Minimal Invasive Surgery the in COVID

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), the virus that causes India with a current population of 1,392,234,846 is currently in second wave of disease spread.

COVID-19, is a respiratory pathogen. The global pandemic has impacted each field of the society. The healthcare sector being at the epicentre of this has many challenges and are most at risk, not simply of catching the virus, but of getting its most severe form of it.

As disease is getting severe more and more number of health care workers are being affected. Hospitals have reduced the number of non-emergency surgeries in order to utilise the staff and resources in a more efficient way. This also protects the patients and the doctor of unnecessary viral exposure.

Since emergency surgeries are continuing, Laparoscopy surgery for the Gynaecology patients during COVID-19 pandemic presents numerous hurdlesto reduce virus transmission from asymptomatic, suspected or confirmed case of COVID-19 to patient, the surgeon and the operation room staff.

Nevertheless, despite the reassuring data, precautions should be taken to reduce any potential or theoretic risks during the pandemic. There are several safety considerations for clinical teams who participate in laparoscopy gynaecologic surgery during this time.
Guidelines are constantly being updated, and the information presented is subject to change as new data becomes available

Evaluationbefore surgery.

Laparoscopy may offer the best surgical approach and outcomes for most of the gynaecological conditions. Every patient should be tested for COVID-19 status on the day of surgery including history, physical examination, regarding flu-related symptomsand exposures. As tests are more rapid and readily available, universal testing for COVID-19 may be recommended. Since there are high chances for false negative results all cases should be delt in the same way.

In Operation theatre.

Laparoscopy most commonly involves general anaesthesia, with intubation, extubation, and mechanical ventilation, which may produce airborne viral droplets in a patient who is COVID-19 positive/negative. General anaesthesia is not contraindicated in patients with COVID-19 positive status, but the surgical team should minimize exposure to airborne route.

The COVID-19 virions are approximately 0.125 mm in size and are most commonly transmitted as larger (>20 mm) respiratory water droplets. these are detected primarily from human upper and lower respiratory tract specimens.

The N95 or the conventional surgical mask have 95% efficiency to filter the particles that are larger than 300 nm in size. Any surgical team in the operationroom should don adequate personal protective equipment (PPE), including face shields, N95 filtered masks, impermeable gowns, and gloves, head cover, eye protection and shoe covers. Movement of staff in and out of the OT should be limited. Trainees should be restrictedto avoid overcrowding.

The virus may also be aerosolized and transmitted in smaller droplets (<10 mm) in gas suspension. So the concern of smoke production through the hand instrument of electrosurgical device at the time of surgery is there because it can be transmitted to the operating room environment.

In addition, the sudden release of trocar valves, nonairtight exchange of instruments, or specimen extraction through abdominal or vaginal incisions may potentially expose the healthcare team to aerosolized viral particles.Virus has also been detected in blood and stool specimens, but it is unknown if infectious virus is present in these extrapulmonary specimens.

The concerns are valid but to date, no studies have identified SARS-CoV-2 in surgical smoke, and even if found, it is not known whether these viral particles are infectious. In addition, viral RNA detected in the blood has not been documented to transmit COVID-19through this route.

Several techniques can be utilized to minimize the potential risk of airborne virusduringlaparoscopy.

-Maintain low intra-abdominal CO2 pressures and limiting the use of energy instrumentsat low power setting to reduce smoke production with pneumoperitoneum .

-Avoid rapid loss of pneumoperitoneum at the time of instrument exchange or specimen delivery

-Minimize blood/fluid droplet spray or spread.

-Minimize leakage of CO2 from trocars (check seals in reusable trocars or use disposable trocars)

-In addition, use of a smoke evacuation/filtration/suction system which allows for controlled release and filtration of the surgical smoke.

-Most operation theatres have positive pressure ventilation which prevents nonsterile air to enter the sterile zone. But this makes the spread of aerosols faster. Therefore, a negative pressure ventilation is required to prevent this from happening. Moreover, the air conditioners should be started after the induction of anaesthesia and should be stopped 20 min before extubation.

-1% hypochlorite solution should be used for cleaning OT tables and anaesthesia instruments

Summary

We can agree that there is a theoretical risk of transmission of virus from the abdomen of an infected case during laparoscopy but scientific evidence is lacking.Since there are high chances for false negative results all cases should be delt in the same way.
Many of the changes that have been instituted during the COVID-19 pandemic are the new reality, As the scenario is at present, the virus is going to stay with us for a long time and we will have to learn to live in harmony with it by accepting these changes.

Centers for Disease Control and Prevention. Healthcare professionals. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/.

Zheng M.H., Boni L., Fingerhut A. Minimally invasive surgery and the novel coronavirus outbreak: lessons learned in China and Italy. Ann. Surg. 2020 Mar 26:26
Gu J., Han B., Wang J. COVID-19: gastrointestinal manifestations and potential fecal–oral transmission. Gastroenterology. 2020 May 1;158(6) 1518-9.
AAGL. Joint statement in minimally invasive gynecologic surgery dur- ing the COVID-19 pandemic. Available at:https://www.aagl.org/news/ covid-19-joint-statement-on-minimally-invasive-gynecologic-surgery/. Accessed March 28, 2020.

Dr Shrikant Ohri

MS (Obgyn) Gold Medal
Fellowship – Gynaecology Laparoscopy Surgery – Israel
Diploma – MIS – Oldenburg, Germany
Diploma – Post Graduate Diploma Of Medico Legal System
Certified Lap surgeon by The European Academy of Gynaecology Surgery – Belgium