideally, a dedicated theater should be designated for operating on all suspected or confirmed COVID-19 patients.[29] This should be away from the high-traffic areas in the theater complex
  • All nonessential items should be removed from the OT
  • It is preferable to have an anteroom for donning and doffing of personal protective equipment (PPE)
  • All nonessential items including pagers, cellphones, and pens should be left out of the OT
  • Only items required for the surgery should be kept inside the OT
  • If possible, the patient should be observed in the OT rather than being shifted to a recovery area before being transferred out
  • Most modern OTs have a positive-pressure ventilation system, which may lead to dissemination of the virus. The OT should have negative pressure, more than 25 air changes per hour, good air mixing and directional airflow, a high-efficiency particulate air filter, adequate seal, and no leaks in the exhaust network[30]
  • All equipment and surfaces in the OT which are likely to be “high touch” should be wrapped/covered in plastic sheets to facilitate later decontamination[31]
  • A detailed process for converting a positive-pressure theater into a negative pressure has been described in the context of the SARS,[32] and this can act as a guide for those wishing to undertake this exercise.


Use of energy sources

  • When in use, electrocautery units should be set to the lowest possible settings.


Evacuation of smoke in open surgery

  • If available, electrocautery pencils with attached smoke evacuators such as PlumePen Ultra (Buffalo Filter LLC, Lancaster, USA)[33] or Remora (Applied Medical Technology, Brecksville, USA)[34] should be used
  • If these are not available, simple modified devices which have been described may be used.[35]


Cleaning and sterilization of instruments

  • All the instruments used during surgery should be handled with care and separated from other instruments
  • They should be processed and sterilized according to established protocols.


After the surgery

  • The clinical waste should be placed in biohazard trash bags, labeled, and disposed safely[36]
  • All instruments should be sent for decontamination and sterile reprocessing
  • Surfaces of all medical devices should be cleaned with disinfectant wipes
  • The OT should be cleaned with sodium hypochlorite solution and if possible treated with ultraviolet-C irradiation
  • All staff should shower and change into a clean set of scrubs
  • Names of all the participating personnel should be recorded to facilitate contact tracing
  • Extra turnaround time should be provided between surgeries as more time is needed for decontamination.



  Safety Measures For Laparoscopic Surgery Top


The recommendations, issued at the beginning of the COVID-19 pandemic, that laparoscopic surgery should be avoided altogether have now been tempered. Nevertheless, it is prudent to take the following precautions:[37],[38]

  • For establishing the primary port, a Verres needle and a sharp trocar may be preferred so as to minimize the chance of gas leak around a trocar placed by open laparoscopy
  • The carboperitoneum pressure should be set to the minimum possible level
  • Use of steep Trendelenburg position should be avoided
  • Minimum number of incisions and ports of appropriate size should be used to reduce leakage of gas
  • All the trocars should have intact seals
  • The exchange of instruments via the ports should be minimized
  • Special precautions should be taken during introduction of needles, gauze, etc., into the abdomen via a reducer, as well as their extraction
  • Use of energy sources should be minimized and they should be used at the minimum possible setting
  • During the procedure, some form of smoke evacuation device (see below) should be attached to one of the ports to facilitate intermittent release of the carboperitoneum
  • The inlets of all the ports other than the ones used for insufflation and evacuation should be plugged
  • At the conclusion of the surgery, prior to removal of ports, all the carboperitoneum should be evacuated by a combination of active suctioning and release via the port with an attached filter
  • Use of a fascial closure device should be avoided in the presence of a distended abdomen
  • An adequate-sized incision should be made for extraction of the specimen
  • Closure of the fascia at port sites should be performed under vision after complete evacuation of carboperitoneum.



  Smoke Evacuation Devices Top


Though there is little evidence to indicate transmission of the virus in laparoscopic smoke, most guidelines, as an abundant precaution, recommend use of an ultra-low particulate filter capable of removing at least 99.999% of all particles with a minimum size of 100 nm (0.1 μ) during laparoscopic surgery. The filters are of two types: (a) passive filters: connect to one of the ports with a Luer-Lock adaptor and the other end can be attached to a suction system/canister and (b) active filters: these are similar to the laparoscopic insufflators with two tubing for active insufflation and real-time filtration of the smoke. The website of the Society of American Gastrointestinal Endo Surgeons provides a comprehensive review of the available filters.[39] As these filter systems are likely to be difficult to procure presently, surgeons have reported innovative, albeit nonvalidated, designs for filters made from readily available materials in the OT.[40],[41]


  Personal Protective Equipment Top


PPE include respirator (N95 or FFP2 or FFPs standard), face shields or goggles, protective gown, and gloves. Hand hygiene forms an important part of the protection detail. While undertaking a surgical procedure during the COVID-19 pandemic, the surgical team, anesthetist, and nursing personnel should all wear appropriate PPE. The World Health Organization (WHO) recommendations for HCWs working in an aerosol-generating environment should be followed.[42] The sequence of donning and doffing the PPE can be found on the website of the Centers for Disease Control and Prevention.[43] In the non-OT areas of the hospital, surgeons should use PPEs as per the settings described by the WHO guidelines. Instructions on how to reuse the PPE, in case there is a shortage, can also be found in the WHO recommendations.[42]


  Resumption of Elective Surgery After the COVID-19 Pandemic Top


Evidence suggests that elective surgery undertaken in patients who may in the incubation period leads to poor outcome. Lei et al. reported on 34 patients who inadvertently underwent elective surgery during the early stages of the pandemic in China.[44] All patients subsequently developed COVID-19 pneumonia, 44.1% required admission to the ICU, and 20.5% died.

The duration of postponement of elective surgery is difficult to predict, but could be at least for a few months. In countries with state-run health systems like the United Kingdom, this is easier to implement, where the NHS hospitals have been directed to suspend elective surgery for 3 months from April 15, 2020.[45] In other countries where a significant part of health care is provided by private hospitals and smaller setups owned by individuals, market forces are likely to influence risk–benefit decisions. In these countries, particularly, a mindful, graded plan for resumption of elective surgery is warranted.

Advance plans should be put in place to safely manage the backlog of cancelled and postponed elective surgical cases once the pandemic wanes. An extensive joint statement[20] prepared by four associations in the USA suggests that multiple factors should be considered, some of are:

Timing of resumption

Elective surgery should resume only once there is a sustained reduction in the new COVID-19 cases over a period of a few weeks in a given city/state. Needless to say, such resumption should be authorized by the authorities.

Facilities in the hospital

The hospital restarting elective work should ensure adequate resources to last at least a month, and have adequate number of trained medical, nursing, and paramedical staff to be able to offer surgeries without compromising safety of the patient or staff.

Availability of COVID-19 testing

Ideally, all surgical patients should undergo a RT-PCR as well as antibody testing. Policy for testing of HCWs and steps in dealing with those who test positive should be clearly outlined.

Scheduling and prioritization of cases

A system for prioritization of cases within each specialty should be developed to optimize the use of available resources.

Preparedness and risk mitigation surrounding the second wave

One of the unknowns in the fight against COVID-19 is the likelihood of the second wave. Hospitals need to balance the haste in recommencing elective surgery with preparedness to tackle the eventuality of a second wave.


  Limitations Top


It is likely that by the time this paper is peer reviewed and published, newer insights may make part of what is written here outdated. The readers, therefore, are advised to update their knowledge by regularly visiting the official websites of several surgical associations and other organizations cited in the review. More importantly, several of the best clinical practice recommendations outlined here may have to be modified to adapt to the prevailing regulations and available resources in a given setting.


  Conclusion Top


The epidemiological triad of disease consists of agent, host, and the environment. Traditionally, surgeons have focused predominantly on hosts; their immunity, risks for anesthesia and surgery, and their prognosis. The COVID-19 pandemic has forced them to address the epidemiology of a novel agent, and the environmental precautions that one needs to take to protect patients and HCWs from a potentially lethal disease it causes. While surgeons have a duty of care to their patients, they need to remind themselves of the first principle of medicine “Primum non nocere” (First, do no harm). The key tools in not compromising on the quality of care offered to patients, while minimizing the potential harm to both the patients and HCWs, are stratification of the need for surgery, optimization of the surgical conditions from infection prevention perspective when surgery becomes necessary, and choosing modality of surgery least likely to endanger the patient and the HCWs alike.

Acknowledgment

The authors thank Ms. Avanti Bhandarkar for her help in drawing [Figure 1].

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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Abstract
Introduction
Severe Acute Res...
Severe Acute Res...
Stratification o...
Preoperative Tes...
Considerations t...
Intraoperative C...
Performance of S...
General Consider...
Safety Measures ...
Smoke Evacuation...
Personal Protect...
Resumption of El...
Limitations
Conclusion
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