General recommendations

In the scenario of the COVID-19 pandemic, planning of surgical interventions needs to be adapted and could be modified depending on the new information and on the dynamics of the pandemic phase each region is going through. The situation of human resources and hospital supplies, and the availability of general ward and intensive care unit (ICU) beds should be considered in the decisions. Given the continuous changes in the knowledge of a completely new entity, it is worth mentioning that these recommendations are mainly based on expert recommendations and are subject to modification in view of new scientific evidence of higher quality.

This Committee agrees to accept the local regulations of limiting the surgical activity to emergency or oncological cases that cannot be postponed according to the conditions described. Nevertheless, he possibility of starting to schedule surgeries should be considered given the quarantine flexibilization by the authorities and the announcement that, if a peak occurs, it will continue to move away (it is currently expected by the end of June), the gradual opening of medical offices, and the accumulation of patients with pending surgeries in those institutions where phase 2 has not been reached and which have no difficulties with equipment supply. If the PCR test is available at the institution where the surgery will be performed to identify COVID-19 carriers, and the results are available in less than 24 hours, testing could be done the day before to avoid exposing patients who are in the incubation period to a potentially higher risk and optimize the use of resources.

A recent experimental study has shown that aerosol transmission of SARS-CoV-2 is similar to that of SARS-CoV-1 (the human virus most closely related), with the ability to remain in aerosols for 3 hours or more, and on surfaces for up to 72 hours. Although there is some evidence about the presence of viruses in surgical smoke and aerosols, neither this nor the probability of transmission have been established for the present case. In laparoscopic surgery, surgical smoke and aerosols are contained in a closed cavity and are evacuated through filters and the surgeon stands at certain distance from the patient. These factors could have a protective effect for the surgical team since the effectiveness of smoke management in open surgeries is at least questionable and the operating rooms with negative pressure are exceptional in our country. A simple and effective measure for the evacuation and entrapment of smoke and aerosol is needed and due to the limited availability for reliable filtering and evacuation system for pneumoperitoneum gases, we suggest the filtering system used by anesthesiologists for the airway (an appropriate system for a region where infection is likely to occur and not probable as pneumoperitoneum). This is a simple, low cost and readily available method in all the operating rooms. The suction system can be connected to twin-tubed bottle with water and sodium hypochlorite; yet, this system was not described in the original design.

The benefits of the laparoscopic approach for patients are known and include a shorter postoperative length of stay and a lower incidence of respiratory complications, which should be particularly considered in times of high bed occupancy rates.

The aerosols generated by the electrocautery in open gastrointestinal surgeries and the greater contact with the surgical gloves may cause micro-tears on the barrier mechanisms. Thus, the general recommendations indicate to specifically weigh the risk/ benefit ratio in the use of the laparoscopic approach in patients with SARS-CoV-2 requiring emergency surgery. In this sense, it is important to consider the experience of the surgical team involved, so it is recommended not to make changes in the approach usually used. It is also recommended limiting the number of the medical staff in the operating room and the leader of the team must be the one better trained. The individual protective protocol must be strictly observed. All the staff should wear N95 respirators, hermetic goggles, face shield, fluid-resistant gown, double hair caps and double shoe covers for the surgeons and nurse scrub. The second scrub person does not need to wear a fluid-resistant gown unless he/she needs to be in close contact. As with all the recommendations, the use of this equipment will be subject to the epidemiological situation and the availability of resources.

The use of the electric scalpel and other sources of energy is also discussed. The presence of the virus in the surgical smoke or the infectiousness of the smoke have not been proved, as the temperature of the instrument will probably destroy the virus. In any case, until there is solid evidence, it is recommended to minimize the continuous use of the electric scalpel or other energy sources and, if necessary, set them at a low intensity and suction the smoke with a seal water system and sodium hypochlorite.

Recommendations for management of pneumoperitoneum:

1. Keep the system closed and use new trocars or those with adequate and hermetic seal.

2. The lowest pneumoperitoneum pressure should be used if it does not compromise the exposure of the surgical field. The pressure should be set between 8 and 10 mmHg with a maximum flow rate at 10 liter per minute.

3. Maintain adequate muscle relaxation and minimize the operative time.

4. Avoid placing COVID+ patients in the Trendelenburg position for a long period to prevent adverse effects on the cardiopulmonary function.

5. Completely evacuate the pneumoperitoneum using a filtering device before closure, removing trocars and specimen, or converting to open surgery.

6. Clean up instruments contaminated with blood or other body fluids.

7. Once the trocars are positioned, the taps should not be opened. If movement of the insufflating port is required, the port should be closed before disconnecting the tube and the new port should be closed until the insufflator tube is connected. The insufflator should be “on” before the new port valve is opened to prevent gas from back-flowing into the insufflator.

8. During desufflation, all escaping CO₂ gas and smoke should be captured with a filtration system and desufflation mode should be used if available. Although some guidelines suggest desufflation through a suction system without previous filtering, it is not our recommendation since the risk of contamination of the tubes of such systems is unknown.

9. If the insufflator used does not have a desufflation feature, close the valve on the working port that is being used for insufflation before the flow of CO2 on the insufflator is turned off (even if there is an in-line filter in the tubing). If this warning is not respected, the intra-abdominal CO₂ can be pushed into the insufflator when the intra-abdominal pressure is higher than the pressure inside the insufflator.

10. The patient should be flat and ideally the lowest port should be utilized for desufflation.

11. Specimens should be removed once all the CO₂ gas and smoke is evacuated.

12. Surgical drains should be used only if necessary.

13. Suture closure devices that allow for leakage of insufflation should be avoided. The fascia should be closed after desufflation.

14. Hand-assisted surgery can lead to significant leakage of insufflated CO₂ and smoke from ports and should be avoided.

The risk of respiratory complications that might be associated with pneumoperitoneum in patients with pneumonia is a matter of debate. Laparoscopic surgery is not recommended in patients with confirmed infection and severe pneumonia requiring mechanical ventilation (MV). In confirmed COVID-19 patients, asymptomatic or with mild pneumonia, even with oxygen requirement but without need for MV, laparoscopic surgery does not imply greater risk than an open surgical approach.

Abdominal wall surgery

Emergency surgeries in abdominal wall conditions should be limited to incarcerated or strangulated hernias, eviscerations, rapidly evolving malignant tumors, and severe wall infections requiring surgical debridement. The indication for surgery should not be changed in the initial phases of the pandemic (phases I and II), and alternative treatments should only be considered in advanced phases when human resources and the availability of hospital beds and supplies are seriously affected. In these cases, consider the possibility of manual reductions of complicated hernias or incisional hernias, instruments for gastrointestinal decompression, use of antibiotics for abdominal wall infections and other palliative procedures with strict patient monitoring.

Changes in the type of approach are not recommended, especially in the early stages of the pandemic, and always considering the availability of resources and the experience of the surgical team. The surgical technique and approach must be those with the greatest benefit to the patient, considering the risks and benefits at each phase of the pandemic. However, the laparoscopic approach should be limited to teams with sufficient experience and resources. If the optimal conditions are not fulfilled, laparoscopy is not recommended, and the open or conventional approach should be chosen.

Colon and rectal surgery

The recommendations for colon and rectal surgery do not differ from the general recommendations for laparoscopic surgery. Since we are not talking about emergency procedures, anastomoses are not banned as long as the treating surgeon has a low dehiscence rate.

The opening of the gastrointestinal tract involves a greater risk of aerosolization because the presence of viral particles in the bowel content is greater than in the blood. Therefore, intracorporeal anastomoses are not recommended due to the potential risk of fecal contamination. Yet, these anastomoses could be considered in teams highly trained in the technique and after testing hermetic sealing and adequate functioning of the filtering and suction systems for pneumoperitoneum gases. For the same reason, in these cases PCR testing, if available, is needed to rule out COVID-19.

The same criterion is applicable for transanal resections (TAMIS or TaTME). However, these procedures should be avoided due to the difficulties in the management of surgical smoke with these techniques and the increased risk of sudden release of CO₂, as the percentage of false negative tests in use is still unknown. For the time being, we recommend postponing TAMIS, which is indicated in benign tumors or early malignant rectal cancers. The laparoscopic resection is recommended for total mesorectal excisions.

Hepato-pancreato-biliary surgery

The recommendations for this type of surgery are in line with the general recommendations during the pandemic.

In particular, and only for the purposes of organization, emergency biliary procedures could be deferred with minimal risk. The approach should not be changed due to the evident benefits of minimally invasive surgery. The epidemiological scenario is crucial at this point, as the usual early resolution of the complications of cholelithiasis may be appropriate if PCR testing is negative. In COVID-19 patients, it is recommended to defer surgery and wait for the disease to evolve with negative PCR test until patients are released from isolation.

Surgery of benign pancreatic cysts should be deferred. Inflammatory diseases and their possible complications should be observed and managed with non-surgical measures or minimally invasive procedures.

Cancer surgery should be deferred until hospitalization in clean critical units can be ensured due to the high rate of usual complications to avoid compromising the long-term outcomes.

Finally, liver surgery is not recommended as it cannot be safely performed in this unfavorable scenario. In general, the availability of blood products is low and the risk of transmission due to the usual use of section instruments or electric devices is high, which would require a significant change in the usual techniques. Thus, chemotherapy is recommended with frequent reevaluation of the epidemiologic scenario.

In conclusion, if the circulation of the virus in the community is low and the institution ensures a safe path for COVID negative patients, availability of beds in critical care areas and PCR testing before surgery, the usual minimally invasive techniques can be performed; if this is not possible, it is better to postpone surgery and monitor the clinical outcome.

Upper gastrointestinal surgery

Scheduled non-urgent surgical procedures of the upper gastrointestinal tract should be postponed or rescheduled to avoid exposing patients and health care workers to unnecessary risks of transmission of COVID-19.

Elective surgery:

▪▪Fundoplication.

▪▪Hiatal hernia repair (unless emergency presentation).

▪▪Heller’s cardiomyotomy.

▪▪Surgery for esophageal diverticula.

▪▪Surgery for non-aggressive upper gastrointestinal benign tumors.

▪▪Leiomyoma.

▪▪Schwannoma.

▪▪Mini‐GISTs without high‐risk features.

Patients requiring surgery for cancer in whom other cancer treatment is not possible should be tested for COVID-19 the day before surgery.

Surgery can be performed using the approach most used by the surgical team, since the aim is to reduce the operative time and avoid postoperative complications. Whether the laparoscopic or the thoracoscopic approach or both are chosen, the measures previously described and the general measures for the rest of the specialties should be followed.

Percutaneous interventions

As the risk of transmission of the SARS-Cov-2 is directly related to the degree of contact with COVID-19 positive patients, protective measures are mandatory for the interventional team.

Besides the measures recommended for all the surgical procedures, the following recommendations are suggested:

▪▪Consider bed-side procedures whenever possible to minimize patient transfer.

▪▪Ideally identify one suite dedicated for interventional procedures with negative air pressure or switch to neutral pressure in case the suite was equipped with positive pressure.

▪▪Define urgent criteria and plan the activity by establishing priorities (see list 1)

▪▪Identify high-risk procedures for the surgical team (see list 2). Consider direct admission of the patient in the operating suite. There should be clean access to the suite.

▪▪Limit staff members to those required for the procedure and avoid any changes in staff members during the procedure, whenever possible.

▪▪Perform procedures in the shortest possible time to reduce staff exposure time (less than 15 minutes when possible).

▪▪Reduce the interventional work teams to the institutional needs.

▪▪Discuss the creation of two independent rotating teams to avoid physical contact between them.

Priorities in interventional procedures:

▪▪1.Urgent procedures (within 24 hours)

◦◦Biliary drainage (sepsis)

◦◦Drainage of collections (sepsis)

◦◦Cholecystostomy (sepsis)

◦◦Any other intervention fulfilling the same criteria

▪▪Short-term planning (within 7 days)

◦◦Central venous access and PICCs

◦◦Nephrostomy

◦◦Drainage of collection

◦◦Airway/gastrointestinal tract stenting (obstruction)

◦◦Biopsies of transplanted solid organs

◦◦Any other intervention fulfilling the same criteria

▪▪3. As soon as possible (no more than 30 days)

◦◦Percutaneous malignant tumor ablation

◦◦Airway/gastrointestinal tract stenting (no obstruction)

◦◦Gastrostomy/jejunostomy

◦◦Tunnelled peritoneal/pleural catheters

◦◦Needle biopsy

◦◦Acute pain percutaneous management

◦◦Any other intervention fulfilling the same criteria

▪▪4. Acceptable to be planned after 30 days

◦◦Tube drainage change

◦◦Chronic pain management intervention

◦◦Any other intervention fulfilling the same criteria

Interventions in patients with COVID-19 patients presenting a high risk for transmission to the interventional team:

▪▪Endocavitary intervention on airways, esophagus and stomach

▪▪Bronchial embolization

▪▪Thoracic drainage

▪▪Thoracic biopsy

▪▪Intervention that requires intubation/extubation in the interventional suite

▪▪Intervention on patients with tracheostomy

▪▪Intervention on patients requiring CIPAP/BIPAP or similar equipment

▪▪Implantation of central venous catheter

▪▪Hybrid intervention requiring endoscopy of airways/ esophagus

Survey

This Committee wishes to distribute the following survey among all the members to get a more accurate idea of the real situation of the surgeons in our country.

https://es.surveymonkey.com/r/9WF52WD

This survey is short and simple to answer. We appreciate your participation and will notify you of the results.

Appendix

Results of the survey “Impact of the COVID-19 pandemic on surgical practice”

The Committee on Videoendoscopic and Minimally Invasive Surgery of Asociación Argentina de Cirugía prepared a brief survey that was attached to its Recommendation Guidelines for the COVID-19 Pandemic, that was later distributed through the social networks and the AAC mailing.

The survey was responded by more than 530 surgeons of different ages, from different regions of our country, and from different types of institutions (private, public, university and non-university hospitals), so we believe that it is a fairly representative sample of the universe of the MAAC.

The results are shared below.

Question 1: How many years have you been practicing as a specialist?

▪▪0-10 years: 29.86%

▪▪10-20 years: 32.96%.

▪▪20-30 years: 20.41%.

▪▪20-30 years: 20.41%.

Question 2: Where do you practice the specialty and in what type of institution? (multiple answers were accepted)

▪▪CABA: 30.97%

▪▪GBA: 32.46%

▪▪Inland (< 300,000 inhabitants): 22.95%

▪▪Inland (> 300,000 inhabitants): 24.63%

▪▪Public hospital: 49.44%

▪▪University hospital: 13.06%.

▪▪Community-based hospital: 5.78%

▪▪Private hospital: 67.91%.

Question 3: Has the laparoscopic approach been sus pended in your workplace?

▪▪Yes: 10.26%

▪▪No: 50.75%

▪▪Suspended initially but not now: 36.75%

▪▪Not suspended Initially no but suspended now: 2.24%

Question 4: If the answer is yes, who made the deci sion?

▪▪Crisis committee: 39.11%.

▪▪Anesthesiology department: 6.27%

▪▪Operating room paramedical staff: 3.32%

▪▪Head of surgery: 51.29%

Question 5: If the answer is yes, please explain why

▪▪Lack of PPE or other supplies: 11.24%

▪▪Because it was considered a high-risk procedure: 78.65%

▪▪Lack of labor risk insurance: 0

▪▪Other (specify): 10.11%

Question 6: Which PPE do you use in surgeries for pa tients without suspected COVID-19?

▪▪Standard surgical equipment: 45%

▪▪PPE level 3 (N95 respirator, hermetic goggles, double pair of shoe covers and caps, fluid resistant gown): 55%

Question 7: Do you think that the use of PPE should be changed for the laparoscopic approach?

▪▪Yes: 20.65%

▪▪No: 79.36%

Question 8: How do you manage the pneumoperito neum in the laparoscopic approach? (You may choose more than one option)

▪▪As usual: 22.29%.

▪▪Evacuation through HEPA filter used with anesthesia machine ventilators: 32.76%.

▪▪Evacuation through the central suction system: 28.57%

▪▪Water seal drainage system: 44.95%

▪▪Commercially available smoke management systems: 2.48%

▪▪ULPA filter: 2.67%.

Question 9: Do you consider that management of smoke is safer in laparoscopic approach than in open surgery?

▪▪Yes: 71.27%

▪▪No: 28.73%

Question 10: Do you know of any COVID-19 infections occurring during a surgical procedure? It may not be from your workplace.

▪▪No: 95.15%

▪▪Yes, from a laparoscopic approach: 1,12%

▪▪Yes, from an open procedure: 3.73%

In summary, 46% of respondents reported that the laparoscopic approach was suspended in their workplace during the pandemic. In 78% of cases this occurred because this approach was considered more dangerous for the health care team, as opposed to 71% who considered the laparoscopic approach to be the safest for the management of surgical smoke.

In most cases, pneumoperitoneum is managed with non-commercial filtering systems (water seal drainage system, central suction), and in 32% of cases with the HEPA filter used with anesthesia machine ventilators. Commercially available systems are rarely used, possibly because of their low availability before the pandemic.

Most survey respondents do not consider that PPE should be different according to the approach, and very few of them have heard about cases of infection within the surgical setting.