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 Table of Contents  
Year : 2020  |  Volume : 15  |  Issue : 1  |  Page : 144-148

Surgical protocols for patients with COVID-19

Department of Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed University), Wardha, Maharashtra, India

Date of Submission28-Mar-2020
Date of Decision10-Apr-2020
Date of Acceptance14-Apr-2020
Date of Web Publication13-Oct-2020

Correspondence Address:
Dr. Meenakshi Yeola
Department of Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed University), Sawangi (Meghe), Wardha - 442 107, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_142_20

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A cluster of pneumonia cases of unknown etiology were reported in Wuhan, Hubei Province, China, on December 31, 2019. China reported a novel coronavirus in the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) phylogenetic group as the causative agent of this outbreak on January 9, 2020. The associated disease is now referred to as novel coronavirus disease 2019 (COVID-19). The clinical presentation of COVID-19 ranges from asymptomatic to multiorgan failure, which may result in death. Coronaviruses are believed to be transmitted through the respiratory droplets from person to person, through inhalation, or mucosal surface deposition. The transmission of coronavirus through other routes includes contact with contaminated fomites and inhalation of aerosols. Novel coronavirus has also been detected in fecal and blood samples.The lack of standard infection prevention measures leads to the risk of health-care-associated transmission, while handling COVID-19-infected patients. The current COVID-19 pandemic underlines the significance of a conscious utilization of resources (human and financial) and preserving resources. It is salient to ensure the ability of surgeons and specialized professionals to function through the pandemic. A mindful effort should be made to minimize infection in this sector. A high mortality rate within this group would be disastrous. All hospitals should develop dedicated protocols and health-care workers training as the part of the effort to face the current pandemic. Literature search was done using PubMed and Google scholar search engines, searching terms “COVID-19,” “SARS-CoV-2,” “Coronavirus,” “surgery in COVID-19” titles, abstracts and keywords. The data were reviewed, analyzed, and presented.

Keywords: Coronavirus disease, COVID-19, emergency surgery, health-care worker safety, pandemic, severe acute respiratory syndrome coronavirus 2

How to cite this article:
Kalagani B, Yeola M, Zade A. Surgical protocols for patients with COVID-19. J Datta Meghe Inst Med Sci Univ 2020;15:144-8

How to cite this URL:
Kalagani B, Yeola M, Zade A. Surgical protocols for patients with COVID-19. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2020 Oct 28];15:144-8. Available from: http://www.journaldmims.com/text.asp?2020/15/1/144/297966

  Introduction Top

The current situation of COVID-19 pandemic,[1],[2],[3] when the catastrophic effects of novel disease overpower the capability of a given community to meet the demand for health care,[4] such scenario demands the best disaster response. During such disasters, financial and human resources preservation is crucial. A good organization and a preventive approach are mandatory in the phase of disaster management response. Resource exhaustion is minimized by well-organized and balanced use of the surgical appliances and staff.[5] Surgeons and health-care workers (HCWs) in general are a valuable resource during disaster. In order to preserve the ability to face surgical emergencies and associated activities that will continue to occur or perhaps increase during disaster, infection, or death of HCWs must be minimized.

All routine surgical procedures on all suspected COVID-19 patients should be postponed until confirmed infection clearance. Minimal staff should be involved in the intervention when postponement is not possible. If a large number of surgeons are exposed to infected patients, the possibility for them to become infected and require quarantine will arise and could potentially result in an alarming absence of senior expertise within surgical teams. Resource usage should be carefully considered when planning scheduled procedures, particularly with regard to materials, HCWs, supportive devices, intensive care beds, transfusion products, etc.

In this article, we aim to describe recommended surgical protocols for COVID-19-positive patients requiring emergency surgical care.

Surgical protocols are classified into the following sections to provide a high-level outline of technical measures and resources for reducing the risk of transmission of COVID-19 in health-care settings. The strategy for infection control against COVID-19 is targeted at four key areas: (1) preoperative, (2) intraoperative, (3) postoperative, and (4) before and after operation, after leaving the operation theater (OT)/hospital.

  Preoperative Protocols Top

Categorization of patients to stratify risk of COVID-19 transmission

Patients are categorized into the suspects and confirmed cases.[6] All known or suspected COVID-19-positive patients requiring surgical intervention must be treated as positive until proven otherwise to minimize infection spread. Protocol based clearly defined pathways must be available to health-care professionals for caring these patients.

Preoperative assessment

Assessment should include detailed history taking about prior travel to any region with a high number of infected COVID-19 cases, contact with any COVID-19 case or history of fever, cough, body aches, breathlessness, and upper respiratory tract infection. Reverse transcription polymerase chain reaction/enzyme-linked immunosorbent assay tests for COVID-19 should be done. All due precautions should be taken considering every patient as potentially infected until and unless proven.

Reorganization of the operation theater

Reorganization of the OT is required to minimize the transmission. Designated COVID-operating areas (COA) must be allocated to COVID patients. Limit traffic in the OT, all elective surgeries to be ceased and efforts are directed at treating the COVID-19 patients. The OT closest to the entrance of the OT complex entrance should be the first one designated to COVID patients.

Patient transport

Patient transit to and from the COA must be as quick as possible. A predefined direct path must be kept as short as possible and away from other patients and people in general within the hospital to minimize the chances of infection. Transfer personnel should be specifically trained and equipped with personal-protective equipment (PPEs). Limit patient movement within the OT by strict supervision. Geographic segregation within the OT complex is necessary to minimize the contamination by patients. Once all the OT preparations are done, then the patient is shifted into the OT. Specific routes and dedicated elevators should be used for patient transport within the hospital.

Operative personnel

Minimum personnel should be present inside the OT. Every person should be aware of possible risks of COVID-19 transmission and precautions to be taken. The surgeon should supervise the training and education of the OT personnel in this matter.

Operation theater preparation

Equipment kept in each OT must be minimized to what is strictly necessary on a case to case basis. Once the operation starts, all efforts must be made to use what is available in the room and minimize staff transiting in and out the OT, in order to minimize infection risk. Standard anaesthetic trolleys should be replaced with dedicated preprepared ones with minimal but adequate stock. All required surgical material (i.e., instruments, sutures, and scalpel blades) must be preoperatively organized in a sterilizable basket. Alcoholic solution for hand hygiene must always be available.

Personal protection equipment

All operative personnel (i.e., surgeon, anesthetist, nurses, technicians, and helpers) must wear the required PPE before contacting the COVID-19 patient. The patient's receiving personnel inside the COA filter area must perform hand hygiene and wear full PPE prior.

Personal protection equipment includes

  • Filtering Face Piece (FFP2) facial mask
  • FFP3 or N95 facial mask (for maneuvers with a high risk of generating aerosolized particles)
  • Disposable long sleeve waterproof coats, gowns, or Tyvek suits
  • Disposable double pair of nitrile gloves
  • Protective goggles or face shields
  • Disposable head caps
  • Disposable long shoe covers
  • Alcoholic hand hygiene solution.

Anesthesia protocols

Intubation during the administration of general anesthesia results in aerosolization, putting the anesthesia team, and OT personnel at risk.[7] Hence, surgeries can be performed under regional anesthesia (open surgery) should be given preference. All aerosol-generating procedures (AGP) should be avoided if possible. They include intubation, extubation, bag masking, and bronchoscopy.[8]

For all interventions, the guidelines issued by Anesthesia and Airway Societies are followed.

Intubation protocols:

  • Full-body PPE kit to be worn along with N95 mask and face shield
  • Video laryngoscope to be used for intubation
  • Proper fitting N95 mask worn and to be changed after each case
  • If possible, intubation and extubation are performed in a negative pressure room
  • Create a hood over patient head while doing airway procedure if feasible
  • Avoid positive pressure ventilation prior intubation. Use rapid-acting muscle relaxant for intubation. Rapid sequence intubation protocol is followed at all times
  • Air conditioner (AC) or laminar flow not to be started until the completion of intubation procedure
  • Use bacterial/viral filter (e.g., high-efficiency particulate air (HEPA) of Portex) only. Heat and moisture exchanger filter not to be used. All contaminated materials, which needed to be reused, i.e., video laryngoscope device to be immediately kept in separate bag for sterilization
  • Extubation should be done with same precautions as in intubation. Minimize cough reflex while extubation. Stop laminar airflow or AC 20 min before extubation.

  Intraoperative Protocols Top

  • Once the patient is shifted into the OT, the door must be kept closed at all times[6]
  • Supplying materials to the OT during the surgery should also be discouraged. The scrub nurse, in collaboration with the operating surgeon, should anticipate what is needed during the operation before the procedure
  • During intubation, minimum personnel should be there within the OT. The surgical team should wait outside till intubation has been done
  • Surgeons should preferably perform the operation with materials available in the OT once the operation started
  • All operative personnel present in the OT during the surgery should not leave the room till the completion of procedure
  • The patient will be draped by the surgical team according to the surgical procedure, replacing the surgical mask with FFP2 filter and wearing long shoe covers. All personnel in direct contact with the patient must wear a double pair of gloves at all times
  • The electrocautery should be used at the lowest power setting and charring of tissues should be avoided to minimize the creation of smoke/aerosols. Smoke evacuator/suction devices should be used to evacuate excessive smoke and aerosols, when electrocautery is used. The use of electrocautery is considered as a AGP[8]
  • Electromedical devices (i.e., ultrasound) and surfaces must be used with adequate protective cover and adequately sanitized at the end of the intervention. After the patient left the OT, there should adequate spacing before the next procedure takes place to reduce possible air contamination
  • This time spacing between the procedures depends on the number of air exchanges/hour of the OT by the HEPA filters[5]
  • Efforts should be made to minimize the contamination risk associated with specimens sent for histopathology.

  Laparoscopic Surgery Protocols Top

There is not much scientific evidence to support the belief that minimal invasive surgery (MIS)[9] poses a higher risk to the OT personnel as compared to conventional surgery, specific to COVID-19 patients. However, laparoscopy is considered as a potential AGP.[8] Sudden desufflation through the main cannula outlets at the end of the procedure, defective valves allowing leakage of gases during instrument exchange, and sudden desufflation for specimen extraction are the events which can potentially release aerosolized virus particles into the OT environment. Few studies have reported the presence of viruses from infected tissues in surgical smoke. Precautions as enumerated below should be taken during these steps.

The potential benefits of laparoscopy are minimum direct contact with body tissue, inability to filter the aerosolized particles in open surgery, shorter hospitalization stay with reduced morbidity when MIS is adopted as compared to open surgery should be weighed when considering laparoscopic versus open approach. Some of the important measures to prevent aerosol generation includes:

  • The incision ports should be as small as possible to avoid any leakage around the cannulas once pneumoperitoneum is established
  • At the end of the procedure, the complete desufflation should be done gradually through the appropriate filter of the designated side channel
  • Closure of port sites ≤10 mm should only be done after complete desufflation
  • To allow optimum lung function, the intraoperative pneumoperitoneum[8] pressure should be kept the lowest possible (10–12 mmHg) and the time duration in which the patient is in Trendelenburg position should also be minimum
  • In case of conversion to open or before removing any specimen from the abdomen, complete desufflation should be done as described above.

  Postoperative Protocols Top

  • Only anesthesia team should remain in the OT during extubation. Remaining members should exit the OT and wait but NOT remove their PPEs in case their assistance for some complication is required inside the OT[6]
  • Personnel responsible for transferring the patient away from the operating room must follow separate access routes and wear PPEs different from the ones worn in the OT
  • Clinical documentation must remain outside the OT
  • Staff not directly involved in the patient's care should leave the OT at the end of the surgery and remove all PPEs in a dedicated doffing area following the sequence described below. Any clean area should be accessed only after the doffing procedure is complete
  • Proper doffing of the PPE and its safe disposal should be done. After removing PPE, no one should enter the OT till it has been cleaned and sterilized
  • Instructions for PPE doffing/removal:[6]

Every HCW must take utmost care to avoid getting infected while doffing PPE; this must be done following a sequential procedure preventing recontamination of the operator's clothing and hands.

The first pair of gloves is likely to be heavily contaminated and must be removed first. All other PPEs must be considered infected as well and removed with care during the doffing sequence. Protective gown/suite, shoe covers, and head cap must be subsequently removed. Face shield, goggles, and mask must be then removed, taking care to handle the face mask by the ear laces and without touching its external side.

The second pair of gloves must be removed as the very last PPE and hands disinfection with alcohol-based solution must be accurately performed immediately after.

  • PPE must be removed and disposed off in dedicated doffing areas outside the OT ensuring the virus is not transmitted to the HCW
  • The OT and surrounding donning/doffing exchange areas must be sanitized as soon as possible after each procedure, with particular attention to all objects used when caring for infected patients. Similarly, all areas where COVID patients have transited must be carefully sanitized too
  • The OT and instruments should be considered as potentially infected and adequate cleaning and sterilization of the same should be done before scheduling another case in the OT
  • At the end of each intervention, all disposable materials must be disposed of and all surfaces and electromedical devices accurately cleaned and disinfected
  • The OT personnel in charge of cleaning and sterilizing the OT should be the last to exit the OT and the last to remove their PPEs
  • It is advisable to set up an exclusive container for hazardous medical waste immediately outside the OT, to immediately dispose of all contaminated disposable material and PPEs. Containers should be closed and sealed before being transferred to the collection point for further disposal
  • After each procedure, all involved personnel, whenever possible, should shower
  • Recovery phase after surgery must be continued in OT, before transfer of the patient to isolation ward/intensive care unit (ICU)
  • Exit sequence from OT:

1st: Surgical team

2nd: Patient after extubation

3rd: Anesthesia team

4th: Cleaning and sterilization crew.

  Before and After Entering the Operation Theater Top

  • Remove clothes worn from home and keep in garment bag before entering the OT[10]
  • Wear hospital scrubs before entering the OT
  • After completion of surgery and doffing PPE, remove scrubs; consider showering before changing into a clean scrub suit or home clothes
  • Wash hands frequently and maintain safe social distancing.

  After Leaving the Hospital Top

  • Keep hand sanitizer or disposable gloves for use of ATM, petrol pumps, and transfer of items at the time of purchases[10]
  • Clean your cell phone frequently before and after patient care activities. Cell phones may be kept in a Ziploc bag during work activities. The phone can be used while in the bag
  • Consider removing clothes and washing them upon arrival home
  • Consider washing hands frequently and reduce physical contact with family members
  • Clean exposed surfaces at home with an effective alcohol-based disinfectant solution.

  Discussion Top

The COVID-19 outbreak revealed the significance of infection control measures to prevent highly infectious diseases. Execution of adequate infection control successfully requires strict complying of protocols and exercise of individual discipline in enduring the inconveniences of daily temperature monitoring, repeated hand washing, avoiding touching face, properly fit mask usage always during patient exposure, and donning of standard and enhanced PPE whenever required. In practice of medicine, patient safety has always been a highest priority.[11]

The COVID-19 outbreak led to a phenomenal re-evaluation of HCWs safety. This became a prime concern instantaneously. Coordination and collaboration at all levels are essential to ensure that all patients and HCWs are adequately protected. Appropriate rationalization of any equipment use, during the initial period is required to preserve the limited resources to be diverted to the necessary high-risk areas of work. Regular review and modification of processes are done and reorganization of priorities accordingly.

The practice of surgery is significantly affected by the implementation of infection control strategies. HCWs designated to the COVID-19 designated OT consisted of the minimum required for efficient functioning and to minimize exposure; and the entire donning and prepping session of PPE is itself a tedious activity.[11] Usage of standard PPE is often inconvenient and arises difficulties such as the restricted field of vision and communication impairment with the surgical team during the operation. Adversity of operative procedures is further aggravated by the following factors: (1) trivial positioning; (2) in patients on anticoagulation therapy before surgery, attainment of surgical hemostasis is difficult; and (3) critically ill patients could not tolerate long periods of apnea and positive end-expiratory pressure loss. An experienced surgeon is therefore required to reduce the risk of complications and to perform the procedure quickly.[11]

One of the chief national propositions at present is to have an exclusive hospital for the treatment of all COVID-19 cases and similar diseases. An independent facility to manage COVID-19 and similar disease outbreaks is to be planned accordingly. This facility should consist of screening center, isolation rooms, an ICU, and an OT. With such facility, the need for discontinuance of elective and semiurgent surgical work may not be necessary in future outbreaks. In terms of personal protection, HCWs should treat all contact areas, including their own hands, as contaminated and avoid contact with mucosal membranes (eyes, nose, and mouth) without immediate previous washing or decontamination. These methods of personal protection are considered to be more important than the physical protection provided by PPE and failure to follow these protocols may lead to emergence of infection despite use of PPE. It is important to note that all these measures are targeted toward the prevention of transmission by respiratory droplets and contact.

In summary, a persistent high level of vigilance (personal, institutional, national, and international) is required for the prevention of infection and to control the transmission of COVID-19. Successful containment of another COVID-19 outbreak would require rapid identification of the disease and communication.

  Conclusion Top

It is mandatory to formulate precise well-established protocols to perform unavoidable surgical procedures and emergencies on COVID-19-positive patients. Specific internal strategies should be devised by hospitals and organise adequate training of the involved personnel.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organisation. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). World Health Organisation; 2020. Available from: https://www.who.int/docs/default-source/coronavirusewho-china-joint-mission-on-covid-19-final-report.pdf. [Last accessed on 2020 Mar 11].  Back to cited text no. 1
Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H, et al. First case of 2019 novel coronavirus in the United States. N Engl J Med 2020;382:929-36.  Back to cited text no. 2
Rothe C, Schunk M, Sothmann P, Bretzel G, Froeschl G, Wallrauch C, et al. Transmission of 2019-nCoV infection from an asymptomatic contact in Germany. N Engl J Med 2020;382:970-1.  Back to cited text no. 3
Goodwin J. NAEMT National Survey on EMS Preparedness for Disaster and Mass Casualty Incident Response. 2017. Available from: http://www.naemt.org/docs/default-source/ems-agencies/EMS-Preparedness/2017-naemt-ems-preparedness-report.pdf?sfvrsn=0. [Last accessed on 25 Sep 2020].  Back to cited text no. 4
Wong J, Goh QY, Tan Z, Lie SA, Tay YC, Ng SY, et al. Preparing for a COVID-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in Singapore. Can J Anesth 2020;67:732-45.  Back to cited text no. 5
Coccolini F, Perrone G, Chiarugi M, Di Marzo F, Ansaloni L, Scandroglio I, et al. Surgery in COVID-19 patients: Operational directives. World J Emerg Surg 2020;15:25.  Back to cited text no. 6
Luo M, Cao S, Wei L, Tang R, Hong S, Liu R, et al. Precautions for intubating patients with COVID-19. Anesthesiology 2020.  Back to cited text no. 7
Spinelli A. University of Michigan. Emergency General Surgery for COVID-19 Patients. 2020. Available from: http://www.med.umich.edu/surgery/mcccn/documents/Emergency-General-Surgery-in-a-COVID19-Patient-3_19_20.pdf. [Last accessed on 2020 Mar 24].  Back to cited text no. 8
SAGES. Available from: https://www.sages.org/recommendations-surgical-response-covid-19/. [Last accessed on 2020 Apr 01].  Back to cited text no. 9
American College of Surgeons. COVID-19: Considerations for Optimum Surgeon Protection before, during, and after Operation. Available from: https://www.facs.org/covid-19/clinical-guidance/surgeon-protection. [Last accessed on 2020 Apr 02; Last updated on 2020 April 01].  Back to cited text no. 10
Ter Chee VW, Khoo ML, Lee SF, Lai YC, Chin NM. Infection control measures for operative procedures in severe acute respiratory syndrome–related patients. Anesthesiology 2004;100:1394-8.  Back to cited text no. 11


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