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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 15  |  Issue : 1  |  Page : 153-155

Minimally access surgery and endoscopic procedures in COVID-19 pandemic


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

Date of Submission05-Mar-2020
Date of Decision06-Mar-2020
Date of Acceptance15-Mar-2020
Date of Web Publication13-Oct-2020

Correspondence Address:
Dr. Harshal Tayade
Plot No. 29 “Bhagya-Harsh”, Dr. Sushila Nayar Nagar, Ward No. 4, Warud, Wardha - 442 102, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_139_20

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  Abstract 


The growing spread of COVID-19 pandemic has caused unprecedented changes in how health systems and health institutes deal with patients and health care. More attention is focused on containing the outbreak and avoids further infection and transmission. Hospitals have attained a wartime atmosphere in hotspot areas and health-care workers including surgical team have been deployed to take care of this respiratory illness. Rationing of services has however affected the management of non-COVID disorders and people are suffering unduly due to restricted access to care and lack of quality care. Hospitals are overwhelmed, bed availability, and availability of health-care personnel is compromised leading to restrictions on performing routine procedures especially if they are of surgical variety. However, some emergent conditions need immediate attention, failing which the disease may get aggravated, duration of illness will get prolonged and patient may land into a life-threatening condition increasing associated morbidity and mortality. With the advantage of minimum direct contact with body tissue and rapid postoperative recovery, minimal access surgeries greatly reduce hospital stay therefore reducing the risk of infection. Endoscopic procedures can aid in settling down acute illness following which definitive surgery can be planned later. This brief addresses the issues, concerns, and recommendations for minimal access surgery and role of endoscopy in ameliorating emergent and semi-emergent surgical conditions in the present pandemic situation.

Keywords: COVID-19, endoscopy, minimal access surgery


How to cite this article:
Pate MY, Tayade H, Singh AK. Minimally access surgery and endoscopic procedures in COVID-19 pandemic. J Datta Meghe Inst Med Sci Univ 2020;15:153-5

How to cite this URL:
Pate MY, Tayade H, Singh AK. Minimally access surgery and endoscopic procedures in COVID-19 pandemic. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2020 Oct 23];15:153-5. Available from: http://www.journaldmims.com/text.asp?2020/15/1/153/297965




  Introduction Top


COVID-19 has spread exponentially throughout the world, with 2,250,689 confirmed cases and 154,256 deaths till date, affecting both developed and developing countries with community spread seen in many countries afflicted with the virus.[1] The propensity of spread of the virus has affected the health-care systems and overwhelmed health-care institutes leading to flooding of hospitals and intensive care units. Hospitals have attained a wartime atmosphere in hotspot areas and health-care workers including surgical team have been deployed to take care of this respiratory illness. This has adversely affected the care related to non-COVID disorders including surgical illnesses. Frontline health workers are getting exposed/quarantined leading to sudden reduction in the available workforce. Nonavailability of public transport, fear of infection and transmission, and diminished health workforce have resulted in problems of access to care and quality of care. Certain recommendations have been provided by the WHO and surgical organizations' around the world, to stop elective procedures, thus upsetting clinical practices as well as availability of care.[2] However, certain procedures if delayed may lead to aggravation of disease or longer duration of hospital stay, increased morbidity and mortality due to unavailability of hospital services especially in rural setups further increasing the risk of COVID infection.[3] Minimally access surgery has played a lead role in diagnosing and treating various surgical illnesses, however in this COVID era, dilemma exists regarding its continued use for care of patients. This review addresses the issues, concerns and recommendations for minimal access surgery and role of endoscopy in ameliorating emergent and semi-emergent surgical conditions in context of the present COVID-19 affliction.


  Issues and Concerns Top


Although minimally invasive surgery (MIS) improves short-term patients' outcomes and is associated with a faster recovery in comparison to traditional approach, there are concerns related to the adoption of MIS in patients potentially infected by COVID-19. Potentially, infective viral components have been identified in surgical smoke and could potentially transmit disease.[4],[5] Postprocedure desufflation, defective valves, and the leakage of gases during change of instruments may potentially release the aerosolized virus into the OT environment. There is evidence that suggests that laparoscopic surgeries can lead to aerosolization of other blood-borne viruses. COVID-19 has to be considered exhibiting similar properties of aerosolization until availability of solid evidence that suggests otherwise. The release of aerosol through the trocar valves, might potentially expose the OR staff to Covid-19.[6] Moreover, surgeons and associated members will be exposed to increased risk of infections while performing endoscopy and airway procedures. Hence, OT personnel and surgical team should be made aware of the possibility of viral spread and strict precautions should be taken to minimize the risk of infection. Evidence is needed to better understand the risk of OR staff and provide the best treatment for our patients even during COVID-19 pandemic outbreaks

Recommendations for rationing of elective procedures

To aggressively address COVID-19, the conservation of critical resources such as ventilators and personal protective equipment (PPE) is essential, as well as limiting exposure of patients and staff to the severe acute respiratory syndrome coronavirus 2 virus. A tiered framework is essential to inform health systems as they consider resources and how best to provide surgical services and procedures to those whose condition requires emergent or urgent attention to save a life, preserve organ function, and avoid further harms from underlying condition or disease. As per the guidelines and recommendations from the WHO and surgical organizations worldwide like SAGES and AMASI, elective cases are to be avoided until the pandemic is controlled.[7] Emergent life-threatening situations and semi-emergent conditions are to be considered for surgery after careful evaluation by consultant surgeon. Urgency of the procedure, current and projected COVID-19 cases in the facility and region, availability of PPE, ventilator Beds, ward beds, essential staff, health and age of the patient, comorbidities such as hypertension, diabetes, obesity, and risk of COVID infection should be taken into consideration during decision-making. It is advisable to postpone healthy patient with not life-threatening illness requiring low acuity surgery such as cataracts, esophagogastroduodenoscopy, and release of carpel tunnel.[7] However, healthy control needing high acuity surgeries like most cancers, neurosurgery with highly symptomatic patients should not be postponed and operative procedure should be carried out with proper precautions.

Recommendations for minimal access surgery and endoscopy

There is very little evidence regarding the relative risks of MIS versus the conventional open approach, specific to COVID-19.[8] Although previous research has shown that laparoscopy can lead to aerosolization of blood borne viruses,[6] there is no evidence to indicate that this effect is seen with COVID-19, nor that it would be isolated to MIS procedures. With the advantage of minimum direct contact with body tissue and rapid postoperative recovery, minimal access surgeries greatly reduce hospital stay therefore reducing the risk of infection. Endoscopic procedures can aid in settling down acute illness such as common bile duct (CBD) stone following which definitive surgery can be planned later. Hence, wherever possible, minimal access surgeries and endoscopy should be considered with the following recommendations. Some examples of conditions for which minimally invasive surgeries should be considered are listed below:

  • Unresponsive appendicitis or appendicular perforation
  • Symptomatic cholelithiasis not responding to conservative treatment with cholangitis
  • Diagnostic laparoscopy for malignant diseases.


Endoscopy should be considered for endoscopic stenting for CBD stones with cholelithiasis and/or cholangitis not responding to conservative management, esophageal stenting for tracheoesophageal malignancies, diagnostic and therapeutic endoscopies for gastrointestinal malignancies, etc.[9] However, for any procedure, preoperative assessment with special focus on symptoms such as fever, myalgia, history of upper respiratory tract infection, travel history to COVID hot spot, and contact history with positive patient is mandatory. The consent should be taken with risk of potential exposure to disease and its consequences, as the disease if the present and asymptomatic may progress into a more severe manifestation in postoperative period. Occupational therapy (OT) personnel should be made aware of the possibility of viral spread and trained accordingly to minimize the risk of infection. All personnel should wear appropriate personnel protective equipment including N95 masks, gowns, and face shields. Minimize the number of personnel for OT procedures with 2 surgeons, 2 anesthesiologists, 1 nurse and 1 cleaning personnel for laparoscopy and 1 endoscopist, 1 anesthesiologist, 1 nurse, and 1 cleaning personnel for endoscopy. Intubation should be done as per anesthesia and airway societies guidelines.[7] General considerations such as laminar air flow should not be started until intubation is complete, the use of video laryngoscope if available and attachment of viral filter/thermo vent HEPA to endotracheal tube (ETT) before intubation. Positive pressure ventilation to be avoided as much as possible, if un-avoidable, tight fitting mask is to be used with gentle positive pressure, while the ETT is cuffed and connected to the circuit. Minimize the size of incision for the insertion of ports to avoid leakage of air into the OT environment. Minimize the CO2 insufflation pressure up to 10–12 mmHg. If available, ultrafiltration/smoke evacuation systems should be used. Pneumoperitoneum should be safely evacuated before closure or conversion to open surgery. Electrocautery if required should be used at the lowest possible setting to avoid charring of tissue and minimize smoke. On completion of procedure only anesthesia team should remain for extubation and other personnel should exit the OT however PPE should not be removed in case assistance is required for complications.[10] Laminar flow should be stopped 20 min before extubation and same level of precaution must be taken, with special care to minimize coughing while extubation.

Proper PPE removal with safe disposal should be done with the exit sequence as follows:[11]

  1. Surgical team should exit first as soon as closure is done and PPE can be removed and disposed after extubation is completed
  2. The patient should be shifted out after extubation
  3. Anesthesia team should exit after all contaminated re-usable material and equipment are transferred to a separate bag for proper cleansing
  4. Cleaning personnel should exit after cleaning and sterilization of the OT.


All surgical and anesthesia equipment should be sterilized and cleaned with 1% hypochlorite solution. Washing of OT slippers and clothes should be done immediately after the procedure is complete. After shifting the patient, the stretcher should be sprayed with 1% hypochlorite solution. At least 30 min of deep cleaning and 30 min of ultraviolet sterilization should be done therefore at least 1 h gap should be given between two procedures.


  Recommendations for Personal Protective Equipment Top


The use of PPE is recommended by the Centers for Disease Control for every operative procedure performed on a patient with confirmed COVID-19 infection or a patient where there is suspicion for infection.[12] The type of PPE used when caring for COVID-19 patients will vary according to the setting and type of personnel and activity. Among the general public, persons with respiratory symptoms or those caring for COVID-19 patients at home should receive medical masks.

For persons without symptoms, wearing a mask of any type is not recommended. Wearing medical masks when they are not indicated may cause unnecessary cost and a procurement burden and create a false sense of security that can lead to the neglect of other essential preventive measures. Respirators (e.g., N95, FFP2, or equivalent standard) have been used for an extended time during previous public health emergencies involving acute respiratory illness when PPE was in short supply. This refers to wearing the same respirator while caring for multiple patients who have the same diagnosis without removing it, and evidence indicates that respirators maintain their protection when used for extended periods. However, using one respirator for longer than 4 h can lead to discomfort and should be avoided.[13] Specifically, for aerosol-generating procedures (e.g., tracheal intubation, noninvasive ventilation, tracheostomy, cardiopulmonary resuscitation, manual ventilation before intubation, and bronchoscopy) health-care workers should use respirators, eye protection, gloves, and gowns; aprons should also be used if gowns are not fluid resistant.[11] Importantly, the use of gloves does not replace the need for appropriate hand hygiene, which should be performed frequently.[14]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
WORLDOMETER. Coronavirus Update (Live): 2,250,689 confirmed cases and 154,256 deaths from COVID-19 Virus Outbreak – Worldometer. 2020.  Back to cited text no. 1
    
2.
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. 2
    
3.
Surgeons, A.C.O. COVID-19: Elective Case Triage Guidelines for Surgical Care. American College of Surgeons; 24 March, 2020.  Back to cited text no. 3
    
4.
Bogani G, Raspagliesi F. Minimally invasive surgery at the time of COVID-19: The OR staff needs protection. J Minim Invasive Gynecol 2020;27:1221.  Back to cited text no. 4
    
5.
Gloster HM, Roenigk RK. Risk of acquiring human papillomavirus from the plume produced by the carbon dioxide laser in the treatment of warts. J Am Acad Dermatol 1995;32:436-41.  Back to cited text no. 5
    
6.
Zheng MH, Boni L, Fingerhut A. Minimally invasive surgery and the novel coronavirus outbreak: Lessons learned in China and Italy. Ann Surg 2020;272:e5-6.  Back to cited text no. 6
    
7.
Pryor A, SAGES and EAES recommendations regarding surgical response to COVID-19 crisis, 2020. Available from https://www.sages.org/recommendations-surgical-response-covid-19. [Last accessed on 2020 Mar 02]  Back to cited text no. 7
    
8.
Choi SH, Kwon TG, Chung SK, Kim TH. Surgical smoke may be a biohazard to surgeons performing laparoscopic surgery. Surg Endosc 2014;28:2374-80.  Back to cited text no. 8
    
9.
Repici A, Maselli R, Colombo M, Gabbiadini R, Spadaccini M, Anderloni A, et al. Coronavirus (COVID-19) outbreak: What the department of endoscopy should know. Gastrointest Endosc 2020;92:192-7.  Back to cited text no. 9
    
10.
Elizabeth Brindle M, Gawande A. Managing COVID-19 in surgical systems. Ann Surg 2020;272:e1-2.  Back to cited text no. 10
    
11.
Udwadia ZF, Raju RS. How to Protect the Protectors: 10 Lessons to Learn for Doctors Fighting the COVID-19 Coronavirus. 2020; 76:128-31.  Back to cited text no. 11
    
12.
Éirinn R.C.o.S.i.I.C.R.n.M.i., Updated Intercollegiate General Surgery Guidance on COVID-19; 2020.  Back to cited text no. 12
    
13.
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 Anaesth 2020;67:732-45.  Back to cited text no. 13
    
14.
Evaluation of Abdominal Malignancies by Minimal Access Surgery: Our Experience in a Rural Setup in Central India. World Journal of Laparoscopic Surgery 2018;11:115-20. Available from: https://doi.org/10.5005/jp-journals-10033-1350. [Last accessed on 2020 Jan 10].  Back to cited text no. 14
    




 

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