key: cord-355636-mq7xb9d4
authors: Booth, R.; Aliozo, C.; Mureb, A.; Ahmad, M.; Clarke, A.; Nash, G; Qureshi, T.; Siddiqi, N.; Parvaiz, A.
title: Minimally invasive surgery in the COVID‐19 pandemic: An early single centre experience
date: 2020-08-21
journal: Br J Surg
DOI: 10.1002/bjs.11986
sha: 
doc_id: 355636
cord_uid: mq7xb9d4

nan

Surgical practice has changed dramatically during last few months owing to the COVID-19 pandemic. Concern for the safety of patients and staff with concerning outcomes reported by some units worldwide has generated controversy 1 . Various surgical societies published guidelines which were not in favour of minimally invasive surgery (MIS) due to the perceived risk of virus spread from aerosolisation 2,3 .

Initial experience from China and Italy favours open surgery over laparoscopic 4 . Variability in surgical practice was noted globally due to poor understanding of how the virus is transmitted 5 . As of 15 th May 2020, the global death toll from COVID-19 had passed 300,000 with nearly 4⋅5 million people infected worldwide. Overall, there have been 45 deaths in our hospital.

MIS has become the standard approach across several disciplines including general surgery, gynaecology and urology, in the elective and emergency setting. MIS leads to better short term outcomes including, less post-operative pain, wound infections, chest infections and shorter length of hospital stay. As open surgery is associated with an increased hospital stay, it may increase exposure to nosocomial COVID transmission, with added pressure on resources and ITU capacity. Guidelines have suggested caution with a perceived risk of virus spread through aerosol generating procedures (AGPs) including laparoscopy and robotic surgery. They have advocated a shift in practice towards open surgery and conservative management where appropriate.

The risk of virus spread with AGPs can be minimised by using ports with balloons, smaller skin incisions and avoiding 5 mm instruments through 10 mm ports. At the end of the laparoscopic procedure and before making an extraction site for specimen retrieval, careful evacuation of CO2 using special filters and suction would reduce leakage of CO2. We report our single centre experience during this pandemic. MIS was only performed in emergency and urgent cancer patients across three specialities (Upper GI, Colorectal and Gynaecology). Patient data was collected over eight weeks period retrospectively, from 16 th March to 15 th May 2020. A total of 128 cases were performed of which 86 were minimally invasive, breakdown of data is shown in Table 1 . All patients for elective surgery were self-isolated for two weeks and had COVID-19 test performed 48 hours before the procedure. Emergency surgery patient underwent PCR COVID-19 test prior to their procedure where feasible.

During the study period, there was no COVID-19 positive case reported amongst the patients in the MIS group or theatre staff. Balloon ports were used for all laparoscopic procedures. All robotic and initial eight laparoscopic cases were performed using AirSeal ® (CONMED, Utica, New York, USA) system and standard CO 2 system for the others. Ultralow particulate filtration system and suction was used in all laparoscopic cases to evacuate the gas at the end of the procedure. Theatre staff including surgeons wore full PPE including fitted N95 masks with face shields when working within 2 meters of the patient. Surgeons who performed robotic surgery used 3-ply surgical mask when operating from the console.

This data would suggest that, with appropriate screening of patients and protection of theatre staff as outlined, MIS is safe and feasible. With improved test kits and shorter turn around time the screening of patients provides an additional layer of safety to perform MIS surgery. We also recommend the use of closed circuit evacuation of the smoked CO2, or an ultralow particulate air filtration system. We believe that the risk of viral spread through MIS has been overstated and with appropriate safety measures it can be safely performed, with benefits to both the patient and healthcare providers. Patients should not be denied the clear advantages of laparoscopic surgery over open surgery during the current COVID-19 pandemic.

COVID-19 pandemic: perspectives on an unfolding crisis

SAGES and EAES Recommendations Regarding Surgical Response to COVID-19 Crisis

The Association of Coloproctology of Great Britain and Ireland Urgent Intercollegiate General Surgery Guidance on COVID-19

Minimally Invasive Surgery and the Novel Coronavirus Outbreak: Lessons Learned in China and Italy

COVID-19: What are the challenges for NHS surgery?

We would like to thank upper GI, gynaecology and emergency surgery department to contribute their data in the paper.