Laparoscopic Surgery in COVID-19 Era: History
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Subjects: Others
Contributor:
Dragos Serban
,
Catalin Gabriel Smarandache
,
Corneliu Tudor
,
Lucian Nicolae Duta
,
Ana Maria Dascalu
,
Cătălin Aliuș

Chemicals, carcinogens and biologically active materials, such as bacteria and viruses, have been isolated in surgical smoke. However, the only evidence of viral transmission through surgical smoke to medical staff is post-laser ablation of HPV-positive genital warts. The reports of SARS-CoV-2 infected patients who underwent laparoscopic surgery revealed the presence of the virus, when tested, in digestive wall and stools in 50% of cases but not in bile or peritoneal fluid. All surgeries did not result in contamination of the personnel, when protective measures were applied, including personal protective equipment (PPE) and filtration of the pneumoperitoneum. There are no comparative studies between classical and laparoscopic surgery. 

  • laparoscopy
  • aerosolisation
  • Sars Cov 2
  • filtration systems
  • guidelines

1. Introduction

COVID-19 pandemic has a deep impact on the social and economic life worldwide and is considered the most severe sanitary crisis since the Spanish flu, a hundred years ago. The etiologic agent, called SARS-CoV-2, is an RNA virus in the Coronavirus family, generally responsible for benign respiratory infections, except for the causative agents of Middle East respiratory syndrome (MERS) in 2012 and severe acute respiratory syndrome (SARS) during 2002–2003 outbreaks [1]. With an estimated fatality rate of 0.5–1% [2] of the total number of infected people and 5% of those diagnosed [3], SARS-CoV-2 infection remains a global threat, months after the onset of the pandemic, due to the unpredictability of the clinical course in subjects in apparent good health, the extremely high contagiousness and the absence of specific antiviral treatment. Pulmonary decompensation may occur suddenly, after days of asymptomatic or oligosymptomatic evolution of the disease, with O2 desaturation, requiring ventilatory support. Although comorbidities and advanced age are factors statistically associated with increased mortality, the existence of severe forms in young adults and among medical staff has increased the psychological pressure of those treating patients suspected or infected with SARS-CoV-2.

The ways of intra-community transmission of the infection are via droplets, in the area of 1–2 m from the infected person, with possible oronasal or conjunctival entrance gates, by contact with infected surfaces, and by inhalation of aerosols with viral load. Aerosols are smaller particles, under 5 μm, which can travel by air currents and can be inoculated at the entrance gates (nose, eyes, mouth). Due to their small size, they can reach the broncho-alveolar level directly, along with the inspired air [1].

Since the time of SARS-CoV, in 2003, there has been convincing evidence that aerosol-generating procedures (AGP) could potentially result in aider human-to-human coronavirus transmission radius [4]. Bioaerosols range in size from 0.3 to 100 μm and particles up to 5 μm remain airborne and can travel distances of more than 100 m, which may be a transmission path for SARS-CoV-2. Based on these considerations, as well as taking into account that the SARS-CoV-2 virus was also identified in conjunctival secretions, blood, feces, digestive tract mucosa, or cerebrospinal fluid [5], the general recommendations of all medical and surgical societies were to avoid all procedures generating aerosols, including laparoscopic surgery, in patients with uncertain or positive COVID-19 status [6][7][8][9][10][11].

2. Results

2.1. Aerosolization risk in laparoscopic surgery 

The SARS-CoV-2 pandemic brings to attention a neglected subject in previous years, namely that of health risks related to exposure to plume and aerosolization during laparoscopy. Laparoscopic procedures have a theoretical risk of generating aerosols particularly during maintenance and evacuation of a pneumoperitoneum, CO2 leakage at the level of trocar orifices or changing instruments, and while using energy devices due to smoke generation. The size of the aerosolized particles depends on the type of energy used [12][13][14] (table nr.1).

Table 1. Dimensions of aerosols generated by different energy sources used in surgery.

Energy source

Dimensions of aerosols

Electrocautery

0.007–0.420

Ultrasonic scalpel

0.35–6.5

Laser

0.1–0.8

Chemicals, carcinogens, and biologically active materials, such as bacteria and viruses, have been isolated in surgical smoke. Previous studies show that chronic exposure can cause respiratory problems (cough, laryngitis, chronic bronchitis), eye irritation, headaches, and even carcinogenic potential. Aerosolization of blood-borne viruses like hepatitis B virus, HIV, and HPV has been previously detected in surgical smoke during laparoscopy [15][16][17][18][19][20][21][22][23][24][25]. However, the only evidence of viral transmission through surgical smoke to medical staff reported in the literature was post-laser ablation of HPV-positive vaginal warts. The previously studied viruses are not respiratory viruses, so the previous knowledge cannot be totally applied to SARS-Cov 2 infection.

Superior protection consisting of a respirator mask, FFP2 or higher, wrap-around goggles, and air filtration devices was discussed even before the Covid-19 pandemic but implemented only partially and non-unitarily [13][19][26][27][28]. The reduction of the pneumoperitoneum insufflation pressure, the reduction of the power, and the duration in case of using energy devices are associated with the decrease of the aerosolized particle concentration.

2.2. Viral transmission in open versus laparoscopic surgery

The previously published studies are on a limited number of cases and the methodology used differs significantly. The conclusion is that viral particles from the tissue treated by laser, electrocautery, or ultrasound are present in surgical smoke, along with a multitude of toxic compounds. There are no comparative studies between classical and laparoscopic surgery. On the one hand, minimally invasive surgery has an additional potential to aerosolize when evacuating the pneumoperitoneum or near the trocar holes, but on the other hand, if high efficacy filters are used, surgical smoke may be easier to manage than in case of using the same energy devices in open surgery [29][30][31][32][33][34][35][36]. In the current COVID-19 pandemic, open surgery should not be seen as risk-free as long as energy sources are used that produce surgical plume and an appropriate capture device should also be used [29].

2.3. Regulations for increasing safety in laparoscopic surgery

Preoperative testing of surgical patients with RT-PCR for SARS-CoV-2 2 is strongly recommended, but it does not guarantee lack of infectivity due to a demonstrated false‐negative rate of up to 10-30%, including the patients in early incubation period or post-infection, with a minimal viral load at the level of nasopharynx [37].

The surgical smoke filtration systems are proved to be useful in preventing its toxic and infectious potential. SARS-Cov-2 virus size ranges from 0.070–0.075 μm. The recommended filters are HEPA, with an efficiency of 99.97% in removing particles> 0.03 μm diameter or ultra-low particulate air (ULPA) filters, which can filter particles> 0.05 μm size. Although these measures are discussed as safety rules in recent years, taking into account the findings related to the toxic and infectious risk of surgical smoke, their implementation is inhomogeneous, largely lacking in the usual equipment of surgical teams.

All surgical societies (SAGES, EAES, AMASI, IAGES) [6][7][8][9][10][11] have adopted a set of measures to minimize the emission of aerosols during the intervention, consisting of the reduced pressure of the pneumoperitoneum, tight incisions to prevent leakage at the trocar orifices, minimum use of energy devices and use of cold hemostasis whenever possible, integrated insufflation devices comprising smoke evacuation and filtration mode, HEPA or ULPA type and valve type valves to prevent gas loss when changing the instrument. Hand-assisted surgery and specimen removal are associated with significant leakage of CO2, as a consequence, they must be performed after insufflation. Surgical drains should be utilized only if necessary.

Table 2: Recommendations of international societies for safe laparoscopic surgery during COVID-19 pandemic

 

SAGES/ EAES

ELSA

ALSGBI

ESGE

Sizing the incisions

Incision ports as small as possible

Purse-string suture or disposable trocar with skin blocking system should be used

Balloon/self-sealing trocars

+

Creating pneumoperitoneum using the most familiar technique

 

+

 

 

Low CO2 insufflation pressure (10-12 mmHg)

 

 

+

+

+

+

Minimal use of electrocautery

+

+

+

 

The low power setting of electrocautery

+

prevent plume formation by low energy, keeping instruments clean, limited dissection, frequent suction

 

 

Ultra-filtration of smoke

 

HEPA/ULPA filters are strongly recommended

passive or active filtration systems of pneumoperitoneum

+

+

Disposable instruments to prevent viral contamination

 

+

 

 

Drain only if necessary

 

+

 

 

Attach a CO2 filter to one of the ports for smoke evacuation if needed, do not open the tap of any ports unless they are attached to a CO2 filter or being used to deliver

the gas

 

 

 

+

Minimize introduction and removal of instruments through the ports as much as

possible

 

 

 

+

All pneumoperitoneum safely evacuated via filtration system before closure, trocar removal, specimen extraction, or conversion to open

+

+

+

+

Footnotes: SAGES: Society of American Gastrointestinal and Endoscopic Surgeons; EAES: European Association for Endoscopic Surgery; ELSA: Endoscopic and Laparoscopic Surgeons of Asia; ALSGBI:  Association of Laparoscopic Surgeons of Great Britain and Ireland; ESG: European Society for Gynecological Endoscopy

3.  Conclusions

Previously published data showed there is possible infectious and toxic risk related to surgical smoke but not particularly proven for SARS-CoV-2. As the COVID-19 pandemic seems to be still far from ending, healthcare personnel must up-date the clinical protocols, to increase safety but without stepping back from the achievements of modern medicine. The impact of avoiding a minimally invasive approach could be a health burden due to prolonged hospitalization and post-operatory complications.

On the other hand, in certain situations, the doctors could be faced with ethical dilemmas, as they have to decide whether to opt for their safety or to choose the less harmful option for their patients. Human resource is the most important in health and must be protected, even the risk is low. Respecting the strict regulations regarding PPE remains the most effective protective measure to mitigate the infectious risk both for open and laparoscopic surgery. Implementing standardized filtration systems for pneumoperitoneum and smoke evacuation during laparoscopy, although increases costs, is necessary to increase the safety of minimally invasive surgery during the COVID-19 pandemic and it will probably remain a routine also in the future. Although laparoscopy was firstly regarded with extreme prudence, the effect of the COVID-19 pandemic will be most probably progress in the safety regulations regarding laparoscopic smoke, drawing attention to this overlooked subject. As a professional, one must keep in mind the evidence and make the best decision in specific challenging cases.

This entry is adapted from the peer-reviewed paper 10.3390/diagnostics10090673

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