key: cord-315170-ykqnbsqe authors: Amore Bonapasta, Stefano; Santoni, Simone; Cisano, Claudio title: Emergency laparoscopic surgery during COVID-19: what can we do and how to do it safely date: 2020-05-21 journal: J Trauma Acute Care Surg DOI: 10.1097/ta.0000000000002784 sha: doc_id: 315170 cord_uid: ykqnbsqe nan Conversely, other authors consider that laparoscopy remains the preferred surgical approach. Such an assumption is based on the lack of data to support that COVID-19 is transmitted by surgical smoke or pneumoperitoneum, the well-known health benefits for patients and the opportunity for containment and filtration of the surgical gas with smoke evacuation systems, which are widely recommended. So, although we disagree with the gross but reasonable change of policy, according to which Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. Appendectomy. The appendix-mesoappendix complex can be freed from its adjacent, often inflamed, tissue with blunt dissection. Then the appendix can be removed through either an antegrade (the mesoappendix is ligated first) or a retrograde technique (the appendiceal base is exposed, dissected and transected first). Many different techniques can be used for both mesoappendix dissection and appendicular stump closure, without using energy devices. They can be stapled or safely managed with simple ligation, endoscopic clip, endoloop or Hem-o-lok. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. In our opinion, in order to avoid the electrosurgical use, the retrograde approach could be easier, especially when the appendix is very inflamed or it's surrounded by inflammatory tissue. Our preference is to close the appendicular stump performing a simple intracorporeal ligation, tying off the base. Another cost-effective and safe option is to use Hem-o-lok. Once the appendix is divided, mesoappendix can be ligated with ties, endoloop or endoscopic clips. In stable patients, perforated peptic ulcers smaller than 2 cm can be treated with a laparoscopic primary suture, which does not require any energy. Laparoscopy allows for complete abdominal exploration and peritoneal lavage, if needed. Single adhesion causing small bowel obstruction. In case of small bowel obstruction, the laparoscopic approach can be beneficial for selected Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. cases, without very distended loops of bowel and multiple complex adhesions. One cause of small bowel obstruction is a single fibrous band which produces an overhanging or a rotation of an intestinal loop. In such a case, the fibrous band is usually coagulated and cut. We simply suggest to place endoscopic clips and cut between the clips. We congratulate Dr Di Saverio and coauthors on their study, although we wish to emphasize that we should not stop to perform emergency laparoscopy tout-court, because it allows optimizing patient care and outcomes. On the other hand, when clinically appropriate, we have to determine if it is safely feasible. Unfortunately, in the current climate, patients are reticent to access to hospital care even for emergency conditions, because of fear of exposure to COVID 19 (5). Delayed access can lead to more complex local inflammation, for which electric devices (as bipolar energy) are often required, or to conditions of abdominal distension or hemodynamic instability that contraindicates minimally invasive surgery. Patients should be made aware of the risks of delayed access to the emergency department. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. Laparoscopy at all costs? Not now during COVID-19 and not for acute care surgery and emergency colorectal surgery: a practical algorithm from a Hub Tertiary teaching hospital in Emergency surgery in suspected COVID-19 patients with acute abdomen: case series and perspectives What Is the Appropriate Use of Laparoscopy over Open Procedures in the Current COVID-19 Climate? Kickboxing kick: Laparoscopic management of jejunal perforation after blunt abdominal trauma-Video vignette